Minor Q: Salvage Radiotherapy - Morning or Afternoon

I have a fairly high stress job, where "regular" expected hours is more than "standard". So I will ask for reduced hours, not only due to need for daily appointments, but also so the expectation is set with my employer that health comes first, and I will need a reduced work load.

I think I may ask for afternoon sessions, as it's easier to set expectation that I need to stop work at a certain time to go to my appointment, and then I wouldn't check e-mails or work again for the remainder of the day.

So I start my treatment on Tuesday! Extremely quick as I was in the system before COVID19 slowed inflow of new patients and lead to cancellation of many procedures and tests. I only had my higher PSA result at the end of April, and will be starting radiation treatment within 1.5 months.

Since then I've had Bone Scan, CT Scan, Ultrasound (to double check a lesion in one kidney unrelated to prostate), and clinical trial for the latest PSMA PET 18F-DCFPyL scan -- all negative. Had my planning CT scan and tattoos on Tuesday, and starting treatment next week.

I'm pretty regular with my bowel movements, so no mini enema required. They told me I'm well hydrated as my bladder was too full for the planning scan after drinking the required amount of water, so they did two takes of the planning CT scan, the second one after I let some urine out to get the bladder to a more comfortable size. They suggest I drink a little closer to the appointment time to be more comfortable.

Unlucky to have PC, and that surgery alone is not sufficient. But feel fortunate to be getting top care very quickly. .

Had my first salvage radiation session yesterday.  

Dave's post made me curious about full bladder vs empty bladder,  so I asked the radiation therapist why they want full bladder.  She said a full bladder pushes the small intestine further away from the prostate bed.  

When I got home,  did some internet searches and it seems three possible protocols are:

(1)  Full bladder with exact instructions on how much you drink and when.  Can take more time if bladder too full, or not full enough.

(2)  Comfortably full bladder (less precise instructions).

(3)  Empty bladder (as Dave said easy for patient, and staff as well).

Some studies suggests there is no statistically significant difference in results.    Other studies prefer the exact protocol.    

Hi, I was treated at Christie's in Manchester. HDR Brachy followed a week later by 37.5 Gy in 15 sessions of EBRT, so it was primary RT.

I am fairly certain that everyone at Christie's had the empty bladder protocol. The treatment machines was a VersaHD. after lying on table and getting tattoos lined up they usually did an imaging scan (everytime in first week less so in latter weeks) before treatment. Maybe the imaging and reasonably modern machine means that the radiation can be targeted sufficiently accurately that the lifting of prostate from bladder/intestine is not too important compared to being able to get the patients in and out fast with little messing around.

Perhaps the fact the EBRT was only about half the regular dose for EBRT alone made protecting other organs less critical.

At Mount Vernon, around 80-90% of us had to full bladders and the rest empty bladders. Empty bladder scrunches up near the prostate, whereas full bladder tends to push most of the bladder away and push small intestine further away. I guess it depended on the treatment pattern, and maybe if the seminal vesicles were being treated too. It was explained at the teach-in beforehand that different people need different protocols. I wish I'd asked about the difference at the time, because I've been asked about it several times since then.

Janus, thanks very much for asking, and the reply makes perfect sense.

Mount Vernon do the precise positioning every treatment too. They insert gold markers for patients having just external beam radiotherapy, which are lined up using a pair of X-rays. However, they do a lot of combined EBRT and HDR Brachytherapy, and if you're having HDR, you can't have the gold markers (they get in the way). In that case, the precise alignment is done using a Cone Beam CT scan (CBCT) instead of the X-rays. That takes longer and they can't treat as many people per hour on the LINACs when they need CBCT scans each time.

I had HDR too, so I had the CBCT scans, and not the gold markers.

The barcode scanner is part of the Varian patient management system which lots of hospitals use. Same at Mount Vernon, and it tells you which of their 9 LINACs you will be on that day. The drinking protocol was you were told to start drinking about 30-40 before they thought you'd go in. For prostate cancer patients, it was a litre. You let them know exactly what time you finish drinking. I would go for a pee first so I had a known starting point. You were supposed to have at least 300ml in your bladder. On one occasion, I was told to go out and have a fart and come back again - not easy when you have a full bladder you are trying not to lose, and no sense of needing to fart, but somehow I managed it.

We had a stage 3a in your scheme - adjust the table offset from the tattoos same as was necessary for yesterday's treatment. Treatment took 2 mins - two complete revolutions of the LINAC head, 1 minute each. (This is not to be confused with the CBCT scan beforehand, which took another revolution of the LINAC head.) This was for a 2Gy dose. Some people had 3Gy doses - don't know if they got 3 complete revolutions, or if the beam ran at a higher power.