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Trying to decide on treatment for prostate cancer
Being new to prostate cancer and from all my research it has become a hard decision what treatment to start! I have been seen by 2 of the top hospitals in the US. I'm unfavorable intermediate risk because of high PSA. 4+3. Clear PSMA & MRI (Stats below)
The treatment options offered: First is a trial with HDR Brachytherapy boost, 5 sessions of Proton therapy & 4-6 months of ADT. Second option from the other cancer center of excellence is HDR brachytherapy boost, 23 sessions of "adaptive" IMRT radiation & 4-6 months of ADT. I'm having a hard time deciding, the trial looks really good with only 5 sessions but no long term data yet (similar trials have been done with HDR brachy, SBRT, etc and good results ) but the other option with Brachy & 23 sessions "adaptive" IMRT has proven data of around 90% success rate 10 years out. They both would use some radiation in the pelvic region as well because of the high PSA. Also SpaceOar gel will be used. The PSA is higher in my case partly due to the fact the localized cancer is only in the Transition zone which will typically present with higher PSA. Was hoping someone could comment that had same or similar treatments, side effects, etc. Especially with the Brachy boost & short course of Proton or SBRT.
Really a tough decision and having a hard time deciding. May come down to a coin flip...... Thanks in advance
Age: 68, PSA 40, Gleason 4+3 Grade 3
MRI:
FINDINGS: PROSTATE GLAND: measures approximately 5 x 4.4 cm corresponding to a volume of 45 mL. PERIPHERAL ZONE: No evidence of prostatitis. CENTRAL GLAND: Moderate changes of BPH. Lesions 1 PI-RADS score: 5 Location: Right TZ Mid at 11 o'clock Max dimension: 3.66 cm (slice: 14) Volume: 9.492 ml Extraprostatic extension: - NONE
Extraprostatic Tumor Extension: Slight bulging of the prostatic capsule but no visible tumor extension beyond the capsule. Neurovascular Bundles: Normal. Seminal Vesicles: Normal. Urinary Bladder: Normal. Pelvic Lymphadenopathy: None. Pelvic Osseous structures: No suspicious osseous lesion identified.
Biopsy , 17 cores 14 cores benign, 3 cores from same area (transistion zone) (50-60% pattern 4)
(2nd opinion on slides reviewed by chief pathologist at Univ of Penn who concurred with original findings)
PSMA:
1. Marked PSMA-avid disease in the prostate consistent with biopsy-proven prostatic adenocarcinoma.
2. The minimally PSMA avid largely symmetric pelvic lymph nodes are favored to reflect reactive/inflammatory uptake. No suspicious PSMA avid lymph nodes identified.
3. No radiotracer avid distant metastases
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A podcast discussion between two radiologists about what goes into a decision by a radiologist about unfavorable intermediate risk PCa:
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1 Reaction@jeffmarc @heavyphil
im a high risk guy, about to start orgovyx and then apalutamide (Luminal B cancer), which seems right based on my research. Im debating on the type of radition. Would like the convenience of 5 dose SBRT, but is there is enough data to justify this? Ive seen some promising info, but dont think it is standard care. Because of my risk factors, I need to radiate the pelvic lymph nodes as well as pelvic bed. i have read the larger the area, the more you should spread out the sessions. And the whole proton debate continues with competing arguments.
Your input would be appreciated. PS Decipher .93 (.75 post surgery), cribiform, EPE. no vesicles, nodes (but only 3 dissected). Pre surgery PSA 5, post uPSA .069, .039. .036, .056, .051 every 6-8 weeks. Apprehensive!
Last, looking for a experienced high risk RO for second opinion. Any references would be great! Currently working with Dr. Daniel Song at JHU.
@heavyphil
It seems this points to the purpose “ combining two radiation treatments, delivered in fewer sessions with a higher dose each time,”
Right now, they will deliver the exact same radiation each time. This is trying a different way of doing it by increasing the dose.
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1 Reaction@mlabus3
Here’s a list of some really great doctors at JHU
Bethesda Maryland
Sibley memorial hospital
Johns Hopkins, school of medicine
GU Oncologist
Dr. Channing Paller GU Oncologist
Dr. Mark C. Markowski GU Oncology
Dr Deville RO
Is your cribriform Large or small. Makes a big difference if you have large cribriform.
With such a high decipher score, I would want to speak to one of the GU oncologist for recommendations.
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2 Reactions@mlabus3 I must defer to Jeff Marchi on this one - he always ‘knows a guy’ since he is plugged into a few organizations.
As for your radiation question, I had SRT of 25 sessions to the bed and nodes with no long term SE’s to date…that can always change.
But as a practical matter, you do have a more aggressive PCa and a wide area approach makes sense to me so that would involve a form of EBRT.
I do not know if an SBRT approach is really ideal - or if it can be tweaked- to accomplish SRT.
By definition it is a much higher dose and sensitive tissues (bladder esp) can be damaged.
My 25 sessions was a marked reduction from the standard 39; they might even be able to go with even less in the future if they run another study.
Proton vs Photon will probably be debated for the next couple of decades so I wouldn’t focus too much on that myself.
But if you are in a situation to get salvage therapy with proton beam radiation, and it seems better to you, well why not?
Outcome-wise, however, there’s no difference.
Phil
@jeffmarc
first, I have large cribiform.
I'm a little confused. I have a surgeon (pavolich) an RO (song). How does the GU oncologist fit into the mix?
@mlabus3
The GU oncologist is an expert in prostate cancer treatment. The surgeon is an expert in surgery and some of the early treatment of prostate cancer.
If you can get an appointment with a GU oncologist they can review and help plan out what the ideal treatment would be for your case.
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1 Reaction@heavyphil
thanks!
@mlabus3
I was presented with the same options for a very similar diagnosis - 28 sessions of EBRT given at a local clinic and after a second opinion at a center of excellence 5 sessions of SBRT. The RO recommending the SBRT said he could give me 28 sessions but the outcomes would be the same. I had SpaceOAR inserted along with fiducials and 5 months post-treatment I'm feeling fine. I would recommend finding a center that has the equipment to perform SBRT, go there and get a second opinion. I went to MSK but could have gone to UVA.
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1 ReactionHi,
In my humble non medical opinion Proton therapy with ADT is the way to go. Proton has a fixed beam length which stops at the tumor site. No damage past the tumor which would impact your bladder or colon. There are some newer ADT drugs in pill form which have milder side effects. Your doctor team should be able to advise.
Dave 3+4