pre-existing rectal problems and appropriateness of radiation

Hopeful…Damned if you do
Hopeful…Damned if you do damned if you don’t as the saying goes…

From everything I read any type of radiation treatment has of a likelihood of “side effects” with the colon… The only side effect that I know of with surgery is a “nicked” colon and that is rare (surgeon error)…

I had hemorrhoids and a fissure prior to surgery and I do not have them now…I run like clockwork but I am sure a lot of this for me is diet… Whatever your decision I wish you the best and believe in it…

hopeful111 said:

a couple of thoughts - thanks for the information
Kongo,

The information and feedback you sent is very helpful and gives me a better context for communicating with the Drs about this.

The one radiation dr I saw said nothing about it during the exam,
but when I asked directly about it some weeks later (once it had been pointed to me by other dr as a potential issue) said that yes it could
be a problem as to perhaps increasing severity of any rectal side effects that might occur from radiatioan, and related to more difficulty in having surgery in those areas later.

Hearing it not up front has been stressful and will talk with other
radiation Drs about this and don't know if its a message per se about
the quality of his treatment planning and of the facility itself.


You mention imrt and sbrt, and was reading some threads about that
as to what might be better and especially that sbrt, at least the cyberknife (that do have facilities in my area) that does not have
longer term studies compared to imrt/igrt.

I will look into it more to see at least if it might be less stressful
to rectal areas than imrt/igrt.

Yet in my mind is the question - if its as good or perhaps better than
imrt/igrt, and especially with 2-5 visits only, why are most men who
do the external radiation do the imrt and/or imrt/igrt with the many visits. Any thoughts on that question or should I ask it in a separate thread ?

Thanks again - hopeful111

Choices
hopeful,

There is a very recent paper published which goes over in some detail a summary of all the CyberKnife studies and outcomes that can answer many of your technical questions. It can be found at:
http://www.tcrt.org///mc_images/category/4309/04-katz_tcrt_9_5.pdf

I understand your frustration when doctors don't go over all the potential side effects up front and you have to dig it out of them later. Most lay patients, particularly early on in their diagnosis while they are still learning, haven't a clue as to what should be asking and we seldom read the fine print in the medical release forms. I found that in my own situation, I needed to do a great deal of research on whatever procedure I was visiting a specialist for and drill down into the weeds to get them to fully elaborate on all the potential side effects. Too many men simply don't do their homework and many doctors (in my opinion) harbor an attitude where they only tell their patients what they think they can handle. I realize it's a fine line but in my mind, you can't get too much information about this disease.

With respect to EBRT and your questions about rectal prolapse, I would imagine that the older forms of EBRT (which covers a broad scope of different types of radiation delivery methods) that basically radiated the entire pelvic region have a much higher potential for rectal toxicity than newer forms such as IMRT, IGRT, Tomography, or SBRT. This may be what your doctors were referring to when they indicated that it might be an issue. Based on the delivery methods of IMRT and SBRT I think that the accuracy of dosage placement is so precise that it would much less of a potential issue with prolapsed tissue at the anus.

IMRT and SBRT have both been around about the same amount of time and both deliver very precise dosages of radiation...with IMRT doing it is about 40 fractions while SBRT (CyberKnife) doing it in five or less. So, the studies that compare the two have about the same amount of time. One difference between the two (besides the number of fractions and the fractional dosage) is in how the two different methods compensate for movement of the prostate. In IMRT, the prostate is located each day that radiation is delivered and the machine is adjusted for the prostate position at that time. In CyberKnife, the prostate movement is tracked in real time and the machine adjusts its delivery constantly. Since each IMRT fraction is a much lower dose than a CK fraction, the potential damage to surrounding tissue that may be inadvertently radiated when the prostate moves is not that great. CK, which delivers a much higher dose of radiation during each fraction needs the real time tracking system to avoid potential damage to surrounding organs and tissue. The end result is that CK has less chance of causing damage than IMRT because all of the dosage is concentrated within the prostate according to the radiation plan and the real time compensation for movement of the prostate, which surprisingly can be quite significant. Of course, in both methods some radiation must pass through the skin, internal tissue, and organs to reach the prostate but its level is well below that shown to cause harm. The total effect is achieved when the radiation beams converge in the prostate and generate the equivalent dosage necessary to kill cancer but not damage the surrounding area.

In my opinion, there are several reasons why most men who choose radiation end up having IMRT instead of CK. First, IMRT is more readily available across the United States and the machine which delivers the radiation can be used for a wide variety of cancers besides PCa. While most large urban areas have a CyberKnife center, there are many parts of the country where it doesn’t make economic sense to have one. At this point, CK is only used to treat cancers in the brain, spine, lung, liver, kidney, pancreas, and the prostate. Many hospitals simply can’t afford to have every potential option for radiation equipment. Another factor is that not all CK centers treat prostate cancer, which requires radiologist specialists in PCa. Another factor is insurance. Although Medicare approves CyberKnife in most parts of the country, it is not approved everywhere. Many insurance companies will not cover CK unless lengthy appeals are filed and many men find this simply too much of a hassle. And finally, I think there is an educational aspect involved. Most men who choose CK generally do so after doing their own research but overall, I suspect that most men follow the recommendations of their urologists or if they seek a radiologist specialist, go with what they recommend.

You can believe what you choose about studies and how long they should be. Given the pace of technology, if one chooses to wait for a 10-year result study (for example) they’re choosing ten year old technology. The paper I referenced earlier outlines all of the major studies which all show similar positive results and which can be compared to other forms of treatment at similar stages. Is there some uncertainty? Absolutely. Are there risks? You bet. Side effects? Of course. I think it comes down to how comfortable you are with the data that’s out there, your individual tolerance for potential side effects and quality of life. In any case, every treatment option has its side effects and I think you’re pursuing a smart course in trying to scope them all out before making a decision as to what treatment is best for treating your individual prostate cancer.

ghdeaver said:

appropirateness of radiation
Hopeful,
I have UC (ulcertive colitis) and went through the same questions you are asking. I consulted with my GI, a radiation oncologist as well as a surgeon. The surgeon and GI STRONGLY recommended against radiation as I already had bleeding and any further irritation ( which radiation was sure to produce) would cause even more irritation. Even the oncologist was iffy on whether I should consider radiation. For that reason I opted for surgery and , in the end I am glad I did as the biopsy grossly underestimated the extent of cancer and surgery was probably the best choice given the extent of cancer. In the end I had negative margins and my 3 month PSA was a zero. I am mostly continent after 3 months. One interesting side effects is the use of viagra for impotence. The viagra causes increased bleeding (the objective of viagra is to increase blood flow to that area so it all makes sense). Most of my issues now actually have more to do with overcoming UC and its symptoms than the recover from prostate surgery.

Agree
GH, I think you're spot on about the potential impact of radiation with colitis. Although IMRT or SBRT would have less effect than older forms of EBRT, any unnecessary radiation to the colon for someone suffering from UC could only exacerbate that condition.

Although hopeful didn't elaborate on the extent or severity of his rectal prolapse, which is broadly defined as a weakening or collapse of the walls of the rectum allowing some of the tissue to extend through the anus, I still wouldn't think that condition is nearly as vulnerable to radiation. For one thing there is some distance between the anus and the prostate and the radiation dose plans (at least in my case) never came near that area (or the penis or scrotum for that matter). Either IMRT, which can allow the radiation beams to be designed to confrom to the exact shape of the prostate, or SBRT which can completely avoid the area of the anus would, in my opinion, not be a factor in the treatment of PCa in a man who also had rectal prolapse.

Obviously this is a situation where hopeful should seek counsel from both surgeons and radiologists about the best way to handle the situation. It just seemed to me that rectal prolapse, in many cases, is easily treated through minor surgery or even by increasing dietary fiber, and that condition alone should not be a reason to rule out some of the newer forms of radiation delivery if that is what he feels is best for him. UC is a completely different complication and I wish you best in your recovery from your surgery and that your UC is resolved soon.