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Johns Hopkins Health Alerts: Talking About CyberKnife

bdhilton
Posts: 758
Joined: Jan 2010

Should you consider CyberKnife for your prostate cancer treatment? Here's what we know about this new treatment ...

Talking About CyberKnife

Recently a subscriber to the Johns Hopkins Prostate Bulletin asked: I am 63 years old and I was diagnosed last week with prostate cancer (4.7 ng/dL PSA; Gleason 7). I have begun my due diligence to find an appropriate therapy. My doctor recommends radical prostatectomy surgery, but I have now read a lot about a treatment called CyberKnife. What are your thoughts about this prostate cancer therapy? Since many of you are interested in learning about prostate cancer treatments, we thought we'd share our reply ...

CyberKnife is a type of conformal beam radiotherapy that uses implanted "seeds" in the prostate to guide and adjust the accuracy of the beam in real time during surgery. The expectation is that this will improve precision in beam delivery due to small adjustments and changes in position during treatment, and can allow for a greater, more accurate concentration of the beam to the prostate than might be available by other methods.

Like many new forms of treatment, this therapy raises expectations that prostate cancer outcomes will be improved and complications will be reduced, but this has yet to be determined. The CyberKnife hasn't been around long enough for its effectiveness in prostate cancer treatment to be confirmed.

Like brachytherapy (seed radiation implants), CyberKnife relies in part for its accuracy of radiation delivery on target seeds that are placed by hand into the prostate, using needles and guidance systems. Conventional external beam radiotherapy relies only on CT-guided images for accuracy. The need to place seeds by hand into the prostate introduces a potential for error that is dependent on the experience and skill of the person placing the seeds.

In general, it takes a long time to prove the value of any new technology in medical care, but the public -- and many members of the medical profession -- are often quick to embrace new technology and make bold claims for its effectiveness.

The Men's John Hopkins web site is http://www.johnshopkinshealthalerts.com/alerts_index/healthy_living/757-1.html

steckley
Posts: 100
Joined: Aug 2009

I am sure I would have considered Cyberknife ... if I had known about and if my HMO had it!

Based on my very limited knowledge of Cyberknife (gained through posts on this site) the only question I have is, "Is the resolution of the scanning devices used to determine where tumors are good enough to spot the small muti-focal tumors common with PCA?".

viperfred
Posts: 20
Joined: Jun 2010

Hi steckley,

Good comment.

The CyberKnife(CK) treats the complete gland volume with the prescribed dose volume and a margin of 0 to x which is defined by the Dr. Typical CK plans have 0-2 mm next to the rectum and baldder, other areas are 1-3 mm. Zero margin for prostate movement vs 7 mm margin with IMRT to compensate for movement. Imaging is an important element which continues to improve. Men today have several good radio therapy options.

steckley
Posts: 100
Joined: Aug 2009

Hi Viperfred,

Thanks for the answer to my question. But now I'm a bit more confused, and hope you can answer some additional questions.

I had thought CyberKnife focused on just the tumor and not the whole prostate; therefore, I was wondering if the resolution of the scanning devices used to target tumors in the prostate could detect small local tumors.

If I am reading your reply correctly, it seems that CyberKnife radiates the entire prostate, similar to Brachy? Is this correct?

Also, you mention imaging as an important element which continues to improve, do you know the current lower limit of scanning devices (i.e. the smallest tumor that can be dected?)?

hopeful and opt...
Posts: 1315
Joined: Apr 2009

to ALL posters who have contributed to this thread.......since I am evaluting various forms of therapy to included Cyberknife I am gratful for the information that was provided....I believe all the posts were made with excellent intentions and were informative.....thank you.

I hope that future posts in this thread, and elsewhere will be directed at developing knowledge about the treatment, and not "deflecting" to win a point or a position by directing comments toward fellow posters....of course, we want to let others know how to improve their posts so we can all gain informaton. which need to be done in an assertive way.

I hope that this thread will continue.

My two cents

Ira

steckley
Posts: 100
Joined: Aug 2009

I am sure I would have considered Cyberknife ... if I had known about and if my HMO had it!

Based on my very limited knowledge of Cyberknife (gained through posts on this site) the only question I have is, "Is the resolution of the scanning devices used to determine where tumors are good enough to spot the small muti-focal tumors common with PCA?".

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

While the posted link to Johns Hopkins connected to several options to spend money on the hospital's reports, I failed to find the referenced article.

My impression is that trying to conjure up supposed risks to the CyberKnife procedure based on the fiducial placement is nonsense. The fiducials are placed by trained surgeons using a detailed plan developed by the radiologists who oversee the CyberKnife treatment and are guided by real time ultrasound imagry throughout the process. Following placement, detailed MRI and CT scans are conducted to ensure the fiducials are in the right place and haven't moved. They are also checked and double-checked each time you go in for treatment. Suggesting that the success of CyberKnife is a function of the experience of the physician placing the fiducials underscores the lack of knowledge within the medical community about this procedure. Fiducial placement is no more difficult than a biopsy and very similar in approch. Fiducials are a common procedure used in treating many cancers in soft tissue with radiation.

CyberKnife is not a "new" procedure. It was approved by the FDA to treat cancer in 2000 and has been used since 2004 to treat prostate cancer with exceptional results since 2004 (a year before DaVinci surgery was approved for use in treating prostate cancer). Nearly 4000 men have had this procedure and its use is growing rapidly as an effective, relatively inexpensive, and quickly accomplished procedure that is highly appropriate for men with early prostate cancer.

I have read every study, paper, and internet blather about CyberKnife since I chose this proceure for myself. I have never heard of a single case where the procedure was compromised by fiducial placement or even a discussion on the procedure where it went wrong. There are too many double-checks on this during the process for this concern to have any credence.

I have great respect for Johns Hopkins as an institution and am quite familiar with the many advances in science it has pioneered. I am also aware that it is one of the strongest advocates for surgery and the amount of money that flows to that institution as a result prostate removals. The first RP was done there early in the last century (the patient expired after a few months) and Dr. Walsh developed the nerve sparing technique there during RP that has enabled thousands of men to have some semblence of a sex life following RP. The post to the question of the 63-year old does not, in my opinion, meet the standards for which Johns Hopkins is supposed to represent.

====================================
Age at Dx - 59. Dx PSA 4.3. Biopsy 1 of 12 cores positive with 15% involvement. DRE normal. Stage T1c. Gleason 3+3=6. No physical symptoms.

CyberKnife treatment in June 2010. Side effects to date. Zero.

viperfred
Posts: 20
Joined: Jun 2010

Agree with Kongo 100%

There are 1,000's of published studies for radio therapy. Radiation has been known to kill prostate cancer for a 101 years. Major advances have been made in the last 20 years (total dose of 60 Gy was typical). Imaging technology, Radiation sources (linear accelerators) have made major advancements in power, beam control and software to control treatment planning. Localized External Beam Radiation advanced from 2D-RT, 3D-RT, IMRT, Proton Therapy, IGRT-IMRT, CyberKnife/SBRT. Few studies follow patients over 5 to 8 years. The published data suggest that increasing the total dose improves cure. This is tricky as the increasing dose also results in collateral damage. Fixed beam Gantry system limit the dose per session/fraction/day to 1.8/Gy when treating prostate cancer. The number of sessions for IMRT is now up to 45 (9 weeks, 5 days a week) with a total of 78-86.4 Gy. The long term data is a good reference but of limited value for todays therapy. It takes 10 years to provide 10 year data at which time the therapy is obsolete.

What is known:

1. Increased total dose improves cure rates.
2. Increased (hypo fraction) dose per session/fraction increases cure and reduces total dose. Hypo fractionation (7.25-9.5 Gy per session) is delivered by HDR Brachytherapy, the CyberKnife and at least one new clinical trial using the Novalis Tx.
3. Lowering the dose to critical structures reduces side effects. This continues to improve with improving imaging, planning and in the case of the CyberKnife prostate tracking during the treatment. IMRT and Proton therapy use CT scans before the session without automatic beam correction for prostate movement.
4. The three year cure rate has improved from 60-70% 20 years ago, to over 90% with the present advanced therapies such as the CyberKnife likely to be 98-99%.

Look at studies for all therapies to be an informed consumer. Surgery is no longer the Golden Standard. A treatment center tell you the CyberKnife is a good option if they do not have a CyberKnife. Most treatment centers with a CyberKnife also have IMRT and many also offer Brachytherapy. Doctors make more money from IMRT as they get paid per session. 45 sessions is a nice paycheck. The CyberKnife treatment is 4 or 5 days. The total cost of treatment is lower with the CyberKnife than IMRT . Always follow the money when consulting with doctors to filter out their bias and self serving interest. It is reasonable for a doctor of a specific modality to emphasize the features of his speciality. It is not professional for a doctor to be critical of a modality that they do not have expertise and or have current data to validate their claims.

I completed treatment for prostate cancer with the CyberKnife May 5, 2008. Have zero side effects, initial PSA was 5 ng/mL, Aug 5, 2010 my PSA was 0.34ng/mL. The PSA value after radiation is a relative number, evidence of the meaning of a PSA value is lacking. What is known, a PSA decline is good and a repeated increase may indicate recurrence. However radiotherapy has PSA bounces (0.01 to 1.6 ng/mL typical bounce range), in 20-30% of the patients, in the first 24 months after therapy.

The John Hopkins comments are a good example of an attempt to mislead patients. What they call seeds are small gold targets also used with IGRT-IMRT. Calling them seeds makes one think of Brachytherapy. In my opinion their comments are border line dirty politics. There are many good doctors at JH and they do not deserve to be put in the same kettle of fish as those associated with their CyberKnife article.

Be an informed consumer!

FredK,
Gleason Score 6
PSA 5 before CyberKnife (completed) May 5, 2008
PSA 0.35ng/mL, Aug 5, 2010
"Zero" side effects

Swingshiftworker
Posts: 634
Joined: Mar 2010

I agree w/Kongo and ViperFred.

My CyberKnife treatment at UCSF is just 2 weeks off. Nothing I was told indicated that the accuracy of the treatment depended on the placement of the non-radioactive markers -- only that they were used to aid in defining the treatment area as mapped by CT/MRI scans.

It is misleading to suggest that the CK markers are any way similar to the radioactive seeds used in brachytherapy. In fact, the reason I decided against BT was because of the 70-100 radioactive seeds that are used in BT and the fact that they remain in your body forever and have a 1/2 life of at least 1 year (ie., you're actually radioactive for that time).

I just had the 3 CK markers placed on Tuesday (the day before yesterday) via TRUS. Took just a 30 min visit to the office; only a couple of mins for the actual placement; not painful; just some minor discomfort; much less than the biopsy. DRE negative - prostate still not enlarged or hardened. The urologist took several ultrasound pics of my prostate from various angles as well. Going to have my CT/MRI scans next Tuesday. Then, they'll be planning and programming the computer for 4 treatments, every other day starting on 9/15 through 9/22. Hoping for zero side effects, just like Kongo & ViperFred.

Note to ViperFred: Amazed that your PSA #'s dropped so quickly after treatment. Hope that I get that result as well!

bdhilton
Posts: 758
Joined: Jan 2010

I as everyone here hopes and prays your your treatment goes well. The information provided is 100% verbiage from John Hopkins. I as most of us are well aware they want to sell you the complete report but if you have issues with what John Hopkins has published then attack them not me…Just reporting what is out there from credible medical institutions. I along with most medical professional would view John Hopkins information as credible…

Just because you do not agree does not make it any less credible…Folks are here to get facts pre and post surgery sorry if I have hit some nerves… Just becuase you are having the treatment does not make it a good fit for others...Peace

bdhilton
Posts: 758
Joined: Jan 2010

You respect John Hopkins but they do not know what they are talking about here? Are we getting things out of proportion? CyberKnife therapy may be an absolutely wonderful form of treatment for localized prostate cancer.

The CyberKnife® system was initially developed as a method to treat tumors in places like the brain that were inaccessible to physical surgery, and was originally approved by the FDA in 1992. Now it is being touted as “the next thing” in “radiosurgery” for prostate cancer.

In 2003 an article was published by King et al. that reviewed the theoretical potential of the CyberKnife in treatment of prostate cancer. And a Phase II clinical trial has been initiated to explore whether CyberKnife surgery really does have potential in the treatment of prostate cancer. The trial hopes to enroll nearly 300 patients and won’t report outcomes until some time in 2014. This is the sort of thing that can happen when large number of people start to present with a treatable condition: the numbers and types of treatment start to expand, sometimes exponentially.

Of course, because the CyberKnife is already approved, there is nothing to stop CyberKnife users from carrying out such “radiosurgery” today. And some centers clearly are. If you want to get an idea of the marketing that is already in place, have a look at this link (just as an example)http://sdckc.com/Prostate-Brochure.pdf . This morning in my mail I received an invitation to an “eSymposium” on CyberKnife use in the treatment of prostate cancer, in which one of the speakers is an employee of the manufacturer of the CyberKnife technology...hummmm

Here are some questions that need better answers than those offered below:

•Is CyberKnife as effective and as safe as other forms of therapy for the treatment of localized prostate cancer? Answer: We don’t know.
•What is the cost of CyberKnife treatment for localized prostate cancer? Answer: We don’t know, but the equipment alone costs around $4 million.
•Is the average health insurance carrier reimbursing for CyberKnife treatment of prostate cancer? And what about Medicare? Answer: We don’t know, but it would surprise us if they are.

Again, CyberKnife therapy may be an absolutely wonderful form of treatment for localized prostate cancer. But what we know at the moment is that:

•Many men who get actively treated for localized disease may not need treatment at all (especially some of the older ones).
•Most men who have treatment for early stage disease do well with available therapies.
•The available data on the short-term (let alone the long-term) outcomes of CyberKnife therapy for prostate cancer are minimal at best.
•There are only three papers on CyberKnife therapy for prostate cancer in the PubMed database (and not one of the three offers peer-reviewed clinical data)-This is prety critical....
•Several centers are actively promoting this form of therapy, despite the limited outcomes data available..

I am justing stating the facts

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Once again you seem to be off on one of yor CyberKnife tangents while twisting what I wrote. I said I had great respect for Johns Hopkins as an institurion but that the particular citation (an unamed doctor who was not referring to any studies or evidence and, incidently, could not be found on the link you posted) was nonsense by trying to tie the accuracy of CyberKnife to fiducial placement. As others have noted, using terminology similar to that used in brachytherapy is, in my opinion, misleading.

You can cite just about anything from any study to try to make a case but what's the point? You seem to have an agenda with CyberKnife. I don't know whether it's buyer's remorse on your own treatment or you just like poking bears in general, or you enjoy raining on someone else's party.

Posting an unreferenced opinion to a question by an unnamed doctor as "here's what we know" is absurd. Trying to use that as a basis for your general platform about CyberKnife is BS. As far as "just stating the facts" it's clear to me you have a penchant for twisting facts. Why don't you just state your opinion based on what (limited) information you know about the procedure at let it go at that.

And Bronx, I like most of what you say BUT WHAT IS WITH ALL THESE CAPS? It's hard to read and it's the internet equivilant of shouting.

Now I feel better.

BRONX52
Posts: 156
Joined: Apr 2010

SHOUTING--I think not. The point I was trying to make is that the treatment options are numerous and I believe that each treatment option has its pros and cons. I've had two major treatments (surgery and imrt)but I don't endorse either as being the best. It was the best option for me and only me. You seem to get yourself all worked up when cyberknife is questioned. My advice to you is to settle down and not take cyberknife posts so personally. We are all in the same cancer club and should support all who try to contribute in whatever way they can without retribution. Have a drink !! NOW I FEEL BETTER !!!

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

I've had the drink, thank you, and the next round is on me. I'm not all worked up on CyberKnife. It seems to have worked for me and for that I am very grateful and I always encourage men with similar pathologies to investigate it as one of several options that might work for them and to make the best decison for themselves based on their own situation and the advice of their medical team. I do object to a small group of people who tend to distort availabe information or present any so-called "facts" out of context. There is too much conflicting information out there already for newly diagnosed men to sort through and we don't need to stoke that fire. And my only objection to your previous posts was the use of all caps and thank you for toning it down. And here's a toast to you. I'll be in NYC next month for a week and if you are actually in the Bronx, I'd love to meet, buy you a glass of your favorite whatever, and we can commiserate about how life plays tricks on us.

Best,

BRONX52
Posts: 156
Joined: Apr 2010

Thanks the invite but although I grew up in the Bronx I have lived in Hawaii for the last 39 years. I still visit NYC every now and then to see relatives. If you ever happen to be in the islands let me know. I'll buy the rounds !!! As far as this particular thread is concerned, I think we've beaten it up enough. Time to move on.--take care ----DAN

bdhilton
Posts: 758
Joined: Jan 2010

All of us guys that have had treatmetn or are about to have tretment are all the same...I really wish you would just except facts as outlined instead of personal attacks on folks here reporting facts and specifically me…I was extremely factual on my posting of Cyberknife…I am sorry this hit a nerve with you.

As I said in my 1:59 PM comment today, “CyberKnife therapy may be an absolutely wonderful form of treatment for localized prostate cancer…” What I read from you is your endless “left handed” comments abut ED and incontinence with surgery is a bit much…You claim that since 2004 the FDA approved cyberknife specifically for prostate cancer therapy…this is misleading…

You state that since 2004, 4000 men have been treated by cyberknife…Ok, 250,000 men a year are diagnosed with PCa and are treated so since 2004, 1,500,000 men have been diagnosed and treated for PCa and 4000 of them have selected Cyberknife…I could be wrong but from my math that is .26% of the PCA population since 2004 have used this therapy plus the medical community has stated that there will not be any reliable long term data until 2014…

I am beginning to think you work for this cyberknife outfit in San Diego… I have nothing more to say on this subject and will not commnet on this string again except that I wish everyone the best in what every therapy they choose for their treatment…

Peace

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Perhaps it was a date problem of the PubMed database "fact" that is causing the problem here but there are 323 papers in the PubMed database today using "Cyberknife" as a search term. Narrowing the search to "cyberknife prostate" yields 23 papers, not the 3 you say are "just the facts."

"Davinci", on the other hand, gets 148 hits.

And BTW BD, I didn't get my CyberKnife treatment in San Diego. If you're going to suggest I'm involved in something like being a paid shill for a treatment center, at least get the facts right about who is supposedly paying me off.

bdhilton
Posts: 758
Joined: Jan 2010

Please stop attacking me. You have yet to answer any question with facts, You continue to “spin”. 100% of what you “paste “and claim to be fact is directly from the CyberKnife website. What 23 medical institutions have done studies on Cyberknife?

According to your numbers, Cyberknife has done .26% of the treatments since 2004 (the 4000 number comes from you). .Your past posting claim you are from San Diego and in your past post stated you had your treatments in San Diego and now you are denying this? Who are you? ..

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

BD, I never said anything about 23 institutions. I said, in reference to your earlier post that only 3 papers about Cyberknife and prostate cancer where in the PubMed database, that today the search yields 23 papers. Fell free to go to pubmed.gov and enter the search terms yourself.

Not sure why you have your shoe stuck on gum about the percentage of people getting CyberKnife treatment or what that statistic is supposed to mean. Didn't your mother ever tell you that just because everyone else is jumping off a cliff it doesn't mean you have to follow suit? More and more men are choosing this treatment for a lot of reasons but I would be very surprised if it became the most common method of treating PCa. As we all know each case of prostate cancer in unique and it will always be a challenge to sort out which treatment is best for any one individual.

I had my treatment at CyberKnife of Southern California at Vista, not at a center in San Diego. Vista is a town about 40 miles north of San Diego. There is a center in San Diego and it is highly respected. I just didn't go there.

BD, I didn't attack you in this thread. I stated that I felt the argument in your original post that fiducial placement was somehow critically tied to the experuience of the surgeon placing the fiducials which made critical was nonsense, that the doctor was unnamed and that there was no study or other evidence cited. In other words, I rebutted the information you posted, not you.

If you go back and review the posting series on this thread I think you'll find you were the one that started attacking me and frankly, I was extremely offended by your aspersion that I am somehow working for some treatment center. I don't believe you actually beleived that and stating it in the forum was beyond mean spirited.

bdhilton
Posts: 758
Joined: Jan 2010

The information provided is 100% verbiage from John Hopkins. I as most of us are well aware they want to sell you the complete report but if you have issues with what John Hopkins has published then attack them not me…Just reporting what is out there from credible medical institutions. I along with most medical professional would view John Hopkins information as credible…

Just because you do not agree does not make it any less credible…Folks are here to get facts pre and post surgery sorry if I have hit some nerves… Peace

BRONX52
Posts: 156
Joined: Apr 2010

TOO MANY PEOPLE GET DEFENSIVE WHEN THEY SEE VARIOUS POSTS THAT MAY NOT SHED THE BEST LIGHT ON A TREATMENT THEY HAVE CHOSEN. SEEMS LIKE A TURF WAR. I LOOK AT IT LIKE THIS----I CAN DO MY OWN RESEARCH AND FIND DRAWBACKS ON EVERY KNOWN TREATMENT FOR PROSTATE CANCER. I CAN TALK TO HUNDREDS OF DOCTORS AND GET HUNDREDS OF DIFFERENT OPINIONS. BOTTOM LINE IS THAT THERE IS NO "BEST" TREATMENT OPTION FOR PC. ONE SIZE DOESN'T FIT ALL. I DON'T DISMISS ALL OF THE MEDICAL RESEARCH REPORTS I READ. I JUST PUT THEM IN A PILE WITH ALL OF THE REST OF THE REPORTS I HAVE READ. IT STILL COMES DOWN TO THE INDIVIDUAL TO CHOOSE WHAT IS THE MOST APPROPRIATE TREATMENT FOR HIS SITUATION WHETHER THAT BE SURGERY, RADIATION (ALL FORMS), HORMONE, CHEMO ETC;. AS FAR AS I'M CONCERNED THERE IS NO RIGHT OR WRONG, BEST OR WORST,TREATMENT FOR PC. THE BEST TREATMENT IS THE ONE THAT WORKS FOR YOU !!!

bdhilton
Posts: 758
Joined: Jan 2010

Amen…most of this PCa outcome is the “luck of the draw”… It is a beast and we all need to stay open minded and help all with what is best and from my perspective is providing facts not fiction on this site…

Peace

viperfred
Posts: 20
Joined: Jun 2010

Sorry post error

viperfred
Posts: 20
Joined: Jun 2010

Post error

viperfred
Posts: 20
Joined: Jun 2010

Prostate cancer outcome is luck of the draw for the uninformed consumer!

dbhilton is not well informed about the CyberKnife or advanced radio therapy. "His" facts are copied from a 2008 post http://prostatecancerinfolink.net/2008/07/28/cyberknife-robotic-radiosurgery-for-localized-prostate-cancer/

There is a lot of misinformation regarding the CyberKnife and other Modalities for treatment of localized prostate cancer. The economics opportunity from prostate cancer patients is a very large market. The leadership of ASTRO has also misrepresented the CyberKnife in print and digital media.

CMS and private insures’ have started to use a phrase ” Evidence Based Health Care” as their guide lines for coverage. There is one big problem there is no “Evidence” gathered in randomized trials with controls to support a scientific conclusion. There was a MEDCAC meeting April 21, 2010 at CMS headquarters in Baltimore, MD for the treatment of prostate cancer with all forms of Radio Therapy. On a scale of 1 (low) to 5; the “Evidence” for each modality was rated as a 1. No modality has “Evidence” of superiority. My impression from this meeting is that Medicine is as much art as science and there is a lot of room for improving studies.

“Evidence” for ever modality including robotic surgery takes years to develop.

Surgery has dominated this market for many years and still is a major modality. The surgeons get the first bite at the apple. They give us our biopsy results and say the good news is that they can remove our prostate cancer. Most of us are in shock with the diagnosis of PCa and jump at the opportunity to have it removed. What we are not told are the surgical risk which are extensive, the short term risk and long term risk of recurrence.

In the last 20 years radiation therapy and imaging have made dramatic advances. The result is lower risk of recurrence, no surgical, short term risk very low, long term risk will be available in the long term. However based on the 101 years, of knowledge, for radiation treatment of PCa, the long term risk of side effects are low.

The latest study by Dr. Alan Katz http://www.ncbi.nlm.nih.gov/pubmed/20122161 supports the finding from the Naples study, Don Fuller CyberKnife Centers of San Diego,
Dr. Alexander Gottschalk at UCSF, Dr. Jerome Spunberg, CyberKnife Center of Palm Beach and Dr. Clinton Medbery, III, St. Anthony Hospital Cyberknife Center Ok City, OK. These are the pioneers of CyberKnife treatment in the US currently treating PCa patients. The first PCa patient was treated with the CyberKnife in Dec. 2003 at Stanford in a clinical trial started by Dr. CR King. Dr. King was the visionary for treatment of PCa with the CyberKnife.

The first clinical trial at started at Stanford was closed when Dr. King moved to UCLA to head the radio therapy dept. of their new institute of urology. He published an update in 2008 and is working on a new update. Consider every technology has a learning curve, the CyberKnife results from that learning curve are no worse than any other option at the same post treatment time-line and better patient outcome during the learning curve for other modalities. I am one of the patients in Dr. King's clinical trial with zero side effects. PSA pre CK was 5.0 ng/mL, completed treatment 5-5-2008, 27 month PSA, Aug 5, 2010 is 0.034 ng/mL.

There are 1,000's of published studies for radio therapy. Radiation has been known to kill prostate cancer for a 101 years. Major advances have been made in the last 20 years (total dose of 60 Gy was typical). Imaging technology, Radiation sources (linear accelerators) have made major advancements in power, beam control and software to control treatment planning. Localized External Beam Radiation advanced from 2D-RT, 3D-RT, IMRT, Proton Therapy, IGRT-IMRT, CyberKnife/SBRT. Few studies follow patients over 5 to 8 years. The published data suggest that increasing the total dose improves cure. This is tricky as the increasing dose also results in collateral damage. Fixed beam Gantry system limit the dose per session/fraction/day to 1.8/Gy when treating prostate cancer. The number of sessions for IMRT is now up to 45 (9 weeks, 5 days a week) with a total of 78-86.4 Gy. The long term data is a good reference but of limited vale for todays therapy. It takes 10 years to provide 10 year data at which time the therapy is obsolete.

What is known:

1. The CyberKnife has very few side effects, confirmed local failure rates at 30 months median follow up are less than 1%.
1. Increased total dose improves cure rates for any radio therapy.
2. Increased (hypo fraction) dose per session/fraction increases cure and reduces total dose. Hypo fractionation is delivered by HDR Brachytherapy, the CyberKnife and at least one new clinical trial using the Novalis Tx.
3. Lowering the dose to critical structures reduces side effects. This continues to improve with improving imaging, planning and in the case of the CyberKnife prostate tracking during the treatment. IMRT and Proton therapy use CT scans before the session without automatic beam correction for prostate movement.
4. The three year cure rate has improved from 60-70% 20 years ago, to over 90% with the early detection and higher dose, and today's advanced therapies likely to have cure rates of 98-100%.

Look at studies for all therapies to be an informed consumer. Surgery is no longer the Golden Standard. A treatment center t a good option if they do not have a CyberKnife. Most treatment centers with a CyberKnife also have IMRT and many also offer Brachytherapy. Doctors make more money from IMRT as they get paid per session. 45 sessions is a nice paycheck. The CyberKnife treatment is 4 or 5 days. The total cost of treatment is lower with the CyberKnife than IMRT . Always follow the money when consulting with doctors to filter out their bias and self serving interest. It is reasonable for a doctor of a specific modality to emphasize the features of his speciality. It is not professional for a doctor to be critical of a modality that they do not have expertise and or have current data to validate their claims.

Be an informed consumer!

mrspjd
Posts: 693
Joined: Apr 2010

Kudos and many thanks to Viperfred and Kongo for setting the record straight and citing verifiable research facts and studies to refute the manipulated so-called "facts" & unsubstantiated info in the J-H article and subsequent comments posted by the CSN member who initiated this thread topic when posting the misleading article in the first place.

I'm all for a good debate and discussion based on verifiable facts, references, etc. I also believe in being a responsible poster when initiating a thread on this PCa forum and therefore, posting articles that cite verifiable names and medical/scientific studies with facts and stats & research that support the claims or findings being put forth. Just because an article or statement comes from a respected institution or organization, say, Johns-Hopkins or the American Cancer Society (as in "most men only need PSA testing after age 50"--hogwash!), it does not make it factually accurate. Not only were the so called "facts" of the J-H article unsubstantiated, incorrect and manipulated, the article did not even list the author's name, a further clue that no one from J-H wanted to claim responsibility for the original misguided incorrect info, and that the article's agenda was far more a marketing tool for J-H PCa treatments & newsletters, etc. than a responsible educational discussion of valid alternative treatments for early stage PCa.

Johns-Hopkins didn't post the article on CSN, a CSN member made the post. IMHO, if a CSN member is going to post a thread containing an article he/she believes has valuable credible important PCa info, please be responsible for that thread and be prepared to back it up with facts and references that can be verified. Don't confuse opinions and personal experiences with scientific fact. If you want to post info for discussion, that's great, but state that from the beginning by making your objective clear. When others cite credible & opposing info with real verifiable research and info, don't be defensive and hide behind the "don't attack the messenger, I'm just posting the article" argument (which by the way, is the exact argument the same thread poster used when I challenged another article they posted several months ago: http://csn.cancer.org/node/191271

If you can't stand the heat, either get out of the kitchen (as in "I have nothing more to say on this subject and will not comment on this again" or better yet, just admit you haven't done your homework!) or be responsible, ready to cite verifiable names & studies when you post an "article" thinly veiled as a fact.

Thanks again to Kongo and Viperfred for doing the in-depth research and articulating the info so well, and thereby, making this a valuable PCa discussion after all!
mrs pjd

steckley
Posts: 100
Joined: Aug 2009

I know I've posted links that I can not defend (such as the one to Dr. Muhall's ED lectures ... I couldn't defend what he was saying if my life depended on it). Do you really feel that a poster should be prepared to defend anything they post on this site with "real verifiable research and info"?

Most of us are posting to get information or to provide others with insights we have stumbled across. I feel that is what bdhilton was doing. I also feel Kongo was right in giving a rebutal to the "study" ... he was probably wrong for shooting the "messenger".

mrspjd
Posts: 693
Joined: Apr 2010

When CSN members (messengers) make irresponsible posts to support their obvious agenda, with info in the guise of a thinly veiled "factual" article that supports the posters biased point of view, then yes, I do expect some add'l info to verify the claims put forth. If the article is posted in the form of, say, "What do you think, let's discuss whether this info/article has merits," then, no, the verifiable facts will emerge in the discussion. In the case of Dr. Muhall, his name and research are easily googled, verified, etc. The J-H article had no author and even I recognized that many statements in the article were down-right incorrect and misleading. This poster has consistently used the "don't attack the messenger..." and claimed "personal attack" as an argument when confronted with verifiable studies and info that refute general PCa articles with a biased agenda. With all due respect, and as well-intentioned as this poster may be, this is a disservice to the readers seeking unbiased PCa info on this forum.

steckley
Posts: 100
Joined: Aug 2009

I agree with yes and I agree with no ... I do not agree that either bdhilton or Kongo have a "biased agenda". Why would they? Financial gain, bragging rights? I don't think so. I feel that both are presenting information they think is correct ... and I thank them both for there efforts, and passion, in presenting it.

PS. I'd still like to get information on the resolution of scanning devices ... can they see microscopic tumors? I have not been able to find any information on this subject.

hopeful and opt...
Posts: 1315
Joined: Apr 2009

I'm not sure if this is what you are looking for, but here are two different tests that may be applicable to your question.

There is a molecular test performed by a company Aureon, where they , I guess take samples from the sldes from your biopsy and look for aggressive tumors...they then mathematically compare it with other factors such as PSA, gleason, etc to approximately 1000 men who have had radical protectemy, and come up with the likelyhood of the the cancer progressing 8 years in the future.

But be cautioned on the following; there is a sensitivity of 74percent and a a specificity of 64prcent. What that means is tat among 100 bad tuors, for example, they only can identify 75 of them. And among 100 good tumors, they identify as bad in 36. to be honest this is notmuch different than achieved withjust your psa and gleason and percent tumor.

I believe that you can contact Aeuron www.aureon.com or 1-888-797-7284

-----------------
MRI

There is an MRI scan for prostate cancer that is done with a special coil in the rectum. This are certain major hospitals that have a Tesla magnet. There is a 1.5 Tesla magnet, the effective resolution is limited to tumors 0.5cc or larger. There is also a 3 Tesla machine which may have a bit finer resolution.

The most effective MRI for the prostate is called a MRSI (MRI/MRS) and includes the ability to identify cancer metabolites using spectographic analysis.....Basically using the spectoscopy with the MRI provides more accurate results, both the MRI and the spectroscopy are done at the same time.

The MRI is generally covered by insurance, however the spectroscopy is considered investigational and is not covered by medicare which I use.

The test indicates if there is any nodule involvement, if there is involvement in one or two lopes , wll show size of prostate, any evidence of extracapular extension, will stage your disease.

steckley
Posts: 100
Joined: Aug 2009

Hopeful,

Thank you for the information. Very helpful.

It would appear to me that based on these resolutions, a procedure that uses these scanning devices (and statistical methods)to target PCa tumors will miss small tumors.

hopeful and opt...
Posts: 1315
Joined: Apr 2009

the test that Aureon does is on a molecular level, and analyzes tumors, both good and bad, however in my opinion the test needs to be improved for accuracy......I believe that we will probably see other companies doing this type test, that will produce better results in the near future...... This test does add so one can better predict progression in the future.

The MRI Tesla machine does find very small tumors, but not on a molecular level. The Tesla machines , as I understand are the state of the art. The spectroscopy improves the results of the MRI.

For my active surveillance program, I first get an MRI, no spectroscopy, using a Tesla machine, then a targeted biopsy using a state of the art three dimensional machine that is able to target these lesions found in the MRI to see if they are cancerous......

steckley
Posts: 100
Joined: Aug 2009

Hopeful,

Thank you for the information on your AS testng protocol. I was not aware of what AS patients did for screening ... I assumed they just did repeat biopsies. Nice to know the biopsies can be targeted.

I find the rapid inprovements in technolgy astounding. Twenty years ago, who would have dreamed that you could remotely resolve images as small as what can be seen today. Amazing.

I'm guessing that in the not so distant future we'll be able to wave a flashing light (think Star Trek and Dr. McCoy) over someones abdomen and make a diagnosis.

Thanks.

hopeful and opt...
Posts: 1315
Joined: Apr 2009

...this is new.........only a few institutions have this capability....I am enrolled in a study ......I have to go thru extra stuff to include , but not limited to an MRI before getting the biopsy...........this whole thing is a pain in the ass( an in joke ).

Also, many doing active surveillance do not have repeat biopsies , but instead do other less invasive things to monitor how they are doing.

Ira

bdhilton
Posts: 758
Joined: Jan 2010

Viberfred,
Personal attacks on me are not going to make Cyberknife any better or worse. I am very informed about the CyberKnife and unlike some folks here I keep an open mind. I asked the gentlemen pushing Cyberknife some basic questions and instead of just providing answers I get attacked? Humm….
Yes I copy and paste many things to inform pre and post PCa guys. Why is this issue because I do not post what you want to hear? Sorry I do not understand your point…
I keep saying that “CyberKnife therapy may be an absolutely wonderful form of treatment for localized prostate cancer…” and I say that about every treatment you believe will work for you as I am not hear to push an agenda that a few people are so clearly attempting to do if it is as innocent as they just want to believe that their treatment is the best for everyone or as sinister as pushing this treatment for monetary gains.
Ok since 2004, 4000 men have been treated by cyberknife…Ok, 250,000 men a year are diagnosed with PCa and are treated so since 2004, 1,500,000 men have been diagnosed and treated for PCa and 4000 of them have selected Cyberknife…I could be wrong but from my math that is .26% of the PCA population since 2004 have used this therapy plus the medical community has stated that there will not be any reliable long term data until 2014…
Your “What is known” list is not scientific or factual in the less. Sorry but I am not going to “stick my head” in the sand and pretend that Cyberknife is magically and wonderful as you are stating without facts …I believe that it is a treatment option for PCa and I would personally look closely at it if I was having radiation as a first line treatment…
We are here to help each other and I as others do not like the fact that some folks come in here with agendas…
Best to all and have a great weekend-Peace

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Fred,

Great job in uncovering the link which had been copied verbatim and pasted in this thread without citation, making it appear to be original thoughts on the matter when in fact it was someone named “Sitemaster” posted on a web site for a “not for profit” company out of Virginia that blatantly advertises its medical director’s very much for profit Krongrad Institute in Florida. In other words, the post came from a site which has as one of its main purposes the promotion robotic surgery at a profit.

Pretty clear to me what the agenda there is all about. Whether the poster realized that or not is a whole other matter but I prefer to think he was just taken in like so many of us are when we search the internet for answers to questions about prostate cancer.

Another reason, in my opinion, that we should cite our sources where it makes sense so that others can look at the purported "facts" in the original context and clearly indicate opinions as opinions and not try to pass them off under some sort of medical "gold standard" mumbo jumbo.

bdhilton
Posts: 758
Joined: Jan 2010

thanks

mrspjd
Posts: 693
Joined: Apr 2010

but--get over it! IMHO, as a woman...stop beating your chest and get off your soap box! OK, now I feel better.

BRONX52
Posts: 156
Joined: Apr 2010

This website provides valuable information for those seeking help to deal with their prostate cancer issues. This particular thread has created quite a stir among many members and has come down to a turf war. To continue to argue about one treatment or another, citing studies, demanding verification of facts and the personal attacks is really demoralizing. I realize that both sides in this issue feel they have a right to state the facts. Some can be verified while others cannot. The tone of this discussion, in my opinion, has taken a turn for the worst. Others viewing this thread won't be able to see the valuable information provided because of the constant bickering and name calling. It certainly has turned me off. I think I need a break from this website!!!

bdhilton
Posts: 758
Joined: Jan 2010

I have read your postings for months with "reserve"... I am dropping this discussion with you as you have yet to provide any facts outside that you post 100% from the Cyberknife web sites and you just attack me with nonsense...I believe we are all smarter than that here…

Again, the purpose of this site is to inform and support folk’s pre and post treatment and you seem incapable of this without your “cyberknife” spin. You let everyone know how “important” you are (that raises red flags) so my latest question is where do you find so much time to post...I find this most interesting...I am going to go enjoy my weekend… I hope you do the same...

viperfred
Posts: 20
Joined: Jun 2010

Hi dbhiltion,

The link to Dr A. Katz study is provide in my post above. It has citations if you are interested. Do a search for Christopher R. King CyberKnife 2003. This publication cites the background supporting the CyberKnife for PCa.

I am happy to provide evidence to support all my statements. Please be specific so the proper publications can be provided.

Mis-representation of fact is done by those who are mis-informed or have a specfic agenda.

My agenda is for men to make an informed choice.

Swingshiftworker
Posts: 634
Joined: Mar 2010

Gone for just a day and things have really heated up here. I haven't read such an "interesting" tread for months! :)

FWIW, I agree w/mrspjd and I still agree w/Kongo and ViperFred. I also don't see how anything Kongo or Viper have said can be interpreted as a "personal attack" on BD but I'm glad (if it's true) that BD is dropping the matter, because tit-for-tat rebuttals (such as we've seen in this thread) never seem to add anything of value to the discussion of the topic at hand -- be it CyberKnife or anything else.

It's usually just guys having a pissing contest and the only thing that happens in that case is that your shoes or feet get wet and smelly. So, enough already. ;)

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