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First Session of Radiation Called Off While on Radiation Table
Hello,
My husband has Gleason 9, cribriform prostate cancer, with PTEN-loss, which appears contained in the prostate based on scans. The cancer is diffused with no specific tumor, but cancer cells are throughout the prostate. He’s been on ADT (Orgovyx and Nubequ) for two months and yesterday’s labs show PSA of .05 and testosterone under 10. He plans to take ADT for 18 months to two years.
He started his radiation yesterday – or should have. Once he was on the radiation table, they told him his bladder was too full, so he let some out. Then they made him adjust body parts. Later, the doctor came in and said his anatomy had changed since the planning (which was on May 19, so not long ago) and they could not do radiation until they “tweaked” things. He left without getting treatment, and we drove 3.5 hours home. I asked him what the next steps were, and, of course, he had no idea because he didn’t ask questions (other than they mentioned he may have been gassy when they did the planning:). I was not present for any of this and wonder how two weeks after fiducial markers, a rectal spacer, and radiation planning were done, his anatomy changed enough that radiation was not possible.
The following notes were added by the radiation oncologist two days ago - the day before my husband’s first radiation treatment:
Procedure: simulated supine. Serial axial CT images are obtained of the abdomen and pelvis for treatment planning. Fiducial markers and rectal spacer are present. The bladder is sufficiently full and the rectum sufficiently empty. I have personally reviewed and approved the images for treatment planning.
I reviewed the simulation images. On each axial image, I contoured critical normal structures, including the rectum, bladder, penile bulb and femoral heads. I also contoured the prostate (CTV). A customized PTV1 was then developed to cover CTV1 with a margin of 3-5 mm to allow for daily setup variation and organ motion.
Normal tissue constraints and PTV coverage requirements have been specified on the constraint sheet.
Has anyone experienced this? Do they need to do all the planning again? Should we worry about incompetence? We are at Duke. Thanks for any insight!
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"Careful" is good. If your husband is on ADT and it's working (which it is), the timing of next steps is nothing to worry about.
@scary1
My testosterone returned to the lower end of the normal range 9 months and continued to rise for 24 months following cessation of the lupron and AAP . For testosterone tests, early morning blood draws will result in somewhat higher results (+10%) for 70 year old men and significantly higher results (+20-30%) for younger men.
I didn't notice any side effects attributable to the RT (proton pencil beam) dispite the RO's decision not to use SpaceOAR due to the location of the tumor and EPE. Only time will tell if an RT related complication will develop down the road.
Bill
I'm currently undergoing 20 sessions of external photon beam on an Ethos Hypersight machine somewhat capable of real-time adaptive planning depending on what changes are observed in the target from day to day. Its early days for AI, but AI planning assistance is touted as one of the features. It can also deliver SBRT. It has an advanced CT scanning system that improves the ability of the operators to know if they are hitting the target.
I saw a Duke webpage dated January 2025 announcing that they had one of these. Your husband may even be being treated on one. If that machine was involved, because it can cope with patient changes more than most machines, things must have been pretty far out of whack for the operators to call things off.
I would welcome any delay like what you describe. The last thing you want is high powered radiation directed at the wrong target causing side effects. These treatments are dangerous. There are possible side effects that are very difficult or not possible to deal with effectively that have drastic implications for quality of life.
It takes me 3 1/2 hours to get to the treatment center, and because of that I rent a room in one of the somewhat subsidized housing units the treatment facility has for the 5 days of each week I get treatments. Nevertheless, I would not complain if the treatment schedule was revamped no matter what inconvenience it caused me.
One of the prime factors in my decision as to whether I would accept being treated by this doctor at this facility was do I believe in my Radiation Oncologist. My confidence is based on do I trust him, and do I think he is at the top of his field.
I believe in my RO. I'm grateful to be his patient. I still present him my doubts and with any questions that come up in my mind. Every time I get a serious doubt I do some research to try to get up to speed, and I discuss things with this guy. So far, I am always reassured by his answer.
Your husband's doctors will produce a report that explains what happened. If what you describe happened to me, I'd be studying that report, and questioning the RO.
It sounds like they are very competent and unafraid of re-doing everything they've done so far if they think it warranted, i.e. like a new simulation and plan. It is most likely that their prime interest is that the outcome of their treatment on your husband is the best they can do.
I hope things go well for your husband.
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Thanks for your reply; you gave us even more insight. It turns out my husband was initially on Duke's "yellow" machine, which is the Ethos Hypersight machine. This is where they could not get him properly lined up and called off the radiation. He has now been assigned to the "grey" machine for the start of radiation next week; this is the older, TrueBeam machine. So now I'm concerned. Does the newer RO not understand the Ethos machine? I still don't know what happened. I looked in my husband's Duke chart for an explanation, but nothing has been noted about June 4. I also sent a message in Mychart on Friday, June 5 asking what occurred but have not heard anything yet. I agree that calling off the treatment was likely a good thing, but why completely switch machines? They are not doing any new planning or simulation - just jumping straight into his first radiation session when we return.
That is the gist of me posting in this forum: I have full confidence in the MO, but the RO is very young, and seems somewhat uncertain. He may be stellar, but he supports and recommends five sessions of SBRT to only the prostate when my husband's cancer is being treated with ADT for two years based on its aggressive nature (Gleason 9, cribriform, PTEN-loss, and 9/12 biopsy samples positive for cancer). I questioned the focused radiation that ignores the surrounding lymph nodes, but the RO seemed to think this would offer fewer side effects, and my husband is only 61. The RO did post studies and documents to support his treatment approach in MyChart. Of course, my husband wants SBRT based on fewer side effects.
I was treated at Duke Cancer Center six years ago for colorectal cancer and received chemo and 29 radiation sessions. I know Dr. Czito, my RO, saved my life. I was stage 3 and booted from Duke in August 2025 for clean scans - thank goodness.
I just want to approach my husband's treatment in the smartest possible way.
Thanks for sharing and thanks for listening to me!
@scary1
I would imagine that the machine might be fully scheduled too far in advance for your husband to be able to get treated by it, After the Treatment had to be stopped.
They had an opening on the other machine so they switched you over.
This is something you could ask about, but it may delay your treatment start date a lot if you try to get it on the other machine.
I heard a presentation where the lecturer said that the evidence for less side effects with SBRT compared to treatments consisting of many more days, i.e. 20 or so, hasn't been published for high risk patients. I.e. they said oncologists, at this point, don't know.
They pointed to the PACE-B trial. I haven't studied that trial, because patients in my risk group were regarded as too high risk. (GGIII, Gleason 4+3, cT3b, i.e.seminal vesicles are invaded). My RO describes my case as "at least "high risk" although as there is no proof it has spread beyond the seminal vesicles, it is described as "localized". They are treating with curative intent. They are radiating some lymph nodes based on past experience with patients similarly staged.
PACE-B only studied SBRT vrs longer course external beam treatments applied to low or intermediate risk patients with localized cancer. Its aim was to prove "non-inferiority" with patients of similar staging. All patients with any NCCN defined high risk features were excluded. I.e. no Gleason 9, or for that matter, no one with anything more than Gleason 3+4. No one slated to take ADT or who was taking ADT was studied.
PACE-C is studying patients with more advanced cases. Preliminary 2 year data was published in Nov 2025. "Conclusion: At two years, bowel toxicity was similar between SBRT and MHRT, while the incidence of urinary toxicity was higher with SBRT, as measured using RTOG, CTCAE and EPIC-26. Five-year toxicity and efficacy outcomes are awaited." https://www.sciencedirect.com/science/article/pii/S0360301625061693
I haven't heard any oncologist lecture about a recently published study I found a report about just now, but, it also studied only intermediate risk patients. ASCO published an article: "Shorter radiation improves patient experience but not disease control for intermediate-risk prostate cancer" https://www.astro.org/news-and-publications/news-and-media-center/news-releases/2025/shorter-radiation-improves-patient-experience-but-not-disease-control-for-intermediate-risk-prostate
No one is going to be able to advise you unless they know a lot more about your husbands case than you've described.
There are loads of factors that go into deciding on what stage a patient's cancer is, and I don't know all of them. The experience of the RO, things like whether he knows the people who did the most influential studies, i.e. how much weight to actually put on them, and what that RO thinks the patient wants, etc., etc. At this point, where you've accepted a treatment proposal and laid on the table ready to let them blast, its pretty late to suddenly do a lot of research so you can hold your own in questioning what your RO has decided.
The Truebeam is made by Varian, as is the Ethos, and newer versions of both can be equipped with the Hypersight supposedly whizbang latest tech. It delivers the radiation with a big moveable gantry thingy that takes longer to move than the internal whatever it is inside the Ethos which zips around into new positions faster. It may be "older", but it may be just as good for your husband depending on what they were asking the Ethos to do, because the Ethos is capable of delivering SBRT with or without using some of its whizbang features.
What studies did your RO post that he seemed to think were the best guides to use in considering your husband's treatment?