Is there a Brachy boost option with SBRT

Give the results of the ASCENDE-RT trial which (quoting the general consensus) "demonstrated a strong statistical improvement in outcomes for intermediate and high-risk prostate cancer patients when brachytherapy is combined with external beam radiation (EBRT) and hormone therapy (ADT) versus EBRT and hormone treatment alone", I had basically decided to take this route for my high risk Gleason 8 localized PCa.

However, given the strong sentiment here, I also journeyed 2 1/2 hours up to UCLA to consult with Dr. King. While the meeting went well, I don't feel that spending more or less three weeks dealing with LA traffic (even though it's 5 treatments, there over two weeks and then there's the gold seeds and the simulation / planning) is something that I wish to endure. In fact, when the took my blood pressure at UCLA, it was 20 pts higher than it's ever been in my life.

Given that Dr. King would start ADT two months before SBRT, and UCSD wanted ADT three months before IMRT (25 sessions at UCSD), I decided to start ADT while I further ponder SBRT vs IMRT. To this plan, I had my first 3 month Lupron shot two days ago -- so now the clock has started.

I've done more investigation as to who offers SBRT in the San Diego area. It looks like there are three places I could consider. Two are Cyber-Knife equipment, the other True-Beam/Novalis TX (I believe this is whats used by UCLA).

The True-Beam/Novalis TX is with San Diego Radiosurgery which has some type of relationship with Palomar Hospital, which is about 5 miles from my house -- a plus in terms of stress and work schedules. But from everything I can find, this is a pretty small group -- latest technology in a place that doesn't treat lots of high risk patients. I've made a consult appointment (I've hit my out of pocket limit, so all in-network visits are now 100% covered) and will be asking lots of questions -- like who makes the treatment plan (where to radiate, what does, what margins, include the pelvic lymph nodes (King said he would for my case), etc. But a question to the group, is the planning largely automated by the software? Does the RO matter critical to the outcome?

Another San Diego group with SBRT is Genesis Group -- it looks like they are a larger practice / see more patients.

Any forum members have feedback or recommendations on local SBRT treatment facilities?

The best summary study I can find on SBRT is here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638714/

The reoccurrence /biological failure of these SBRT trials for high risk seems higher than that of the ASCENDE-RT trial -- so that begs the question of whether there is any use of Brachy boost to SBRT and/or should there be?

The RO I know in San Diego who does SBRT is Don Fuller. He has been doing it almost as long as Dr King. He uses CyberKnife equipment (but the equipment doesn't really matter.) He also uses a 4-day treatment plan and something called "heterogeneous planning" which more closely simulates HDR brachy. I don't know if he treats high risk patients, however, and I wouldn't do it outside of a clinical trial with its own protocol.

CADogsRUs said...
The reoccurrence /biological failure of these SBRT trials for high risk seems higher than that of the ASCENDE-RT trial -- so that begs the question of whether there is any use of Brachy boost to SBRT and/or should there be?

I don't know how you would know that. The only info on SBRT treatment for high risk comes from Alan Katz, who treated fewer than 100 high risk patients. Dr King treats high risk patients as part of a clinical trial he is running. His goal is 85% bRFS - same as ASCENDE-RT - but it's too early to tell. Here's some info on SBRT for high risk:

/pcnrv.blogspot.com/2016/08/sbrt-for-high-risk-prostate-cancer.html
/pcnrv.blogspot.com/2017/03/sbrt-for-high-risk-prostate-cancer.html

The ROs job is vitally important. The care he takes in working out the treatment plan make all the difference. That means that doses, a variety of dose constraints, and margins must be set. The process is iterative and trade-offs are made. You want an experienced RO (and physicist) who knows how to best do this.

Brachy boost therapy is the tried-and-true for high risk pc. It comes with a higher price tag in terms of expected toxicity compared to a monotherapy. You can do it with either LDR brachy or HDR brachy -- available at either UCLA (Chang) or Cedars-Sinai (Kamrava). You can arrange to have the 20 IMRT part of the treatment done locally.