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SBRT versus IMRT for BCR after prostatectomy

Posted by pamperme @pamperme, Jan 11 5:17pm

I am 72 years old and had< .02 PSA for two years after my prostatectomy. My PSA went up to .05 then jumped to .15. My onocologist recommended 35 IMRT sessions and I got a second opinion which agreed with radiation but would do 5 SBRT sessions to the pelvic and lymph node area. I am trying to find out advantages and disadvantages of each one.
My decipher score was .92 and I had two locations with no margins and EPE. I am currently on Orgovyx and am on hold since 3 spots of low emissivity showed up on psma/pet test. They are going to take a second test in 10 weeks after being on Orgovyx and if the emisivity stays the same they will determine it is non cancerous and I will go for radiation. If the emisivity disappears then it will be considered cancerous. I do not think the spots are cancerous. My second opinion recommended doing an MRI also. I would appreciate information on SBRT and IMRT for the reoccurence at 3 years. Thank you everyone for all the information I have learned from this site in the past.

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heavyphil | @heavyphil | Jan 13 9:47am
In reply to @islander2025 "@jeffmarc Wow well VMAT is being used in many places , Cleveland clinic for example, here..." + (show)
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@jeffmarc Wow well VMAT is being used in many places , Cleveland clinic for example, here in PR also.. also referred to as true beam radiation high prescision. I attached 2 pics of info

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@islander2025 You are going to hear many acronyms all for the same thing: EBRT, IMRT, VMAT, IGRT.
They all use programmed treatments based on your simulation visit; all attempt to minimize tissue toxicity, and all need a full bladder and empty rectum.
They usually involve 20-40 sessions depending on the preferences of the RO and your particular needs. Hope that helps,
Phil

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jeff Marchi | @jeffmarc | Jan 13 10:57am
In reply to @islander2025 "@jeffmarc Wow well VMAT is being used in many places , Cleveland clinic for example, here..." + (show)
Profile picture for islander2025 @islander2025

@jeffmarc Wow well VMAT is being used in many places , Cleveland clinic for example, here in PR also.. also referred to as true beam radiation high prescision. I attached 2 pics of info

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@islander2025
It really does look like a great way to do this treatment. I have just never heard of any of the people in all of the meetings I go to discussing the fact that they had it.

I will actually ask about this in meetings To see what people’s results were.

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islander2025 | @islander2025 | Jan 13 12:14pm
In reply to @jeffmarc "@islander2025 It really does look like a great way to do this treatment. I have just..." + (show)
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@islander2025
It really does look like a great way to do this treatment. I have just never heard of any of the people in all of the meetings I go to discussing the fact that they had it.

I will actually ask about this in meetings To see what people’s results were.

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@jeffmarc yeah that would be great I know it’s still not like Proton.. although supposed to be really good I don’t know if the side effects are more.. my RO says not much difference, but to me saving my parts is important if I had the 60-100k they say proton cost I would gladly pay for it 🤣

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pamperme | @pamperme | Jan 14 6:57am
In reply to @jeffmarc "What you are having recommended seems very strange. The normal technique is to do the 35..." + (show)
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What you are having recommended seems very strange. The normal technique is to do the 35 IMRT sessions. That’s done to the lymph nodes and the prostate bed. I had that done 12 years ago at 65 and know many people that have had the exact same thing done. None of them have had SBRT under the same conditions.

There is no SBRT equivalent. There are studies of doing SBRT instead of IMRT but they have not been proven to be successful. I think this is an experiment you may not want to be involved in. Did they tell you it’s a clinical trial?

Normally, they want to do salvage radiation when your PSA hits .2. I had a prostatectomy and it took 3 1/2 years before mine hit .2 at which point I had 8+ weeks of salvage radiation. I was not on ADT until my PSA hit .2, if I had been, my PSA would almost definitely have remained undetectable.

These PSMA pet tests you are getting are a real problem. When the PSA is as low as yours is, they frequently can’t be anything seen in the pet test. The PSA is too low. They usually want it to be at least .5 or .7 before doing a pet test. The other problem is the PSMA Pet test cannot see Metastasis smaller than 2.5 mm and the UCSF radiologist says even 5 mm is hard to see. So I’m a little concerned about what you’re hearing about what’s going to be found, or not found. If you just started Orgovyx Then it is very likely your PSA will drop to undetectable and the scan will show nothing.

It sounds like your oncologist has a much better feel for what to do than whoever else you’re talking to. Waiting until your PSA hits .2 and then doing the salvage radiation is what is usually done? If they just put you on Orgovyx Then your PSA will probably become undetectable, Nothing will be found so they will want to do radiation. That is a very strange way of doing this.

At this point, it might make sense to go to a center of excellence and get a third opinion.

An MRI can show metastasis if they already know where they may be. It’s just that that’s not the standard way to find them and it really needs to be a very sensitive MRI to see what’s truly going on.

I wish you luck.

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@jeffmarc
From what I find on line more hospitals are using SBRT for prostate reoccurence. There is a 5 year study in NIH showing SBRT has similar results to IRMT for intermediate cancer I did note in my Drs clinical notes who is using the IMRT that if I took the option to wait for the PSA to go to 1-2 that they would use SBRT . This would be used to target the cancer. SBRT seems to be or is becoming a standard of practice for reoccurrence.

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heavyphil | @heavyphil | Jan 14 7:57am
In reply to @pamperme "@jeffmarc From what I find on line more hospitals are using SBRT for prostate reoccurence. There..." + (show)
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@jeffmarc
From what I find on line more hospitals are using SBRT for prostate reoccurence. There is a 5 year study in NIH showing SBRT has similar results to IRMT for intermediate cancer I did note in my Drs clinical notes who is using the IMRT that if I took the option to wait for the PSA to go to 1-2 that they would use SBRT . This would be used to target the cancer. SBRT seems to be or is becoming a standard of practice for reoccurrence.

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@pamperme SBRT is the standard for targeting ‘visible’ metastases…but it’s the invisible ones that IMRT will get.
Did that NIH paper discuss tissue damage done by SBRT to a large regional area (pelvis) or did they just focus on visible metastases?
A rising PSA with no visible manifestation of cancer offers no target for SBRT, which is, by nature, targeted. So I don’t know if they’re really talking about traditional ‘salvage’ radiation…do you have a link to that particular paper? Thanks!
Phil

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jeff Marchi | @jeffmarc | Jan 14 11:11am
In reply to @pamperme "@jeffmarc From what I find on line more hospitals are using SBRT for prostate reoccurence. There..." + (show)
Profile picture for pamperme @pamperme

@jeffmarc
From what I find on line more hospitals are using SBRT for prostate reoccurence. There is a 5 year study in NIH showing SBRT has similar results to IRMT for intermediate cancer I did note in my Drs clinical notes who is using the IMRT that if I took the option to wait for the PSA to go to 1-2 that they would use SBRT . This would be used to target the cancer. SBRT seems to be or is becoming a standard of practice for reoccurrence.

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@pamperme
The thing that sticks out to me is that the NIH report on using SBRT says further studies need to be done, the final conclusion says.

“ SBRT for local recurrence in the prostate bed may offer encouraging control and acceptable toxicity. Therefore, further prospective studies are warranted.”
https://pubmed.ncbi.nlm.nih.gov/37012102/.

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pamperme | @pamperme | Jan 15 7:46am

The NIH for the above is 2023. There are trials which show positive results and people are using it. While short term results are positive or tolerable the long term data is not in. The short duration and the lower cost is an advantage and MRI guidance that Sloan uses helps accuracy. While I like the idea of 5 and done and the short term results are good, it is new and long term results are not available. Like everything there will be a learning curve and they will determine who should be using it and what people should not. Does SBRT do a better job at killing the cancer?

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heavyphil | @heavyphil | Jan 15 8:32am
In reply to @pamperme "The NIH for the above is 2023. There are trials which show positive results and people..." + (show)
Profile picture for pamperme @pamperme

The NIH for the above is 2023. There are trials which show positive results and people are using it. While short term results are positive or tolerable the long term data is not in. The short duration and the lower cost is an advantage and MRI guidance that Sloan uses helps accuracy. While I like the idea of 5 and done and the short term results are good, it is new and long term results are not available. Like everything there will be a learning curve and they will determine who should be using it and what people should not. Does SBRT do a better job at killing the cancer?

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@pamperme That paper talks about RE- irradiation using SBRT. In other words, recurrence AFTER prostatectomy AND standard SRT.
This is NOT salvage radiation per se, but the spot radiation we always talk about when it relates to areas outside the prostate bed and pelvic nodes - ie rib, lung, etc…
This paper explores the use of targeted SBRT on an area previously radiated - something we always hear cannot be done. It’s all a question of toxicity after just so much radiation.
Phil

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pamperme | @pamperme | Jan 20 8:12am
In reply to @heavyphil "@pamperme That paper talks about RE- irradiation using SBRT. In other words, recurrence AFTER prostatectomy AND..." + (show)
Profile picture for heavyphil @heavyphil

@pamperme That paper talks about RE- irradiation using SBRT. In other words, recurrence AFTER prostatectomy AND standard SRT.
This is NOT salvage radiation per se, but the spot radiation we always talk about when it relates to areas outside the prostate bed and pelvic nodes - ie rib, lung, etc…
This paper explores the use of targeted SBRT on an area previously radiated - something we always hear cannot be done. It’s all a question of toxicity after just so much radiation.
Phil

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@heavyphil
There are trials phase 2 with 4 years showing good tolerable results. They are for salvage /reoccurrence. But from what I see they have to be very careful and some studies are for intermediate cancer so they can give a lower dose. The higher radiation has to have more affect on tissue but as you say they can better target. They are moving towards using it for reoccurrence but it may end up with limitations on who uses it. The studies are picking out particular groups. I do not think I would fall into these groups. I still have to get past whether my ribs have something then I will have to make a decision. I am strongly leaning to IMRT because of personal reasons.

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wwsmith | @wwsmith | Jan 20 3:21pm
In reply to @islander2025 "@jeffmarc Wow well VMAT is being used in many places , Cleveland clinic for example, here..." + (show)
Profile picture for islander2025 @islander2025

@jeffmarc Wow well VMAT is being used in many places , Cleveland clinic for example, here in PR also.. also referred to as true beam radiation high prescision. I attached 2 pics of info

Jump to this post

@islander2025 As @heavyphil said, VMAT is just another improved variation of IMRT. If you can get VMAT instead of plain IMRT, all the better, but not a significant advantage either.

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