IMRT WITHOUT SPACEOAR PROTECTION (EPE) WORRIED ABOUT RECTUM PROBLEMS (PROCTITIS) & IMRT (20x,28x,???) vs SBRT

[JWS13]

I am going to have to have IMRT for 20 treatments at UCLA as opposed to the 5 Sbrt treatments as the EPE on reread on my Biopsy identified the extracapsular extension.

My Ro thinks that:

Not to have spaceoar as it may trap the Extracapsular extension microscopic cancer cells .

IMRT has more data than SBRT and is safer with the more drawn out treatment and less high velocity treatment as SBRT.

Is the 20 treatment IMRT as good as the 28. What's the difference between , IMRT Condensed, IMRT Dynamic, IMRT Vmat,?

Is proctitis a major concern w/o the space oar and with IMRT treatment. I don't want my rectum burnt. Is IMRT low enough in GY's that the radiation is not generally a problem for the rectum with IMRT? Worried without the Spaceoar protection.

Thanks for responding...Gleason 4+3 , EPE, PSA 7, 68

[TylexGP]

Please take a look at my bio. I did HDR Brachytherapy followed by 20 ImRT treatments 1 month after HDR Brachytherapy. All of this was done without SpaceOar. Some diarrhea at the end of IMRT which resolved and I have had no major issues at 19 months post Tx. I would not fear having IMRT without spaceoar. The new Linac machines are very precise. I wish you well in your journey.

[Tall_Allen]

Is this Dr.Kishan? I'm surprised he doesn't want to do SBRT. Why?

SBRT has intrafractional tracking. The rest don't.

SpaceOAR really doesn't do much:

prostatecancer.news/2017/01...

[JWS13 in reply to Tall_Allen]

talked at length with kishan today..he said both sbrt amd imrt (20) sessions were about equal in non recurrence (even with my EPE ) so the choice is up to me...my other RO's who recommended IMRT because there is "no data" past 5 years on SBRT have never explained what the "no data" means to them...does it mean SBRT can break down and side effects in year 6 can turn up "severe & miserable" or SBRT "stopped killing and aging cancer cells in year 6 or some obtuse other cancer originated" what do they mean by "there is no data..???.. I am on the fence between SBRT AND IMRT..kishan did say.. SBRT with its "higher dose " may be better' as they have found that the higher dose kills cancer cells better, and he said with SBRT being modern, all hands on deck, and more tech" it is probably better than IMRT and if anything certainly as good as IMRT" TA i have 6 days to decide..what is your opinion and also you mention "INTRAFRACTIONAL TRACKING" as a reason to choose sbrt..what is that "interfractional tracking"

[Tall_Allen in reply to JWS13]

Interfractional tracking means they align fiducials once at the start of each session - it is how IMRT is done. Intrafractional tracking means that position is tracked throughout each treatment - it is how SBRT is done. Kishan uses Viewray, which does not use fiducials to align the beams, it uses MRI instead.

Kishan knows more about all this than all the other ROs you talked to.

Since you seem to care how long trials have run....

A. Here is the 12 year report on SBRT from Alan Katz:

renalandurologynews.com/hom...

B. The longest running trial (from MSK) on IMRT is only 10 years and has a much smaller sample:

acsjournals.onlinelibrary.w...

C. The longest running trials (10 -year follow up) on hypofractionated EBRT are these:

ascopubs.org/doi/10.1200/JC...

ascopubs.org/doi/full/10.12...

redjournal.org/article/S036...

[Don_1213]

I'll just mention - my RO felt SpaceOar is over-rated and feels it's not a good thing to stir up the area when there is cancer around. So I didn't have it. I did have 45 zaps, 83Gy total (as high as is given now). I had an issue for the past year or so (radiation was 3 years ago now) of small-hard poops. Rabbit pellet size. Doctors suggested things that did nothing for it.

I finally did "low-dose-naltrexone" and that instantly went away (like overnight - I was amazed.) There are some threads on LDN here - might be worthwhile checking them out if radiation proctitis is a worry for you. One of LDN's primary things is controlling inflammation - body-wide.. including the bowel apparently.

[maley2711 in reply to Don_1213]

You tried 12 cups of daily water plus 1/2 of the standard daily dose of Miralax ?

[Don_1213 in reply to maley2711]

Since I have continence issues - 12 cups of water a day might be interesting. And Miralax? I wasn't constipated - I had hard turds. Little round hard turds. Lots of them. I did go the extra fiber route, additional magnesium, etc.. it really had no effect on them. LDN did overnight. And it continues to be fine - about 9 weeks out on LDN. The "standard daily dose of Miralax" isn't always standard (some RO's don't ask for it), and it's primary purpose to empty the bowel before radiation treatments.

[maley2711 in reply to Don_1213]

Just my experience..... both drinking more water and Miralax have resulted in MUCH softer stool ...previously VERY hard stools and often very small hard stools. I'm talking 1 tablespoon of Miralax daily....not taking the whole container over a 24-48 hr period as is done before colonoscopy. I'm not aware that most ROs direct patients to do a complete cleansing Miralax before initiation of radiation???

[londoncyclist48]

Re space oar. I've mentioned this before but when I inquired about SO, the doctor told me he didn't even offer it to private patients. I think the modern radiotherapy equipment is so accurate, they don't even need it. I was concerned at the time that I wasn't having the very best possible treatment but it sounds like it adds an extra layer of complication to what is essentially a very safe procedure. I've had a great result from radiotherapy and I hope you do too. My PSA is now 0.05

[Gabby643]

I had 40 IMRT without spaceoar and 3 years later rectum etc. are ok. I too want ed"Spaceoar" and RO said you won't need it. Gleason 8 .

[cybertreated2019]

I had spaceOar in 2019 and still had loose bowel issues for at least two years after SBRT treatment. Not sure if it was poor placement or not but urgency and frequency of BM’s lasted a long time

[OldVTGuy]

Sounds familiar to me. My RO noted the location of my tumor (pressing against the rectum) and says he will not use space oar because there is a risk of "trapping" some of the tumor on the wrong side of the gel. Happy to read lack of rectal issues from the other folks here - I start my journey tomorrow with my first ADT treatment.

[JWS13]

same ...good luck...lets stay in touch...are you having it done with kishan..

[Max225]

"Not to have spaceoar as it may trap the Extracapsular extension microscopic cancer cells"

Precisely why I chose not to have SpaceOar. I have had no side effects from IMRT and HDR, except for catheter pain after HDR.

[Mike404]

I had SBRT with Dr Kishan this past fall. Gleason 4+3 with mid-tier suspicion of ECE, but nothing on PET. Tumor wasn’t near the rectum, but we did do the SpaceOAR. I considered it “a belt with my suspenders”. Kishan did 40 Gray with a 42 Gray boost to the actual tumor volume. The ViewRay MRI guided machine is truly a scientific miracle. It tracks the organs in real time, allowing Kishan to add a boost similar to HBT with the external beam. Five easy to tolerate sessions.

If you’d asked me about the SpaceOAR the first few days after insertion, I was quite uncomfortable and would have said skip it. It was a non issue after that and Kishan thinks it likely helped. I had one day of bowel urgency after my last session, easily handled with Imodium, and no problems after.

Some urinary bother, mostly after I stopped FlowMax since it was giving me low blood pressure and near fainting when I stood. My six months of ADT have been easy, in my fourth month, but I’ve exercised heavily.

[JWS13 in reply to Mike404]

did you use orgonovyx for adt?

[SierraSix in reply to Mike404]

I had the same exact treatment from Dr Kishan in Dec 2022. Good to hear

[Mike404]

Yes, I’m finishing up my 4th month. It’s not been that bad. I’m debating whether to pay $6k for two more months or just get the monthly shots, which are covered by insurance.