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RT + LDR Brachytherapy

User
Posted 03 Jan 2024 at 20:19

Diagnosed Tb3a N0 M0 Gleason 4+3 PSA 71.

Prostatectomy not available due to extra capsular extension. Treatment plan is hormone blockers (been on it for 2 months now) followed by radiotherapy, followed by Brachytherapy (didn’t ask whether LDR or HDR was advised).

 

I understand that the normal route is hormone blockers / radio / Brachy. My question is - is Brachytherapy worth the risks / benefits ? Is Radio on its own good enough ? Is Brachy on its own good enough ? If Radio turns out to be not good enough further down the line, can Brachy be instigated if / when PSA starts to rise ? In other words, do I really need Brachy *now*.

 

I have to say that these forums have helped me enormously and I thank you all for all of your the posts !

 

 

Edited by member 01 Jun 2024 at 06:15  | Reason: Not specified

User
Posted 03 Jan 2024 at 22:59

I had a similar diagnosis to you (but PSA 25). I think you will get HDR, but you need to check that. My advice would be the same whether it is HDR or LDR though.

The order for mine was Brachy, EBRT but they can be swapped around. 

The short answer is you need both at the same time. 

The long answer is that there is a lifetime limit to how much RT your body's healthy cells can take. An oncologist will not risk giving you more than that limit, but equally will not risk giving you less than the that limit. It has to be killed, so no half measures.

Most of the cancer is in your prostate, but some is outside, and it may be further than just the Extension, so you need a moderate dose outside the prostate. Brachy puts the radioactive source in the prostate, each source has a range of about 3mm, so with multiple sources they can irradiate the whole prostate with a lot of radiation, whilst leaving anything more than 3mm from the prostate untouched. The EBRT can then further irradiate the prostate and the surrounding area with a much lower dose sweeping up any cancer outside the prostate.

Cancer always has some active cells and some dormant cells, the dormant cells will become active within about a week. Hitting the dormant cells with radiation does not harm them, so you need the RT spread out over at least a week so they will all have been active at some time during treatment. Leaving a long gap between Brachy and EBRT (either way around) would allow the unharmed dormant cells to become active and then regenerate. You would then have cancer, but have used up all your lifetime limit of RT.

You need the brachy *now*

Edited by member 04 Jan 2024 at 12:35  | Reason: Not specified

Dave

User
Posted 04 Jan 2024 at 12:06

Hi and welcome to the club.

My prostate cancer was picked up on a private medical for the renewal of my 7.5 ton driving licence in April 2016 with PSA 2.19 and Gleason 3+4 =7.I was offered robotic surgery at my first meeting but i asked to speak to another specialist about the options of Brachytherapy. I joined this site and asked questions and read up on both options and i felt that Brachytherapy had lesser side affects than robotic surgery.

The Brachytherapy was an easy procedure in and out over two days with little pain just pain killers if i needed them. I had PSA tests every three months for a year and as it was dropping at a good rate i later went over to yearly ones. I am seven years on and was signed off in 2020.If you click on my Avatar you can see my journey so far.

John.

 

Edited by member 04 Jan 2024 at 16:59  | Reason: change end date

User
Posted 04 Jan 2024 at 23:39

The treatment you describe is called Brachytherapy Boost (or HDR Boost or LDR Boost).

It combines the advantages of the two treatments...

External beam radiotherapy spills outside the prostate so it mops up micro-mets (mets too small to show on scans) which would be missed by prostatectomy or brachytherapy and cause recurrence.

Brachytherapy, because it's delivered directly into the prostate without passing through other tissues and has only a very short range, can deliver a higher effective dose into the prostate than can be done with external beam radiotherapy without causing extra side effects.

Brachytherapy Boost delivers around 60% of the standard external beam radiotherapy dose plus about 50% of the standard brachytherapy dose to the prostate and can include the seminal vesicles too if necessary (exact figures may be varied by patient). I had this treatment and I elected to have the external beam radiotherapy include all my pelvic lymph nodes too just in case there were any micro-mets in them (which is also done at 60% of the dose it would have been if there was known cancer in them). 4½ years after treatment, I would almost not know anything had been done (although I can't guarantee that for you).

LDR boost is quite rare but it can be done. LDR brachy can't be used above a certain Gleason score (because it takes 200 days to treat and you don't want to wait 200 days to finish treatment with an aggressive cancer), it has a max prostate size of around 55cc, and it can't treat T3b, all of which can be treated by HDR brachytherapy. HDR brachytherapy is not so good with small/normal prostates, but handles large prostates fine.

Edited by member 05 Jan 2024 at 10:14  | Reason: Not specified

User
Posted 04 Jan 2024 at 15:48

Hi Goose,

I think John had LOW DOSE Brachy given that he had low-intermediate cancer at diagnosis. You would be getting I think the HIGH DOSE brachy which is delivered over a much shorter term and more potent given that your cancer is at a more advanced state.

Hope that helps.

Edited by member 04 Jan 2024 at 15:49  | Reason: Not specified

User
Posted 04 Jan 2024 at 16:22

Hi G oose , I only had Low dose Brachytherapy and no other treatment. Also 5 out of 20 samples taken positive.

John.

Edited by member 04 Jan 2024 at 16:23  | Reason: Not specified

User
Posted 04 Jan 2024 at 21:56

Hi Gooose, 

I’ve just come home today from having HDR brachytherapy and I saw your post and thought I’d reply 😬. The whole procedure was done whilst I was put out with the fairies - I actually really appreciated and enjoyed an excellent rare and uninterrupted sleep under the anaesthetic.
I’m T3A N1 M0, Gleason 4&3, PSA 9.1 in May 2023 down to 0.34 in Nov. I think they decided to throw the kitchen sink at mine as I’ve been on HT (bicalutamide followed by Prostap) for 6 months and will continue for 3 years. I’ve also had 6x3 weekly chemo (docetaxel). 
Followed by RT which is the only treatment where I was offered options either HDR Brachy followed in 2 weeks time by 4 x 5 days EBRT or EBRT on it’s own. I treated it as a personal choice based on all the facts and advice I could get. My approach is to be ‘in for a penny in for a pound’, the HDR Brachy made a lot of sense in terms of how effective it appears to be. I also accept that the list of side effects from all these things is hugely impacting i.e. none of the treatments offer ‘no risk of side effects’. Strangely, it is the hot sweats from HT at night that I’m currently suffering from most and they wake me up constantly affecting my quality of sleep big style - making me tired. Also wakes the wife up, she says it’s like being in bed with an oven.

Anyway, I found the brachy experience relatively straightforward, even the catheter bit of it was fine. I drunk several jugs of water and filled the bag several times over (a good experiment 😁) and I had a laugh with the nurses comparing the bag emptying tactics with that of Nana’s into the sink in the Royce Family. Worst bit though was being kept awake all night from the constant loud moans of one of the other patients on the ward, TBF he did seem to be in a lot of pain, I don’t think his was prostate. I was grateful that I remembered to equip myself with a fully charged IPod to blot out the noise. (Those nurses are saints to put up with all this 😊).

Good luck Gooose with your decision making and treatment.

Spongebob

User
Posted 05 Jan 2024 at 04:30

I had RT [with HT] alone without brachy for a G9 with 3 local lymph nodes and 3 years later all is well. It might depend on the RT equipment and computer guidance systems available in your hospital to determine if RT without brachy would be a good option.

I haven't seen a discussion here on the topic of different RT equipment but LINACs seem to be the latest. In a way the RT is the tip of the iceberg in that these machines are backed by massive computer power, several back-room technicians and a raft of monitoring screens.

Technological advance has been very rapid for radiotherapy, so it's probably worth checking out what your hospital has in place.

Jules

Edited by member 05 Jan 2024 at 04:31  | Reason: Not specified

User
Posted 06 Jun 2024 at 12:15

Well done buddy and good luck. 👍 

Edited by member 09 Jun 2024 at 15:16  | Reason: Typo

User
Posted 09 Jun 2024 at 15:06

Great news welcome to the Brachy club i was feeling lonely on here.Long may it last.

John.

User
Posted 09 Jun 2024 at 17:38

Well done.

The LDR brachy will still be treating - it takes 200 days for Iodine 125 to drop below the effective minimum treatment level, although because most of the dose is up-front due to the way radioactivity decays, at 150 days, you've had around 93% of the dose already.

User
Posted 08 Jul 2024 at 13:19

At this stage, most of that low level is due to the hormone therapy. That masks the effect of the radiotherapy.

It will be around a year after you finish the hormone therapy that you will see the level due to the radiotherapy. It is unlikely to be that low, and you do expect a bit of a rise as your Testosterone comes back.

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User
Posted 03 Jan 2024 at 22:59

I had a similar diagnosis to you (but PSA 25). I think you will get HDR, but you need to check that. My advice would be the same whether it is HDR or LDR though.

The order for mine was Brachy, EBRT but they can be swapped around. 

The short answer is you need both at the same time. 

The long answer is that there is a lifetime limit to how much RT your body's healthy cells can take. An oncologist will not risk giving you more than that limit, but equally will not risk giving you less than the that limit. It has to be killed, so no half measures.

Most of the cancer is in your prostate, but some is outside, and it may be further than just the Extension, so you need a moderate dose outside the prostate. Brachy puts the radioactive source in the prostate, each source has a range of about 3mm, so with multiple sources they can irradiate the whole prostate with a lot of radiation, whilst leaving anything more than 3mm from the prostate untouched. The EBRT can then further irradiate the prostate and the surrounding area with a much lower dose sweeping up any cancer outside the prostate.

Cancer always has some active cells and some dormant cells, the dormant cells will become active within about a week. Hitting the dormant cells with radiation does not harm them, so you need the RT spread out over at least a week so they will all have been active at some time during treatment. Leaving a long gap between Brachy and EBRT (either way around) would allow the unharmed dormant cells to become active and then regenerate. You would then have cancer, but have used up all your lifetime limit of RT.

You need the brachy *now*

Edited by member 04 Jan 2024 at 12:35  | Reason: Not specified

Dave

User
Posted 04 Jan 2024 at 12:06

Hi and welcome to the club.

My prostate cancer was picked up on a private medical for the renewal of my 7.5 ton driving licence in April 2016 with PSA 2.19 and Gleason 3+4 =7.I was offered robotic surgery at my first meeting but i asked to speak to another specialist about the options of Brachytherapy. I joined this site and asked questions and read up on both options and i felt that Brachytherapy had lesser side affects than robotic surgery.

The Brachytherapy was an easy procedure in and out over two days with little pain just pain killers if i needed them. I had PSA tests every three months for a year and as it was dropping at a good rate i later went over to yearly ones. I am seven years on and was signed off in 2020.If you click on my Avatar you can see my journey so far.

John.

 

Edited by member 04 Jan 2024 at 16:59  | Reason: change end date

User
Posted 04 Jan 2024 at 12:42

Thanks John. So pleased to see you've made a full recovery.

 

I was not keen on RP, and but for me it isn't an option anyway. Did you have Brachy before or after RT? What was the time span between the two treatments?

 

It's easy to read up and understand hormone blockers / RT / Brachy etc, but I couldn't understand the if / then / not / why. Daves explanation above is brilliant and now I completely understand.

 

Just waiting on the results of the PSMA PET scan and if that's clear, we're on!

User
Posted 04 Jan 2024 at 15:48

Hi Goose,

I think John had LOW DOSE Brachy given that he had low-intermediate cancer at diagnosis. You would be getting I think the HIGH DOSE brachy which is delivered over a much shorter term and more potent given that your cancer is at a more advanced state.

Hope that helps.

Edited by member 04 Jan 2024 at 15:49  | Reason: Not specified

User
Posted 04 Jan 2024 at 16:22

Hi G oose , I only had Low dose Brachytherapy and no other treatment. Also 5 out of 20 samples taken positive.

John.

Edited by member 04 Jan 2024 at 16:23  | Reason: Not specified

User
Posted 04 Jan 2024 at 21:56

Hi Gooose, 

I’ve just come home today from having HDR brachytherapy and I saw your post and thought I’d reply 😬. The whole procedure was done whilst I was put out with the fairies - I actually really appreciated and enjoyed an excellent rare and uninterrupted sleep under the anaesthetic.
I’m T3A N1 M0, Gleason 4&3, PSA 9.1 in May 2023 down to 0.34 in Nov. I think they decided to throw the kitchen sink at mine as I’ve been on HT (bicalutamide followed by Prostap) for 6 months and will continue for 3 years. I’ve also had 6x3 weekly chemo (docetaxel). 
Followed by RT which is the only treatment where I was offered options either HDR Brachy followed in 2 weeks time by 4 x 5 days EBRT or EBRT on it’s own. I treated it as a personal choice based on all the facts and advice I could get. My approach is to be ‘in for a penny in for a pound’, the HDR Brachy made a lot of sense in terms of how effective it appears to be. I also accept that the list of side effects from all these things is hugely impacting i.e. none of the treatments offer ‘no risk of side effects’. Strangely, it is the hot sweats from HT at night that I’m currently suffering from most and they wake me up constantly affecting my quality of sleep big style - making me tired. Also wakes the wife up, she says it’s like being in bed with an oven.

Anyway, I found the brachy experience relatively straightforward, even the catheter bit of it was fine. I drunk several jugs of water and filled the bag several times over (a good experiment 😁) and I had a laugh with the nurses comparing the bag emptying tactics with that of Nana’s into the sink in the Royce Family. Worst bit though was being kept awake all night from the constant loud moans of one of the other patients on the ward, TBF he did seem to be in a lot of pain, I don’t think his was prostate. I was grateful that I remembered to equip myself with a fully charged IPod to blot out the noise. (Those nurses are saints to put up with all this 😊).

Good luck Gooose with your decision making and treatment.

Spongebob

User
Posted 04 Jan 2024 at 23:39

The treatment you describe is called Brachytherapy Boost (or HDR Boost or LDR Boost).

It combines the advantages of the two treatments...

External beam radiotherapy spills outside the prostate so it mops up micro-mets (mets too small to show on scans) which would be missed by prostatectomy or brachytherapy and cause recurrence.

Brachytherapy, because it's delivered directly into the prostate without passing through other tissues and has only a very short range, can deliver a higher effective dose into the prostate than can be done with external beam radiotherapy without causing extra side effects.

Brachytherapy Boost delivers around 60% of the standard external beam radiotherapy dose plus about 50% of the standard brachytherapy dose to the prostate and can include the seminal vesicles too if necessary (exact figures may be varied by patient). I had this treatment and I elected to have the external beam radiotherapy include all my pelvic lymph nodes too just in case there were any micro-mets in them (which is also done at 60% of the dose it would have been if there was known cancer in them). 4½ years after treatment, I would almost not know anything had been done (although I can't guarantee that for you).

LDR boost is quite rare but it can be done. LDR brachy can't be used above a certain Gleason score (because it takes 200 days to treat and you don't want to wait 200 days to finish treatment with an aggressive cancer), it has a max prostate size of around 55cc, and it can't treat T3b, all of which can be treated by HDR brachytherapy. HDR brachytherapy is not so good with small/normal prostates, but handles large prostates fine.

Edited by member 05 Jan 2024 at 10:14  | Reason: Not specified

User
Posted 05 Jan 2024 at 04:30

I had RT [with HT] alone without brachy for a G9 with 3 local lymph nodes and 3 years later all is well. It might depend on the RT equipment and computer guidance systems available in your hospital to determine if RT without brachy would be a good option.

I haven't seen a discussion here on the topic of different RT equipment but LINACs seem to be the latest. In a way the RT is the tip of the iceberg in that these machines are backed by massive computer power, several back-room technicians and a raft of monitoring screens.

Technological advance has been very rapid for radiotherapy, so it's probably worth checking out what your hospital has in place.

Jules

Edited by member 05 Jan 2024 at 04:31  | Reason: Not specified

User
Posted 06 Jun 2024 at 12:09

Well, here I am, 5 months later having had 46Gy RT and 110Gy LDR Brachytherapy. That’s a LOT of radiation. Primary treatment complete, now just need to hope and pray it’s worked !

User
Posted 06 Jun 2024 at 12:15

Well done buddy and good luck. 👍 

Edited by member 09 Jun 2024 at 15:16  | Reason: Typo

User
Posted 09 Jun 2024 at 15:06

Great news welcome to the Brachy club i was feeling lonely on here.Long may it last.

John.

User
Posted 09 Jun 2024 at 17:38

Well done.

The LDR brachy will still be treating - it takes 200 days for Iodine 125 to drop below the effective minimum treatment level, although because most of the dose is up-front due to the way radioactivity decays, at 150 days, you've had around 93% of the dose already.

User
Posted 08 Jul 2024 at 13:03

So, on Friday, I had a PSA test. This was 6 weeks after EBRT and 5 weeks after LDR Brachytherapy. I'm told it's unusual to have the test so soon after radiation, but this was at my request, to which the Oncologist kindly agreed.

The result has come in at PSA <0.025 !!! I asked the nurse to check the result 4 times and also read back my NHS number and DoB. There was no mistake, <0.025 !

How is this possible ? I'm on Zoladex and Bicalutamide for complete androgen blockade. 

Im very pleased, in fact I'm over the moon ! But something in the back of my mind is questioning the future since further reductions due to RT & BT effects aren't possible. Any thoughts ?

Many thanks.

User
Posted 08 Jul 2024 at 13:19

At this stage, most of that low level is due to the hormone therapy. That masks the effect of the radiotherapy.

It will be around a year after you finish the hormone therapy that you will see the level due to the radiotherapy. It is unlikely to be that low, and you do expect a bit of a rise as your Testosterone comes back.

User
Posted 08 Jul 2024 at 13:52

Thanks Andy. I'm still in shock (in a good way). Over thinking things has always been my speciality. Thanks again.

 
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