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IGRT with enlarged prostate ?

carnut
Posts: 5
Joined: Jan 2012

Diagnosed with low grade 3+3=6 one sample of 12. PSA 4.2. Prostate size is 48.2 gr. I've researched and met with my urologist who would do the robotic surgery if I choose that and also with the radiologist he recommended. My urologist/surgeon said he thought I may have less side effects with IGRT but also said the problems I have now would continue or get worse. The radiologist basically said the same except he thinks they will get worse but should return back within 6 weeks after ending treatments. Both have stated that cure is pretty much the same with either treatment. I was leaning toward radiation but have some real concerns about future side effects since I have large prostate. I'm already on uroxatral and have minimal problems at times. Usually getting going some mornings or if I've sit/driving for long period. Anyone done the 44 treatments have any comments on sides effects short and long term?

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

carnut,

You pose some interesting questions, namely how do you (or should you?) treat your low grade Gleason 6 prostate cancer while dealing with the symptoms of an enlarged prostate?

In your case almost every potential course of action, even active surveillance, leaves you looking forward to a reduced quality of life; either from the potential side effects of treatment or the ongoing effects of BPH.

One thing you haven't mentioned is what the doctors might recommend to reduce the size of your prostate. As men age the prostate enlarges naturally through the growth of non cancerous fibers that tend to push in toward the center of the prostate. Given the physical location of the prostate in the skeletal frame associated with your hip, the expanding size of the prostate tends to compress the urethra which causes the symptoms of difficulty in voiding and not being able to completely empty your bladder.

One thing you might consider before deciding on a treatment for your PCa is a TURP where this excess fibrous material associated with BPH is removed, reducing the size of your prostate and the squeezing of the urethra. Have you discussed this with your medical team or sought a second opinion?

While radiation (IGRT is one of many types of radiation that would likely be very effective if you choose treatment) is an excellent way to treat low risk prostate cancer it will not do anything to relieve the difficulties you have with a large prostate. While surgery will surely eliminate the prostate problem, your doctors will explain to you the likely side effects of incontinence and sexual dysfunction which may be a worse condition in your quality of life priorities than what you are experience now.

Radiation typically has very few side effects in the near term in terms of incontinence or sexual function. In some cases, men who have had certain types of radiation have seen increasing difficulties in achieving and maintaining an erection several years after treatment due to damage to the nerves surrounding the prostate that are essential to getting an erection. Drugs like Viagra and Cialis are effective in treating this condition and in any event, many men find that the natural process of aging alone contributes to a decrease in sexual potency and use these drugs to enhance their sexual performance.

In my own case, I too was diagnosed with 1 of 12 biopsy cores positive and had a PSA of 4.2 at age 59. Gleason 3+3=6 and a normal sized prostate for someone my age (which is larger than say a 30-year old)at 42cc. I ended up choosing CyberKnife radiation and have had absolutely no side effects in the 18 months since treatment. CyberKnife is four or five treatments that is typically concluded in a week.

If I were in your shoes, I would address the BPH issues first and then make a decision about whether or not you even need to treat your prostate cancer since it is such a low threat. Most of the PSA you are exhibing is caused by the BPH (it is squeezing the PSA out of the glandular cells) and not by the cancer.

Good luck to you.

K

carnut
Posts: 5
Joined: Jan 2012

Kongo,
Thanks for your response. I think my symptoms have been so minor that treatment would probably be worse than benefits. Neither of the docs I have met suggested any pretreatment for enlargement was needed. I'm really leaning toward the IGRT but beginning to have a few concerns about BPH during and after the treatments. My urologist who would also do the surgery, which he does like doing, suggested the EBRT and sent me this specific radiologist. He actually told me that he thought I would have less SE with the radiation vs surgery. However when I called him and questioned about the BPH issue he said it could, probably would, would, maybe not, get worse and same for returning back to where I am now before the treatments. He really danced all around the question and I understand since no one can predict the out come of these procedures. The radiologist said it may cause some issues but he would treat with medications and 4-6 weeks after treatments end I should be back to what I was prior to treatments. He didn't mention much about SE 2-3 years down the road. Just said that they are able now with gold markers and better equipment do a better job of controlling the radiation spread. Said lots of the severe SE you hear about with EBRT is from salvage or treatments when the cancer is out of the gland. I've considered active surveillance but at my age and health both my doctors say they would consider any treatment over waiting.
They did say they would assist and support any decision I make.

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

carnut,

It sounds like you have a great support team. Urologists as surgeons always like to cut. I've read that 90% of urologists recommend surgery for even low risk prostate cancer. Of course radiologists like to put you in the microwave.

From my personal experience and from what I have read, the side effects from radiation consist of an increased urgency to urinate. This is caused by the inflammation in the prostate which causes some minor swelling caused by the radiation. There are drugs like Flomax that address this very well but keep in mind there are some ill effects to these drugs as well. I felt some minor urgency on the last day of my five treatments and treated it with Advil and had no more issues. I had a prescription for Flomax but never used it. While urgency seems to be the most common side effect, only about 20 percent of the men receiving radiation experience it and as your doctor suggested, it tends to pass within a few weeks when the prostate settles down.

I had the gold fiducials implanted for my CyberKnife treatment. They allow for tracking the movement of the prostate during radiation. A CyberKnife session lasts about 45 minutes and the prostate can move about quite a bit, actually, so they do real time tracking and the computer adjusts the robot arm delivering the radiation to compensate. If the prostate moves outside the limits the machine actually shuts down until the prostate moves back on target. Prostate movement is caused by breathing, goas movement in the colon, and pressure from the bladder. In IGRT the sessions are much shorter and they adjust the machine before radiation using the fiducials and real time x-rays then basically hope the prostate doesn't move too much during the short time you are getting zapped. While CyberKnife is more accurate, I don't really think the small amount of spillage you might get with the IGRT system makes much difference except that men who have radiation from systems that are not real time tracking tend to have higher rates of urgency, at least according to my radiologist who obviously is biased toward his equipment. You may want to ask your doctors about the details of how they track and develop the radiation patterns. I personally found it quite fascinating.

Modern radiation such as IMRT or SBRT (IGRT is a form of IMRT--CyberKnife is a form of SBRT) are pretty much without serious side effects.

Frankly, if you can live with your BPH now then you can probably live with it following radiation treatment. I think it's improbable that the prostate would continue to expand from the fibrous BPH cells after radiation but that's another question I would ask about. If the BPH is not going to get any worse, the odds are overwhelmingly in your favor that your quality of life will not deterioragte significantly after radiation.

I don't know how old you are but if you are a young man and think that you may ever want to have children after treatment, be sure to bank some sperm in advance.

K

VascodaGama's picture
VascodaGama
Posts: 1528
Joined: Nov 2010

Carnut

I would be careful with their “...assistance and support in any decision you make”.
Just as Kongo comments those doctors like their “trades” and their assistance may fall short of yours expectations if you decide other than “cutting” or “microwaving”.

I would suggest you to get second opinions from a medical oncologist recommended from other sources, before deciding.

The best to you.
VG

carnut
Posts: 5
Joined: Jan 2012

My daughter is a RN, director of patient services at hospital in another state and she gave my reports to the urologist and radiologist there and their recommendations where surgery and radiation respectfully. Go figure. At least they are all consistence.

Kongo, At my age,62, I'm past the fathering children part. Had a vasectomy 30 years ago also. My urologist did tell me when we were talking the the prostate should not continue to get any larger after radiation.
If i may ask, what are your thoughts on treatment if in the unlikely event you have a recurrence. I ask the radiologist this and he said that usually if that happens that it would be 7-10 years down the road and it should be the same type cancer I have now. Considering that it should be a slow growing non aggressive as it is now we would consider my health and age and probably not do anything. I always thought that if the cancer returned after radiation it would be more aggressive. He said this is not the case. He also said that if a treatment was needed that cyro would be a possibility. Also hopefully in the next several years new treatments will be developed for radiated patients.

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Kongo
Posts: 1167
Joined: Mar 2010

carnut,

Some men subscribe to the argument put forth by many urological surgeons that it is better to do surgery because if it fails you can always do radiation where if you do radiation first surgery is not an option. My personal opinion is that this argument is faulty on a couple of significant points.

First, if you have recurrence to either surgical or radiation treatment of what was considered "localized" prostate cancer then what you are really looking at is cancer that has metastasized beyond the prostate. Retreating the prostate by any method is not going to curb the spread of cancer outside the gland where prostate cancer tends to grow faster than inside the prostate. So it's really just an academic argument. When men who have had their prostate removed see a rise in their PSA it is because the cancer had spread to surrounding tissue or seminal vesicules or lymph nodes (fairly rare) or other distant organs. The follow-on treatment is to radiate the prostate bed where the most likely migration point is and hope for the best. Often this is a stop gap measure as it has probably gone beyond the prostate bed. With modern radiation techniques such as IGRT or SBRT the entire prostate is radiated. It's unlikely that anything there is coming back and when there is a rise in PSA it is almost always because the cancer had spread before the treatment.

There are some rare times that I have read about where a man who has had radiation as a monotherapy for localized prostate cancer sees a rise in PSA and a rebiopsy of the prostate reveals another tumor. In those cases I think focal cyrotherapy, as you mentioned, might be work. Other options could be HIFU or another round of radiation. It is possible to remove the prostate at this point but the surgery is more difficult because of scarring caused by radiation. There are surgeons who specialize in this technique so don't believe the argument some urologists use that it is impossible to do this procedure. It's simply not true.

The overwhelming majority of men who see a progression of their cancer beyond initial treatment are dealing with metatastic cancer which if left untreated will eventually kill them if something else doesn't get them first. Hormone therapy is probably what I would look out if I were to see a recurrence that could not be associated with the prostate. Hormone therapy and other techniques essentially kick the can down the road long enough so that you end up expiring of something other than prostate cancer. Since we have such a slow growing disease we are fortunate among other sufferers of cancer in that we die with our disease rather than from it. The number one cause of death for men with prostate cancer is heart disease.

Don't mean to sound pessimistic here, just trying to be realistic. True cures with prostate or any other cancer are elusive. You are fortunate to have discovered your cancer very early with many excellent treatment options that all have roughly the same effectiveness. The devil is in the side effects. I would make a decision choice not on what Plan B should be if Plan A doesn't work but on what is the best choice overall to treat my cancer with the least side effects.

In another post you indicated your urologist (the surgeon?) was nervous about being on AS for three months and you needed to decide something. Perhaps I was reading it wrong but that's BS. You should expect to be on AS for years and years not a few months and your low Gleason score, low PSA history, make you an excellent candidate for this. I suggest you consult with an oncologist who specializes in AS and get a second opinion. I would also commend the book "Invasion of the Prostate Snatchers" to you. Available at Amazon.

Good luck with your decisons.

Beau2
Posts: 232
Joined: Sep 2010

Hey Carnut,

I had an enlarged prostate (70 gram)and PCa. One treatment option I had was brachytherapy. In order to do the brachy the doctor would have had to try to reduce the size of the prostate with Hormone Therapy. Maybe you could do the HT before IGRT?

I finally chose surgery and one of the benefits I had was better urinary function (the enlarged prosate had me going several times during the night and very slowly when I did go).

With your numbers, have you considered Active Survelience?

carnut
Posts: 5
Joined: Jan 2012

Have considered AS but my urogolist tells me his is little nervous for me doing that. Since I've taken so long deciding on a treatment I am basically already AS. The 26th this month will be 3 months since the biopsy so I may do another psa and see what it's doing before I go with a treatment plan.if my numbers are correct I don't think I'm taking too much risk.

JBStuart
Posts: 3
Joined: Aug 2011

I'm 55, dx in early 2011. My stats were almost identical to yours, with the exception of my prostate being an enlarged 58 gr. After the usual opinions and mind gymnastics, I chose radiation and went through 45 courses of IMRT/IGRT, finishing toward the end of August 2011. No ED problems at all, no fatigue and only a couple days of minor bowel issues I'm not even sure were related to the radiation.

I did have some pretty annoying urinary side effects (burning, urgency, hesitancy, etc.) that developed a few weeks into the treatment, but my Oncologist prescribed Flomax, which took the edge off, making them fairly easy to tolerate. Side effects were gone within 6 weeks after treatment. I chose to stay on a smaller dose of Flomax and my plumbing's working better than it has in 10 years.

As far as side effects down the road, who knows? It's all a big waiting game. I don't know if I dodged a bullet or if more side effects will develop later, but for now my PSA is going down and I'm happy with the choice I made.

Good luck!

carnut
Posts: 5
Joined: Jan 2012

I take it you were not on any drugs for the enlarged prostate prior to your treatment. I think my biggest fear with the radiation is that since I'm already taking uroxatral for the symptoms I have now other medications may not help with the radiation effects.

davidp46
Posts: 11
Joined: Mar 2011

carnut,

FWIW, I just finished (42 sessions/fractions) of IGRT/IMRT at Cancer Therapy & Research Center (UT Medicine, San Antonio). Your case seems similar to mine. I was diagnosed last year 2/14/11 with PCa on my 4th biopsy (1st 3 were negative). I went to UTSAHSC on referral from my local uro who couldn't find the cancer. PSA was 60.5 when I went to UT to get a prostate MRI to "pinpoint" the cancer. They found it with a saturation biopsy (35 cores, 20 fragments) with several core groups of Gleason 8:4+4. Did a bone scan and CT to see about mets but nothing certain found. My big problem turned out to be the enlarged prostate (100gm/cc +).
Tentative stage was 2b.

Given that I was classified as "High Risk" (PSA > 20, GS > 7) surgery was not even discussed. In part due to the enlarged prostate, I went on Lupron 30mg on 3/21/11 to both contain/control the PCa and to shrink the prostate in preparation for IMRT. I did the IMRT simulation in mid June with expectation to start RT in early July. The problem was that the prostate was still "too big" and they could not make a plan that would not result in collateral damage to the rectum and bladder. The plan then became to stay on the Lupron and expect the prostate to shrink enough that the IMRT machine could get clear shots at the specified targets without zapping the "good guys" [bladder and rectum, etc].

We started to try IMRT again in late October. Got a CT done to estimate prostate size and it looked viable. Did the Simulation (to build a new RT plan given my body parts at the time) and it looked OK (i.e. doable!) Went back in for the Verification (double check the plan and train me in the daily procedure) and that was OK. My plan called for 78Gy of radiation in 42 fractions of 186 cGy per daily treament (on average). I finished the course of treatments on 2/1/12. Overall, I am very glad I was able to do it. I'll stay on the Lupron (tentatively) for another year.

I can tell you that I had *HUGE* doubts about IGRT/IMRT. I contacted MD Anderson to see if they would take me in their Proton Therapy program; however, my dx (high risk PCa) and my faithful 100g/cc prostate disqualified for PBT, so IGRT/IMRT was the only available first-line option for me.

My experience thus far has been OK. Some standard short-term side effects (very similar to BPH). I'm optimistic about avoiding any long-term side effects. Most of the guys going through the program with me seemed to be having similar experiences. I "love" the machine in San Antonio. It is a Novalis Tx device. There are several web sites about the Varian ARC devices which should make you very positive about how much these machines can do for people in our condition.

if you have any questions, email me at davidp886@gmail.com

Note that there things you can do (diet, supplements) to mitigate the RT experience if you choose that route.

Take care.

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