https://docs.google.com/document/d/1ypy6LUG0SL_pPHy1HOmnfJeT6lS_6uUYyw_TOCVXw44/edit

Average total Gy administered for each patient 36.25, 5 sessions .....generally SBRT ranges from 35 to 40 Gys .....IMRT is considerably more , I think in the 80ies/

hopeful and optimistic said:

Katz 6 year results

https://docs.google.com/document/d/1ypy6LUG0SL_pPHy1HOmnfJeT6lS_6uUYyw_TOCVXw44/edit

 

 

Average total Gy administered for each patient 36.25, 5 sessions .....generally SBRT ranges from 35 to 40 Gys .....IMRT is considerably more , I think in the 80ies/

There is some confusion about the reported radiation dosage for CK prostate treatment and there has been a lot of variation in the radiation dosages adminsitered as indicated in Table 1 of Katz's Oct 2010 report. The closest treatment to mine was listed at the 2nd to the bottom in Table 1 of Katz's report.

See: http://www.firstdaytoncyberknife.com/images/pdfs/ckprostatetcrtak.pdf

CK is generally administered in dosages of 35-40 gys/treatment (usually in 4-5 sessions) BUT the total daily dosage is actually hypofractionated and delivered in 20-30 smaller doses in the 1.5-1.8 gy range (all around and at different angles of attack) AND the total BED (biological equivalent dosage) of all of the treatments is around 92 gy (or at least it was for me) but from Table 1 in Katz's report the BED has ranged from 87 to 125 gy.

So, it is the BED (and not the daily or hypofractionated radiation doseage) that is MOST important to note and BED is the ONLY meaningful measure of the total radiation dosage delivered for comparative purposes between difference radiation technologies using different fractionalized radiation dosages and delivery methods.

CC52 said:

My Two Cents

I am currently undergoing CK treatment at Georgetown University Hospital, in fact had my 2nd session today. As swingshiftworker mentioned, the process is straightforward. My oncologist inserted the fiducials, and the process was suprisingly painless. The markers are inserted by needles through the perineum, so it's more of a mental thing that you'd expect more discomfort from the procedure. In my case, 6 markers. (btw - 62 yrs, gleason 3+4+7; 3 of 18 cores positive, most recent psa, 8.0)

They "set" for a week, then the MRI & C/T scans the following week. Met briefly with my RO the day of my first treatment, then off to meet the CK techs and a tour of the room, questions answered and then the treatment. In my case, both sessions have lasted about 35 minutes. In fact, I've taken my iPod in and I don't think I listened to more than 6 songs. 

The machine is one incredible piece of technology. It's relatively quiet, most of the noise is from the machine's movements through it's various positions. You will hear a slight clicking sound as the radiation is administered. No physical sensation what so ever. Oh, and I will get 36.25 gy's total over my 5 treatments, or 7.25 gy per treatment. 36.25 is considered the norm for CK, and with conventional external beam radiation over 8 weeks you might expect to get double that dose.

Side effects of urinary/bowel issues have hit me already, but as of this writing are manageable.

Best wishes to you as you continue toward defeating the beast.

 

Hope your CK treatment is as effective and uncomplicated as mine way, but your total BED (biolodigcal equivalent dosage) of radation over the 4 days of treatment will probably be somewhere around 92 gys, which was what mine was.  See discussion above.  Since you're currently undergoing treatment, you should as your RO for the BED estimate, which should be substantially different that the 36.25 gys you stated above.

hopeful and optimistic said:

To add more confusion

No doubt in my mind that SBRT is a better option. I think that giving less Gys than IMRT is an advantage. See this first statement by Dr. Katz.

"The CyberKnife system delivers roughly quadruple the usual dose of radiation per day and about one-half as much total compared with a standard course of IMRT. “If you’re going to give large doses, you want to give it accurately and want the dose to be conformal, to hug the prostate, and to give as little as possible to surrounding healthy structures,” Katz says. “Using the CyberKnife, we’ve been able to accomplish both.”

............................................................................................................

 

July 2011

SBRT for Prostate Cancer
By Beth W. Orenstein
Radiology Today
Vol. 12 No. 7 P. 24

While early results appear promising, critics in radiation oncology say longer-term data are needed before widely offering the treatment to men.

When Accuray’s CyberKnife Robotic Radiosurgery System was introduced in the 1990s, facilities acquired it mostly as an alternative for treating head, neck, and spinal tumors—tumors that would otherwise be difficult, if not impossible, to reach. In 2001, the FDA cleared the CyberKnife system to treat tumors anywhere in the body. Since then, many facilities are offering it as an alternative treatment for other cancers, including of the lung, breast, liver, and prostate, which is the second leading cancer killer among men.

Prostate cancer strikes more than 186,000 men in America each year and kills more than 28,000. CyberKnife treatment—called stereotactic body radiation therapy (SBRT)—is a high-dose radiation treatment. Physicians inject tiny gold fiducial markers into the prostate to help target the beams. The robotic arm swivels around the patient, shooting beams of radiation from multiple angles into the target.

Advocates believe SBRT will revolutionize prostate cancer treatment and that it is a better option because less healthy tissue is affected by the treatment; treatment can be completed in four or five days vs. six to eight weeks; and the treatment is just as effective as external beam radiation therapy or seed implants.

“I believe that CyberKnife treatment is as good, if not better, than conventional treatments for prostate cancer based on low PSA [prostate-specific antigen] levels and low recurrence that we are seeing today and … that it’s only five days makes it even better,” says Alan Katz, MD, of Flushing Radiation Oncology CyberKnife Center in Flushing, N.Y.

A multicenter study of 41 patients (at UCLA and in Naples, Fla., presented in the January 10 issue of the online journal Radiation Oncology) found 93% of patients treated with the CyberKnife system had no cancer recurrence at a median follow-up of five years. The authors indicated the rate compared favorably with results obtained with other treatment modalities, including surgery and conventional radiation therapy.

However, some in the medical community are concerned that finances, not efficacy, is motivating CyberKnife centers to expand the surgery to include prostate cancer treatment, claiming that not enough evidence has been accumulated to show SBRT is even an equivalent treatment.

“The idea of the treatment for patients with low-risk prostate cancer is great,” says Gerald Chodak, MD, a former practicing urologist who writes for Medscape on prostate issues. “If you could treat someone in five days vs. eight weeks and get comparable outcomes, that would be great. But there’s absolutely no proof yet that long-term outcomes are going to be the same.”

The five-year data that were recently presented are positive, Chodak says, but five years is not long-term and until the long-term data are available, he wouldn’t recommend offering SBRT as an option for patients with prostate cancer, which one man in six will get in his lifetime.

Chodak also fears that “money is driving this more than anything else.” Facilities are investing millions in CyberKnife machines and may be expanding to prostate treatments largely to get more use out of them, he says.

Katz has treated more than 700 prostate cancer patients with the CyberKnife system—more than anyone else in the world, he says. While he doesn’t have as much five-year data as the authors of the Radiation Oncology study, he has hundreds of patients with four-year data that he presented at the annual American Society of Radiology Oncology (ASTRO) meeting last year. He has been accepted to present his updated data at the ASTRO 2011 meeting in October.

“What we’re seeing,” he says, “is that if you treat with CyberKnife … you can get control rates that are better than standard IMRT [intensity-modulated radiation therapy] at four-year follow-up.”

The CyberKnife system delivers roughly quadruple the usual dose of radiation per day and about one-half as much total compared with a standard course of IMRT. “If you’re going to give large doses, you want to give it accurately and want the dose to be conformal, to hug the prostate, and to give as little as possible to surrounding healthy structures,” Katz says. “Using the CyberKnife, we’ve been able to accomplish both.”

Katz says he doesn’t necessarily need 10-year data to be convinced CyberKnife is a valuable alternative. “This is because data from the use of radioactive seeds shows that low PSA nadirs are an excellent predictor of 10- to 15-year outcomes. Why wouldn’t the results be applicable to other forms of radiation such as SBRT? Our four-year data shows median PSA nadirs of 0.1 following treatment with CyberKnife; that’s lower than levels following IMRT. To me, that’s a good indicator that we will have positive long-term outcomes.”

PSA levels are important for various reasons, Katz notes. One reason is if a patient’s PSA level goes up, it could prompt additional biopsies and treatments, he says.

If SBRT can achieve similar results but the treatments require only 45 minutes per day for four or five days—rather than spread over six to eight weeks—that alone makes it a better alternative for men, especially those in their 50s and 60s who are more likely to be working and have less time to devote to the longer course of treatment, Katz says.

Katz’s research has shown that about 80% of CyberKnife patients retain sexual potency, which is higher than with other treatments, and that urinary and bowel side effects are also very mild. “These are very important considerations when patients weigh their treatment options,” Katz says. Side effects of radiation treatment can include incontinence, bleeding, problems urinating, and impotence.

Katz also says CyberKnife treatment costs less than conventional radiation treatments. So the argument that radiation oncologists are pushing it to make money is hollow, he says.

“If treatments are much cheaper, you can’t just let someone say this is about money,” he says.

Citing Medicare’s 2011 global number, Katz points out that CyberKnife treatment in a hospital setting averages $21,917, while treatment with IMRT in a hospital costs on average $26,806. Medicare and private insurers in many parts of the country cover the cost of the treatment; however, some insurers have taken a wait-and-see attitude and do not.

Dwight Heron, MD, FACRO, chairman of the department of radiation oncology at the University of Pittsburgh Medical Center (UPMC) Shadyside, an early adopter of the CyberKnife system, finds the recently released five-year data for prostate cancer encouraging.

“The five-year data says to us the outcomes are not inferior to the other modalities and indeed are superior to some,” he says. “It offers us encouraging data that this shorter course is no worse in toxicity and certainly no worse in outcomes, and that’s really good news.”

Heron says he would like to see seven- to 10-year data on the effectiveness of CyberKnife for prostate cancer, especially because prostate cancer is typically slow growing, but believes the information will eventually come.

“I think it’s only a matter of time before that data emerges as well,” he says.

 If the outcomes are equal, he adds, many men may prefer CyberKnife because it requires only a week of their time. “Lots of men tell me they’re professionals—lawyers or businessmen—and they can’t afford to be away for eight weeks of treatment,” he says. When he presents them with their treatment options, “That’s a conversation we often have.” Also, he says, if the treatment is quicker, it means the side effects of the radiation may resolve more quickly, which is important to many patients, especially those who are still working.

However, Chodak, author of the book Winning the Battle Against Prostate Cancer, who recently had a urology practice in Chicago and now spends his winters in Florida and summers in Indiana, believes the five-year data on CyberKnife for prostate cancer are being made to seem better than they are.

“The short-term outcomes are being interpreted as a predictor for long-term outcomes,” he says, “and you can’t legitimately make that leap.”

Chodak provides an example of why short-term outcomes are not reliable predictors of long-term outcomes: A randomized study done in Australia and New Zealand looked at men with early-stage prostate cancer and compared those who were treated with radiation alone with those who had radiation and hormone therapy for three months and those who had radiation and hormone therapy for six months.

“They found that those who had six months of hormone therapy had a higher survival than the other two groups,” Chodak says, “but those getting only three months of hormones had a similar PSA recurrence rate and metastatic rate as those getting longer therapy. If only the PSA data was considered, the wrong conclusion would be reached, namely that three months is as good as six months of hormone therapy.”

Chodak says he’s surprised the five-year study did not include information about the impact of SBRT on sexual function. (CyberKnife proponents say the information wasn’t included because it wasn’t the focus of the report and that these data will be in future studies.)

Chodak says he can see the potential benefits for patients in terms of convenience, as the CyberKnife treatment takes much less time than standard radiotherapy. Still, he says, he’s not convinced the data are there for physicians to be able to tell patients it is a comparable treatment. “Five years of results in a series of 41 patients treated for low-risk disease means very little,” he says.

It’s possible, he says, that because prostate cancer is slow growing, many of these men don’t need to be treated at all. Long-term survival is the outcome that matters the most, he says, particularly for men with low-risk prostate cancer. He believes it’s too soon for prostate cancer patients to be offered CyberKnife as a treatment option.

Rohit Inamdar, a senior medical physicist and senior associate in the Applied Solutions Group at the ECRI Institute in Plymouth Meeting, Pa., a nonprofit organization that evaluates medical products and processes, agrees with Chodak that the clinical evidence on the use of the CyberKnife for prostate cancer is “a little early … and a little weak. It’s still developing and cannot stand on its feet.”

Inamdar is also concerned about the financial issues. Some physicians might be presenting CyberKnife as an option for their patients because they’ve invested $5 million in the equipment and can’t afford to have it sit idle, he says.

“One fear I have is that it’s like a hammer looking for the nails,” Inamdar says. “If you paid $5 million for it and you’re paying for staff, now you have to put it to use.”

However, Inamdar says the controversy that’s been brewing over the use of CyberKnife for prostate cancer may be out of proportion to its use. While the use of the CyberKnife for prostate cancer has received a lot of media attention recently, its use is not as widespread as the stories make it seem, he explains.

“A couple months ago, there was a survey done by the University of California in San Diego. It was sent to 1,600 radiation oncologists and 550 responded. Most said they were using it to treat lung cancers (90%), spine tumors (68%), and liver tumors (55%). Only 8% reported using it to treat prostate cancer,” he says. “There’s all this media hype over the use of CyberKnife for prostate cancer, but what are facilities actually doing? The numbers using it to treat prostate is actually very small—less than 10%.”

Although watchful waiting is an alternative treatment for low-risk cancers, many men want to treat their prostate cancer, Inamdar says. At most radiation therapy facilities, he says breast cancer and prostate cancer are the bread and butter.

“But,” he adds, “it seems as though in the SBRT world, it’s a little different.”

— Beth W. Orenstein is a freelance medical writer based in Northampton, Pa. She is a frequent contributor to Radiology Today.

 

 

- See more at: http://www.radiologytoday.net/archive/rt0711p24.shtml#sthash.aNPcGcxi.dpuf

 

Thanks for the most informative post.

The part on the low proportion of SBRT patients being PCa related was especially interesting. I know that here in Denver I have not seen a single Rockies game on TV that did not have an Anova commercial that targeted PCa. If I had guessed, I would have thought the majority of their patients were PCa patients. They must see PCa as a growth area; maybe, due to the drop in the number of smokers, the number of lung cancer patients is dropping off?

Kinda too bad someone can't do as effective advertising for AS .... indeed, as I reported in the past, there was one brachytherapy add that said brachytherapy was a preferred option to AS. I couldn't quite figure this out; doing AS does not preclude a guy from doing brachytherapy in the future ... maybe they were referring to not having to live with the psychological stress of AS. Don't know ... maybe AS is cutting into the brachy business?

Anyhow, I enjoyed the info. Thanks again.

Beau2 said:

Confusion

Thanks for the most informative post.

The part on the low proportion of SBRT patients being PCa related was especially interesting. I know that here in Denver I have not seen a single Rockies game on TV that did not have an Anova commercial that targeted PCa. If I had guessed, I would have thought the majority of their patients were PCa patients. They must see PCa as a growth area; maybe, due to the drop in the number of smokers, the number of lung cancer patients is dropping off?

Kinda too bad someone can't do as effective advertising for AS .... indeed, as I reported in the past, there was one brachytherapy add that said brachytherapy was a preferred option to AS. I couldn't quite figure this out; doing AS does not preclude a guy from doing brachytherapy in the future ... maybe they were referring to not having to live with the psychological stress of AS. Don't know ... maybe AS is cutting into the brachy business?

Anyhow, I enjoyed the info. Thanks again.

Beau2 - just a point to clarify that the article shared by hopeful was written 3 years ago, and CK was likely not that well known or considered as a recognized PCa treatment.

I'd agree that in my area too (Wash D.C.) there has certainly been an increase in advertising CK for PCa since my diagnosis.

mcin777 said:

Thanks Swingshiftworker.

Thank you for sharing your experience.  Have you had any incontinence...ED?  How many treatments did you undergo over what span of time?

Typically, CK treatments are every other day. Five treatments, each lasting about one hour, are common for patients with low-risk prostate cancer (Gleason = 6). For more serious cases (intermediate to high-risk) three CK treatments followed by 25 IMRT sessions are used in some centers (like Georgetown U Hospital). For better advice, it would be helpful to get info on your situation.

Whereas the CK protocol doesn't involve frequent interaction with the Radiation Oncologist, it is clearly a very complex ('high-tech') procedure that requires a team of experienced professionals. Thus, I would want to know how many procedures have been performed by the team and for how long.

Moreover, the placement of the fiducials requires invasive surgery and I would want to have this done by a doctor who has an excellent track record for this procedure.

With respect to outcomes and side effects, I urge you to read clinical study reports in the medical literature. These involve many patients and are consequently much more meaningful than the experience of one person (whether it be Swingshiftworker or me).

Look for publications by Alan J. Katz (Flushing NY),

SP Collins (Georgetown U Hospital), and

CR King (Stanford; currently UCLA)

These three individuals have been particularly active applying CyberKnife technology towards the treatment of prostate cancer in the US.

I particularly liked the following (rather recent) article because it represents a joint effort from the three centers just mentioned.

Int J Radiat Oncol Biol Phys. 2013 Dec 1;87(5):939-45.

Health-related quality of life after stereotactic body radiation therapy for localized prostate cancer: results from a multi-institutional consortium of prospective trials.

King CR¹, Collins S, Fuller D, Wang PC, Kupelian P, Steinberg M, Katz A.

PURPOSE:

To evaluate the early and late health-related quality of life (QOL) outcomes among prostate cancer patients following stereotactic body radiation therapy (SBRT).

METHODS AND MATERIALS:

Patient self-reported QOL was prospectively measured among 864 patients from phase 2 clinical trials of SBRT for localized prostate cancer. Data from the Expanded Prostate Cancer Index Composite (EPIC) instrument were obtained at baseline and at regular intervals up to 6 years. SBRT delivered a median dose of 36.25 Gy in 4 or 5 fractions. A short course of androgen deprivation therapy was given to 14% of patients.

RESULTS:

Median follow-up was 3 years and 194 patients remained evaluable at 5 years. A transient decline in the urinary and bowel domains was observed within the first 3 months after SBRT which returned to baseline status or better within 6 months and remained so beyond 5 years. The same pattern was observed among patients with good versus poor baseline function and was independent of the degree of early toxicities. Sexual QOL decline was predominantly observed within the first 9 months, a pattern not altered by the use of androgen deprivation therapy or patient age.

CONCLUSION:

Long-term outcome demonstrates that prostate SBRT is well tolerated and has little lasting impact on health-related QOL. A transient and modest decline in urinary and bowel QOL during the first few months after SBRT quickly recovers to baseline levels. With a large number of patients evaluable up to 5 years following SBRT, it is unlikely that unexpected late adverse effects will manifest themselves.