MSK Experience - RO vs Surgeon

@thmssllvn As a follow up on that, I consulted with Dr Nagar in 2019 when he was at Weil-Cornell. I chose him because WC was the only hospital in NYC with the MRIdian linac machine at that time.
My cancer was very extensive Gleason 4+3 unfavorable and Dr Nagar was very confident that he could treat me successfully with the addition of ADT, which you probably won’t need.
Dr Nagar had been trained extensively in brachytherapy yet he never even suggested that as an alternative; since then I am sure he’s got a lot of cases under his belt (no pun intended) and if he says you have a 90% chance of a cure, I would trust him. He has also co-authored many papers and been a presenter at ASCO so the man knows his stuff! Best,
Phil

@heavyphil When I hear the word brachytherapy I wish it would always be qualified by
the letters HDR-B or LDR-B.
He did not mention it as an
option but was the subject mentioned? I mentioned it to the Surgeon he laughed and said “Find One” The RO said
an unspecified boost by brachytherapy may be added.
That begged the question why not ‘brachytherapy’ first
and an IMRT boost?

@thmssllvn
There was a study done in Japan, where they did brachytherapy First followed by IMRT. Definitely seemed different, but it worked.

I just wish I’d saved the link to that study.

@thmssllvn Check how much is paid for 20-28 IMRT fractions vs LDR-B and you will have your answer (applies to both site and doctor charges). Just no money in LDR-B. This is used a lot more in the EU with the government medical systems. The few doctors using LDR-B in USA stop at 3+4. Probably too much risk of something outside prostate to treat higher for their malpractice insurance except as boost to EBRT.

@thmssllvn No mention was made of it at all, which surprised me a bit; his CV showed extensive training in it but I don’t know if it was H or L.
My thought at the time was that this newer MRI guided form of SBRT was simply superior to ‘old fashioned’ seeds. But my thinking has evolved the more I study it, and I myself might want HDR+IMRT+ADT as primary treatment if radiation was a consideration.
Phil

I was treated by Dr Nagar last year at MSK. I had one spot of G9 (4/5) and 3 or 4 other spots that were G6 and 7, all on one side of my prostate. There were also two small lesions in adjacent lymph nodes. No metastases found elsewhere. For my treatment he used a machine which did not have MRI- guidance, the Varian (now Siemens) Ethos which adjusts treatment each day based on a daily, real-time CT scan. Side effects lasted about 10 days. He had the option of using the MRI-guided machine and I was confident that he made the correct choice.

As for RO vs Surgeon —> What I found was that unlike with a prostatectomy where you want a surgeon who has done a zillion surgeries (because its his/her hands that will actually be inside you, or guiding the robot’s hands inside you), with radiation the RO isn’t doing any of the treatments.

As a point of reference — my RO was never in the treatment room when I was receiving my 28 proton radiation treatments. (Not once, nada, zero, zilch.) We met with him for an hour on Fridays to discuss my status and the next week’s planning.

Yes, you do want an experienced RO to lead the team. But the RO is more like a team manager/captain - he knows all the plays, but he isn’t the one on the field batting, throwing or catching the ball. It’s all the others who are on the field.

I come to find out that it was the dosimetrist, the physicist, and the radiation team specialists who were doing the heavy lifting.

So, my questions for my RO were more targeted for technical answers I wanted to hear from the dosimetrist, the physicist, and from the radiation team specialists.

Those answers, and the physics behind proton beam radiation (e.g. the Bragg-Peak) are what ultimately led me to choose proton (28 fractions @ 2.5 grays per fraction + 6 months of ADT).

@brianjarvis
The problem with speaking to those three people is that the RO sets up the requirements for the treatment, the dosimetrist designs the customized radiation plan for prostate cancer, determining exactly how to angle beams and distribute doses to destroy the tumor while sparing healthy tissue. They create a computer-modeled plan—including machine settings—that radiation therapists use for treatment delivery. That then goes to the RO who approves it.

So speaking to the technicians is not really useful, maybe the dosimetrist Could provide some interesting information, but the RO is really the one that approves everything they configure. The technicians don’t have any say in what’s happening other than to tell you if you have enough liquid in your bladder (another CT/computer defined amount) And if you are positioned right.

I had eight weeks of IMRT and only spoke to the RO at the very end.

I had three sessions of SBRT and again only spoke to the RO at the end.

Not sure it really makes any sense to speak to other anybody, but the RO.

@jeffmarc I didn’t need to speak directly to the dosimetrist. I asked the RO specific questions that the dosimetrist could provide:
> the calculation of my biologic effective dose for the number of fractions I had chosen. (I had to choose from 20, 28, or 30 fractions. I wanted to see what they did with that.)

> how much radiation (with a drawing) will hit my prostate and how much would hit nearby organs?

> (there were others)

At each visit, I had a few more detailed questions. (Same for physicist-level questions.)

The RO is (basically) a generalist; he undoubtedly knows a lot about a lot of things. But, He’s like a manager at work - signs off on everything, but it’s the engineers who do the work and understand everything. I wanted the specialist’s inputs. They actually did show me planning information. I wanted to see how they calculated the dose equation for my treatments.

As for the machine settings, I asked questions about the machine itself and the settings. I doubt if the RO knows those low-level details. (At one point the RO commented that “No one asks the type questions you ask.”).

At each of my treatment sessions, I also asked the technicians similar technical questions about the setup of the machine, what the information on the monitors meant, and more; great conversation. At each of the 28 sessions, I had at least one question for them. (Sometimes they had answers; sometimes not. It was a very informative experience.)

I wanted to know exactly what was happening and how, when, and why……

@bens1
I went to Dr. Nagar at MSK for a second opinion last year and decided to use him for treatment. He chose to use an Ethos machine for SBRT which doesn't have MRI guidance. Instead, it adapts treatment every day based on a real-time CT scan which shows if any of the organs have shifted and adjusts the radiation accordingly. My results were fine but I'm still curious as to the advantages of one machine to the other. I did have fiducials inserted which I don't believe are required for the machines with MRI guidance.