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HD Brachy + EBRT + ADT Anyone with experience to share?

desperate for hope
Posts: 44
Joined: Oct 2016

Our Radiation oncologist says that there is no data to compare HD Brachy+ EBRT + ADT (neo + 2 yrs ) to RP + EBRT.

I'm concerned about outcomes and side effects. 

My husband (age 59) is very high risk. GS 4+5, PSA 28, all cores +, N0, M0 (Ct/bone scan)

Maybe RT has very long term effects for younger men? 

 

Thank you. 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3208
Joined: May 2012

Congrats on seeing the Rad Oncologist and moving forward in knowledge...

Any treatment for anything has side-effects.  While your husband is younger and side-effects are more of a resaonable concern at his age, the Radiation Oncoliogst I met for consultation said that any rational person, in addressing PCa, whould have three worries, and in this order:  (1) Eradicate cancer; (2) Urinary control; (3) Sexual function.

Most of what is written about here is mild, early stage PCa.  His is of a more aggressive variety, and the conventional wisdom is not applicable.

RT side-effects are virtuallty always delayed, not instaneous, such as what men get following surgery.  But the side-effects from RT generally are milder than with surgery. Possible side effects are buring of the colonand  bladder control issues, even E.D. But these are rarer after RT than after surgery.

The conventional wisdom regarding surgery for aggressive, high Gleanson disease is that it complicates radiation, and slows down when radiation can begin, for little potential benefit.  In other words, pain and recovery for no apparant reason.

My view: Focus on #1 above: kill the disease.  Side-effects are seconday, by definition.

desperate for hope
Posts: 44
Joined: Oct 2016

I agree with the priority and I know that they need he'll need multimodality treatments to give him longer. I fear years of bladder and bowel incontinence and the inability to work or leave the house. ED is a foregone conclusion. I fear depression and life that is worse than death. We need to know what is likely and possible. 

VascodaGama's picture
VascodaGama
Posts: 2942
Joined: Nov 2010

Hope,

Though you have started this new thread on treatments, the previous, discussing the diagnosis and investigation, are important for the decision you may have on a therapy. In that respect I would suggest to those reading this thread or advising, to follow the discussions/story of the thread in this link; https://csn.cancer.org/node/305811

The treatment in the title (HD Brachy + EBRT + ADT) is very appropriate if the "localized" status is confirmed. I think that treatments depend on a clinical stage and this has not yet been attributed to your case. The biopsy and bone scan may indicate it to be T2 and probably a M0, but the high PSA and prostate size leads to think that T3 may be appropriate. In addition to this, if lymph nodes are found to be positive (N1) then his case is considered advanced T3 with likely woods of a T4.

In any case, I believe that your mind setup is leaning for a radiation therapy (mono protocol or combined), and I think it inevitable, in the presence of the above results. Below it is a very useful link to PCa Treatment Research Foundation where they publish a practical interactive table comparing treatments. The data serviced for comparison are collected from real experiences and reliable sources, provided by their outcomes along the years of free biochemical survival. You can choose from the various treatments in sets of low, intermediate and high risk cases. For instance, for a high risk cases they include the outcomes for 28,422 patients. Braky plus EBRT plus ADT, provide the best result.

http://www.pctrf.org/comparing-treatments/

The Table above serves only to create ideas. One needs to choose among the options appropriate for their case. One aspect regarding your case is that if T4 is "declared" and cancer is found in places difficult or prohibitive of being radiated (bladder sphincter) then the radiologist may opt for reserving the radiation to other purposes, such as to treat only the critical spots or reserve it for pain control at a later stage.

http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-staging

All treatments have risks and side effects that you should know in advance. Radiation is prohibitive in guys with apparent ulcerative colitis, so that I would recommend your husband to have a colonoscopy done now while waiting for final diagnosis to access his colon status.

Best wishes and courage in the fight.

VGama

MEtoAZ
Posts: 37
Joined: Feb 2016

Given that surgery really isn't a good option in your case, there are multiple RT choices still available.  I would not think Brachy would be ideal as it sounds like the cancer is not contained in the prostate is what brachy is most effective at killing.  Cyberknife can radiate around the prostate with precision and real-time imaging during the procedure whereas conventional radiation just hits an entire area which can result in more side effects, especially over time.

Unfortunately, the docs doing conventional radiation, Brachy-therapy and the cyberknife docs don't really play together much so you would have to investigate with different docs most likely.  At least that was my experience.  I had Cyberknife done in April at 53 but only 2 cores and 3+3, 3+4 so much less progression of the disease at time of treatment.

Good Luck with your treatments whichever path you choose.

desperate for hope
Posts: 44
Joined: Oct 2016

According to information from the company, Cyberknife is not suitable for high risk PCa. http://www.cyberknife.com/uploadedFiles/CyberKnife_Treatments/Prostate/FINAL_CyberKnife%20_Information_Guide_Prostate_Treatment.pdf

I'm curious-- why do you think surgery isn't a good option? We've been told that there are no studies that compare RP+Adt+RT with HDBrachy+EBRT+ADT. We are still trying to figure it out. Both treatments have been offered. 

My husband is having a cystoscopy to see if the cancer is near the bladder neck. The ultrasound looks suspicious. The Rad Onc said that if it is, surgery is the better option because she couldn't radiate so near to the bladder. 

Thank you for your good wishes!

 

MEtoAZ
Posts: 37
Joined: Feb 2016

Thanks for article.  I would say that as a stand-alone treatment for advanced PCA that Cyberknife isn't a good option but it is an option in combination with additional treatments which in our case will always likely involve multiple treatments reginmins.  Hormone therapy (ADT) is certainly one of them.  My doctor wanted to use ADT on me but I declined as in my case, the "increase" in projected cure was around 1% so I didn't believe that the additional side effects that I would have to battle were worth another one percent when I was already in the 93-94 percentile. 

I presumed that the side effects and potential complications with surgery when other treatments are known to be required starts to minimize the upside of removing the prostate tho remove the cancer.  That is generally the largest upside with surgery.  If contained within prostate, you have removed the cancer when you remove the prostate.  In this instance, it didn't sound like that was the case. 

That was why I indicated surgery didn't seem like a great option.  I am not a doctor (nor do I play one on TV :) ) so my comment was just based on the information I had see thus far.   I would think brachy would have same issues as other options in terms of needing additional treatments.  Sorry if I addded confusion.

desperate for hope
Posts: 44
Joined: Oct 2016

It's interesting that some of the long term studies report almost identical outcomes for RP vs Rt for very high risk localized cancer. However, these reports were bofore the inclusion of EBRT + ADT. I might be wrong, but I sense that for a younger man. long term effects of radiation might become significant.

Regarding side effects, my husband's cancer is so risky that we are focused on doing whatever treatment will allow him to live the longest. We are ready to accept the worst side effects in terms of ED and Incontinentce. 

Thank you so much for your input! So appreciated! And you didn't confuse me- I value your perspective.

Old Salt
Posts: 720
Joined: Aug 2014

I also suggested to consider SBRT (CyberKnife) as part of the treatment plan, but patient doesn't have that option nearby (see the earlier thread: http://csn.cancer.org/node/305811)

Now with respect to those side effects: Yes, they definitely happen, but the severity varies a lot patient-to-patient. If you want to be semi-scientific, make a list of them and compare them (if possible, quantitatively) for each treatment that is under consideration.

PS: I don't think that ED is a foregone conclusion (is surgery still being considered?) and neither is long-term depression. Quality of Life after treatment may be different, but can be OK.

 

desperate for hope
Posts: 44
Joined: Oct 2016

Thanks Old Salt. 

I searched and was surprised to find that cyberknife is available at a different hospital but as I wrote above, it doesn't seem to be suitable for high risk, according to the company's specs. 

 

Old Salt
Posts: 720
Joined: Aug 2014

SBRT/CyberKnife may not be suitable as a MONOTHERAPY for high-risk patients, but I suggested that it could be part of a 'triple-play" plan of attack:

SBRT + IMRT + ADT.

But if your radiation oncologist advises that surgery would be preferably because of possible bladder neck toxicity from the radiation, I would follow her advice. We are just bystanders without full knowledge of your husband's situation and without a medical education.

 

PS: My situation (also high-risk) was close to that of your husband (Gleason = 9 etc) and my (academic, with many publications) radiation oncologist recommended SBRT + IMRT + ADT. But I was 73, which by itself precluded surgery. So, in that context, my status was different from that of your husband.

desperate for hope
Posts: 44
Joined: Oct 2016

Thank you Old Salt. How are you doing now? It's been 2 yrs since your diagnosis? Am I correct that there are no outcome statistics related to your treatment regime? There are no outcome stats related to RP + EBRT + Adt either. 

It's true but if there is something at the bladder neck, we might not have a choice to make. 

Thank you again for sharing. 

Old Salt
Posts: 720
Joined: Aug 2014

I didn't spend a great deal of time searching the published (medical) literature, but there are at least three papers with data on studies that involved combined therapies (SBRT + IMRT) and high(er) risk patients:

Anwar et al (Radiat. Oncol. 2016)

5-year biochemical failure-free survival = 90% (intermediate and high-risk patients)

Mercado et al (Front Oncol. 2016)

5-year biochemical control rate 82% for high-risk patients

 

Lin et al (Front Oncol. 2014)

92% biochemical failure-free survival for high-risk localized prostate cancer patients

 

Please note that the number of high-risk patients in these trials was rather small, but the overall outlook appears hopeful.

desperate for hope
Posts: 44
Joined: Oct 2016

Thanks Old salt. I'll take a look at those. I have access. Now they have found prostate cancer in the neck of the bladder. A whole new can of worms I think. We are waiting for an MRI. I can't help but continue to be haunted by the fact that all of this was due to my husband's doctor not doing PSA screening during physicals. 

ak61
Posts: 2
Joined: Dec 2016

To answer your question- YES- there have been several studies which compare outcomes of men that have been through the treatments you identified. Two publication websites are journals which publish current data and have been adjudicated for accuracy. 1- The ASTRO journal (American Society of Radiation Oncologists) has published several comprehensive reviews which made significant advancement in treatment recommendations back in June of 2016.  2. Journal of Prostate Cancer Research Foundation, and 3- The National Comprehensive Cancer Network which publishes an easy to use table of suggested therapies, based on results of various tests. An updated NCCN guideline will be published in January of 2017.

My husband ( age 62)  had aggressive PCa,  8 of the 12 cores showed Gleason 8 or 9. He had a 3 pronged therapy. He was in excellent health, muscular and eats a healthy diet. His PCa was confined to the prostate. ADT for 6 months was used to remove testosterone- NO side effects. Next, at 5 months from start of ADT, he had 6 weeks of daily EBRT. 3 months after EBRT he had brachytherapy. Its been 4 years and he is fine, test results are great. Please note, however, that NEW studies show that when PCa is found later in life, 10 year survival is common, even if NOTHING is done. Your radiologist should have all of these studies at his fingertips and should share with you the treatment options based on your husband's test results.  Most alarmists and surgeons instantly promote surgery. This is a false premise that when the prostate is removed all of the cancer goes away.  If you would like the URL's to any of these 2015, 2016 studies, id be happy to send them. Best of luck to your husband.

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