Advice Needed-thanks

[Jean-Pierre]

Hello

I need an advice regarding two types of treatments...

My situation: age 58, Gleason 3+4, less than 5% of 4 type in biopsy in lesions, one 1.4 cm, the other two less than 0.5cm. Been on active surveillance for two years but I'm ready for treatment as my PSA jumped to 12 from 8 two years ago. I think it's time to act. I feel comfortable with putting this whole thing behind and go on with my life. DRE at Sloan done this week- Negative (thank God) doc says some firmness noted. I have decided for Zelefsky SBRT. I'm offered a clinical trial with focused SBRT on index lesion while the other parts gets the normal radiation or even less, pending the mapping by radiologists. OR...I stay with standard SBRT (8Gy) with normal excited results. I'm concerned regarding the index lesion getting the 9Gy and causing more side effects of it is close to bundle. I asked that question, but said they won't know till mapping and if I change my mind to go back to regular treatment, more delays expected. I'm a visitor and staying expensively

Last tiny question for those who did SBRT...can I fly immediately after SBRT...a day or two after.

Thanks for advice

Jean-Pierre

Big Question

[Tall_Allen]

What they are experimenting with is technically called a "simultaneous integrated boost" to the "dominant intraprostatic lesion," or "dose painting." You can read more about it, including pros and cons, here:

pcnrv.blogspot.com/2016/08/...

I had SBRT 8 years ago (5 treatments of 8 Gy each). My RO does not favor dose painting. He argues that if he thought a higher dose were really necessary to kill the cancer, then he should give the higher dose EVERYWHERE. Prostate cancer is most often multifocal, so the index tumor is not all there is.

I also agree with you that the location of the index tumor is important. If it is close to the urethra at the base or apex, the higher dose may result in more urinary irritation. If it is close to the rectum, there is danger of rectal injury. Although 45 Gy everywhere has not increased side effects in dose-finding trials, 50 Gy has been disastrous. Zelefsky conducted his own dose finding trial.

I found SBRT treatments themselves to be a big nothing. I went to the gym everyday (this helps the radiation work better), had no fatigue and no side effects of treatment during the treatment period. About 10 days after treatment (there's usually a delay), I had the expected irritative urinary (frequency, urgency) and rectal (tenesmus, bleeding on toilet paper) side effects that lasted for about 2 weeks. I took Rapaflo for the urinary side effects, which worked well. I also took nightly Viagra for 6 months and have had no erectile problems. I did lose semen, though.

[Jean-Pierre in reply to Tall_Allen]

Thanks sooo much Allen

My gut feeling is telling me to go with regular SBRT. Though, it's good to know that escalated dose to a total 45 produced identical side effects...any other links to this? Please.

If so, why don't people select the 45 option? Is it for long-term effects lack of data? Just trying to get more and more information to decide as I still have a couple of weeks to make up my mind. Btw, any links of side effects to weight, prostate size, age, et?

I'm reading right and left articles...any one stop shop for reading reliable updated sources?

Sorry to load with so many questions, but I think and hope that others might benefit from the info.

Thanks Allen

[Tall_Allen in reply to Jean-Pierre]

It's because 40 Gy does an excellent job - 97% 5-year bRFS. The dose/response follows an S-shaped curve with increased dose on the flat portion on top only contributing toxicity and not cure.

pcnrv.blogspot.com/2016/09/...

There was an SBRT dose escalation trial at UT - Southwestern:

pcnrv.blogspot.com/2016/08/...

I think that going from 45 Gy to 50 Gy only increased the 5-year bRFS marginally and not enough to justify the increase in side effects.

But Zelefsky did his own trial, which I think is completed, but he has not yet published. You should ask him what he found.

Of course, I'm partial to my own blog:

pcnrv.blogspot.com

[Jean-Pierre in reply to Tall_Allen]

Thanks Allen...great blog 👍🏻

I'm leaning to trust Dr. Zelefsky with the dose painting plan...pending further thinking as there's not so much to read about the study except direct questions to Dr. Zelefsky. Any issues or questions you recommend? Aside from the results of his study you mentioned. By the way, I had a chance to go to NYU Langine for faster appointments, but decided to be patient and stay with Dr. Zelefsky. He convinced more with his plan. Anyway, NYU has only the regular treatment plan.

Have a great day and weekend

Jean-Pierre

[Tall_Allen in reply to Jean-Pierre]

In addition to his trial results. I'd want to know:

• What dose will the rest of the planned target volume get?

• What are the risks? How will it affect the doses to the organs at risk? He should run the plan both with and without the SIB to the DIL and go over the two dose-volume histograms with you.