SBRT or IMRT for salvage treatments

Hi Everyone,
It looked like my husband would need to have the Salvage treatments done soon, and we have had consultations with top ROs in both IMRT and SBRT. IMRT has been around for a long time with good track records when SBRT is relatively newer and has not had enough data yet on the recurrence. The treating time is pretty much about the same for both or just a little shorter with SBRT. Radiation doses are higher per session with SBRT than IMRT, so I am worried because nothing will be used to protect the other organs. Because the surgeon didn’t remove or test the lymph nodes at the RP, ROs suggested to having both the prostate bed and lymph nodes radiated 😢. I believe this is called Whole Pelvic Treatments; is that correct? What are the side effects of it? I don't think I have read if anyone here has had SBRT for salvages. I would like to ask for your opinions, pro and con, for these two types of radiation. Also, has anyone had Proton for Salvages? What are the long-term outcomes of Proton treatment?

Thanks for your inputs/comments.

Long term data is difficult to find regarding SRT as so many things have changed in recent years. The best recent summary I found is in this link:

https://www.urotoday.com/conference-highlights/asco-gu-2024/asco-gu-2024-prostate-cancer/149384-asco-gu-2024-salvage-radiotherapy-options-for-biochemical-recurrence-after-local-treatment.html

Best thing to do is find a respected RO that you trust and weigh the alternatives vs. benefits/risk.

I had ART in 2019 and accelerating the RT schedule was not recommended as lower dosage over longer period was the general rule to get best coverage and minimize side effects.

The only difference I have seen with SRT is no one is rushing to do SRT at really low increasing PSA levels. Evidence seems to point to a PSA > 0.20 as time for action but 0.50 is the max. Some studies suggest best results < 0.35.

Thanks all. I just entered the signatures for references. @Djin, thanks, we haven’t looked at Proton but i thought i would asking it here. My husband is 65 now, other than the PC, he is very healthy. Even though his PSA has not yet reached .2, but both ROs that we have consulted with said that treatments can be started now. The RO at the center that he was treated for RP insisted on waiting until PSMA Pet scan showed something, but This scan is not perfect as It still gives negative results at a lot higher PSA. @Mumbo, the RO that my husband talked to at that center has 6 years of experiences and I dont think thats enough. We asked to consult with someone else, but our request was denied and she said we are doctor shopping!

Post Edited (ConfW) : 11/19/2024 3:19:16 PM (GMT-5)

"We asked to consult with someone else, but our request was denied and she said we are doctor shopping!"

That is ridiculous.. A second opinion is a standard medical practice and covered by most insurance. Even third opinions sometimes. Now, if you have seen multiple doctors and she is the last one, I could understand that comment. However, doctor shopping is your choice with the only question being whether insurance covers additional visits at some point. If your insurance says he has to go to this RO then you have a problem.

The standard seems to be PSA >0.20 now for SRT so he may be considered a bit premature to some doctors but the whole medical file would would advise an RO whether it is prudent to start now or wait, different opinions with different doctors?

ConfW - The statistics of SRT are pretty well known and provide reasonable success (60%?), probably a little better if lymph nodes are included. It is quite dependent on classification and risk factors so the RO has to evaluate the whole picture when looking at options. I suspect that most RO’s would recommend SRT at >0.20 with his pathology so that is why you see a couple hoping for confirmation of a plan. Differences have to be reconciled.

It is pretty clear that success rate goes down as PSA increases at some point (>0.35 or >0.50). I do not think there is much information that would support the benefit of waiting for a higher PSA after primary treatment to possibly show something on a PSMA scan given the newness of these scans and lack of history. That does not mean that you skip a PSMA scan at a lower PSA level but at some point have to make then SRT decisions and blaze ahead. The argument is easier after secondary treatment has failed and the solution becomes more difficult. Stay after it with his doctors.

Thanks Halbert and Mumbo. At first, my husband had the same NP for almost a year. She then was on leave so he saw different ones each time, and he feels that they were not productive meetings. The reason we asked to see another RO because we saw his presentations on YouTube recommend salvage treatments to start with 0.1. The radiation department scheduler was the one that refused to give us any appointments with this particular RO. Someone else at this center has suggested us to file a formal complaint. At this time I am not going to delve into all the negatives; I just wanted to focus on our difficult roads ahead. My husband had a meeting with the RO two days ago, and he still wants my husband to wait for the PSMA Pet scan. My husband will be on Medicare next year, and he was told that Medicare will pay for the scan regardless of the PSA reading. Does anyone know if that is true? @Mumbo, only 60% success rate for salvages? I hope my husband will be one in the 60%. All the ROs are suggesting Whole Pelvic treatments, and I am concerned about Lymphomas, but if that is what he needs to improve his chances of success then we have to do it. I would like to hear from others that either have had it done or have knowledge about it. SBRT for salvage is out of the picture now as my husband does not qualify for it because of its toxicity to the urinary. Now we will need to decide between the two, IMRT (37 treatments) or modified hypo-fractionated IMRT (25 treatments). The original IMRT has been around along time so I am more inclined towards it than the modified ones. However I still love to hear your opinions about this newer, hypo-fractionated IMRT. It may be the most successful radiation treatment in the future but with the limited following up, I am not so confident about it.

Thanks Halbert. Yes, we were told to stay away from the Advantages plan, its really a disadvantages one. I have looked at your signature and my husband the same stages as you but you are the luckiest one. Best wishes.

Thanks so much Mumbo. You are always there whenever I posted my questions, I am appreciated your help. So if i understand it correctly, the survival is increased with lymph nodes treatments but the toxicity is higher and in conclusion, there’s no significant improvement. All the doctors we have talked to suggesting that lymph nodes should be treated 😢