Cyberknife After RP and SRT

mrspjd said:

Chernobyl...LOL...
But Japan sounds best. Glad all went well. FYI, my husband was on ADT3 including Lupron & Casodex, had no major problems and tolerated the drugs well.

I look forward to your updates and reports of good news and success! Re Medical Tourism (the new meaning), perhaps PCa patients can get a group discount

Chernobyl in “medical tourism”

Jane

I am sincerely sorry for what is developing in Tim’s case. Maybe we should joke with the medical tourism, as you posted for at least “stress relief”, but I can imagine how worried you both may be.

Tim’s chronology of PSAs post SRT confirmed the failure of the treatment and I really hope for the arrest of the metastases with the intervention with HT and focus RT.

I would like to suggest you to investigate on the so called oligometastases mentioned by Mrs PJD above. Dr. Myers is a strong believer on the theory that cancer firstly passes through this status with fewer metastases (oligo-phase) before it becomes systemic. He believes that patients in this status still got chances of CURE by radiating those spots.

The resent discussed Ultra Small Superparamagnetic Iron Oxide (USPIO) MRI test with Feraheme is adviced for patients in similar status because it successfully can distinguish metastatic from non-metastatic lymph nodes. This is the substitute of the defunt Combidex MRI test done in Nederland in the past successfully.
Dr. Myers has been working with Dr Bravo at Sand Lake Imaging Center on the USPIO test and promised to reveal his findings on the matter soon. Some patients have reported successful testing and tyreatment.
Other newer scans with sensitive contrast agents (F18 and C11) are in practice too and have been successful in identifying smaller metastases in bone which additionates to possibilities in locating the “oligo-cancer”.

Dr. Myers has been recommending radiation of the lymph nodes in the iliac in combination with ADT3 (total hormonal blockade). His case was identically treated and rendered his present status of “Cancer Free”.

You can listen to his video at the site indicated by Mrs PJD above. The origins for this clinical oligometastatic disease (as it is called) comes from an hypothesis idealized by Hellman and Weichselbaum in 1995, which refers to a stage when a patient with a few number of detectable metastatic tumours/lesions, is considered to be in the transitional state between localized and systemic.
This notion it is now adapted by many doctors in other sort of cancers. Dr. Myers has been following his patients for this oligometastatic cancer and has commented about the matter in his Newsletters and at his last speech in the PCRI Conference.

You can read about the theory in these sites;

http://aboutcancer.com/oligomets_milano_0108.htm
http://jjco.oxfordjournals.org/content/early/2010/01/04/jjco.hyp167.full.pdf
http://www.nature.com/nrclinonc/journal/v8/n6/full/nrclinonc.2011.44.html

I hope you both find a practical way to follow and that things become better to Tim.

Wishing you the best.

VGama

janekirstine said:

Great Dr. Meyers' Videos
Tim and I are doing wonderful and have a very positive outlook. The goal is always going for the “CURE” and praying that it is attainable. We will confirm tomorrow that it was a Sodium Fluoride F18 scan that identified the sacral tumor which was targeted with CK. We will meet with our medical oncologist mid December and will surely discuss other diagnostic scans that would be beneficial to us (C-11 chlorine and/or USPIO). I watched all the Dr. Myers’ video reference oligometastatic disease and again will discuss this with our doctor. We, too, would travel across the country to get the best care that is needed and have frequently talked of doing so if we were not satisfied with the care we are currently receiving (or for multiple opinions). Ironically, we lived in Virginia for 8 years. But we will probably go to Calilfornia as there is family there. Florida not out of the question either if USPIO necessary.

We hope for arrest of the metastases with the HT and the focus radiation on the sacrum. PSA already down to 0.37. Praying for another fall this month. Strict diet is working on Tim – I have been a vegetarian since I was 18 years old so it has been an easy transition for him. Also taking the supplements Dr. Meyers recommends.

Has anyone gone to Florida for the USIPO MRI?

Thank you for the kind thoughts and wishing you all the best. J

Brilliant discussion, Thanks
Thank you janekirstine for starting and stimulating this brilliant discussion. The education I am getting as I approach my first Cyberknife treatment for contained TC1 prostate cancer is remarkable and calming.
I will pray also tonight for you and your husband, Tim, just as an additional treatment plan for your ongoing battle.
Wayne

randy_in_indy said:

Education on here is endless
That's the great thing about this site...there are many who have traveled the path and done mountains of research..you all know who you are....thanks to them many have better informed... or worse case have the tools to ask the right questions to help find a path for their situation that they can trust and believe in...CSN is an invaluable service...invaluable.

Randy in indy

Thoughts, etc.
I thought some overall clarifications would be worthwhile. Re SBRT: doctors & patients sometimes refer to SBRT (Stereotactic Body Radiation Therapy) medical equipment/systems by their brand names, such as Varian’s RapidArc® Novalis Tx™ or Accuray’s well-marketed CyberKnife®. To date and to the best of this writer’s knowledge, there have been no comparative clinical trials or evidence finding that one brand of SBRT delivery equipment has any significant tx benefit, outcome, or technology advantage over another brand. This is especially true when attention is given to accurate clinical PCa staging and when the expertise & skill of the radiation teams are equally superior, including the radiation oncologist, the dosimetrist/physicist, the SBRT technician, and use of up to date modern RT delivery systems. I have no vested interest in one brand of SBRT vs another and, to avoid any bias or show of favoritism, SBRT will be the preferred term used in this post rather than a brand name, whenever possible.

SBRT is one form of hypofractionated RT. High Dose Rate Brachytherapy (HDRB) is another form of hypofractionated RT and is one of three neo-adjuvant primary txs that my husband, PJD, elected for aggressive tx of his T3 stage, locally advanced high volume PCa. HDRB is different from, but often confused with or lumped together with, LDR Brachytherapy aka “permanent seeds.” Hypofractionated RT, such as SBRT and HDRB, is generally defined as a radiation treatment that is divided into fewer individual sessions but with correspondingly higher doses of radiation.

Re studies: On our own PCa journey, and in general, I believe there is much value to be gained from reviewing clinical studies/papers and research findings; however, the data must be interpreted within the context of the study parameters if the research findings and conclusions are to provide meaningful & significant information, individually and/or comparatively. To relegate the value of clinical studies/findings to a mere “bunch of papers,” as another here has described, is nonsense. Certainly, when analyzing and interpreting clinical study data & research findings, there are many, many factors that must be considered. Some factors are apparent, others not so apparent, but all factors and any variables must be critically evaluated--not the least of which is whether any conflicts of interest exist between the study investigators/authors and the company whose medical product (equipment, pharmaceutical drug, etc.) is being studied; or whether a study, a paper, or its author/investigator was funded partially or fully by the company whose product is being investigated/evaluated. Some studies are double blinded and/or have control groups for these and other research purposes. Clinical trials and investigators’ evaluations must be independent, impartial and unbiased, with no ties to the product being evaluated or its company, if the integrity of the investigator and the study findings/conclusions are to be maintained. Standards and ethics are dictated and must be followed.

In an entry titled “Response,” the poster references Dr. Katz’s published paper on 5 year CK results, i.e.: “Dr. Katz, who recently published a paper about his 5 year CK results…” Perhaps the poster is confused as he has made the same error previously http://csn.cancer.org/node/224205#comment-111807. To date, Dr. Katz does not have a published paper or a study reporting on his 5 year CK results. Katz does have a published STUDY titled “Stereotactic body radiotherapy for organ-confined prostate cancer” http://www.ncbi.nlm.nih.gov/pubmed/20122161. In his study, Katz reports on the results of men with clinically dx’d organ confined PCa, who were treated with SBRT, using a median follow up of 30 mos and 17 mos, NOT 5 YEARS. Dr. Katz’s published summary PAPER (different from his STUDY) titled “CyberKnife Radiosurgery for Prostate Cancer,” is an informative summary and compilation of many different studies and study authors pertaining to hypofractionated therapies such as HDRB, SBRT, SBRT/CK, in combination with, and without, neo-adjuvant IMRT, and so on. It’s worth noting that under the “Conflicts of Interest” section of Dr. Katz’s summary paper, disclosure is made that Katz received speaker’s honoraria from Accuray, Inc, the manufacturer of CyberKnife.

Dr. Christopher King, not Katz, has published a 5 year STUDY titled “Stereotactic Body Radiotherapy for Low-Risk Prostate Cancer: Five-Year Outcomes.” (King & Katz=easily konfused names?) The study authors, Drs. C. King & D. Freeman, reported on a total of 41 patients with organ confined low/moderate risk PCa tx’d with the CK brand of SBRT. While the study results are considered impressive by some, the comment is often heard that the study participants would have had equally impressive results with a mono tx protocol of Active Surveillance/Monitoring for low risk PCa. BTW, according to Accuray’s website, Dr. Debra Freeman, who is one of the study authors, is listed as--drum roll please--Accuray’s senior manager of clinical development for CyberKnife.

Re opinions: Recently, I was given undue credit for some “theory.” While I appreciate the accolades, perhaps the poster is either mistaken or confused again because I honestly don’t have any “theory.” I don’t even have an hypothesis! In a previous opinion statement, I commented: “For higher risk tumors or where disease beyond the tumor or gland may be likely, tx of less Gy spread over a longer length of time with A HIGHER TOTAL GY MAY BE SUPERIOR TO A TX consisting of less fractions over several days at higher dosing, convenience factor or not, WHERE TOTAL GY IS LESS.” While biologic equivalent dose (BED) between IMRT and forms of hypofractionated RT (HDRB, SBRT) may be comparable, my comment simply implies that a higher total Gy dosing is associated with superior long term tumor control. (Higher dosing is also attainable with neo-adjuvant RT tx’s such as HDRB or SBRT in conjunction with IMRT. Delivered using this protocol for higher risk PCa tumors, hypofractionated RT is sometimes referred to as a RT “boost.”) The concept of higher total Gy dosing is supported by research studies, such as Zelefsky’s study cited below, indicating that higher IMRT dosing is well tolerated, safe and associated with excellent long term tumor control: “Ten Year High Dose IMRT Study Sloan-Kettering” http://www.ncbi.nlm.nih.gov/pubmed/21061333 Conclusion: To the authors' knowledge, this report represents the longest followed cohort of patients who received high-dose radiation levels of 81 Gy using IMRT for localized prostate cancer. The findings indicated that high-dose IMRT is well tolerated and is associated with excellent long-term tumor-control outcomes in patients with localized prostate cancer.

In a previous post, along with the caveat that I am not an expert on the matter (& far from it on other PCa matters also, just like all posters on this CSN site), I shared thoughts about treating an isolated PCa bone met with IMRT vs SBRT. While my choice of wording may not have been the best, if it was confusing for some, then please forgive me. My background is in the humanities, not science. Based upon definitions of radiation therapy for cancer from the respected National Cancer Institute (NCI) http://www.cancer.gov/, my intention was to refer to the fact that, with IMRT a larger volume of tissue overall can be treated and exposed to radiation. The goal of IMRT is to increase the radiation dose to the areas that need it and reduce radiation exposure to specific sensitive areas of surrounding normal tissue. IG/IMRT has a 10+ yr history of proven safe and adequate levels of Gy dosing protocols for the tx of PCa with good rates of long term PCa tumor control, especially with regard to treating higher risk PCa tumors. Focal radiation therapies such as SBRT or SRS use smaller radiation fields and deliver high doses of radiation in fewer sessions or in a single session, respectively, for the tx of smaller and/or lower risk PCa tumors, or small tumors with well-defined edges (according to the NCI definitions). Treatment of isolated PCa bone met tumors using SBRT is being performed on select patients by some radiation oncologists as a single session SBRT aka SRS (Stereotactic Radiosurgery), such as that described above by Janekirstine for her husband, Tim (user name=nuclearduck: http://csn.cancer.org/node/225406), in the tx of one PCa hot spot/bone met identified on the sacrum via F-18 PET imaging. While initial results may look promising for SRS as a tx to mitigate isolated PCa bone mets, IMHO, it’s too early to determine long term PCa bone met tumor control outcomes using SRS. That doesn't mean SRS shouldn't be offered to patients as a tx option for isolated PCa bone mets, it just means that one needs to be an informed medical consumer/patient who fully understands the potential risks as well as the possible benefits, especially when compared to any other viable option(s) for the same type of tx. No doubt, pro and con arguments can be made by medical professionals and nonprofessionals alike, with regard to the radiation field features, dosing methods, patient safety, side effects, curative vs palliative and so on, pertaining to IMRT and SBRT/SRS txs for isolated PCa bone mets and PCa in general.

Re patient safety in SRS & SBRT: Interestingly, an executive summary paper titled “Quality and Safety Considerations in Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy,” released this year, was commissioned by the American Society for Radiation Oncology (ASTRO) and approved by the ASTRO Board of Directors to address patient safety. The document was part of a series of white papers relating to patient safety considerations, etc. The executive summary paper states that “Given that very high-dose fractions of radiation are delivered, the margin of error for SRS and SBRT is significantly smaller than that of conventional radiotherapy and therefore special attention and diligence is required. A SMALL ERROR IN TARGET LOCALIZATION FOR ANY 1 FRACTION RISKS UNDERTREATMENT OF PORTIONS OF THE TUMOR BY 20% OR MORE, AND INADVERTENT OVERDOSAGE OF ADJACENT NORMAL TISSUES COULD ESCALATE THE RISK OF SERIOUS INJURY TO A MUCH GREATER DEGREE THAN AN EQUIVALENT TREATMENT ERROR IN A COURSE OF RADIOTHERAPY WHERE A SUBSTANTIALLY LOWER DOSE PER FRACTION IS USED [IG/IMRT].” Of course, as with any cancer treatment, the skill & expertise of the treating medical doctor/team are critical.

I hope and pray that we never have to face the challenge of PCa bone mets, because, frankly, I’m unsure what choice(s) PJD would make. I do know that if isolated PCa bone (or node) mets were identified on newer imaging technology, we would research the issue 24/7 (as we did for primary tx options after receiving the PCa dx), searching for data/evidence on long term tumor control rates with drugs and proven & safe RT dosing protocols for isolated PCa bone mets, if that was the case and RT was a viable option. Almost certainly, PJD would treat systemically with ADT (as he would for evidence of a recurrence) and most likely, Xgeva also would be added immediately & proactively to address/mitigate any bone met(s). Xgeva (Denosumab) is in a class of drugs called RANK ligand inhibitors and works by decreasing bone breakdown and increasing bone strength and density (thickness), taken with calcium and vitamin D supplements. Unless contra-indicated because of potential interaction with other drugs, I would think that Xgeva would be worth considering in Tim’s case if it hasn’t already been discussed or suggested by his doctor(s), in addition to the ADT and SRS following his salvage IMRT after RP.

Re lay-advice: No two PCa cancer patients, no two cancers, no two treatments or tx outcomes, including potential range and intensity of side effects, are exactly alike. The concept of “Caveat Emptor,” or "Let the Buyer Beware” has been a topic of discussion on previous CSN PCa forum threads and reinforces the advice here that one must be an informed/educated medical consumer/patient. IMO, the message & emphasis must be that each person must do their own independent PCa research and form their own personal conclusions based upon what is best for their own unique situation. PCa is a passionate subject for survivors and loved ones, men and women. Discussions and/or debates, dissenting opinions, and sharing info are an integral part of this forum and a way to begin learning and developing new and/or different PCa perspectives; however, IMO, independent personal follow-up & research from reputable & respected PCa sources is necessary and mandatory in the PCa education process.

While some posters need no assurances, I will assure others that I have no platform or agenda to promote pertaining to any specific brands of medical equipment, PCa treatments, medical tx centers, drugs, etc., and I am not a shareholder in any branded medical product, equipment, or pharma companies. My sincere desire is, and has been, to advocate for PCa awareness & education for men AND women and share lay-opinions & information based upon my and my husband’s personal experience with Prostate Cancer.

Be well.

mrs pjd

P.S. Re Janekirstine’s question about USPIO: You may find it helpful to visit the following CSN thread link for information on imaging using USPIO (Feraheme) with the T3 MRI: http://csn.cancer.org/node/221178

(Originally posted 12/14/2011)