Phase 2

Boomer…Either surgery or radiation is likely to offer a cure. Focus on the side effects between the two. I would point out that RO’s typically specialize in specific types of radiation treatments so if you’re interested in a specific type look for an RO who does it. For us that required traveling a few hours each way. In the end it was clearly worth the effort. I’d be glad to share any details. Terry

Hello Boomer,

The surgery questions are easy, how many has the doctor done? How many per week? What is his/her results with incontinence and ED? You want to have confidence on the doctors’s track record as robotic surgery is a skill that requires practice to get good at and stay good at.

The RO is bit different but you still want to assess experience level with the treatment types they offer and the equipment used. If you are interested in SBRT or HD brachytherapy then you may have to look harder to find RO’s that specialize on those methods which seem to have good results.

Are you going to Boston for any of your consults? Quite the medical Mecca for those needing attention.

As has been mentioned, I think the key issue for the RO is the type of radiation he/she practices. If it was only IMRT, I'd be reluctant to have that long a course of treatment and instead would be more inclined toward either SBRT or brachytherapy. You will also want to ask about whether you would need ADT, which seems to be a *sometimes* recommendation with a Gleason 4+3 diagnosis. Ask both the uro and RO about SEs!

Good luck to you and let us know how it goes.

Nothing to add except...your definitely do your homework and that will bode well on your journey...good on ya...

Thanks guys. Mumbo, I'll ask about the hypo-fractionated treatments. There's really a lot to learn before I make this decision. Part of me wants to gather all of the information from my meetings with the RO and urologist, find a remote cabin in the woods of NH, VT or ME for a couple of days and go over everything without any interruptions except to eat and sleep (of course).

I would ask the surgeon if he thinks the cancer is organ-contained. If he says "yes," ask why he believes that.

When you talk with the surgeon, I would ask what his/her plans are for bilateral lymph node dissection. Basically you want to know how many they plan to remove, and what would cause them to deviate from the anticipated dissection.

You might also ask whether there will be a pathologist standing by to make sure that surgical margins are clean. Some surgeons have one available but I don't think it's that many.

I'll leave the radiation stuff to others as my husband, back then, wasn't a candidate. He starts salvage radiation next week so we'll see.

Good luck!

It's interesting that he recommended the combo IMRT-brachy treatment, which is typically used in higher risk cases. Generally, as a G7 you would have brachytherapy as a mono-treatment. You are on the more serious side of G7 with your 4+3 diagnosis, so that could be it. But then at the same time, he didn't recommend ADT, which is used with higher risk diagnoses.

This leads me to another question: did you have a second opinion on your biopsy slides? If not, that could be helpful in getting a handle on whether or not your G7 score is 3+4 (favorable intermediate) or 4+3 (unfavorable intermediate). That could help with a decision about the combo radiation treatment. (Although if you decide on surgery, I'm not sure the second opinion would be that helpful.)

And I totally agree with you about the value of having a spouse/partner with you! Glad you have the support and the extra set of ears.

I need to apologize for reporting that the RO was going to use Brachytherapy after IMRT. I read Michael-T's post and I started to question what I may have heard, so I called the RO this morning for clarification. He called me back and explained that he believes that the IMRT will be sufficient in treating my PCa. He stated that he doesn't believe that Brachytherapy would be necessary. So, I want to apologize for confusing everyone and greatly thank Michael-T for his post.
Yes, I have submitted my prostate Bx slides to Johns Hopkins for a second opinion.

Boomer and Michael. I just finished 28 sessions of Hypo-Fractionated radiation. I had 2.5 gy a session. The idea is to deliver a higher dose over a shorter period of time. As I saw from previous posts, some here had IMRT over a longer period of time. Since they have improved RA over time by better focalization of the prostate, higher doses are used. Boomer I am a GL-8, so ADT was added. You still might be a candidate down the road for ADT, but if it hasn’t been mentioned yet, I wouldn’t push for it. My best wishes and the veterans here helped me through the art of keeping the water in or out, LOL, during your daily ritual. Sure is different at first, but becomes routine after a few days. Keep up a positive attitude and see you on the the other side. Surgery or RA, is your choice, then don’t look back. However, RA was pretty easy and with almost no SEs for me.
Jack

Boomer…For both convenience and effectiveness there is a trend a in RT to move to higher dose radiation with fewer fractions. SBRT uses only five fractions with some centers trialing even fewer. I believe the improved accuracy of the treatments makes this possible. It also appears that the higher dose volume of fewer fractions is more effective at controlling the cancer. Medicine is sometimes very slow at change and Doctors practice what they know and have been trained in.

We live close to Pittsburgh where we could only find IGRT with 42 treatments. A little over 2.5 hours driving time we have Cleveland Clinic delivering SBRT. We had a total of eight visits to CCI. The first was to see if I was a candidate and to review my slides which I hand carried. The second was to have my gold markers place. The third was the longest with scans, body cast, tattoos etc. done and visits 4 through 8 the actual treatments. The treatments were every other day M, W, F, M, W. In the end we spent less driving time and expense then driving to Pittsburgh. The actual treatments were non events and most treatment days I could still make my cycling classes at our local YMCA. I found the treatment very convenient and the results incredible. Concord is a relatively short drive to Boston so the availability of some of the very best treatment centers is doable.

Boomer - You may have to meet with yet another RO to get a realistic professional opinion about SBRT. As one of the other posters mentioned, not all RO's are able (or willing) to speak about treatment modalities that they do not deliver. After all, they are salesmen as well as doctors. Why would they "sell" you on a product they can't deliver to you? (Some will be incredibly unbiased, but how can you know which ones they are?)

If "your" RO tells you "Why SBRT? This (whatever he/she can do) is just as good." -- try another doctor.

One of the points in favor of SBRT is that early research found that fewer treatment fractions, each delivering a higher radiation dose, actually afforded superior disease control than the conventional 40-fractions.

The other point in favor of SBRT is that its dosage distribution is technically very close to matching that of HDR (High Dose Brachytherapy), the "best of the best" for dose distribution.

Depending upon the type and brand of machine used for SBRT, the individual treatments can range from about 10-15 minutes up to 45-60 minutes. For comparison, if you have IMRT at 40 fractions, each treatment is about 10 minutes. My own SBRT regimen consisted of 36.25 Gy delivered in 5 fractions of 7.25 Gy each. Each treatment took about 60 minutes total, with 45 minutes of that actually "on the table."

If I come across as biased toward SBRT, I am. I had mine over 5 years ago and I'm still pleased with my choice.