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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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@cadaddy interesting. There is a growing sentiment in the field about using the 5 session SBRT. vs the 35 or 39 session IMRT. Lots of mixed reviews. Was this for salvage? did you do both the pelvic floor and the lymph nodes? Ive read the larger the area to be radiated, the more you want IMRT. SBRT good for more specific targets. Boy, i would love the 5 sesssion plan.
Id love a contact and MSK. i tried them for a second opinion, but they wouldnt take me until my PSA was .2! Waiting that long might kill me. there must a high risk group at MSK, havent been able to find them
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1 Reaction@jeffmarc Won't my RO include a GUO in planning. im fine reaching out to a GUO, but just assume the RO will engage with one. Maybe I shouldnt assume. Thoughts?
@mlabus3 My treatment was not for salvage. The treatment targeted the lesions in the prostate and two lymph nodes, all with 8 Gs each day for 5 days. A smaller dose of 5 Gs was given to the lymph node area. I contacted MSK by finding an RO on their website and requesting an appointment with him.
@clevelandguy
At the Mayo Clinic monthly online meeting a couple of days ago, the radiation oncologist discussed proton radiation. He said the Mayo Clinic now has four proton machines and is adding two more. He said he personally has only used it twice. When people ask about it, he tells them that there is really no significant difference between proton and photon.
This is from a radiologist at Mayo, Interesting point of view.
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1 Reaction@mlabus3
A GU oncologist will usually not be involved in treatment unless they are working with a patient. Radiation oncologist are familiar with handling cases though in bigger medical offices/hospitals they do use a team approach To go over the treatment. That’s usually a group of RO’s doing it.
@jeffmarc
Hi,
The difference between the two is that the Proton beam has a fixed length and does not extend the beam past the cancer and cause collateral damage in the bladder or rectum. With photon they typically use a jell between the cancer and bladder/colon for protection. Also Proton can be used in the same area once you have maxed out with radiation dosages.
Dave 3+4
@mlabus3 Hard to get insurance approval for 35-39 fractions anymore with most hospital charges fixed per fraction. Favor hypofractions at 2.4-3.0 Gys per fraction (vs. 1.8-2 Gys) to deliver the same dose with 20-30 fractions. A middle ground that cuts their cost by 30%+ with some increase in acute and about the same long term side effects. SBRT has higher cost per fraction but can cost less at 5 vs 20 fractions.
@clevelandguy
I’m quite familiar with protons differences and how it’s supposed to reduce the effect on close tissue. Unfortunately, we’ve had people on here reporting urinary problems and other problems after having proton so it doesn’t seem to be a panacea.
I think that’s one reason why that RO said he doesn’t use it very often.
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3 Reactions@mlabus3 Which MSK hospital are you going to? I went to the Commack facility on Long Island.
I was treated by Dr Andrew Barsky - a real gem!
He didn’t wait for 0.2 - he saw the steady rise and got me at 0.18.
Ironically, after it hit .18 he told me it would probably drop down again to about .15, which it did! But in any event, he said the trend was steadily upward and we should treat now. Took Orgovyx for six months and did just fine.
Phil
I just finished 5 days of SBRT with SpaceOAR and no ADT. I had no side effects during the process and have a few minimal effects a couple days after treatment stopped - but nothing that is impacting my quality of life. The whole process in retrospect was very easy and I am so glad I did it. I would encourage anyone trying to decide on a course of treatment to review the numerous videos available through the Prostate Cancer Research Institute (PCRI). They provide treatment perspectives that don't come from a surgeon who owns a surgery machine or an oncologist who owns a radiation machine. I know that post-treatment-choice-regret is a big problem when all is said and done and you are stuck with the side effects of whichever course you chose. Please educate yourself on as much as you can on any treatment to eliminate that regret. God Bless and good luck.
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