New Guidelines for Salvage Radiation ... - Advanced Prostate...

Advanced Prostate Cancer

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New Guidelines for Salvage Radiation Dimensions

Tall_Allen profile image
32 Replies

GFRU expanded the contours for prostate bed coverage and NRG Oncology expanded the contours for pelvic lymph node coverage.

prostatecancer.news/2021/05...

Worth discussing with your RO to make sure he is aware of it if you are considering salvage radiation after failed prostatectomy.

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Tall_Allen profile image
Tall_Allen
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ragnar2020 profile image
ragnar2020

TA,

I’ll be very interested to read reports concerning how the proton beam therapy ROs evaluate the toxicity results of Salvage Therapy with PBT for their patients. If expanding the treatment area for Salvage Therapy improves BCR outcomes, then reducing toxicity should be the next major goal.

Jeff

Tall_Allen profile image
Tall_Allen in reply toragnar2020

So far, toxicity of proton is no different from X-rays.

ragnar2020 profile image
ragnar2020 in reply toTall_Allen

TA,

Though not proven by RCT because doing so is impossible, many of the PBT patients who have had ART would disagree with your point of view. This is an issue that continues to be debated, debated and debated without resolution. One évaluâtes thé PBT treatment and compares it with alternatives and makes a decision of where to get one’s treatment.

Jeff

Tall_Allen profile image
Tall_Allen in reply toragnar2020

It is far from impossible- in fact, there is an RCT ongoing for primary therapy:

clinicaltrials.gov/ct2/show...

How on earth would anyone disagree without looking at data? The proton guys have so far posted toxicity results (like those below) that are no better than X-rays.

prostatecancer.news/2016/08...

This is why insurance rightly refuses to cover the extra cost.

ragnar2020 profile image
ragnar2020 in reply toTall_Allen

TA,

It is too bad that you are bias against the very therapy that will eventually replace most radiation procedures for treating PCa. Hopefully, gents on the forum will be curious and investigate PBT themselves and not accept the old tired arguments used when PBT is mentioned.

The trial you reference is attempting to quantify toxicity outcomes based upon patient surveys. The surveys have been going on for several years and will continue to monitor patient’s opinions of their SEs for many years in the future. There is no way to definitely establish toxicity results except through patient opinions.

So, anyone considering whether to use PBT for treatment needs to talk with men who have used PBT themselves. This is possible if one contacts any of the 35+ PBT facilities in the US and asks for contact information of treated patients. The facilities are transparent with the information. Not so the 4500 radiology departments around the country.

Medicare and independent insurers pay for PBT continually in the states with PBT facilities operating within the state borders. Those PBT facilities have gone through the process to qualify for reimbursement. Many states have no PBT facilities within their borders and thus, those states have not applied for reimbursement. Many states are attempting to protect the radiological facilities within their borders from competition because of the superior technology of PBT.

As always, it is about the money and the protection of a fading technology by those who stand to lose a lot of business as the patients move to a newer technology.

You are arguing a losing issue. Give it up.

Jeff

Tall_Allen profile image
Tall_Allen in reply toragnar2020

I'm not at all biased. I welcome evidence. I have equipoise - I don't really care if protons are better, worse or the same as photons. Beliefs like yours do not replace science. Science does NOT involve hearing the opinions of patients like you who have drunk the kool-aid and believe things without evidence. The study like the one above has to be randomized to prevent bias.

Unfortunately, proton facilities cost a LOT of money and the the builders need to see a return on investment. That is why they spend millions to convince unwitting patients like yourself that there is an advantage. To his credit, Zeitman at Mass General, the first proton facility, stopped doing protons for prostate cancer patients until the evidence is in. They certainly have a role to play in pediatric tumors.

ragnar2020 profile image
ragnar2020 in reply toTall_Allen

MHB is the OJT center for Harvard Medical School that has trained thousands of radiologists. The New England states have intentionally held back advancing PBT because of protectionism for their medical schools and their graduates.

Look at the list of states where PBT centers are located, and then ask why there are no PBT facilities in the New England states except at MGB. Why does MGB refuse to use their PBT facility for prostate cancer treatments? I doubt that it is because one RO decided that he didn’t want the technology used. No doc has that influence. It was a business decision made at many pay grades above that doc’s level. I don’t think that is a valid argument.

Hopefully, the men who are reading this tread will question why some states have PBT facilities within their borders and why other states do not. It is the lobbyists for the radiological industry that promote what you put forth as your arguments. It is financial protectionism not medicine.

Jeff

Tall_Allen profile image
Tall_Allen in reply toragnar2020

I am not arguing - only you are. I am perfectly willing to look at any evidence you have. So far, you have proffered none. What is silly are conspiracy theories- I do not know any lobbyists. Anthony Zietman is the Medical Director, MGH Proton Therapy Center. The only thing preventing a new proton facility is money - they are very expensive. To turn a profit, they must entice true believers like yourself to pay extra for a therapy that so far provides nothing extra.

dentaltwin profile image
dentaltwin in reply toragnar2020

Facilities may not release patient information without explicit release in writing. It is quite possible that facilities trying to expand their market may pressure patients into a release like this--and it is quite possible that those who have had a positive experience are more likely to grant it. That is why a RCT is the only way to go with this issue

Graham49 profile image
Graham49 in reply toragnar2020

Consensus Statement on Proton Therapy for Prostate Cancer

Curtis M. Bryant, MD, MPH ; Randal H. Henderson, MD, MBA ; R. Charles Nichols, MD ; William M. Mendenhall, MD ; Bradford S. Hoppe, MD, MPH ; Carlos E. Vargas, MD ; Thomas B. Daniels, MD ; C. Richard Choo, MD ; Rahul R. Parikh, MD ; Huan Giap, MD, PhD ; Jerry D. Slater, MD ; Neha Vapiwala, MD ; William Barrett, MD ; Akash Nanda, MD, PhD ; Mark V. Mishra, MD ; Seungtaek Choi, MD ; Jay J. Liao, MD ; Nancy P. Mendenhall, MD

Int J Part Ther (2021)

doi.org/10.14338/IJPT-20-00...

Conclusions

As an established and effective treatment for patients with prostate cancer, proton therapy reduces the excess radiation delivered to healthy tissues surrounding the prostate when compared with photon-based radiation therapy. Several prospective and retrospective studies have been published documenting the safety and efficacy of proton therapy in the management of prostate cancer and some long-term follow-up data are available and are accumulating. Consequently, proton therapy should not be considered experimental in the management of prostate cancer. It is efficacious when delivered to patients with localized prostate cancer or when delivered postoperatively. It also can be delivered safely to patients requiring pelvic nodal radiation for high-risk or node-positive disease. Although the radiobiologic uncertainties of proton therapy are not fully understood, as our knowledge grows, the advantages and limitations of proton therapy will become clearer. Soon, the results of multiple prospective studies will also contribute to our understanding of the comparative safety and efficacy of proton therapy in the management of prostate cancer. Because the costs associated with proton therapy continue to decrease, further evidence of proton therapy as an effective platform for hypofractionation may prove it to be a cost-effective treatment modality in the management of prostate cancer.

ragnar2020 profile image
ragnar2020 in reply toGraham49

Hi Graham49,

Thanks for posting that link. I hadn’t seen that report, and it provides a lot of informative information for men to investigate proton beam therapy so they can make their own decisions about PBT use for their own PCa care. You did what patient advocacy forums are designed to do - help patients find legitimate information about their disease and their care without injecting your own personal bias.

Good for you...

Jeff

GreenStreet profile image
GreenStreet

Thanks. Very topical for me!

rust profile image
rust

"treatment should not be delayed until such tumors become apparent on imaging." Yah just because a PET don't show it.

Tall_Allen profile image
Tall_Allen in reply torust

Yes! Even a Combidex scan like GreeenStreet got has a size limit of 2 mm. Waiting until they grow is a self-fulfilling prophecy.

Cooolone profile image
Cooolone in reply torust

One of the most unnerving part to a patients understanding "what's next" when persistent or recurring PSA shows. That they benefit by waiting for the PCa to grow to a point where it presents a target.

I might be wrong, but I recall there hasn't been any extraordinary result of adjuvant RT (blind) over Salvage RT (targeted) therapy.

rust profile image
rust in reply toCooolone

This is a very interesting question? I have often thought about this especially in the context of my disease. When I had initial salvage RT in 2013 12 months after RP my PSA had risen to 0.12 and I had read research then that the sooner the better (lower PSA value) in terms of outcomes. Fast forward to my BCR in 2017. In the 12 months prior to BCR I had supplmented with Androgel for 1 year with a half topical dose daily. PSA began rising with doubling time of 2.6 months afterwhich I tried Enlzalutamide monotherapy under clinical trial and my testosterone on Enazalutamide skyrocketed to 800 over 8 months while my PSA went undetectable. After treatment vacation and with newly charged T levels my PSA rocketed again at 2.6 month DT. Then I sought PET imaging and further treatment. But back to your point I can't help but wonder if the testosterone replacement therapy activated or flushed out remaining dormant cancer cells in regional lymph nodes "cancer seeds" and the highly T responsive cancer cells then grew to provide a good size target for identification on PSMA Ga 68 and Choline C11 PET imaging studies in clinical trial at Mayo Clinic. What if testosterone replacement therapy actually grew a clinical target (therefore facilitating identification of a treatment plan) and it saved my life? Or maybe it was just a really bad idea in the first place.

Tall_Allen profile image
Tall_Allen in reply torust

I don't see how it "saved your life."

rust profile image
rust in reply toTall_Allen

What if my recent course of radiotherapy targeted to nodes is successful in long term remission? I am way out on a limb here but what if Testosterone supplementation could be used as a catalyst to grow any residual cancer after primary therapy so that it could help reveal (through increased emission of PSA) and make tumors more avid with the new PET radio tracers in development . The goal being to identify targets for the irradiated field. I am suggesting that there might be a treatment window between cancer occurring at the primary tumor site and wide spread metastasis or distribution of cancer cells thought the body. What if spread begins in the lymphatic system and is treatable. The goal being to stop the dominos from falling.

Tall_Allen profile image
Tall_Allen in reply torust

It is a mistake to target specific nodes, as was shown in a recent Mayo study:

prostatecancer.news/2020/12...

By making tumors bigger with testosterone, you are also increasing the probability that they will spread. Growth and spreading go hand in hand.

Tall_Allen profile image
Tall_Allen in reply toCooolone

"I might be wrong, but I recall there hasn't been any extraordinary result of adjuvant RT (blind) over Salvage RT (targeted) therapy."

I'm confused by that statement. Adjuvant RT isn't "blind" and salvage RT isn't "targeted." They are both aimed exactly the same way. There is no advantage to adjuvant radiation (immediately after RP) over early salvage (3 consecutive uPSA rises or PSA=0.1) . They are both done without PET scans.

Cooolone profile image
Cooolone in reply toTall_Allen

Early Adjuvant therapy when PSA is so low, there are no targets identified. Sometimes I type but don't explain my thoughts... And yes, technically blasting the prostate bed is a target per say, but that's not what I mean either. It's all good...

Tall_Allen profile image
Tall_Allen in reply toCooolone

Adjuvant RT means right after RP, before a PSA is taken.

SuppWife profile image
SuppWife

Maybe this is a stupid question, but can additional radiation be done to cover an area outside the original treated area? Particularly the area of the pelvic lymph nodes? I just don’t understand much about radiation. I wish I’d had a better handle on it before my husband’s treatment in fall of 2020. I also do not have a copy of his report.

Tall_Allen profile image
Tall_Allen in reply toSuppWife

Perfect question! Yes, as long as the treatment area doesn't overlap, it can be done. Ask his RO for a copy of his treatment plan (good to have for your files anyway). That will tell you the Planned Target Volume (PTV).

SuppWife profile image
SuppWife

That’s great! Thank you so much, TA!

Ralph1966 profile image
Ralph1966

Hi TA,So is it better to do whole pelvic SRT rather then only prostate bed Radiation? In my case I had 63 local LNs removed during RRP surgery and after 15 months (undetectable PSA) following surgery my PSA went up slowly to 0.11 and the RO said that I need only SRT to the prostate bed. I am wondering if it was better to include the pelvic LNs too?

treedown profile image
treedown in reply toRalph1966

That's a lot of LNs do you have lymphedema?

Ralph1966 profile image
Ralph1966 in reply totreedown

After 1 year following the surgery, I got some right leg and ankle swelling. Luckily it disappeared after few weeks. I used compression socks at that time.

Tall_Allen profile image
Tall_Allen in reply toRalph1966

As I think treedown is suggesting, radiation on top of ePLND can have serious consequences. I am not a fan of ePLND.

j-o-h-n profile image
j-o-h-n

To bake or not....

youtube.com/watch?v=f1gfZwe...

Good Luck,Good Health and Good Humor.

j-o-h-n Wednesday 05/19/2021 8:08 PM DST

LastMohikan profile image
LastMohikan

Hi Dear TA, according to my outcome, I can have idea that whole pelvic SRT is better than just to prostate bed and also adding Adjuvant therapy. I had RP at 2017, after 15 months later my PSA was reached to 0.2 than RO decided to SRT to prostate bed without hormonal therapy. After 2 years later my PSA was 0.364 unfortunately I had 1 point bone metastases. I always that question in my mind (if SRT was added with adjuvant and whole pelvic included than I could not have bone metastases in a short time with 0.364 psa value)

Tall_Allen profile image
Tall_Allen in reply toLastMohikan

It is likely that that bone metastasis was there from the start of all your therapies and nothing you could have done would have caught it in time.

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