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3C, PPC 8/12, highest GG5; T1c N0 M0 - 5 SBRT sessions to Prostate?
Hi everyone,
Thank you for all the valuable information.
My husband has been staged as 3c because of the aggressive, cribriform patterned cells found in 8 of the 12 biopsy samples (high risk, PPC 8/12, highest GG5, pre-treatment PSA 13 Stage: T1c N0 M0).
While the cancer is prevalent in the prostate, the PET scan shows no spread. Nothing lights up – not even the lymph nodes. The oncologists want to treat his cancer as if it has metastasized and treat him with Orgovyx and Nubeqa for two years. The Nubeqa was not approved by the insurance based on his lack of metastasis, but if anyone is familiar with the Stampede trial, this is the reason behind this approach - we are in appeal. Two to three months into the ADT, the radiation oncologist suggests 5 fraction SBRT. He thinks that any stray microscopic cancer cells that have migrated beyond the prostate will be eradicated by the two-year double ADT treatment. I thought these drugs cripple and paralyze prostate cancer cells but do not reliably kill them off. When I questioned the approach, he said we could opt for the 20 session radiation and hit the nodes and pelvis. My husband prefers the five sessions, but I worry about a recurrence; the oncologists at Duke Cancer Center say they are going for a cure rather than just treatment, and the chances of the cancer returning are about 25% with this treatment. They said surgery would put him at about 60% chance of a recurrence. Do you think 5 SBRT treatments is the smart approach?
Thanks for any insight! Sarah
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@scary1 I can empathize with both of you: A wife always wants what’s best - a husband always wants the quickest and easiest! Or so he thinks….
Phil
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1 ReactionI must agree with the previous posts, you need a second opinion. I had a similar decision to make as yours from a different PC problem. I had very low PSA (less than 2) during diagnosis and MRI negative (invisible) cancer that based on the biopsy was a large lesion. The doctors were concerned that even my PET PMSA scan might not be accurate and that it could have spread outside the prostate and not be detected by tests.
They did not want to treat just the prostate. The radiation choices recommended were IMRT that would target the prostate and the lower pelvic area or SBRT w/ SIB (Simultaneous Integrated Boost for lymph nodes) however the SBRT was over 2 weeks as I recall. They euphemistically referred to these as "broad net" radiation treatments.
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1 Reaction@beachflyer
Thank you for the reply. My husband's MRI only showed (what they thought to be) inflammation, but this was because the cancer was diffused, like salt and pepper, throughout the prostate.
Did you ultimately choose the IMRT? And how are doing today?
So my cancer was on a more cellular level and did not provide a good return on the 3T MRI. According to my surgeon about 10% of us get significant PC with negative MRI. My situation was odd in that I also had very low PSA (less than 2 before diagnosis) in addition to a large lesion that was MRI, Ultrasound, and DRE negative.
One of the members of my medical team (associated with Moores Cancer Center in San Diego) stated that while he would normally steer 67 year old men with Gleason 7 to SBRT or IMRT, my low PSA and large lesion was concerning. He said my ratio of "lesion size to PSA" was the most significant he had seen in 30 years. The issue he stated is that radiation lowers PSA after treatment progressively over a year or two and that my falling PSA number might mask still active lesions somewhere else or make BCR harder to detect. The exact words the doctor used was "we can treat this with radiation, but you would do well to get to PSA zero". Funny he could not say surgery. So I went with surgery 17 months ago. no incontinence, but still have some ED. So far PSA undetectable..time will tell. I am so glad I got a second opinion by the way as it did help with solidifying a treatment plan.
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3 Reactions@scary1 I agree with the others saying that 5 sessions of SBRT is likely insufficient for his case. A very safe way to radiate both the prostate gland the greater pelvic region is to use 26 IMRT sessions for both the prostate and the pelvic region and then follow that up with one HDR Brachytherapy session as a boost to the prostate. This is what I did for my 3+4 case with a 0.81 Decipher. Two years of ADT is quite a bit of time for his case and if you get second opinions, some RO's would likely recommend only 18 months or possibly as little as 12 months. See my bio for more info.
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2 Reactions@scary1
Just to follow up on a doctor at Duke
While you want to see a radiation oncologist, you really should get a GU oncologist involved in this case because you have a serious cribriform problem.
This doctor is really highly respected and well-known as an excellent oncologist. You would be better off contacting him and getting help. He will refer you to a radiation oncologist that would be ideal for your situation..
Duke North Carolina
Dr Daniel James George GU Oncologist
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1 Reaction@jim18 I had SBRT, 36.25 Gy with a focal boost to 40 Gy and my RO stated if I got BCR both HDR and SBRT would be _possible_options. While the current NCCN Guidelines do not list them as First Line Treatment options, under specific criteria they are framed as investigational or highly selected salvage modalities
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1 Reaction@scary1 After being on ADT a few months your husband will probably realize the number of treatments is not much of an issue compared to ADT. Usually with more / wider radiation fewer months of ADT are recommended.
I hope you get Nubeqa approved. Step therapy of Abiraterone (generic Zytiga) often required especially with no metastasis. That delivers about the same suppression, but with worse side effects. Saves insurance about $250K.