MRI Guided SBRT & Aberaterone question

User

Posted 13 Oct 2021 at 19:17

Hi Folks - I'm currently T3b, N1, M0 - Prostate Cancer spread to Lymph nodes, seminal vesicles and quite a lot in my prostate itself. Here in Hong Kong, have one doctor at the top hospital offering to do MRI Guided SBRT on the lot. I have another doctor saying it can't be done with SBRT and that EBRT is the way to go.. Just wondering if anyone else has had this type of SBRT treatment ? - it looks pretty new (at least the machine does) and I'm wondering how effective it is. Doctor also recommends spaceOar/Hydrogel thing to protect against rectal damage (what fun).

I've also been recommended to go onto ADT and 1000 mg of daily Zytiga (Abiraterone) at the same time, although needless to say my insurance won't cover the £3500-£5k a MONTH cost of Zytiga here !. Doctor here us saying 3 years of ADT and 2 years of Zytiga/Abiraterone... Am now trying to track down some friends in India to try and get my hands on some there, which looks a lot cheaper. Would be interested in anyone else who might have been able to get their hands on some at something approaching a price that isn't going to bankrupt me !

Doctors here seem very good but of course astromically expensive and company health insurance will be quickly maxed out so am trying to see what I can source separately, Am told that bone mass can reduce 5% YoY so to expect to take Calcium, Vitamin D, possibly some steroids. Have been told to keep playing sports, do more gym, etc.

Am a fit 54, just diagnosed with a pregnant wife so trying to see how long I can last/keep working as long as possible ! Will keep eveyone posted in any case. I do see new drugs/treatments seem to be coming up regularly so some hope there for all of us at T3/Stage 4a+ at least.

Thanks, J

User

Posted 13 Oct 2021 at 23:03

So a curative pathway - great news!

SpaceOar / Hydrogel - great idea - do ask them how much cancer they believe is at the front of the prostate (next to the bowel) and whether they consider there is a risk of the SpaceOar preventing the RT getting to all the places it is needed.

SBRT - if you were my husband, we would be going for EBRT on the basis that SBRT is really for small defined tumours and that doesn't sound like it applies to you. However, I would be seeking confirmation that the EBRT is actually IGRT or IMRT. SBRT to the whole lot seems like a misnomer to me. You could also ask whether brachytherapy / EBRT is available in HK.

Abiraterone - unnecessary - and you wouldn't be offered abi or enzalutimide if you were in the UK, if the HT is only to accompany the RT.

3 years of HT is less common now in the UK - research suggests that 18 months is just as effective as 3 years.

Bone density - the HT can reduce bone density but you wouldn't generally be given steroids or Zometa in the UK unless you were on lifelong HT. For 18 - 36 months, it shouldn't be necessary. A healthy balanced diet is always a good thing though.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 13 Oct 2021 at 23:35

I mostly agree with Lyn.

If they're going to target all the pelvic lymph nodes (some of which go around the rectum), which is probably a good idea since you're N1, I'm not sure how much benefit a rectal spacer is. That's something you could ask.

Completely agree on SBRT verses EBRT (which would be IG-VMAT in the UK). EBRT spills outside the target area in a way which is probably advantageous to you, for mopping up micro-mets (any mets too small to show on scans). Brachytherapy boost might be useful to boost the effect inside the prostate and seminal vesicles (needs to be HDR brachy to include seminal vesicles), and this would be done in addition to EBRT at a lower dose, but I'm not completely sure if that makes sense if you're N1.

Abiraterone is offered with neoadjuvant/adjuvant hormone therapy (that's hormone therapy before/after radiotherapy) in many countries now with claimed better outcomes. There was already some evidence that getting PSA lower before radiotherapy improved outcomes and Abiraterone will help with this, but that's probably not the only effect at play. We've known for some time that hitting cancer from several directions at once can help outcomes, and the Abiraterone is another direction.

On the NHS, I managed to get some of this effect (without Abiraterone) by extending my neoadjuvant hormone therapy until my PSA was down to 0.1 - that took me 5 months rather than the 3 months neoadjuvant hormone therapy they originally suggested. This doesn't extend the total time on hormone therapy (indeed, there's research suggesting you can reduce it if you get down to 0.1 before starting RT).

Since you are young and in the process of having a family, you should also look into sperm banking before you start on the hormone therapy.

Edited by member 13 Oct 2021 at 23:38 | Reason: Not specified

User

Posted 13 Oct 2021 at 23:48

Think I would view SBRT as a rifle bullet and EBRT as a shotgun. With quite a large tumour I think I would want it blasting with a shotgun, even if the aim is a little to one side it's still going to get blasted, and assuming you have about 15 to 20 fractions it will get a lot of hits. Of course there will be collateral damage, and the rifle approach would reduce that.

Maybe SBRT would be in addition to EBRT just to pick off the lymph nodes.

I think abiraterone is over the top, yes if the cancer was hormone resistant it would be necessary, but relatively cheap HT should be enough for you. Of course as Andy says if you can chuck a few more things at the cancer then all the better, and if you can get it at an affordable price may be worth adding it but I bet the benefit is marginal.

Dave

User

Posted 13 Nov 2021 at 16:50

Great Post and replies... I'm on a similar journey with T3b but nodes are OK. I've researched and 3rd opinioned and I'm probably going for SBRT rifle shot as tumour is small at 7mm although in lhs seminal vesicle.

Bit worried about acute and long term urinary toxicity as Pace B study only included T1/2 participants. Both Urologists all thought imrt/ebrt was fine with same outcome but Dec 20 Research Paper from various authors incl one from Royal Marsden think adaptive mri real time control and underdosing risks are better handled through sbrt, especially when SVI has occurred... Apparently the SV and Prostate move independently so are difficult to target even with gold fidicial location implants. GL Jono

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User

Posted 13 Oct 2021 at 23:03

So a curative pathway - great news!

Abiraterone - unnecessary - and you wouldn't be offered abi or enzalutimide if you were in the UK, if the HT is only to accompany the RT.

3 years of HT is less common now in the UK - research suggests that 18 months is just as effective as 3 years.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User

Posted 13 Oct 2021 at 23:35

I mostly agree with Lyn.

Since you are young and in the process of having a family, you should also look into sperm banking before you start on the hormone therapy.

Edited by member 13 Oct 2021 at 23:38 | Reason: Not specified

User

Posted 13 Oct 2021 at 23:48

Maybe SBRT would be in addition to EBRT just to pick off the lymph nodes.

Dave

User

Posted 14 Oct 2021 at 07:26

Thanks a lot guys for your replies, that's really helpful. I've sent the doctor some more questions and will keep you posted on his reply/what I choose for treatment plan. So much to learn ! Am educating all friends of 40+ on how important PSA bllod tests etc are !

User

Posted 13 Nov 2021 at 16:50

User

Posted 06 Dec 2021 at 15:35

Hi Folks, FYI, I've just completed 5 sessions of MRI Guided SBRT. Doctor thinks there is a decent chance of cure, despite lymph node and SVI. Eaach session lasts around 1-2 hours and is not a huge amount of fun, but 5 sessions has been a lot more bearable than the 26-41 of IMRT in my view. What I found really interesting in speaking to my oncologist, is that unlike IMRT it seems that you can go back again for follow up radiation if they need to irradiate a lesion (for example). This apparently is due to how precise the beam is.

Incidentally, they are building a Photon machine as well, aparently this is even better in terms of accuracy/dispersion, hopefully I won't need to be anywhere near another LINAC for some time (fingers and toes crossed).

So now I'm back onto Lupron, will keep you posted as to how I go. Happy to answer any questions about my treatment if you have them, Cheers,

User

Posted 06 Dec 2021 at 18:53

Thanks for the information on this Jono. Interesting development. Hopefully all will be well for you now.

I take it when you say they are building a photon machine as well you mean a proton therapy machine?

All the best,

Ido4

User

Posted 06 Dec 2021 at 20:14

Yes Photons are are like the continuous x ray effect as for example used in EBRT or SBRT. Protons are light particle atoms that come under the heading of Hadrons.

Barry

User

Posted 04 Apr 2022 at 11:18

Hi - yes it is actually a Proton Therapy machine.. Supposed to be even more precise at delivering treatment to cancerous areas.. New Hitachi machine is planned to be online at the end of this year...

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