Johns Hopkins Health Alerts: Talking About CyberKnife
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
Comments
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Cyberknife
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?".0 -
Cyberknife
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?".0 -
CyberKnifesteckley said:Cyberknife
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?".
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.0 -
Johns Hopkinssteckley said:Cyberknife
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?".
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.0 -
CyberKnifeKongo said:Johns Hopkins
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.
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 effects0 -
Just Had My CyberKnife Markers Placed At UCSFKongo said:Johns Hopkins
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.
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!0 -
The information provided is
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… Peace0 -
John Hopkins is misleading?Swingshiftworker said:Just Had My CyberKnife Markers Placed At UCSF
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!
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...Peace0 -
TOO MANY PEOPLE GETbdhilton said:The information provided is
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
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 !!!0 -
KongoKongo said:Johns Hopkins
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.
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 facts0 -
Bronx-AmenBRONX52 said:TOO MANY PEOPLE GET
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 !!!
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…
Peace0 -
Cyberknifeviperfred said:CyberKnife
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.
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?)?0 -
BDbdhilton said:Kongo
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
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.0 -
KONGOKongo said:BD
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.
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 !!!0 -
KongoKongo said:BD
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.
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…
Peace0 -
Hey Bropnx,BRONX52 said:KONGO
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 !!!
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,0 -
KONGOKongo said:Hey Bropnx,
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,
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 ----DAN0 -
CyberKnife mis-informationbdhilton said:Bronx-Amen
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
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!0
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