6-year update of PACE-B randomized trial continues to show no difference in outcomes. This month is my 13th anniversary getting cured with SBRT with no lasting side effects.
For low-risk patients and even some favorable intermediate-risk patients, active surveillance is preferred.
For high-risk patients, SBRT is still considered to be experimental, and brachy boost therapy with a year of ADT is a standard-of-care. PSMA PET/CT should rule out distant metastases.
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Tall_Allen
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Re the quotation "For low-risk patients and even some favorable intermediate-risk patients, active surveillance is preferred."
Medical professionals who offer active surveillance as an option for intermediate (favorable) risk...hmm! I'sa wonder how many of these medical professionals who make these assertions have had intermediate, (favorable or otherwise) prostate cancer?
If you have, say, one core that has a small amount of pattern 4, and pattern 4 is 5% of that core, active surveillance may still be a good choice.
"The use of active surveillance for men with favorable intermediate-risk prostate cancer has increased markedly. Over half of men with favorable intermediate-risk prostate cancer on active surveillance remained free of treatment 5 years after diagnosis. Most men on active surveillance will not lose their window of cure and have similar short-term oncologic outcomes as men undergoing up-front treatment. Active surveillance is an oncologically safe option for appropriately selected men with favorable intermediate-risk prostate cancer."
unfortunately i was 3+3 with 1% of 1 core and went on active surveillance and here i am advanced PCa. Luckily for me i had found on my dime i had FGFR4 mutation which predicted 5x chance of my cancer becoming metastatic and 6x chance of becoming aggressive. I had the urologist take my prostate out and they discovered it had escaped and also PNI. I was upgraded to 3+4.
I really think genetic testing should be done sooner rather than later.
Anyways TA i am so happy for you and I thank you for being the go to guy on SOC options.
Kudos to you for catching that! I agree that with germline genomic testing being so fast, cheap, and widely available, that everyone with a PCa diagnosis or cancer in their family should have one. If anyone has a PCa diagnosis, it is free and you just spit in a bottle they mail to you:
After RP and BCR I did this in advice from Pat Walsh at Hopkins and have 2 CHEK2 “variants of unknown significance “ at Invitae but my MO says CHEK2 is aggressive and therefore will prescribe taxotere earlier(?) Is that what we might expect in guidance from a germline genetic test?
Just enrolled hubs for this program. From what I understand, this genetic testing could possibly guide him in his quest for best possible treatment? Is that correct? So glad you posted that information!
I haven't read, nor could I probably interpret the meaning of these studies however, we know that prostate biopsies are notoriously inaccurate because they only sample a small amount of prostate tissue. But, on the whole, the statistics are what they are and that is very hopeful for many.
Are there anybodies out there reading this who are/were on active surveillance or were offered it who have/had favorable intermediate risk prostate cancer per the criteria in Allen's example, '... one core that has a small amount of pattern 4, and pattern 4 is 5% of that core.' ? If so I'd like to hear your POV.
Several men in my groups have had that diagnosis. Even Johns Hopkins, which used to have very strict criteria (The Epstein Criteria) have now relaxed it, and allow such men in their program.
I remained on AS after my second biopsy where two of ten cores were GS 6 and one was GS 3+4 (2% GS 4). I progressed to GS 4+3 two years later and had MR guided SBRT with four months on ADT (Orgovyx). I was under the care of MSK… followed by Dr Ehdaie for AS and Dr McBride who did the MR guided SBRT.
Thanks for your reply. I read your history in your bio and I suggest other interested parties do the same who are considering AS.Question: If you had to do this all again, what might you had done differently? Hard one I know.
Prostate disease is so idiosyncratic which can make treatment decisions a crap shoot. I went very aggressive with my treatment (see bio) and nearly 4.5 years later believe/feel I made the right choice? after doing as much research and meditation and contemplation this one man could stand. I'm grateful for modern medicine and technology, but I also know that when I decided on my treatment options it was because I was my own best counselor and advocate. I read the latest research/ best educated guessing but know I am the one who lives with his decisions.
Very hard to say in retrospect, and retrospective thinking is something I rarely do. Decipher and mpMRI/PIRADS were not available back then and there was limited data from Klotz. I agree that we all have to advocate for ourselves.
Hi rosenjpj, I am GS 3+4 and classified intermediate unfavorable. Dr at Duke recommending 6 month ADT plus 5 sessions of SBRT. SBRT to only the prostate not lymph nodes. due to low odds of spread and fewer side effects. I was curious if MSK included lymph nodes or confined yours to prostate.
Happy Anniversary, TA. Over that time, you have continued to provided so much knowledge and support and recommendations to other brothers and their loved ones. Many thanks.
Thank TA for all you do. And congrats on your excellent outcome. You and so many on this forum have told me I should seriously consider AS because I have G6. I am now considering that. The urologist and RO are saying I can, but because 5 core fragments out of 12 had cancer, that volume would lean them toward SBRT now rather than later. Although they said I can easily wait a 6 months to a year if I want. Not sure what to do, but I’m still taking it slow. Waiting for genomic testing to come back as well. Thank you again Tall Allen.
I had, I think, 9 cores out of 17 with GS6. There wasn't as much data then on AS. Knowing what I know now (mpMRI and Decipher weren't available), I might have chosen AS (but hard to say in retrospect). I did take 9 months to decide and talked to 6 specialists.
After prostatectomy, one must be careful about irradiating the area without the prostate in place to block the full power of the X-rays. Urinary side effects are higher with any knd of salvage radiation. SBRT is not used as salvage after RP, except in clinical trials. However, moderately hypofractionated radiation (like 52Gy on 20 treatments) has been found to have no worse side effects compared to conventional fractionation.
I'll play the devil's advocate on active surveillance for a 3+4 Gleason score. That was my initial score at the time of diagnosis. After surgery the biopsy came in at 4+3 and sure enough, after 6 months they found a metastasis in my pelvic bone which necessated SBRT with 2 years of Lupron/Eligard/Orgovyx. Alls well that ends well, I'm currently 3+ years at <.02.
The way active surveillance works in men with GS3+4 is they would have a confirmatory mpMRI-targeted biopsy, analysis of volume of pattern 4, genomics, and annual PSAs and biopsies. You were never on active surveillance.
Correct, but my original urologist recommended AS the second one was all for surgery asapThe point I was trying to make was that sometimes the biopsy can be wrong if they don't sample the right spots.
In hindsight I think I would have gone with radiation rather than surgery.
Also, I got a kidney stone 10 days after surgery which caused a severe sepsis infection in my kidney and they couldn't take it out because the area was not healed . Long story short, they ended up putting a Stent between my kidney and bladder which was horrifically painful for two months .
I agree - a single biopsy is often wrong. IMO, and in the opinion of most of today's AS programs at major hospitals, one is never on AS unless there is a confirmatory mp-MRI-guided biopsy.
I am a Gleasin 9 and got SBRT at Georgetown the after CTAnd bone scans there was no evidence any where else. NIH had me on active surveillance for 3 years and it cost me dearly. Don’t ever go on active surveillance ever. I’m lucky I’m on lupron and my PSA is undetectable at least for now.
If you were Gleason 9, you were never on "active surveillance" (AS). AS is only a term used for non-treated low-risk and some non-treated favorable intermediate risk patients.
I was a Gleason 6 when I went there. The would mri once a year and biopsy me every 3 but my PSA kept rising and they said I was ok. Then I was biopsy in 2018 and was a Gleason 9.
Congratulation Allen. I was hoping to sign up for SBRT salvage trials post-op, mostly because of MRI precision delivery, but had second thoughts after evaluating possible side effects. I'm heading for 25 sessions of more conventional IMRT instead.
Congrats. You've been an advocate for PCa treatment plans for a long time. I personally thank you as I wouldn't have gotten a second opinion at John Hopkins without your expertise. 👍
It was a clinical trial run by Chris King at UCLA (he first used it in 2003). 40 Gy over 5 treatments, done with RapidArc. Now they use MRIdian on most patients.
Do you believe there is any value to the germ line genetic test if you have already pursued a curative therapy? I was treated with SBRT for favorable intermediate PC almost five years ago. PSA drop was a bit bumpy. Anything gained for me or my family in a genetic test post treatment?
For you, probably not. For your family, maybe it may alert them to be more vigilant with diagnostics. For men everywhere, adding your info to the PROMISE registry builds a database that may help create the preventions and treatments of the future.
Congrats Tall_Allen! Thank you for sharing knowledge with us all. And thank you for guidance regarding my husband's initial RT (finished 3 mo ago). We wanted to go the SBRT route but three ROs we consulted suggested 20 sessions. Guess because it was/is SOC. He continues to say "the blog people" have better advise than his doctors.
congrats on the outcome and more importantly perhaps how you’ve used those years to help so many others of us. Years well spent on that alone and no doubt you are happy in life as well! Thanks
Tall Allen, I am G8. Had failed FLA in 2021. PSMA 12/22 showed 'some' uptake only in the gland. I am scheduled for proton ultrahypofractionation over 7 visits. Most ROs wanted 40 over 8 weeks because of the compromised tissue FLA left behind. I understand Dr. Kishan at UCLA does SBRT after failed FLA.
Am I taking too big of a risk (because of the 'scar' tissue) in doing ultra hypofractionated proton or photon SBRT for that matter ?
Would 7 proton sessions be similar to 5 SBRT sessions?
Would proton be as 'precise' as cyberknife?
I understand outcomes are considered equivalent between PT and Photon. Do you have any other factors to consider when doing Proton? We know it stops at the target which at least intuitively sounds better. Appreciate all your comments and thoughts. Many thanks, Tim
Braggs peak is a theoretical framework that does not occur in real life. In real life, protons generate secondary particles and there is diffraction from the nozzle head. It seems to be just as toxic to neighboring organs at risk as X-rays. But there are no direct comparisons because proton centers refuse to do the randomized clinical trials that would prove an advantage if there is one. If they are so sure of it, what are they afraid of?
Thank you for your thoughts. I had failed Focal Laser Ablation in October of 2021. Would 7 Ultrahypofractionated Proton sessions be too toxic for the residual FLA scar tissue... or photon SBRT for that matter? If proton radiation and photon radiation are so similar, why wouldn't I choose protons simply from an intuitive standpoint? I appreciate all your advice.
What I would choose depends on availability, convenience, the experience of the ROs involved, and my expected out-of-pocket costs. So what I would choose has no relevance to you.
Hello - I've been reading all your posts. Thanks so much. My situation: my PMSA PET scan said four tumours Gleason 4+3 and one with Gleason 8. All contained within the prostate capsule. I have cribriform pattern and possible intraductal, so those are negatives, but the overall prognosis long term is excellent. I had SBRT in July. After effects (minor rectal bleeding, urination burning) are all resolved. BPH is as it was (I live with it). I'm on Eligard. My SE are not fun, but manageable with diet and exercise. I'm taking calcium, vitamin D, now iron for mild anemia. I'm in month of 7 of 18 (maybe 12). My PSA three months post SBRT is .05. I've read that a nadir below that may suggest that 12 months is OK. I'll talk to my RO in the spring. I'm in Montreal, so I'm at the mercy of our public system here in Quebec (RAMQ) to cover the cost. They do so with Eligard (almost 100%). Is Orgovyx better? How so? If it's covered by the public system, I may ask my RO about it. Any advice would be most welcome.
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SBRT v. Brachytherapy for Favorable Intermediate Risk 
SBRT for favourable intermediate - interested to hear your experience
