Requesting opinions about getting IGRT and seed boost

Welcome George,

I just wanted to expand your options. SBRT (as a monotherapy) has been very effective for intermediate risk cancers like yours. A different kind of brachytherapy, called high dose rate (HDR) brachytherapy is increasingly being used with GS 4+3. The advantage of those over IMRT with a seed boost is that they don't require 5 weeks of IMRT. SBRT is completed in 5 sessions, and HDR brachy is completed in 1 or 2 hospital visits. They are all equally effective.

Thanks Allen and Ed. I don't mind the longer treatment time. My situation is ok going in for that amount of treatments. Because my Gleason is so close to 4+4, my logic is that I might want to treat it like it was higher risk than 4+3. I'm thinking that the overlap of IMRT and seed boost will hopefully prevent any cold spots for cancer to survive, within and around the prostate, as well as the lymph nodes.

Obviously, these decisions are very hard but I need to make a decision. I feel like surgery would be a little like placing a bet that it will be organ contained and a nerve bundle could be spared but if I lose that bet I might end up with no nerve bundles and might not even be able to get an erection with cialas or viagra. The radiation seems to be the middle of the road choice.

ED predictions in books and on websites say radiation and surgery are the same in 5 years for surgery but some people I talked too in the medical industry seem to think the outcomes are more consistently decent with radiation because there is less change of total ED, which happens to people who have both bundles removed during surgery.

I'm not sure what to believe but this is the info I have to work with right now.

Allen and Ed, I appreciate your thoughts and I am happy to hear that your results have been good. Allen, has your ED deteriorated much in five years since treatment? I'd be fine if I could get erections using cialas or viagra.

George

Thanks Allen, I really appreciate the information. Anecdotal evidence - reading the prostatectomy forums on HW show some men who are very unhappy about their ED but I don't read nearly as much of these accounts from the radiation forums. Granted, it may not be scientific evidence but it may be an indicator.

The study results you sent me support my intuitive assumption based on previous analysis and discussions with doctors etc.

If I live into my 70s then I would probably have worse side effects from radiation but I am seeking a little higher QOL in the next 15 years. Because the long term outcomes of surgery vs radiation seems to be pretty close in outcomes I will probably go with the IMRT seed combo.

thanks again,
George

Thanks Andrew, When you say bad bowel issues, does that mean pain in the rectum, or urgency to deficate, or something else? My doctor thinks the likelihood of that is very low because the IGRT is so accurate. From what you are saying, it may not be as accurate as the claims state.

thanks,
George

I had internal hemorrhoids prior to RT and it got worse post RT. Pain, pain while having a bowel movement, constipation, bleeding, burning, etc. I think if I had received laser treatment for the hemorrhoids before RT, it wouldn't have gotten so bad.

Most guys don't get it as bad as I did and your doctor is likely correct in your case. If you had any concerns you could get a colonoscopy before your treatment.

During treatment you can expect to have minor issues that will likely clear up once treatment is over. Mostly during treatment I had some lose bowels, some bleeding and learned not to trust a fart.
Andrew

I'm doing HT, IGRT and HDR Brachy boost. Lots of data showing good outcomes with this.

Tom

ED....viagra, hmm no nerves it does not help...initially tried Trimix, some response. Stop for sometimes cos more important treatments came in...SRT....then hernia surgery. Currently recovering from hernia surgery. Surgeon advice me, need 3 mos before can go for some lifting exercises...lol.
Yah...u r rite, RALP delaying the HT treatments.
My thought....high risk, hit it hard.

George,

If you want a free second opinion consultation, Dr. Dattoli (or his partner Dr Sorace) will review your PSA history and your biopsy results and tell you how he would treat you. He has published results of an 82% "cure" rate for intermediate and high risk patients. I highly recommend him. He treats patients like you with external beams followed by brachytherapy and a "boost" of external beams after that.

I just finished 45 treatments for recurrence 2+ years after DaVinci. I have hemorrhoids and diverticulosis. My rectal SEs were urgency to deficate. This is almost gone three days after my last treatment.

He requires a colonoscopy that is not older than 5 years.

Here is a link to his published report from 2010. He says he could update the report but does not expect a change in the findings or believe it is worth the expense of independent verification of his data:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2933915/

Here is a post I made earlier:

I had a DaVinci RP at Huntsville Hospital in AL. The doctor did a good job as far as side effects is concerned, and I had a clean pathology report...but some cancer cells were left where he sewed the urethra back together (not uncommon). I was PT2C, Gleason 7 downgraded to a Gleason 6 in the pathology report. Two years later my PSA was rising. My urologist was proactive and I obtained a referral to the Dattoli Cancer Center in Sarasota FL. My PSA was .046 before radiation therapy.

Dr. Dattoli consulted with me by phone for free. He was very generous with his time, I think we had a 45 minute conversation.

His published 16 year results in curing intermediate (157) and high risk (164) PCa patients (PSA < .2 ng/ml, nadir +2) published in the Journal of Oncology Volume 2010, Article ID 471375, is 82% (using the technology available then). The data and slides were independently evaluated before publication. These results were derived by combination brachytherapy and external beam radiation. He has evolved his treatments to their current state of the art; Dynamic Adaptive Radiation Therapy that include precise methods to target the suspect tissues while minimizing injury to adjacent tissues.
To the best of my knowledge, this is the highest published cure rate in the world for higher risk patients. And this was with old technology! Dr. Dattoli told me he could follow up with these patients but since the data flatlines at 82% from 10 to 16 years the costs would outweigh the benefits. He expects no change in the data. Dr. Dattoli is constantly studying the best treatment protocols and has the newest technology available.

Dr Dattoli treated Dr. "Snuffy" Myers, the renown Medical Oncologist for his advanced PCA in a lymph node. Dr. Myers definitely knows who the best radiation oncologists are. I think that was 15 years or so ago, and Dr. Myers is in enduring remission (he does not use the word "cure".

So, my choice for salvage radiation therapy was easy. Getting all the pieces to fall into place was a challenge since I had to get all the tests done and find a place to stay (thank you Craigslist). Insurance was not a problem since Dr. Dattoli accepted my Tricare insurance and Medicare. Hooray! My co-pay was actually $200 less than I was expecting. Dr. Dattoli's staff sent me an information packet that helped me find affordable housing and included things to do in Sarasota FL.

I can't recall how many vials of blood the vampires (kidding) took so Dr. Dattoli could evaluate my baseline before treatment ( I think it was more than 10). He is very thorough in everything he does.

I received a Color Flow Doppler Ultrasound test my first day that identified increased blood flow where my Urologist stitched my urethra back together (likely PCa site). Dr. Dattoli has his own CT scanner and lab. The CT scanner identified a couple of enlarged lymph nodes. He told me these sites would be his focus for the radiation treatments.

When all the tests are complete, Dr. Dattoli and his partner, Dr Sorace jointly develop a treatment plan. I had 45 treatments plus 1 year of ADT (hormones mostly, but Dr. Dattoli agreed to my request for Metformin and Celebrex immediately).

I met with the lead Dosemetrist (sp?) who showed me the treatment plan on her computer. The computer fuses data from CT and other scans (e.g. USPIO nanoparticles with MRI provided at Sand Lake Imaging in Orlando and f18 PET scans). I did not have the more expensive scans. The site where the scans indicated probable cancer ( I had no biopsies) were clearly outlined in the plan.

They used an expanding foam "cradle" to keep my legs in the exact same position for each treatment, aligned my body using lasers for each treatment, and taped a sensor on my stomach to monitor my breathing during radiation to maximize the beams' accuracy.

The side effects I had were: nausea the first 3 weeks from the medications, more frequent, slight burning when I urinated and urgent need to evacuate my bowels the last week (better find a potty in the next 20 minutes). I met with a nurse once a week where we reviewed my side effects and effective remedies. Of course, I will have the side effects from ADT for at least a year.

Dr. Dattoli has a foundation for brachetherepy research where he provides education classes every Tuesday tailored to PCa patients. I attended the exercise, nutrition and dosemetry classes. The lecturers were professionals in their field. They were excellent. He also has DVDs you can check out of symposiums he and Dr. Myers have presented.

There were 3 men I met there out of about 30 who were locals (Sarasota or Tampa). The rest were from out of state, including one man from Mexico City. I was out of my element parking my Ford Ranger pickup next to the expensive European cars.

Those who have PCa metastisis need to know that Dr. Dattoli will treat your mets if they are less than 5 (ogliometastatic disease). He questions why we treat localized cancers that go to lymph nodes (like breast cancer) but give up on similar PCA patients. He and Dr Myers partner with Sand Lake Imaging to evaluate advanced PCa with MRIs that use fereheme contrast (an iron nanoparticle that costs $1500 and not covered by most insurance). He reviews the data on every patient periodically and constantly seeks ways to improve his treatment protocols. He is working to get FDA approval for the fereheme scan. I met 2 patients with bone mets who he was treating. There is an excellent Youtube video where he discusses this.

In the off chance I develop bone mets, I will seek treatment with Dr. Dattoli again.

I highly recommend Dr. Dattoli and his crew. If finances are a concern, consider that I was able to complete the treatment for about $2000 out of pocket, including lodging in a private home. A bargain!

Thanks Domino, good information. I have read that study before that yielded 82%. I will contact them and see if I could make it happen. I don't have a lot of flexibility with my insurance. My current hospital for active duty military is walter reed hospital. I don't think they use dart but it does seem like they have good machines that were installed during the past couple of years. The doctor said that the prostate hardly ever moves during treatments so the adjusting machines really aren't necessary. He also said they usually don't target the lymph nodes because it irradiates too heavily in the surrounding tissue. Do you know anything about these topics?
Thanks
George

Thanks Allen, great information.

George