Any experience with Ultra-hypofractionated beam tmt. (5 fractions) with HDR Brachy Boost?

[SongofFred]

My RO at UCLA is offering HDR Brachy but with only 5 high dose fractions of beam treatment.

He says UCLA and MSK are doing it as well as places in Canada.

The few studies I could find show it looks comparable if not slightly more effective with same toxicities as conventional and hypofractionation. Only caveat being the sexual side effects might be a little worse. But all this from very scant data.

I don’t know if they’re offering because they’re curious to see how it pans out, or to save time, or because they have enough data showing it’s safe. I don’t want to be a Guinea pig.

Does anyone have any knowledge of this at all? If it’s more effective, I’d like to try it.

[bkjamjets]

Hi Fred, the 5 treatment SBRT (alone) is one of their standard protocols. I would have done the HDR boost, but I had traveled from out of state for treatment. I didn’t find out about it until I was already there and would have been delayed. I’m not sure if Dr Lee’s clinical trial is 2 or 5 SBRT treatments in addition to the HDR. All the Physicians and staff are fantastic at UCLA RO, you can’t go wrong there IMO

[SongofFred in reply to bkjamjets]

Thanks for your reply.

Just to make sure we’re on the same page,

It sounds like you may be talking about SBRT mono therapy to the prostate itself in 5 fractions which certainly is a standard now at UCLA.

I’m talking about the beam treatment of the whole pelvic area which is part of the Brachy boost treatment. The beam covers the pelvic area, nodes and prostate, the Brachy then gives a boost to the prostate alone. The beam treatment is typically given over several weeks, but they have been reducing the fractions and are recently doing five. So this is a different animal altogether from 5 fraction SBRT mono therapy.

I’m wondering if you could clarify which therapy you are referring to as standard protocol.

Thank you.

[bkjamjets in reply to SongofFred]

Sorry to be unclear… Yes I meant the 5 treatment mono therapy is >one of their< standard SBRT protocols. I didn’t hear about the beam and boost you describe until I was already there and scheduled for the monotherapy. Couldn’t shift gears at that point because I had traveled from out of state. It sounds like a great treatment plan.

[SongofFred in reply to bkjamjets]

Thanks for the clarification.

[timotur]

It sounds like this is HDR-BT + SBRT (5x) instead of HDR-BT + IMRT (25x). I had the latter at UCLA w/ Chang w/ a good outcome.

[SongofFred in reply to timotur]

I might just go for 25 fractions as well. In theory, 5 fractions is supposed to be more ablative, but HDR mono therapy in one fraction was also supposed to be more ablative. That assumption turned out poorly.

Then again, I can’t imagine Dr. Chang would go head without enough evidence. I’m going to ask him tomorrow what evidence he’s basing this on.

Thanks for your reply. Glad all is going well.

[timotur in reply to SongofFred]

You're in good hands with Dr Chang. He coordinated w/ Dr Eintz down here in San Diego for the IMRT. (In other words, you can have the IMRT anywhere after HDR). I like the idea of IMRT as an adjunct to HDR-BT because just my feeling, from the standpoint of toxicity, it's better to have lower intensity pelvic radiation (IMRT) after a concentrated high-dose with HDR to the prostate. Say hello to Dr Chang from Tim/SanDiego-- four years ago this month he treated me, and I'm still <0.02.

[SongofFred in reply to timotur]

Yes, I only hear good things about Dr. Chang. I live in Seattle, but I’m going to try and have my IMRT done in LA in case there’s any chance of non-conformity or mis-dosing due to miscommunication.

I agree about the lesser dose of IMRT with Brachy boost. I hope five fractions has no greater toxicities.

Dr. Chang did say with node radiation it does increase chance of bowels becoming less pliable over time, therefore needing to defecate maybe one extra time per day since it can’t hold as much as before. Can I ask if you’ve noticed that?

[timotur in reply to SongofFred]

Ok Songo, sounds good. When you're treated at UCLA, you may check out lodging at the on-campus facility for patients-- it used to be called the Hawthorne house, but I think they changed the name of it to a generic name.

In my treatment, I had suspected mesorectal node involvement from a PSMA scan, so the radiation map for IMRT included the border with the rectum. Thus, my risk was of rectal SE's was probably higher than most-- but I have not had any at all. My BM's are regular and normal as they were before treatment four years ago. I do eat a lot of fiber, which may help. Also, I had SpaceOar inserted during the BT procedure, and that may have helped prevent SE's. I saw an MRI of the SpaceOar during IMRT treatment, and Chang perfectly placed it symmetrically around the colon giving 14mm separation between the colon and prostate. I would recommend it. Best of luck!

[SongofFred in reply to timotur]

Good to hear you have no side effects! I’m surprised Dr. Chang did the implant himself - I assumed everything would be done by techs and I might not even see him (don’t know why).

One last question. Did they implant fiducials for the IMRT? They’re saying they’re not necessary and that worries me a bit especially with only 5 fractions it seems like they have to be super precise every time and the CT scan can only see so much. Dr. Chang mentioned doing the IMRT on VMAT. You mentioned MRI - was that just for the Space Oar guidance or was your IMRT guided by MRI?

[timotur in reply to SongofFred]

During BT, Dr Chang planted the gold fiducials and SpaceOar. Six weeks later, for IMRT prep, a Cat scan of the fiducials was done to place three dot-sized markers (tattoos) on my hips and abdomen, which were used for alignment on the table for each IMRT session. An MRI was done pre-IMRT, to do the IMRT radiation mapping treatment plan of the pelvis. Maybe SBRT uses real-time imaging of the prostate instead of the fiducials.

[SongofFred in reply to timotur]

Thank you for clarifying so well! Good to know what to expect and what to ask Dr. Chang if things have changed.

[Seasid in reply to timotur]

Correct, I received 38Gy radiation to my prostate. The MRI guidance is especially good to irradiate the particular limph node as it moves in real time. If you wish you can come to Sydney for 3 weeks and do the radiation here. I didn't have any space oar etc. Only the tattoos on my hip etc. They are very small and I dont even know where they are.

[Seasid]

I am multi metastatic in my bones diagnosed 5 years ago but decided to irradiate my prostate six months ago with MRI guided linear accelerator received in 5 fractions 38Gy. My PSA dropped from 1.4 to 0.23.

I asked my RO about HDR brachy therapy. And he said that it is more toxic than the SBRT.

I am not sure how would I decided in your situation but I am more than happy with the SBRT alone as I am not curable and need ADT for life.

Good luck.

[Seasid in reply to Seasid]

Did you have a PSMA scan?

[SongofFred in reply to Seasid]

I did have a negative PSMA scan. SBRT to prostate alone is an option for me, but I’m Unfavorable Intermediate with a very high Decipher score so I need to pull all stops and treat as aggressively as I can.

With your new PSA it was a very good choice for you. That’s good news.

[Seasid in reply to SongofFred]

Please note the toxicity of the HDR brachy. The prostate is sticking to the rectum and it is not possible to do a prostate removal.

With my SBRT with the MRI Linac high precision Swedish machine Elekta Unity probably the prostate would not be sticking to the rectum. I am not a doktor but I can understand that. If I would be you I would only do the SBRT.

Check with your doctors and maybe ask for second opinion, even maybe online from Dana Farber RO.

You can't stop the radiation exactly at the prostate and if the rectum is close than it will stick.

Maybe it is OK for you, maybe you are lucky and you have some natural fat padding between your prostate and rectum.

Again don't rush too much. You may be fine with high precision sbrt alone if you can get it. I believe my SBRT was 1mm precise (but I am not 100% sure in that.)

Good luck.

[Seasid in reply to Seasid]

Here is the link:

healthunlocked.com/advanced...

[SongofFred in reply to Seasid]

Thanks for your concern.

HDR Brachy does have higher toxicity, but maybe not to the degree you’re thinking. There is a spacing gel they will insert to separate the rectum from the prostate.

Also, the 5 fractions to the prostate directly are not what this thread is about. I know it’s confusing because 5 fractions to the prostate alone is very common now. But I’m talking about radiating the lymph nodes in 5 fractions which is a very new approach. That happens after the initial HDR brachytherapy to the prostate alone.

I wish I were a candidate for SBRT mono therapy, but I need maximum treatment and HDR boost has a good track record with more data behind it.

[Seasid in reply to SongofFred]

Am I correct? You are not getting SBRT to your prostate? Only to lymph nodes?

One of our member said that the decipher score is a scam and he things that we should not relay on it to make a decision.

I personally don't know much about that science with the decipher score plus I didn't get a saliva test to determine if the low dose radiation is better for me than the high dose radiation. I was just happy that I can irradiate my prostate with SBRT with the high precision machine and that I don't have to show up 40 times unlike some people. Actually I was hoping to get some immune effect from SBRT. My RO said that it is more if you combine it with immune therapy. Again you may be curable therefore you are more careful. I understand that.

[Seasid in reply to Seasid]

Our member had problems after the HDR brachy.:

"I’m an Aussie.

I had HD brachytherapy for prostate cancer in 2010.

In 2016, I was diagnosed with Carcinoma in Situ in the bladder.

I’ve had multiple rounds of BCG, and I’m now heading towards a radical cystectomy.

My urologist is nervous about the risk of damage to the rectum, because the prostate is “sticky” after the brachytherapy.

I know there are a few centres in the US that specialise in this operation with high success.

I’m trying to find out if there is a surgeon here in Australia who might have worked at one of those centres in the US as many specialists from here train in America.

Alternatively, I’ve been trying to make contact with the centres to see if they know of such a surgeon but so far, no luck.

I hoping that someone in this group might be able to point me in the right direction.

Thank you."

I was also thinking about brachytherapy but my RO said that it is more toxic and on that advice I made a decision not to use it.

Later if we develope toxicity we could use the hyperbaric oxygen chamber.

[SongofFred in reply to Seasid]

Well thanks again for your time. I can only say we view things quite differently. I do appreciate your concern.

[Seasid in reply to SongofFred]

Are you also doing the SBRT of your prostate in addition to the brachy boost?