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Nev Black

Hydrogel for men who undergo radiation treatment for prostate cancer.

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Nev Black

On our telephone meetings some men tell of their experience with radiotherapy treatment for their prostate cancer. As optimal tumor control rates can only be achieved with high local doses, associated with a considerable risk of rectal toxicity, their personal experiences can vary considerably.

I noticed an overseas clinical trial being conducted on the use of Hydrogel, as a spacer, with radiotherapy treatment of prostate cancer.

The link below shows one clinic apparently using Hydrogel in Australia.

https://www.cancer.com.au/prostate-hydrogel

As I have never had radiation and I may be a little naïve, maybe a spacer of some kind has always been used.

I welcome comments from men who have had radiation treatment for prostate cancer with or without Hydrogel.

 

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Sean

Hello Nev

I had High Dose Brachytherapy in Sep just gone followed by 28 External beam radiation sessions. I was aware of Hydrogel and asked if it was used at Alfred Hospital here in Melbourne and was advised no

Its early days for me but i have not had any severe side effects 

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kujhawk1978

I had 39 treatments to my prostate bed (salvage radiation therapy) when my prostate cancer came back 18 months after my (very successful) surgery with a PSA of .2 then 90 days later, .3.

 

My radiologist used the Rapid Arc IMRT, total dosage was 70.2 Gya. I experienced no urinary or bowel side affects (so far, started in March 2016, finished in May 2016).

 

Kevin

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markg

I had radiotherapy recently, and had Hydrogel before.This was done in August this year. My radiotherapist ( who did the procedure) described it as a two part mix which forms a soft gel mix when they are inserted into the are at the front of the rectum and the rear of the prostate. This was done under a short general anaesthetic, and at the same time small gold markers were placed on the edges of the prostate to achieve better visualisation during treatment. The gel is designed to give an extra 3 mm clearance between the prostate and the rectum to reduce possible rectal side effects. I had a total of 20 treatments ( 60 Gy ) to the prostate. On about day 6 I had a small amount of mucous which soon settled and no symptoms since. It seems like a good idea, if it is available. I had mine done at RNSH in Sydney and the team there had done about 20 Hydorgels before mine.

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Barree

Hi Neville,

SpaceOAR or Hydrogel is available in a few hospitals in Melbourne.Dr Andrew See at Epworth Richmond has been running trials of SpaceOAR for quite some time and the results both here in Australia and in other countries are shaping up well - but the economics of SpaceOAR are somewhat questionable.In the case of the trials being done in Australia Hydrogel is made available as part of the trial but I don't think its available on the PBS.

Is it worthwhile to treat all patients? 

The cost of the SpaceOAR hydrogel injection is about $2,500. IMRT patients should not expect any amelioration of bothersome acute rectal symptoms. A cost/value analysis depends upon which toxicity numbers one wants to focus upon.

  1. Even if the difference were statistically significant (and it’s not), only 2.2 percent of patients would avoid bothersome late-term rectal symptoms by using the gel. So to spare one patient bothersome rectal symptoms, 45 patients would have to be treated at a cost of over $90,000.

  2. If we focus on the late-term toxicity improvement, 6 percent avoided late-term grade 2 or higher rectal symptoms by using a spacer. To spare one patient such symptoms, 17 patients would have to be treated at a cost of $42,500.

  3. If we use the 2× MID difference as our guide, 16 percent would avoid low grade late-term rectal symptoms. So to spare one patient those symptoms, 6 patients would have to be treated at a cost of $15,000.

Some would argue that even though the symptoms are relatively mild, late-term symptoms are often longer lasting. Each patient has to decide for himself. Patients who are interested should obtain pre-approval from their health insurance provider. The SpaceOAR hydrogen formulation has been provisionally approved by Medicare in the USA, but Medicare approval in Australia might be a long way off.

 Acknowledgement: This extract is a small part of  an article which appeared in - The “New” Prostate Cancer InfoLink, who thanked Dr. Daniel Hamstra for allowing them to review the full text of the paper, and to respond to questions. Full details can be found in “New” Prostate Cancer InfoLink.

Note the “New” Prostate Cancer InfoLink is published in the USA. The cost of SpaceOAR in this article is quoted in US currency but it is a guide as to what the cost will be in Australia.

 

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Skipper

This is a subject close to my heart having received a RP some 12 weeks ago I have healed well and am fully continent as of about 6 weeks.

However, I am told I have a 2.5mm positive margin in my bladder (I believe) after discovery that the cancer had spread into the bladder and their best attempts at removing it all during the surgery. Currently I have no detectable PSA but have a January appointment to speak with a radiation oncologist about possible radiation treatment to prevent any spread. My big concern is about possible side effects such as rectal incontinence  and other issues that I currently don't have may come into play as a result of radiation treatment. I note the previous writers have not had this misfortune but there are many men who can testify the results can and do go wrong. This Hydrogel procedure may have no relevance to those of us who are post -radical prostatectomy patients? Any knowledgeable  comment on this particular area would be well received by the writer.

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Skipper

It seems Barree has just answered my questions as I was writing. As a public patient I would not qualify for said treatment anyway so that puts an end to the possibility. I will still need to make up my mind if I want to proceed with the radiation treatment or not, a difficult question to answer. Only 3 days ago I sat alongside a gentleman some 4 years my junior who had a RP 12 months ago and he is still badly incontinent and with rising PSA he was given hormone treatment, not sure what else but it made him very ill and he has now declined all further treatment. It is sad that so much seems to be discovered of recent times about this dreadful disease yet we are no further advanced with a cure?

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Kezza2

I wish these things had been around 17 years ago when I had EBRT.  I came home every day after treatment and sat in a bath of warm salty water to reduce the side effects, and used gallons of moisturiser.  I agree totally with Skipper, we have come a long long way with treatment, but I worry that men are still presenting at diagnosis with metastatic spread.  We seem to be winning the battle, but loosing the war.

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Patrick Turner
4 hours ago, Nev Black said:

I welcome comments from men who have had radiation treatment for prostate cancer

I was diagnosed with Gleason 9, Pca outside capsule, high risk tumour, 9/9 positive bio samples, in December 2009.

Open surgery attempted April 2010, but abandoned on grounds that doc would have made too big a mess of me if he'd proceeded, but instead of telling me why, he mumbled BS instead. OK, so I begin ADT and plan is to wait until PG is smaller due to ADT, then give me standard EBRT with 70Gy in 4 directions, 35 sessions over 5 weeks. I have the EBRT OK, and I cycled 20km to hospital for first 2 weeks, but burning pain prevented cycling for next 3 weeks. Psa nadir was about 0.08, the lowest its ever been. 

A month after the last RT session I returned to bicycle OK. Continence OK, no ED. Age then 63. 

But 18 months later I began to have occasional bleeds from rear end. I began to understand Men's Truation.

I also had times of faecal incontinence, where a few SIPE events occurred, ( SIPE = Shit In Pants Event. ) once was while out riding alone and wanting to pee led to an involuntary poop.

But that didn't last long. My research online told me that 2/3 of blokes get rectal bleeds after RT for Pca but its rarely permanent, mostly non life threatening. But one guy I knew bled quite alarmingly for most of the time he and missus went on world cruise.

I also found out that St Vincent's in Sydney had a web page with likely outcomes with standard EBRT. This page is no longer at the St Vincent's site, but it said Pca should be treated when Psa reaches 3.0, not when Psa reaches 5.0. It also said that where Gleason 9 tumors had standard EBRT, the success rate was less than 10%. But best hope for success for EBRT was where Gleason was less than 6.  But there's still a big failure rate.

But there's also a big failure rate for an RP.

Time went by to end of 2 years on ADT, 18 mths after the RT. I paused the ADT, and in 6 months Psa went from 0.08 to 8.0 in 6 months so the EBRT merely tickled my Pca under its chin. Testosterone came back full strength at about 3months after pause, I began to average 5kph faster on the bike, then sex function got real good again. I went back to ADT, Psa drops to 0.2, then slowly rises. 4 years later in 2016 Psa begins to rise too fast, and my onco sends me to Epworth which had just got Calypso and had begun using hydrogel to allow high RT dose to PG, up to maybe 86Gy. Bridge Road Imaging had the new PsMa gallium68 scan, and I had one, it shows two upper lymph spreads but PG was the Big Problem, and it would spread locally if nothing was done.

A month after scan, and a wait of a month for USELESS second opinions from docs who just didn't know the state of the art, I get to Epworth for Gel implant ( costs $2,000 for a disc about 1cm thick x 3mm dia. ) This was part of outpatient service. Also done was implanting of what I was told were three radio transmitters in capsules about 12mm long and 3.5mm dia. These were inserted by an "applicator" with very large dia needle and guided by ultra sound so their insertion needs a very well skilled surgeon, and even then, its a difficult thing to achieve properly. I was the first patient at Epworth to have this done where the patient has had EBRT as primary treatment. But Epworth had done other patients who'd had a failed RP, and the 3 beacons were used.

The beacons allow computer control of direction of X-rays from radiation machine. I had to have an empty bowel and full bladder before PG RT. I had 31Grey to PG over 26 sessions lasting a month.

But the insertion of beacons caused bad bleeding into prostatic urethra and bladder, and I spent 2 days at Epworth until bleeding nearly stopped, cost was $1,700. It should not have happened, but the two docs at E didn't realise that because my PG had already had 70Gy in 2010, it was definitely going to bleed badly when poked maybe many times with huge needle to get beacons in to correct position.

I suspect the bleeding from PG riddled with Pca spread my Pca to many places, but it would be useless to suggest this to Epworth; they'd deny it could be possible, and I didn't want the hassle of a court case about doctoral mis-practice. The docs SHOULD have known that if ANY surgery is done on previously radiated tissues, the blood vessels don't stop bleeding fast like non-radiated tissues. I found some real horror stories at chat groups in USA about this. I have a nice stay at Cheshire-Ryder in Melbourne for the total of 5 weeks, and I concluded all treatment and return to ACT, and all seemed well after a month at end of August 2016, and Psa had fallen from 5.6 before to 0.7 after. BUT, at beginning of this "salvation RT" in July I began daily 50mg Cosadex pills, so just what had happened? did the extra RT kill Pca in PG, or was Psa lowered by Cosudex? By February 2017, it was obvious Cosudex was useless, and Psa began to rise again.

I have a second PsMa scan in June 2017, I have many mets in lymphs, and bone, so I start Zytiga. But this second PsMa scan showed the RT to PG had reduced tumor size there and there was not yet any spread to organs, so it does seem the Calypso RT did good, and it does seem like 70Gy I had in 2010 was nowhere near enough to kill my type of "aggressive cells" and that my best option would have been Brachytherapy which can deliver 156Grey max to PG and nothing else could ever do it, although such BT causes more nerve damage and incontinence and ED etc, but rectum escapes being damage.

BUT, after the first month home in 2016, I get real bad radiation caused bowel colitis for next 2 months with faecal incontinence, diarea , but no bleeding. The Xrays used for EBRT are NOT neatly define beams of energy, they diffuse away from centerline of beam, and they travel through a lot of body before hitting target, then travel out through a lot of body as they exit. So its like a torchlight shining in a smoky room, the beam spreads out. The crossing beams from multiple directions at target cause high RT dose at target, and a lower amount to everywhere else, but this lesser amount is enough to cause irritation to many things.

Calypso specs say beams are well directioned and I don't doubt that, but its still EBRT, and the rays diffuse, and affect bowel away from rectum but rectum still cops a lot of cook. But cook amount IS REDUCED by Gel at the most prone place where rectum is against PG.

So it does seem Calypso RT + Gel is The Best form of EBRT yet devised. Some guys may well need 150Gy to PG. But I met one guy who had the same EBRT I had at Canberra Public Hospital  10 years before he told me he thinks he is OK and Pca has not continued onwards after initial treatment. I know one guy who had same Calypso at Epworth, but to his RP site due to Pca continuation, and with 70Gy and yet Pca has continued again, and hardly responded at all to ADT.

Just because one thing happens in one man, it may not happen in another. And doctors make big mistakes when they should know better.  Cost quoted by Epworth was $22,000. Cost went up to $26,000. I am not insured. Medicare paid $12,000.

Epworth wanted me to pay for each week of treatment on each Monday morning. No Pay, no treatment.

Ryder-Cheshire would not charge me for my 31+ day stay. I gave them a $1,000 donation, and I suspect Epworth paid them $38 a day, from what I was told, so some of the Epworth bill was for my accommodation, but not itemised in bill. I could easily have spent a vast sum on accommodation at a hotel.

So all up, spending $14,000 from my pocket to get extra RT seems to have done good, despite the cock-ups.

But when Zytiga fails, then its chemo, and maybe I qualify to get Lu117, and this Pca I have will still kill me, over time.  

Psa went up to about 7.2 in July, but now is less than 2.8 on Zytiga. Although now 70, Last month I cycled 1,300km.

I did 86km today before lunch, possible because I had a double TKR in Feb while Psa was below 1.0. Continence is fine, no rectal bleeds and recent bowel scan showed no bowel cancer is likely. I am not doing too badly for an old bar stud. But this is sure to not last forever.

Keep well, and I know it is difficult.

Patrick Turner. 

 

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Sisira

Three weeks after my Radical Prostatectomy I did 36 sessions of Radiation ( 74 Gy ) to my prostate bed whilst entering a 2 year continuous course of ADT ( androgen deprivation therapy ) because my PCa was Gleason 9 and my pathology identified focally positive surgical margins. The type of radiation I used was IG IMRT ( image guided intensity modulated radiation therapy ). It is postulated that radiation is more effective when combined with ADT. Up to now I have never had any GI tract problems  including my rectum as a result of any side effects from radiation treatment. I believe IG IMRT will have no side effects or the minimum if administered properly. I was diagnosed at the age of 69 in March 2015 with a PSA of 7.9 with no urinary problems or any other PCa related symptoms. Ever since I started my aggressive treatment regimen, up to now my PSA ( checkrd every 3 months  ) has remained at 0.008 ( undetectable ). 

Good Health and Best Wishes to all!

 

Sisira

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Colin Glover

Thank you very much guys for giving such clear descriptions of your quite stressful journeys. For some, so many life impacting decisions over a long period of time, with never any certainty that life will return to "normal". I'm on ADT with little debilitating impact and my PSA dropping on cue. So I have yet to reach that fork in the road. One good thing in my favour is that I'm a relatively fit almost 78 year old with no known additional illnesses.

Wishing you all good outcomes and a great festive season.

 

Colin

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