urologist and radiation oncologist aren't on the same page

Definitely get a third opinion. My particulars were different to yours, but my situation was similar in that my urosurgeon disagreed with my RO and MO. I got a third opinion at MSKCC, and felt confident going with the recommendation I got there, which was a tweak of the MO’s recommendation. I recently finished my therapy, and so far so good. Although my treatments have been local, my doc at MSKCC has also been following me, and I feel better knowing that if there is a recurrence, I already have a doc there who knows the whole history.

Hi Heavyphil
Small world. Dr Nagar went from using the Mridian, which is still available to hospitals who want to pay $1 million a year for service updates, to another MRI based radiation machine, Elekta, at Memorial Sloane Kettering.

I wonder how long it will take other hospitals to move to MRI based radiation machines from non-MRI based machines, ROI notwithstanding.

An RO at Northwell told me that he didn't like MRI based systems because “they took too long”….he said a single treatment could take 45 mins or more due to the fact that beam turns off if the target is shifted even minutely due to gas, peristalsis, etc….that’s the very purpose of the machine! That’s why margins are so precise and peripheral damage minimal.
He said he could treat 3 or more patients with a Cyberknife in the time it might take him to treat one with Meridian/Elekta. Volume is king, Time is money baby, and that’s why, in addition to the maintenance costs, more hospitals are not buying them….a shame….

Actually, it is the opposite in terms of sales. Elekta's net sales growth in 2024 was up +12% and that is in an environment of higher interest rates for financing.

The Mridian had financial problems, not because of sales but because Scott Blake, the President, did not manage his cash flow and receivables in a timely manner. Sales were strong.

Your right, it takes one extra person, which I perceive as an extra set of eyes, to run the Mri machines. Institutions, even centers of excellence, have to manage these machines in a way that gives them the same ROI as other non-mri radiation machines. They should manage it better because it is better for the cancer patient. It is their job to triage machines and patient needs to achieve an ROI and satisfy the patient. Some do it better than others. When I asked the head of a oncology department of a Center of Excellence whether they would be using the dynamic capability features of the Mridian to treat me, his answer was "if you want to use that feature, you may want to go someplace else." I went someplace else.

We all know how complicated the decisions are for treatment in terms of monies spent whether it is socialized medicine or capitalism medicine but all institutions should, have as its primary directive, to provide the best that is available and manage the costs accordingly. Of course, one institutions manageable costs is another's nightmare.

The Mirage randomized trial proved that lower margins reduced toxicity and side effects with radiation machines that had built in MRI so as a patient, that's what I did and would do it again and I sincerely hope the MRI based machines continue to become more available.

“ Per my urologist and R/Os the hormone treatments do not kill your prostate cancer. The inhibit from growing.” Interesting. My urologist and M/Os stated that ADT starves the cancer and it dies. Are these word choices a reflection of our doctors’ biases and the direction they’d like us to go, or is there a factual discrepancy?

No, two people are the same. Some people on ADT have their tumors shrink dramatically others not so much. I’ve heard of more than one case where the drugs have allowed tumors to shrink to the point that they are not visible on a PSMA pet scan.

Aha, I think we’re talking about two different situations. You’re talking about treating an intact prostate; in my case, ADT was to treat metastatic cancer after a prostatectomy. Sorry for any confusion. I hadn’t finished my first cup of coffee.

In either case, I have never read that ADT alone can KILL prostate cancer cells.
Were that the case, every single man with PCa could be “cured”, ADT discontinued and a complete cure for prostate cancer could be announced.
However, I do think something like that - a la Pluvicto - could be possible some day, wherein a radioactive/hormonal agent could be infused that only goes to PCa cancer cells and kills them completely. Might not be that far away, in fact, when you look back over even just the last 5 years and see how much progress has been made.

I was actually referring to metastasis anywhere in the body not the prostate in particular. Someone reported metastasis in the lung disappeared recently on ADT. In other locations as well over the years.

Thanks to you, I’ve done a bit more research of my own. You’re right. Thank you for helping clear up my misconception.