Patient Forum

The CyberKnife Patient Forum is designed to provide a place for people who have been diagnosed with cancer, their family and friends, to exchange useful information and provide support to one another. The Forum may also help people find answers to questions they have about the CyberKnife treatment experience. Accuray strives to facilitate these exchanges and encourage discussions. Recently we have experienced some aggressive or inappropriate spam postings. We are diligently working to resolve this issue and thank you in advance for your patience.

Birgit Fleurent, Chief Marketing Officer, Accuray Incorporated

  Print 
Gleason 3+4, 8/12 Cores Positive
RichB55
Posted: Monday, July 23, 2018 1:31 PM
Joined: 7/23/2018
Posts: 7


Hello All:

I recently received my biopsy results, which were:

Right side: 6/6 positive cores, 3 at 3+3, 3 at 3+4. PNI confirmed in 2 cores. Total tumor burden from 15% to 35%.

Left side: 2/6 positive cores, both at 3+3. Total tumor burden 5% in both.

The biopsy was triggered by my urologist's DRE, where he identified a potential tumor on the right side graded at T2A.

According to the Sloan Kettering nonograms, I have 31% likelihood of organ-confined disease, 68% of extracapsular extension, 8% of lymph node involvement, 9% of seminal vesicle invasion.

PSA before biopsy was 6.1. I am 62 years old, and in good health.

I am aware of Dr. Katz's excellent long-term results using CyberKnife to treat intermediate risk prostate cancer patients.

But given the facts that the cancer appears widespread on the right lobe, and the relatively high likelihood that it has spread beyond the prostate (per S-K), does CK make sense as a first line of attack?

If so, what is the likelihood I would need to do hormone therapy, and for how long? (Have heard that short term hormone therapy is especially indicated when PNI exists, even in intermediate risk cases.)

If I do CK and it fails, what would the second line of attack be?

I lead an active lifestyle with biking, yoga, and weight training, so the idea of knocking out the PC in 4 to 5 treatments, without having to worry about wetting my pants for the first 3 months, is really appealing.

But my first priority is to lead with the strongest punch (for my situation) first, even if that means a lengthy rehab.

Would that be CyberKnife?

Thanks for any and all information.

RichB55

JAV
Posted: Monday, July 23, 2018 6:59 PM
Joined: 10/29/2010
Posts: 800


Rich : Sorry to hear about you results. Sounds like your question can only be answered accurately by one of the Docs. I would just say surgery would not be a better option than CK, because given your numbers, you are concerned it has spread outside the capsule. Maybe a scan might be in order at this point to get more info. Have you looked at the PCRI website for more info ? https://pcri.org/

Treated with CK 4-2011.  Gleason of 3+4 , PSA 3.7 , two cores positive, 5% & 12%
 PSA on 7-13 0.3  PSA on 11-13 0.3 PSA on 5-14   0.3  
PSA on 7-14   0.2 PSA on 11-14  0.2 PSA on 3-15 0.2
PSA on 7-15, 0.2 PSA on 7-17 0.1 PSA on 1-18 0.13
radsrus
Posted: Tuesday, July 24, 2018 5:24 AM
Joined: 10/10/2008
Posts: 4435


When they say extension outside the prostate capsule, it virtually always means disease within 3-4 mm of the capsule, and most of us add that much margin or more around the prostate and so that would be covered. I think you would be a good candidate for CK. Your risk of recurrence is higher than a low-risk patient, but that is true regardless of what treatment you choose. If you choose surgery, there is a pretty high chance that you would need radiation afterward, and therefore risk of two different modalities. There is no evidence that surgery will increase your chances, although arguably surgery plus radiation has very good results. If it were me, I would go with CK. A for the future, no point in worrying about that right now. You don't want to make a poor choice now on the small chance that you might require something else later.

Clinton A. Medbery, III, M.D. Southwest Radiation Oncology buddy@swrads.org
DXM
Posted: Tuesday, July 24, 2018 10:26 AM
Joined: 9/10/2016
Posts: 20


A mpMRI (or a PSMA PET/CT scan) would certainly help in determining the extent of capsule extension of the cancer (if it has extended) and the probability of lymph node involvement. The imaging would seem to be very important considering the perineural invasion. Dr. Simpson, of Colorado Cyberknife, typically radiates out to 9mm around the capsule.

DAMorris
RichB55
Posted: Tuesday, July 24, 2018 10:54 AM
Joined: 7/23/2018
Posts: 7


Thanks for the feedback, everyone, it is quite helpful.

Dr. Medbery: the reason I asked about second lines of attack is because the surgery advocates argue that if you get a recurrence of cancer after surgery, radiation still works well, but not vice versa, so I was wondering what forms of post-CK salvage therapy there might be besides surgery, how well they work, and how serious are their side effects.

DXM: does it make sense to get a referral to an MRI lab through my existing urologist, or should I wait until I speak to a radiation oncologist that I am seriously considering, because he/she may want to to request special features/parameters on the MRI?

radsrus
Posted: Tuesday, July 24, 2018 12:24 PM
Joined: 10/10/2008
Posts: 4435


There are centers that do surgery after radiation, but the risk of incontinence is significant. There are also centers investigating multiple other forms of treatment, such as brachytherapy with hyperthermia, cryotherapy, HIFU, and more targeted CK. As for MRI - not every center can perform the most advanced imaging techniques. Many of the ones that are touted are pretty hard to find, depending on where you are. The risk of local recurrence after CK is low enough that tailoring your decision around salvage options is not, in my opinion, a wise step.

Clinton A. Medbery, III, M.D. Southwest Radiation Oncology buddy@swrads.org
DXM
Posted: Wednesday, July 25, 2018 11:18 AM
Joined: 9/10/2016
Posts: 20


RichB55 says: DXM: does it make sense to get a referral to an MRI lab through my existing urologist, or should I wait until I speak to a radiation oncologist that I am seriously considering, because he/she may want to to request special features/parameters on the MRI? I think the question to ask your doctor (and maybe get a second opinion) is what could be the consequences of the PNI? The nerves are apparent escape routes for the cancer and the possibility may exist that this happened and that a mpMRI would help determine if this happened. On the other hand, the doctor may look at your case and think the chance is very low that this happened and that an MRI would be a waste. It may be that your insurance would not cover a mpMRI (a regular MRI would be close to worthless) or that a mpMRI would require travel, depending where you are located. In my case, I had PNI and a mpMRI which revealed (to high probability - high, not certain, because only very few tests are 100%) that the cancer was contained.

DAMorris
RichB55
Posted: Wednesday, July 25, 2018 12:22 PM
Joined: 7/23/2018
Posts: 7


DXM: I live in San Diego, so access to good technology is not an issue. I have an appointment with a radiation oncologist at UCSD next week, so I will ask him about the implications of PNI, as well as his recommendation for the appropriate MRI.

Dr. Medbery: any feelings about the need for hormone therapy before treatment? Or would this need to be decided on the basis of the MRI?

DXM
Posted: Wednesday, July 25, 2018 3:31 PM
Joined: 9/10/2016
Posts: 20


RichB55 -- You are in a good location to get good care. If I were there and had your numbers, I would consult with Dr Lam or Dr Scholz of Prostate Oncology Specialists in Marina Del Rey who are prostate oncologists (don't do radiation, surgery, HIFU, etc., so have no biases based on treatment) and would advise you on ADT. They could even do a Color Doppler imaging on you. I made an annual visit to them from Colorado for 9 years. Also, it should be noted that Dr. Alan Katz dismisses the efficacy of hormone treatment if doing CK.

DAMorris
RichB55
Posted: Wednesday, July 25, 2018 9:48 PM
Joined: 7/23/2018
Posts: 7


Thanks, DXM.

I did some background research on Drs. Scholz and Lam, and am seriously thinking of setting up a consultation with them.

radsrus
Posted: Thursday, July 26, 2018 6:53 AM
Joined: 10/10/2008
Posts: 4435


If you are seeking other opinions, you might want to also see Dr. Don Fuller there in San Diego. He has been one of the leaders in both CK treatment of prostate cancer and in the use of more exotic imaging modalities to tailor treatments.

Clinton A. Medbery, III, M.D. Southwest Radiation Oncology buddy@swrads.org
RichB55
Posted: Thursday, July 26, 2018 10:28 AM
Joined: 7/23/2018
Posts: 7


Dr. Medbery:

I have already consulted with Dr. Ijaz, who is part of the same practice group as Dr. Fuller. Dr. Ijaz was the person who first recommended CK to me, although I was not educated enough at that time to ask very deep or specific questions.

Do you think it makes sense to seek an additional consultation with Dr. Fuller?

radsrus
Posted: Thursday, July 26, 2018 10:35 AM
Joined: 10/10/2008
Posts: 4435


Not familiar with Jiaz, so not sure. You might ask if it would be any different

Clinton A. Medbery, III, M.D. Southwest Radiation Oncology buddy@swrads.org
RichB55
Posted: Friday, July 27, 2018 1:54 PM
Joined: 7/23/2018
Posts: 7


Dr. Medbery:

To your observation that the risk of local recurrence of PC after CK treatment is low, so that the options for salvage treatment should not be a factor in decision-making, I came across this study of pooled data from many of the top CK providers, which shows a 5 year rate of freedom from biochemical failure at 84% for intermediate risk patients such as me: https://www.sciencedirect.com/science/article/pii/S0167814013004301

Your thoughts?

radsrus
Posted: Friday, July 27, 2018 5:57 PM
Joined: 10/10/2008
Posts: 4435


I personally know of some of the larger studies that are higher than that by about 5-6%, but let's assume 84% is correct. That includes people who develop metastatic disease, and no form of local treatment alters that. The entire paper is available to me and they do not separate out local recurrences from metastatic disease. I think a better number for local control is about 90%, maybe slightly higher. In my view, that is good enough that you should not make a decision y9ou don't really like now because you are concerned about salvage treatments. I fully recognize that others might think differently, but that is my opinion

Clinton A. Medbery, III, M.D. Southwest Radiation Oncology buddy@swrads.org
radsrus
Posted: Friday, July 27, 2018 5:57 PM
Joined: 10/10/2008
Posts: 4435


I personally know of some of the larger studies that are higher than that by about 5-6%, but let's assume 84% is correct. That includes people who develop metastatic disease, and no form of local treatment alters that. The entire paper is available to me and they do not separate out local recurrences from metastatic disease. I think a better number for local control is about 90%, maybe slightly higher. In my view, that is good enough that you should not make a decision y9ou don't really like now because you are concerned about salvage treatments. I fully recognize that others might think differently, but that is my opinion

Clinton A. Medbery, III, M.D. Southwest Radiation Oncology buddy@swrads.org
RichB55
Posted: Friday, July 27, 2018 7:24 PM
Joined: 7/23/2018
Posts: 7


Thank you, that's very helpful.

 

Jump to different Forum...