Help deciding on treatment

[MrGreenJeans]

Discovered this forum a month ago and have found it to be a wealth of information, with very educated/informed members. Hoping that you can spread some of your wisdom and help my finalize my decision with treatment. I've posted more details in my profile as well as write ups from MSKCC on my Biopsy, MRI and PSMA Pet Scan.

Age 60, Diagnosed March, 2024. MRI -> Biopsy -> PSMA PET

Gleason 4+3=7. 4 of 11 biopsy samples positive, other 3 were 3+3=6. Original biopsy results confirmed by MSK.

PSA 5.5, PI-RADS 3 (or 4?), Decipher .55 PSMA PET – no spread. PET results reviewed and confirmed by MSK.

I’m officially classified as unfavorable intermediate, although I’ve been told that I’m borderline with favorable intermediate based on only 1 sample of 4+3.

Dad diagnosed when he was around 70 (may have been Gleason 3+3). Had LDR and possibly ADT and he has been cancer free since (he’s currently 92).

I’ve spoken with a few Surgeons/RO’s in different practices and have decided on MSK mainly based upon their reputation.

I’ve ruled out surgery and have been given a few options from MSK for non-surgical options:

1 - SBRT + short-term ADT +/- brachy boost

2 - SBRT + brachy boost +/- ST ADT

In my conversation with Dr. Gorovets to discuss brachytherapy, he didn’t think that all three therapies were necessary, but had a slight inclination toward option 1 (SBRT + 6 mos. ADT) given my .55 Deciper score. Gorovets apparently studied under Dr. Zelefsky.

Questions/Thoughts:

How important is a Dr’s. skill in the application of external radiation – IMRT/SBRT? The Long Island-based RO who would be responsible for my external radiation is Dr. Andrew Barsky and he doesn’t appear to have a long track record (completed residency in 2021). I chose (at a significant cost over my primary insurance) MSK based upon their reputation. Is it safe to assume that sticking with a renowned cancer center of excellence should allay my concerns about a particular Dr’s. level of experience? For surgery/brachy I can see that a Dr.’s skill is more critical, but it is my understanding that a lot of the external beam treatment is automated and guided by the fiducial markers. Not sure if this is a correct assumption or not. I believe that if I chose SBRT, I have the option of travelling into NYC, so I’d have the option of a more experienced Dr. I’d need to stay local for 26+ sessions of IMRT which is still an option for me. If I changed course and went with brachy, Dr. Gorovets would be the doc and I'm comfortable with him.

In making my decision about IMRT vs. SBRT, when I mentioned the Prostox test to the MSK resident, he mentioned that it’s not utilized there, so I’m leaning towards IMRT to be on the safe side.

I had preferred going the brachy route, but again, in looking for any additional increased % of cure rate, will most likely go ADT. For ADT was told that it would be injections of degarelix, Lupron, or pill format of Relugolix if approved by insurance. I’d much rather go the pill route as that would allow me to discontinue quickly should the SE’s be too much. I’d then look to change course and go the HDR/SBRT route of treatment. From what I'm reading, the pill format is most likely very expensive and not covered by insurance.

Thanks for any thoughts/opinions!

[ToolBeltZia]

Sorry to have you join our "club".

I was diagnosed at age 68 with PiRAD 3, PSA 7.7. Biopsy found 1 4+3, one 3+3. Decipher was 0.86. PSMA PET showed confined to prostate. I chose SBRT with 6 months Orgovyx. My last radiation was 12/26/23 and I ended ADT on June 4th of this year. My latest PSA on June 28th was 0.19.

I believe the skill of the RO is important in SBRT. My RO was able to visualize my primary lesion on the MRI, PSMA PET, and CT and used that info to assure my urethra did not receive any radiation "hot spots". Additionally while the whole prostate received 36.25 Gy the primary lesion was boosted to 40 Gy. While the RO is generally not in the control room for all of the IMRT fractions my RO was in the control room for each of my SBRT fractions. Additionally he used a Varian Edge linac which is a top of the line unit.

Please check my profile for my posts about my journey, fire away with additional questions, and Stay Strong Brother, we got this.

[MrGreenJeans in reply to ToolBeltZia]

Thanks for the input, hadn't thought about the initial setup portion/visualization. I'm wondering how I go about requesting a specific doctor after I've already spoken to two other RO's.

[Tall_Allen]

I think there is a typo in your post - #1 and #2 look pretty much the same, just in a different order.

Here are representative cure rates:

prostatecancer.news/2018/10...

The RO's expertise and the care he takes in contouring and developing your treatment plan are critically important. At MSK, Sean McBride is excellent!

It is not likely that 6 months of ADT will be intolerable.

[MrGreenJeans in reply to Tall_Allen]

Thanks Tall_Allen. There was no typo, I was given an option of SBRT/Brachy or SBRT/ADT. The RO that I spoke with about HDR brachy had a slight preference for the SBRT and ADT given my decipher of .55.

[Tall_Allen in reply to MrGreenJeans]

For your "unfavorable intermediate risk" PCa, the SOC is one of the following:

1)brachy boost therapy (IMRT to a wider area with a brachytherapy boost to the prostate) with 6 months of ADT:

prostatecancer.news/2017/05...

2) SBRT with 6 months of ADT:

prostatecancer.news/2018/10...

Hitting the prostate with a hypofractionated boost dose (either with brachytherapy or SBRT) is necessary to get the biologically effective dose in the prostate high enough to be curative. It is unnecessary to do both because either can be used alone, and using both adds to the toxicity. SBRT was modelled on the radiobiology of HDR brachytherapy, and can be used instead, not in addition to.

Dr. Kishan has convinced me that a short term of ADT improves results a bit in unfavorable intermediate risk PCa. It was earlier thought that the higher biologically effective dose with HDR-BT or SBRT monotherapy would be enough, but he has found that results can be improved by a few points with ST ADT. It is a judgment call, but your higher-than-average Decipher score should be considered.

[curtisbirch]

My diagnosis was very similar to yours and I was initially considered intermediate unfavorable. Most of those doctors I initially consulted gave me only dual treatment options much like you. Then I was evaluated by a pioneer in HDR brachytherapy, Dr Dimanes out of UCLA (who retired several years back. I ended up going with a student of his Dr Michael Wong because he works out of Kaiser Santa Clara (Kaiser is my provider). The thing with Dr Dimanes, which set him apart, was his confidence in my need to pursue only a single high dose rate (HDR) brachy therapy. His diagnosis was backed by very strong 10-year studies. I was concerned with combining another therapy for lifestyle reasons as I was close to 50 at the time. I am so glad I went this route as my side effects were little-to-none, and you are done with treatment quickly. There are two fairly straightforward procedures. It took me well over years to reach a nadir below 1, which I have learned is a very good thing as far as outcomes. I'd be happy to share more on my treatment if you'd like to learn more. I can say in retrospect that choosing a monotherapy approach was the right decision.

[MrGreenJeans in reply to curtisbirch]

Thanks, I've seen a number of Dr. Dimanes videos speaking on PCRI.org. I don't necessarily have an issue with a dual treatment, but had some concerns about ADT and about choosing the right doctor to administer the radiation.

[rosenjpj]

I had MRI guided SBRT at MSK with Dr McBride in the city and four months of ADT (Orgovyx). Very similar profile as you (unfavorable intermediate risk). I had an excellent experience with McBride and MSK was outstanding in every way. I travelled into NYC from central Jersey for the five treatments and took public transit each time. It was worth it. Now almost a year since SBRT. Six month PSA was .33. Next one coming up in early August. Short term side effects were tolerable and went away after a month. Having a bit of GU side effects now but managed with meds and not really a problem. With Orgovyx I had a quick return to baseline testosterone and recommend it for that reason. You can work directly with the manufacturer for financial help and MSK can help you with getting that set up. I would go with the most experienced doc and agree with TA that McBride is at the top.

[MrGreenJeans in reply to rosenjpj]

Thank you, that's good to know. I'd be taking LIRR in if treated in NYC and would not be a big deal for SBRT, IMRT would be a commuting and work problem. I see that Dr. McBride is recommended by a few here, would need to find out how to see him after already consulting with other RO's. Is it just a matter of asking I wonder? Will also need to push for Orgovyx unless it's prohibitively expensive.

[rosenjpj in reply to MrGreenJeans]

Best way to reach him is the MSK portal.

[rosenjpj in reply to rosenjpj]

Or call the office. 866-889-0718

[MrGreenJeans in reply to rosenjpj]

Thanks, kind of figured that, my slight concern is that I've already consulted with two RO's and now I'm asking to speak and possibly use a different one. Not sure if that will cause any friction.

[tarhoosier]

This is not an answer to your question about which is right for you.

What was/is right for me is to find the best doctor specializing in my condition and stage that I can, without regard to distance and cost involved. I have been fortunate to have the time and money to do so. I am aware that is not possible for others.

[tsim]

TA had some good advice and options, 6 months ADT piece of cake

[AnOrangeADay]

Stereotactic body radiation therapy (SBRT) is a technically demanding prostate cancer treatment that may be less expensive than intensity-modulated radiation therapy (IMRT). Because SBRT may deliver a greater biologic dose of radiation than IMRT, toxicity could be increased.

ascopubs.org/doi/abs/10.120...

[j-o-h-n]

Stick with MSK and us........

Good Luck, Good Health and Good Humor.

j-o-h-n

[Darryl Partner]

Welcome to our Malecare prostate cancer support group