@jeffmarc When I was working with doctors in the spring of 2024 at both MD Anderson (MDA) in Houston and Baylor Scott and White (BSW) in College Station, TX, I was offered a number of options for my 3+4 case (15% of 4) with 0.81 Decipher and two lesions (one Pirads 4 and one Pirads 5) broadly abutting the capsule but no evidence of ECE or cribriform or intraductal. There was also a third lesion (Pirads 4) that was not abutting the capsule. Because of the high Decipher score and two capsule abutting lesions, both RO's agreed that wide area pelvic radiation was needed in case any escape had happened even though my PSMA PET scan was clear outside the prostate. Both agreed that 26 IMRT sessions would be ideal for that and that my local BSW facility could provide that. Both RO's also agreed that my case deserved some radiation boost to the prostate as well as one year of ADT (actually the BSW RO wanted me to go two years on ADT!)

The main difference of opinion (besides the ADT time) was on the prostate radiation boost. The MDA RO gave me the choice of HDR Brachytherapy or SBRT. He explained that MDA was very big on SBRT in that there were even trials about to begin that would use SBRT in the same way that IMRT is used (low dose with broad targeting). Apparently, the SBRT machine is very flexible and programmable such that it can provide radiation in any way desired even though it's original design focused on high dosages at small targets. At that time I was a bit sad that my case was too early for the upcoming trials so IMRT was settled on for the greater pelvic region and I chose SBRT for the prostate boost. But when my BSW RO heard this, he flipped out and said that he would not do the IMRT on me if I was going to follow it with SBRT. He said SBRT is still too unproven and unsafe (might burn a hole in my rectum) and he did not want to be involved in a case where SBRT is used. It turned out that my MDA RO actually had a slight preference for HDR brachytherapy himself so he didn't seem to mind placating the BSW RO and advising me that HDR brachy was actually a bit safer than SBRT because the radiation is so contained in those 16 catheters they insert into the prostate.

So I ended up doing 26 sessions of IMRT and one HDR brachy session. But as the months passed, I looked into how those SBRT trials were going on trying to emulate IMRT and it was not good! There was so much radiation toxicity in some trials that they had to be aborted early. Apparently, they were trying to use slightly higher dosages than what IMRT does for wide area radiation so as to reduce the number of sessions. Because SBRT is so flexible there is no doubt that the doctors can ultimately figure out some optimal programming to emulate IMRT, but I did breathe a sigh of relief that I had just missed going into that trial!