Proton vs Photon

—> What is the disagreement regarding his MRI?

(During April-May 2021 (at 65y/o), for a localized, PSA of 7.976, Gleason 7(4+3) prostate cancer (with no other known risk factors from MRI or biopsy), I chose 28 sessions of proton beam radiation (at 2.5 grays per session) + 6 months (two 3-month injections) of Eligard + SpaceOAR Vue. For me, successful treatment and quality if life were equal priorities.)

Recent clinical trials (COMPPARE & PARTIQoL) show similar tumor control rates and patient-reported quality of life outcomes when comparing proton vs photon. However, as with all clinical trials, it’s difficult to extrapolate from large population results to how a treatment will impact a specific individual.

With statistically equivalent outcomes, insurance companies sometimes have an impact on that decision (given the much greater cost of proton over photon).

Another issue has to do with access. With only 47 active proton centers in the U.S. (https://proton-therapy.org/findacenter/), scheduling photon is often much easier.

Ultimately, it was the science of proton’s Bragg-Peak characteristics (see attached graphic) that persuaded me to use proton (and the fact that Medicare fully covered it, and that there was a top proton center just a 40-minute drive from my home, all helped my decision immensely).

So, I chose a proton center that was (1) a teaching hospital, (2) a research hospital, and (3) a pediatric radiation center that also did adult radiation. My thinking was that if they can hit a pea-sized tumor deep in a kids’ brain with protons and not cause any surrounding brain tissue injury, they can certainly hit a walnut-size gland and not cause any surrounding tissue injury. (All I have to do is to lay still!)

As is typical for me - despite my confidence that proton radiation was the right choice for me - I hedged my decision by still using SpaceOAR Vue.

I’m not sure why proton radiation works so much better than photon with other types of cancer treatments, and wonder if the laws of quantum physics change for prostate cancer? Or does patient compliance play a role in the outcome?

Anyway, those were my thoughts on the proton vs photon option. My radiation oncologist left the choice up to me. So far, nearly 5 years later, the outcome has been as benign as expected. (Most recent PSA was 0.314.)

If you are considering radiation, I have a list of questions that you might want to ask the radiation oncologist that may help in your decision.

Here’s a presentation on proton radiation (by Dr. Rossi) from the 2023 Mid-Year PCRI conference: https://www.youtube.com/live/WTqPnSRYtW4
—> Starting at 3:38:45

"Photon beam therapy is a standard, highly precise, external-beam radiation treatment for cancer that uses high-energy X-rays or gamma rays produced by a linear accelerator. It damages cancer cell DNA to stop reproduction, often affecting surrounding healthy tissue as rays pass through the body, unlike more targeted proton therapy. "
I have had proton beam therapy on my neck and photon for my prostate. I have had proton beam therapy recommended to me, it does seem to have advantages why else was it ever developed?

I have had IMRT salvage radiation, 8+ weeks. It is now 12 years later, The only side effect is incontinence which started six years after the radiation. I did have a prostatectomy before that so it could be the cause as well.

I had SBRT radiation on my spine about three years ago and had absolutely no side effects from that.

My brother had SBRT radiation on his prostate at 77. He’s now 80 and doing fine.

All of those were photon, not proton.

Now here is a Stanford study that we evaluated the results of photon radiation, Something that sort of confirms what the doctors said about their being a little difference.

In a study of about 145,000 men with prostate cancer, the team found that the rate of developing a later cancer is 0.5% higher for those who received radiation treatment than for those who did not. Among men who received radiation, 3% developed another cancer, while among those who were treated without radiation, 2.5% developed another cancer.
https://med.stanford.edu/news/all-news/2022/070/prostate-radiation-slightly-increases-the-risk-of-developing-ano.html

With classic Medicare and a good supplement Proton is covered. Unlikely to be covered by other insurance including Medicare Advantage plans. My decision after looking at studies that showed equal effectiveness was based on cost $0 for photon (had hit max) vs. $150K++ for proton with a cash pay discount. Should always have a spacer with proton since the effects of a miss and hit of rectum are much greater. If using photon get the best (IMRT/IGRT) where they refocus the target with each treatment and spread the entry points to minimize impact to other organs. Since urine passes through the middle of the prostate both treatments can negatively affect urine flow. Either way you should discuss how these can be minimized (my plan had more fractions approved).

It’s an ongoing battle, this debate. However, just want to point out that what @brianjarvis said is fact: no one can predict how any individual will respond to any given therapy.
Scroll thru this forum and you will find men who’ve had serious side effects from proton therapy and others who’ve had NO side effects from photon therapy…and VICE VERSA!!
You must remember that ALL doctors favor either what they are most comfortable with- or what upper management is telling them to do.
Proton machines are VERY expensive to install and need to be used frequently to justify their existence.
There are some cancers for which proton therapy seems to have better outcomes (pediatric brain) but prostate cancer is not one of them.
Phil

An artificial intelligence re-read of the MRI called 'MaleScan' It is now available for $259.00 if 3rd party does not cover it. The source is precisionprostateassociates.com of Maine. They cannot read every MRI for technical reasons. There is no charge if unusable. Unless things have changed they cannot use your copy of the disk but require a direct digital transfer form the MRI facility. The report is generated in two days, Your data is compared to thousands of other prostate MRIs. Prostate cancer tissue is quite similar in appearance on an MRI. The digital comparison I suspect will be standard of care (SOC) in the not too distant future.

Regarding treatment: There appears to be a 'lacuna' (unmentioned oversite?)
Photon therapy: There are more subdivisions in this category:

1) External Beam Radiotherapy: [EBRT]
SBRT about 5 visits & IMRT (MFRT /CFRT): [(20 visits/30 visits)
...the difference is the amount of radiation per visit (gamma rays/'Gys')
....the cancer killing effect is about the same and the ACUTE time limited side effects are about the same
However the delayed (months to years) of urinary tract symptoms is an issue with all three.
Therefore for any form of EBRT the Miradx ProsTOX Ultra test should be done first:
The background for DELAYED symptoms is < /= 5%, for those who test LOW [clinician dependent?]; however
those who test HIGH >15% or more for SBRT may be LOW for the IMRT variety. or HIGH for all three,

2) Interstitial Radiotherapy: (non external) a//k/a brachytherapy

A) Temporary: High Dose Radiotherapy (HDR) often 2 visits separated by a week because the short lived irradiation might be too high for one session. Often Under MRI guidance the clinician visualizes the number one tumor target and gives the highest safe dose, then the secondary tumors less on that or a subsequent visit.

B) Permanent Low Dose Radiotherapy: (LDR) About 20 minute one time procedure under visual guidance by one of 3 imaging sources: Ultrasound, CT (Memorial Sloan Kettering/MSKC in NYC) or MRI (MD Anderson, Houston.
The major advantage of LDR (permanent seeds) is that the total dose over time weeks to months is the optimal amount without passing through radiosensitive tissue in short exposures. [The ProsTox test is not used for internal glandular irradiation as there should be very little or no effects outside?]

A primer on the effect of seeds may be found in You-Tube videos 'Brachytherapy' 101. It was produced by the Prostate Cancer Research Institute.org [PCRI.org] which is a 'arms length' from any recommendations form its guest presenters. (Watch the Q & A after the video.)

@thmssllvn
The MRI review company is unable to review an MRI that has been taken with contrast. That is the reason they are unable to review some MRIs.

You can get an MRI second opinion here is a video about the company and procedure
https://ancan.org/

They were unable to use my MRI because the data source was not good enough . It was a dye test 3T. It was stated that they can do both dye and non-dye 1.5 and 3.5. They preferred that if the MRI was planned rather than done already. it was quicker without the dye. I sent it to look for any lesions that were not as visible. Remember John Dvorak's (PC Magazine) software rule. Only buy Version 3.0 or higher. and make sure it was 3.0! They will work out the kinks.

@thmssllvn
I had a subscription to PC magazine for over 10 years, when it was a thick monthly. Read Dvorak’s articles, always.

Unfortunately, with apps, you don’t get to wait until version three, you really need to start using them pretty soon after they come out.

Quality of early versions has improved.

I am constantly finding errors in Apple apps. Little by little, they are fixing them. Found three bugs in a row in Apple mail, reported all three 2 weeks ago. They affected my ability to manage Mayo mail. Maybe in version 27 they will fix them, version 3 is not enough for some apps.

@jeffmarc From the data you are referencing it looks to me like there is very little to no difference from photon therapy or another therapy. Those differences would be difficult to tease out why the outcomes were slightly different. I like the studies because of the size, but don’t buy you can really tell much else.

I had SBRT Proton because it made more sense to me that photons could result in later cancers due to its trajectory through the body. Your data suggests otherwise. I also chose it because it seemed like less chance of urinary & other side effects. 5 months later it seems borne out, but I think it is too soon to draw conclusions on that.

I chose SBRT Proton because I couldn’t tell much difference between IMRT & SBRT in terms of outcomes. I understand the financial incentives for IMRT and chose SBRT. Certainly not having to go for 40+ sessions was a big plus. I’m 74 and planning on ending my ADT ‘early’ at 15+ months (9 before and 6 after) because none of the studies convince me that it will affect my longterm outcome. That remains to be seen.

I have followed and participated in this forum and feel I’ve gotten better first hand experiences, even if not entirely evidence driven than I’ve gotten from my doctors.