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Why doctors don't talk about brachytherapy YouTube video


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Jim Marshall (not a doctor) said ...

I did not know when I was diagnosed that for aggressive prostate cancer, like mine, high-dose-rate brachytherapy boost would let me survive longer, with fewer side effects, than surgery.

Thankfully, the surgeon I consulted sent me for the brachytherapy, despite my misgivings.

That was more than ten years ago.

The treatment held initially for six years. When PSA started rising at six years, I restarted hormone therapy (ADT) and my PSA became undetectable again, and is still currently undetectable, ten years after diagnosis.

In this YouTube video, Dr Mark Scholz of the Prostate Cancer Research Institute (PCRI) discusses why brachytherapy is seldom recommended by physicians despite it being one of the best treatments according to multiple large studies. 

... end Jim

 

(5 minutes)

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JimJimJimJim

This is just another form of radiotherapy, mostly used as your first treatment.

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Maybe I'm naive but I find it shocking that doctors are prescribing the most profitable treatment option rather than the most effective - it doesn't instil much faith in the health the system and is part of the reason so many go off looking for alternatives. Is this treatment an option for metastatic disease? I have had stereotactic radiation for the one lesion on a rib bone but with out effect -whether that was lack of skill of the physician I can't know. But I have had cyberknife radiation recommended to me as another option. I've had early chemo, three years on Zoladex which I discontinued when it made me suicidal and have had nearly two years on Xtandi alone which I have tolerated well but is no longer holding my PSA  in check.  I'm having a PSMA PET scan tomorrow and my oncologist and I have agreed to have a month zoladex shot to see if it is still effective and see what the scans show. He's recommending cabazitaxel chemotherapy but obviously it'snot a great time to have chemo during a pandemic so if the zoladex buys us even a few months until the worst of this is past, that is probably a good thing, but I'd desperately love to find an alternative to more chemo or more zoladex, both of which severely impact my quality of life. Would love to hear any suggestions. 

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JimJimJimJim

Tim

Brachytherapy is mostly used as a first treatment.

It is sometimes used as a salvage treatment after a primary first treatment where the recurrence is in the prostate.

I can't see that it would fit your situation at the moment.

I'm not a doctor, but the advice to go to the next chemotherapy, Jevtana (Cabazitaxel), would seem to fit with what other members report.

I understand the issues with this awful virus, but your doctor will have had time to consider this well, so tomorrow he will probably be able to make the details clearer.

Jim

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Patrick Turner

During the last 10 years of getting Pca treatment mainly from public hospitals where I didn't pay one cent for anything, nobody mentioned BT, brachytherapy where maybe 100 tiny gold pellets containing a radioactive isotope are inserted to a PG with some form of guidance, maybe ultrasound. But I had a cousin who paid aud $17,000 about 8 years ago for BT, while he suffered dementia, which killed him. I have no idea how well the BT worked. 10 years ago, a urologist quoted aud $7,500 for RP robot. This didn't include anesthetist. So what this doctor in the video said about costs and doctors didn't make much sense because it seemed he was talking about the US doctor situation where its normal to ruin a patient's finanancial condition, and still not get a fix for the Pca. 

Now to get 100 pellets into a PG about golf ball size means stabbing the PG at least 100 times to get pellets into position, and real skill is needed.

But at Epworth in Melbourne in 2016 I had a chat with a doc who had done over 1,500 BTs so it seemed it was available at private hospitals with a few good operators. The pellets give alpha or beta particle radiation, so the treatment is local, without damage done to rectum etc with X-rays going through healthy tissue. Thus the total amount of radiation with BT can be 160 Grey, more than twice than deliverable by EBRT, and the higher radiation dose applied locally is more likely to kill all Pca in PG. But there are side effects the doc in video didn't mention, and damage to nerves wrapping around PG is highly likely, so after BT, the PG and its nerves are a real mess. 

The trouble with local treatment with any sort of RT to PG does not address the problem of Pca spread that is already outside PG when Pca is given if the Gleason score is high, so OS may not be extended by BT.

These days, a preferred form of high dose of RT to PG is via theranostic method using Lu177. The isotope arrives at PG and gathers at tumor sites via blood vessels. The PG is not stabbed 100 times with a big needle, and goodness knows where the needle goes, but is through a lot of nerves and healthy tissues. This does not happen with Lu177, which can be repeated later without worrying about bleeding too much.

I didn't bleed after having Lu177. The BT doc I met said less than 1% of his BT patients bled after such treatment, but if it was repeated I bet a PG would bleed badly.

I had 70 Grey applied to my PG in 2010, and before getting an additional 31Grey in 2016 at Epworth as "salvation IMRT", done with Calypso RT method, a doc inserted 3 radio beacons to my PG about size of a grain of rice to guide Calypso and I bled badly for 2 days afterward, and spent 2 days at Epworth costing $1,660. The doc who did the 1,500 BTs visited me on a Sunday, to discuss the bleeding, and he seemed to not realize that if you cut radiated tissue, it bleeds for a long time. I was first patient in Oz to get salvation IMRT following primary treatment by EBRT to PG, which didn't seem to work well. A cut finger stops bleeding in minutes, but I didn't completely stop bleeding after minor op to install beacons for 10 days. Epworth experts really did not know if I would bleed or not, but should have known. I have no idea if they do salvation IMRT at Epworth any more.

IMHO, Lu177 would now be a far better option than BT. The LU177 also would go to any spread spots of Pca, and not be confined only to PG.

Many of us here would not want any more localized Pca treatment because of a high number of widely spread mets in soft tissues and bones. So BT is not a choice to be made now. It could be effective as initial PG treatment, and a man may not need the full 160 Grey dose. I have read where not only BT was done, but EBRT was also added.

My Psa is rising after a nadir of 0.32 last November, a year after beginning my Lu177 shots. PsMa scan last august showed good response, and healing of bone lesions. But I bet Psa is about 5 now, and I will need more Lu177. A PsMa scan will be done first,  to predict if I will respond well again. Research by Dr Hoffman at Peter Mac said Lu177 can work to give more years with another couple of Lu177 shots as needed, and it is now used as primary therapy. He's also said the PsMa Ga PET + CT scan is the best scan any man should get to show where Pca is at diagnosis. But although PsMa scan is more sensitive than CT scan to show where Pca mets exist, it can't see all mets if they are tiny. A man can have a lot of tiny mets, all suppressed by ADT, and he may think he's winning, and then ADT stops working and all these mets show up. 

I feel well, and am cycling 200km+ per week at age 72, and I'll be fit enough to get more Lu177. Docs here are not sure yet where my rising Psa is coming from, but maybe in 5 weeks I'll have another PsMa scan to find out, and I see no reason why C19 virus would stop me attending the Sydney clinic giving Lu177.  

Patrick Turner. 

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Patrick

1. The prostate is not "stabbed 100 times" in brachytherapy today because:

  • in low dose brachytherapy the seeds are tied together in strings; and
  • in high dose rate brachytherapy there is just one seed, and it only remains in the prostate for the duration of the operation - just minutes.

2. In high dose rate brachytherapy there are just 12 to 18 needles. (I had fifteen.)

3. One of the benefits of high dose rate brachytherapy is that there is much less damage to nerves around the prostate than with surgery. This is one factor leading to the fewer side effects of high dose rate brachytherapy.

4. Bleeding heals, even for the 1% of men you quote from the doctor. In brachytherapy, this healing mostly happens without drama - just colouring the urine for the first few days.

5. Your assertion that "OS may not be extended by BT" may be true in any single case, but Dr Scholz points out that its superiority is borne out "according to multiple large studies".  Big numbers count when looking at evidence.

6. Lutetium 177 treatment early in the prostate cancer journey is as yet unproven. But we do know its use has its own side effects.

7. Australian Medicare rebates for the surgeon (urologist):

  • HDR brachytherapy (item 37227) $574
  • Prostate surgery including lymph nodes (item 37211) $1966

8. For the information of others:

  • Low dose rate brachytherapy (strings of seeds left in the prostate permanently) is only used for low risk prostate cancer.
  • High dose rate brachytherapy is used for high risk (agressive) prostate cancer.

 

[Added later: I wondered where you got "damage to nerves wrapping around PG is highly likely, so after BT, the PG and its nerves are a real mess" from, when the truth is the opposite - preservation of the nerves is a strength of BT. It has since occurred to me that you may be thinking of HiFu and Cryotherapy where this is a concern.]

Edited by Admin
Why nerve damage so wrong?
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Hi Jim

I would like to sing the praises of Low Dose Brachy therapy , which I chose as my treatment back in 2007 aged 63 , with a  Gleason score of 8 and recurring PSA of around 3.2 annually for the preceeding 4 years  , Brachy was my second choice but settled for this as the delay in robotic surgery at the time had a waiting time which my Urologist didn't beat around the bush and insisted that I take immediate action . my treatment was carried out at a renowned Cancer Centre in Melbourne and consisted of in brief 55 seeds of Iodine 125 via 18 needles , the operation was performed in the afternoon and I was out sightseeing in Melbourne by 3pm the next day , the bruising was extensive but the incontinence and bleeding was very shortlived  ,One thing which at the time amused me was that I was issued with tea strainer  and a lead lined pouch to collect any stray seeds during urination ,that might have strayed into  my urethra , but none did as they were subsequently counted under x-ray more than once , I claim it to be one of the best life decisions I have made , the cost back then totalled abt $21,000.00 which was picked up almost in total by my Private Health Insurance company , I am still after almost 13 years having 6 monthly PSA tests done and returning thankfully <0.01 pSA . It was never confirmed but I attribute my extremely low immune system to the radiation ,as this left me prone to several nasties ,like shingles x2 ,( Rheumatoid arthritis ,now in remission ) and severe  bone density issues (receiving prolia  treatment ) . but having said all that ,,,,,I,m still here making the most of retirement life enjoying my extended family grow up and  volunteering at PCFA and CCNSW . In summary as I mentioned earlier one of the best decision I have made . CHEERS JD :)

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