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Old 01-27-2009, 11:06 AM   #1
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CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

Recently the board has been fortunate to have viperfred bring his enthusiasm and knowledge of CyberKnife (CK) radiation delivery under Stereotactic Body Radio Therapy (SBRT) dosing and arrangements for prostate cancer to our attention. He has strongly advocated it as an option, arguing that it is superior to other therapies. He and some other patients who have had the therapy, as well as hospitals who now have this technology, state or imply that CK SBRT has already been proven effective and safe.

The huge appeal of CK SBRT lies in its dosing: just five radiation sessions, spread over one (five daily sessions) to two weeks (a day of rest between sessions). That is far more convenient than the long period needed for, typically, about 35 to 40 doses of 2 Gy ("Gray"; a unit for radiation dosing) each for various external beam radiation therapy programs. The radiation also is not "intrusive" in the sense that brachytherapy is, as the latter requires the insertion of seeds through the body into the prostate whereas CK is external radiation.

This is my shot at a hopefully objective look at the current state of CK SBRT. I could not cover the key ground without making this a fairly long post. If you care to reply, I suggest you quote only short excerpts so the thread does not become even more awkward to handle.

The main issues are whether CK SBRT is as good as other kinds of prostate cancer therapy (or superior), and whether it has a side effect profile that is attractive or at least acceptable, especially compared to existing alternatives. There is some favorable, good quality but limited (not many reports) and early (less than three years average follow-up) information on these points. There is also some fairly well-based theory explaining why CK SBRT should work well, and that theory is able to link with some theory and many years of experience with High Dose Rate Brachytherapy (HDR Brachy).

I was impressed with some of the information and decided to do my own review. Here's the bottom line for me, before getting to the details: CK SBRT is very impressive at this early point for follow-up evidence on how patients are doing, both for cancer cure and side effect burden , but at this point the approach is still investigational with some substantial risk due to unknowns that may be lurking behind the fairly short follow-up of basically less than three years , though with a little luck we will get substantial clarification shortly, especially on the side-effect questions, perhaps in February.

Here's the approach I took. First, I searched for any papers by viperfred's doctor at Stanford U in California, Dr. Christopher King, as I've related in earlier posts. I learned that Dr. King is a leading physician/researcher for CK SBRT at Stanford, which is a very impressive credential as Stanford is one of the leading institutions for radiation therapy research in the US and I believe in the whole world as well. (I know this from paying attention to prostate cancer research for over nine years now, motivated by my challenging case, including attending FDA hearings, attending two national cancer research conventions, and participating in three prostate cancer research proposal reviews.) I then searched for some other papers on CK SBRT, in part leaning on leads provided by viperfred, and I found several. I also looked into what CK SBRT patients were writing about their experiences.

For those interested, the King team's paper is key - the only one with several years of follow-up results. It was published electronically (in advance of hard copy) by the International Journal of Radiation, Oncology and Physics, Vol. pending, No. pending, accepted for publication May 27, 2008, six pages, entitled "Stereotactic Body Radiotherapy for Localized Prostate Cancer: Interim Results of a Prospective Phase II Clinical Trial. The librarian at my hospital was kind enough to retrieve this and several other electronic papers for me. (If anyone has specific, detailed questions about what's in the paper, I can answer them.)

There is not an abundance of other papers on this approach as it is only a few years old for prostate cancer. Other papers I now have include the Fuller team's paper of 2008 in the same journal, Vol. 70, No. 5, "Virtual HDR CyberKnife Treatment for Localized Prostatic Carcinoma: Dosimetry Comparison with HDR Brachytherapy and Preliminary Clinical Observations. The Fuller team is in the San Diego/La Jolla, California, area.

I also looked at an editorial by David J. Brenner, D.Sc., from Columbia U., New York, in the same journal (Vol. 60, No. 4) entitled "Fractionation and Late Rectal Toxicity. And finally I looked at an old, archived paper in the basement of the hospital's medical library entitled "Carcinoma of Prostate Treated by Radical External Beam Radiotherapy Using Hypofractionation [meaning similar to SBRT - lots of radiation in just a few doses] - Twenty-Two Years' Experience (1962-1984), by Lloyd-Davies and colleagues from the UK.

I now possess all of these papers for reference.

Regarding effectiveness in curing prostate cancer in localized cases: The King paper indicates great success - no biological (rising PSA, etc.) or other failures at all for 41 patients with a minimum of six months follow-up who got five doses of 7.25 Gy CK radiation for a total dose of 36.25 Gy. While the minimum follow-up was set at just six months, the median (average) follow-up was 33 months, nearly three years. That's hardly long enough to be a guarantee - we would really like to see at least ten years, but at this point it is impressive, especially with that 100% rate of success!

Comparison with effectiveness of other therapies: The patients in the trial were "low risk": pre-biopsy PSA of 10 or lower, a Gleason Score of 3+3 or lower;, and a clinical T-stage of T1c or T2a/b, with allowance for a Gleason of 3+4=7 if present in fewer than 2 of 10 to 12 core biopsies and involving less than 5 mm in total tumor length. For such a low-risk patient group, other treatment methods typically achieve a very high rate of apparent cure at this early stage of follow-up, but not 100%, at least not by the five year point. A 2004 book by Grimm, Blasko, and Sylvester has a table in Chapter 8 that five year (two years more than the CK SBRT follow-up) disease-free follow-up results for low risk patients of 85% and 83% for surgery, 90% for 3D-conformal beam radiation at Memorial Sloan Kettering, and 94% for Palladium isotope seeds in Seattle. The book "A Primer on Prostate Cancer - The Empowered Patient's Guide," has a table on page 102 that shows five year follow-up results just by PSA range, including, for PSAs up to 10 a 94% disease free rate for Iodine 125 seeds plus external beam (Radiation Clinics of Georgia (RCOG in Atlanta) - Dr. Critz) and 90% for Dr. Blasko and colleagues (Seattle) for Palladium 103 seeds alone. My impression is that patients who are truly low risk across the board - including other risk criteria - have an extremely low rate of recurrence of about 1%.

Side Effects - often referred to as radiation toxicity by researchers: While all approaches, including CK SBRT but excepting Active Surveillance typically have some short term side effects ("acute toxicity" to the researchers), that is not a major issue just since those side effects are not going to last. It's the long-term side effects that we really get concerned about. With radiation, usually the urinary side effects are not substantial; it's the rectal side effects that get most of the attention, with potency also a concern. Moreover, these side effects, unlike those for surgery, typically gradually emerge, sometimes not appearing for several years, but almost always by the fifth year, as I understand it. For instance, I just had a friend who had had seeds from a highly respected expert in Northern Virginia more than three years ago who recently at the three year pointdeveloped a minor rectal bleeding problem.

I was especially concerned about CK SBRT, despite viperfred's protests, because the abstract of the King paper mentioned that a 38% rate of "severe rectal toxicities was observed" with dosing on five consecutive days (with no days off). To me that meant the team was scoring with the Radiation Therapy Oncology Group (RTOG) categories, and the word "severe" grabs your attention. However, the abstract also said there no RTOG grade 3 or 4 side effects, and those are the really bothersome side effects. It became clearer in the paper: the team was using a quality of life questionnaire as the basis for its statement that 38% experienced "severe" side effects instead of the RTOG criteria. From the researchers table on the third page, it looks like "severe" meant the patients had checked either "small problem" or "moderate problem" rather than "no problem" or "very small problem," but the table does not make that absolutely clear as patients with both daily and every-other-day dosing are mixed together. (No one checked "big problem".)

Before treatment, 8 of every 9 patients (89%) checked "no problem" in rectal quality of life, while the remaining 1 of 9 (11%) checked "very small problem" or "small problem." At the two year point after treatment, nearly half (45%) still checked "no problem," nearly half (again 45%) now checked "very small problem" or "small problem," and 9% checked "moderate problem, with no one checking "big problem." That's pretty good!

However, while the 16% who checked "moderate problem" at the three months point had declined to only 4% at the one year point, that percentage had increased to 9% at the two year point. That's why we really need to get those three year follow-up results! The results should be available, as this King paper was revised nearly a year ago in May 2008, and the average follow-up then was 33 months, just a few months short of three years. Viperfred told us about a large conference of CK SBRT users in the first week of February - next month, and hopefully the three year data will be presented then. We might even get some limited four year data.

We have learned from viperfred that the first patient in the King trial was treated in 2003; at the five year point he has no evidence of cancer and no side effects. To me that is encouraging, as it proves it is POSSIBLE to avoid side effects at the five year point; however, it does not help us gauge how LIKELY it is to avoid side effects.

CAUTION!: I was struck, as was the King team, by the contrast for CK SBRT delivery in rectal side effect reported "quality of life" from daily (38% "severe rectal toxicity") versus every-other-day (0% severe rectal toxicity). The King team had given its first 21 patients daily therapy but switched to every-other-day for its last 20 patients after noting the "mildly disappointing" rectal toxicity reports. If it were me getting this therapy, since effectiveness seems about the same, I sure as hell would want every-other-day dosing! (On the other hand, those numbers still mean that a clear majority of men at this point in their follow-up are doing fine with daily dosing. But the researchers don't know who will fall into which group at this point. Viperfred has told us that his dosing was on Monday, Wednesday, Friday, Monday and Wednesday, giving what looks like a key day of rest between doses.)

The twenty two years experience from England (published in 1990, Urology) with "hypofractionation," which is medicalese meaning just a few radiation sessions with more radiation per session, which basically is quite similar to SBRT dosing being used with CK: The UK researchers were trying to determine if they could save money and still get good results by packing more radiation punch in just a few radiation sessions, basically six sessions over three weeks. Their survival rates were not that impressive by today's standards, but they asserted that long term urinary and rectal success appeared excellent. They provided little supporting detail. At the least, it appears they did not have a substantial group of dissatisfied customers. To me, in a general way their results support the likelihood of side effect success with CK SBRT.

My diminished concern with leaning on High Dose Rate (HDR) Brachytherapy results for predicting CK SBRT cure rates and side effects: Viperfred (and CK SBRT researchers) had enthusiastically compared the long track record of HDR brachy (seeds that are briefly inserted via a catheter, and then withdrawn, in just a few dosing sessions) with CK SBRT, believing that the results should be the same since just a few doses of higher dose radiation were used in both approaches. I was concerned they were not that similar since CK is delivered through the body, while HDR seeds have only a very brief exposure to non-prostate cells as they travel to the prostate to deliver a temporary dose.

However, the study by Fuller and team showed that the planned radiation doses for CK SBRT would be highly similar (or even superior) to the HDR brachy doses regarding rectal and other issues, and that provides a lot of assurance that leaning on the HDR brachy results is reasonable. That said, the researchers themselves stated they would like to see other groups confirm their findings.

Is CK SBRT still in the "investigatory" stage versus "standard therapy": As the terms are understood by researchers and Government officials, CK SBRT is still investigatory. (So is my therapy - intermittent triple hormonal blockade with maintenance, though it has been around at least since the 1990s. Being "investigatory" is not necessarily bad.) That doesn't mean the therapy is not fairly widely available; viperfred has told us there are 40 CyberKnife centers treating prostate cancer in the US, and a total of about 100 CyberKnife centers in the US, so there is room there for growth in existing facilities. You don't have to be in a clinical trial to get it. I've read that more than 1,000 patients have been treated with CK SBRT for prostate cancer, and facilities are scattered around the country. Still being "investigatory" doesn't mean that CK SBRT should not be covered by insurance; thanks to hard work by viperfred and others, CK SBRT is now often covered.

But being "investigatory" does mean that wrinkles in the therapy approach are still being worked out, as is dramatically illustrated by the issue of daily versus every-other-day dosing. Also, the King team refers to "evolving refinement" of their methods. It also means that key follow-up data is not in yet. If I were a patient who had had CK SBRT, I would be eager to convince myself that I would continue to do fine if I were doing fine at, say, the two or three year point. But that is just not always so with radiation therapy. It will really help when we get some three year follow-up data, and we can probably have some solid conclusions when we get five year data. The King team clearly recognize this and even anticipate that their patients will see some additional problems as the years tick by, though they express a confident tone in their paper.

Learning curve issues - can any doctor do this well now? A couple of pioneering CK SBRT doctors who interact a lot with the patient community believe that the learning curve is quite short and that many doctors will be able to do a fine job delivering CK SBRT.

I'm not so sure, and I would want to go with a doctor with plenty of experience and a track record he updated, based on disciplined follow up, that he could describe to me. For most therapies, it pays to find an expert if you can. It would be nice if a therapy would emerge that any doctor could deliver well, but regarding CK SBRT, that remains to be seen for my money.

I came across a few patients who were not happy with their CK SBRT experiences. At least one poor guy had suffered radiation burns, something the two doctors above had trouble believing. It seems the poor guy's doctor had cautioned him in advance that he might suffer burns. To me, that would be an alarm bell loudly sounding its warning!

I hope this helps move the CK SBRT discussion forward. I'll admit I'm pretty impressed, but I want to see a bit longer follow-up.

Jim

Last edited by IADT3since2000; 01-28-2009 at 11:04 AM. Reason: Various edits as described in an updating post.

 
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Old 01-28-2009, 11:17 AM   #2
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

I've just incorporated a number of edits in my initial post for this thread.

Here they are:

Changed the description of SBRT from Stereotactic Body Radiation Therapy to Stereotactic Body Radio Therapy.

Noted that the usual dosing for other forms of external beam radiation is from 35 to 40 sessions delivering 2 Gy per session.

Added comment that CK SBRT had some good theory behind it, including a link with High Dose Rate Brachytherapy theory and many years of experience.

Added comment on the number of CyberKnife centers in the US, 100, and the number of those that treat prostate cancer, 40, based on viperfred's posts.

Added comment, based on viperfred's posts, that the first CK SBRT patient in the King trial was treated in 2003, giving us five years of follow-up experience with success in both absence of evidence of disease as well as no side effects at the five year point. Observed that this proves success is possible at the five year point, which is great, but does not indicate how likely success will prove to be.

Corrected comment on viperfred's dosing schedule; originally indicated dosing on five consecutive days; corrected this to M, W, F, M and W.

Noted that the CyberKnife users meeting was coming up the first week in February.

(First edit, right after initial posting: had corrected CyberKnive to CyberKnife.)

Jim

 
Old 01-28-2009, 11:30 AM   #3
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

Thanks for the added info. I think the info from that users' group meeting should be helpful too. I recall looking at the King study after one of the earlier posts, and if I'm correct, the maximum Gleason score for one to have been accepted in the trial was 6.
(Also, I knew you'd go back and fix the "..knive" to "..knife".)

 
Old 01-28-2009, 05:37 PM   #4
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Re: CyberKnive with Stereotactic Body Radiation Therapy (SBRT): Promise & Not Yet Pro

Outstanding summary of the available data on this emerging but heavily promoted therapy. It pointed up my earlier remarks and impressions that Cyber Knife is still neither proven nor mainstreamed for prostate cancer.
My main problem with it is that its very appealing to newly diagnosed patients who are understandably looking for a quick and non-invasive fix which this purports to be. While it meets the criteria of quicker, non-invasive and possibly least toxic of the radiation therapies, and may be the best alternative for older or medically compromised men who can't withstand the more rigorous therapies, it is higher risk for younger otherwise healthier men who have a better chance of being cured or given long term remission by the mainstream therapies which have been proven over much larger populations in major centers of excellance. It was originally developed and used for other types of cancer where high intensity high dose radiation couldn't be used and found its way to the prostate cancer field as kind of an "off label" application.
I instinctively feel that a great deal more evidence and longer term outcome data(10-15 year) is necessary before it should be considered a proven or preferred therapy for P.C.

Last edited by shs50; 01-28-2009 at 05:44 PM.

 
Old 01-28-2009, 05:55 PM   #5
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Re: CyberKnive with Stereotactic Body Radiation Therapy (SBRT): Promise & Not Yet Pro

Quote:
Originally Posted by shs50 View Post
...
I instinctively feel that a great deal more evidence and longer term outcome data(10-15 year) is necessary before it should be considered a proven or preferred therapy for P.C...
I agree with your comments and would like to see more data. Although at some point, one doesn't want to wait forever. I chose proton therapy, which has been used for treating prostate cancer since 1990, but there is still not enough long term data to show its benefits conclusively. Partly, that's because the dosage rate has been increased over the years, the earlier patients were often very high risk, and improvements have been made over time to the techniques. So I was convinced that this was the best form of radiation out there for me (equal or better in cure and fewer side effects because it is so highly targeted- no exit radiation dose). Obviously not everyone feels that way, and I can understand that.

Maybe those that choose Cyberknife now are convinced that it's going to be proven great once more data is in (although the fact that only Gleason 6 people are in the King clinical trial leads me to question the results for others that have intermediate or high risk cases).

Last edited by daff; 01-28-2009 at 05:57 PM. Reason: minor clarification

 
Old 01-29-2009, 02:25 PM   #6
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

Quote:
Originally Posted by daff View Post
Thanks for the added info. I think the info from that users' group meeting should be helpful too. I recall looking at the King study after one of the earlier posts, and if I'm correct, the maximum Gleason score for one to have been accepted in the trial was 6.
(Also, I knew you'd go back and fix the "..knive" to "..knife".)
Hi daff,

I'll blame the "knive" spelling on the computer: there was a screw loose in the operator!

Regarding the participants in the King study, it is correct that they are (trial is still recruiting) primarily aiming at Gleason 3+3=6 patients, but they actually are also including patients at somewhat higher risk, sort of on a waiver basis, probably when their other characteristics look good. Here's a key excerpt of what they said in the "Methods and Materials" section about their first 41 patients - those whom they cover in the paper:

"The median age was 66 years (range, 48-83 years). The median initial PSA was 5.6 ng/ml, (range 0.7-10; 1 patient enrolled with a PSA of 15.6 with Stage T1c, Gleason 3+3, involving 2 mm in 1/12 cores). There were 30 patients with clinical Stage T1c. 10 were T2a and one T2b. Biopsy Gleason grade [score, actually] was 3+3 in 29 patients and 3+4 in 12 patients." I've seen this before, where researchers will include Gleason 3+4=7 patients if other characteristics are favorable.

Thanks to you and shs50 for your kind words.

Jim

 
Old 02-06-2009, 05:15 PM   #7
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

The CyberKnife Society will be publishing abstracts of poster studies presented at the current users meeting (Feb. 4 - Feb. 8), but the Society will not be publishing these abstracts until March 1.

Fred, if you read this, can give us an advanced peek at what went on?

Jim

 
Old 02-08-2009, 06:53 PM   #8
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

I attended the prostate cancer presentations and can report that the results from centers around the World are following the same path as the Stanford.

Cure rate at 3 years seems very high about .995% typical. The side effects peak at 9-10 days and are 100% gone at 2-3 months for the vast majority of patients.
ED is evident in 8-10% at 3 years. Some patients report better than base line sexual function at 3 years. This presenter commented they may have found a new use for the CyberKnife which got a good laugh from the audience. I have looked at a lot of papers for every treatment option and non are close to the CyberKnife for cure or side effects.

The latest models have even better tracking that reduces treatment time and increases tracking accuracy by adjusting the tracking time based on previous target movement. I remember the robot moving away and stopping now I know that was due to movement detected and reacquiring of target. There is no tracking system that can come close to the CyberKnife capability. The dose gradient is steep from target to surrounding structures which results low side effects and high cure.

I did not total the patients but one study had over 300 patients and a couple were in the 100 to 200 range.


Compared to the other options the CyberKnife has no down side except it is lacking the 10 year data point. But based on the excellent data to date there is no reason or theory to expect the results to diverge from their present path of high cure and very low rate of side effects.

 
Old 02-08-2009, 07:00 PM   #9
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Re: CyberKnive with Stereotactic Body Radiation Therapy (SBRT): Promise & Not Yet Pro

Regarding Gleason score and PSA quide lines for treatment.

The clinical studies have defined quide lines.

Several treatment centers are now treating more advanced PCa with very good results.
Most centers and studies accept Gleason 3+3 = 6 and 3+4= 7 with a PSA <10.

Some treatment centers are treating Gleason 4+3 = 7 PSA <20.

There are locations treating more advanced cases but I forget the limitatoins.

Early detection is imporatnt for cure no matter which option is used.

 
Old 02-13-2009, 03:43 PM   #10
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

Quote: Cure rate at 3 years seems very high about .995% typical. The side effects peak at 9-10 days and are 100% gone at 2-3 months for the vast majority of patients.
ED is evident in 8-10% at 3 years. Some patients report better than base line sexual function at 3 years. This presenter commented they may have found a new use for the CyberKnife which got a good laugh from the audience. I have looked at a lot of papers for every treatment option and non are close to the CyberKnife for cure or side effects.

I have just found this website and would like to comment regarding SBRT and welcome any questions you may have. I was diagnosed with PCa in 2006, and after much research, decided to enroll and participate in SBRT treatment for PCa Phase I STudy being offered by UT Southwestern. I received my high dose SBRT treatment in Feb 2007, and had minimal side effects. My PSA, since treatment follows a very unusual pattern when compared to others. From an average of 5.9 before treatment, it shot up to near 15 two weeks after treatment, then gradually dropped to below 4. Then a few months ago (just before my 2 year history, it went up to 5.4). Regretfully, I didn't abstain from sex the night before my blood was drawn for the test. So I suspected that it may have something to do with the rise, or perhaps the classic RT bounce symptom that happened to some people. I had a single APC treatment last December for radiation proctitis and that has stopped the bleeding.

 
Old 02-13-2009, 05:59 PM   #11
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

Quote:
Originally Posted by CommanderData View Post
...I have looked at a lot of papers for every treatment option and none are close to the CyberKnife for cure or side effects.
...
I have just found this website and would like to comment regarding SBRT and welcome any questions you may have.

..I received my high dose SBRT treatment in Feb 2007, and had minimal side effects. My PSA, since treatment follows a very unusual pattern when compared to others. From an average of 5.9 before treatment, it shot up to near 15 two weeks after treatment, then gradually dropped to below 4. Then a few months ago (just before my 2 year history, it went up to 5.4). Regretfully, I didn't abstain from sex the night before my blood was drawn for the test. So I suspected that it may have something to do with the rise, or perhaps the classic RT bounce symptom that happened to some people...
You obviously feel great about the treatment you had, but I must say I've not read that this treatment for cancer is better than any other relative to cure and side effects. In time, we'll know a lot more about this I'm sure, but for now there are many good options. Is your level of PSA two years out considered typical and indicative that the treatment did everything it was
expected to do with regards to killing the nasty cancer cells?

I completed my proton radiation treatments in late 2007 and feel that there's more long-term information about this form of treatment-- and it's a highly targeted form of radiation with fewer side effects than other similar types. It does take much longer, done over a period of a couple months with dosage typically around 80 Gy total.

I'm curious as to what they said about your PSA levels post treatment- as you seem to have a level around 5 two years afterwards. With proton radiation, the levels can be variable, and the important thing by the 2 year point is to be stable, at the nadir reached. In my case, I started with a PSA of about 4, and since then have dropped to 0.6. I realize that levels may change a little more, but I'll be happy if I'm at a stable 0.4 or 0.5 by the two year point.

I'm curious if you checked into proton radiation at the time your were investigating treatments for your prostate cancer. I was 64 at diagnosis, with a Gleason 7 (3+4), stage T1c.

 
Old 02-14-2009, 05:21 AM   #12
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

Hi daff,

We are all searching for the perfect cure for our specific condition.

I considered all options including proton therapy. Trageting is getting better for localized PCa and delivery of Radiation is improving as a result. The only system that offers real time tracking is the CyberKnife. Unless you have access to the planning system that produces the dose prescription you can not appreciate the benefit of the CyberKnifes many beam angles and the resulting dose to target and step drop of dose to the surrounding tissue.

Suggest you look at the latest proton therapy results from the 2008 ASTRO meeting.
Proton Therapy is no better than IMRT.

With radiation the PSA is irratic after treatment showing bounces along the way to nidar. For the CyberKnife nidar is typically reached at 24 months and continues to drop in many with more time.

My total dose was 36.25 Gy delivered in five days.

I have not seen any published data from Proton therapy that shows a better result cure or side effects than IMRT or CyberKnife or Brachrtherapy or surgery.

If you have please share.

At 3 months all functions were at base line or better, now at 9 months the same.
Just completed my 9 month PSA monitor results follow.

Date PSA (ng/mL)
Aug 2007 4.0
May 2008 CyberKnife Treatment
Aug 2008 0.69
Nov 2008 1.09
Feb. 2009 0.49

Data is not meaning full except it not unusual. At 18 months approx 27% of CK patients have a bounce. This is pretty typical for radiation.

We are getting better treatment today and it will be better tomorrow as imaging improves. Many treatments can kill or remove the cancer but non show where the cells may be hiding.

 
Old 02-14-2009, 06:48 AM   #13
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

Quote:
Originally Posted by daff View Post
You obviously feel great about the treatment you had, but I must say I've not read that this treatment for cancer is better than any other relative to cure and side effects. In time, we'll know a lot more about this I'm sure, but for now there are many good options. Is your level of PSA two years out considered typical and indicative that the treatment did everything it was
expected to do with regards to killing the nasty cancer cells?

I'm curious if you checked into proton radiation at the time your were investigating treatments for your prostate cancer. I was 64 at diagnosis, with a Gleason 7 (3+4), stage T1c.
My PCa stage was exactly like yours, except I was 60 when diagnosed. I received 5 hypo-fractionated treatments at 9 Gy each. I was willing to be a calculated "guinea pig" for this study because I feel that previous studies high dose implants have shown comparable treatment to surgical procedure (Andy Grove, ex chief of Intel had this), and I've corresponded with several rad experts before committing to it. It is widely understood that the high does kills the beast better and what the RT community most concerned about high dose was the SEs. I had a mild radiation proctitis and that did not heal itself after 1.5 years, so late last year I had a single treatment of Argon Plasma Coagulation. That did the trick and no more bleeding. My potency remained good, albeit no ejaculates. Although SBRT is a new form of treatment and we have no long term data for it, I am fairly certain that in a few years, hypo-fractionated RT with the new generation RT equipment with lesser number of fractions will be the norm. To me, proton treatment's claimed advantage is depth of field issue, and the claim of lesser SE. Otherwise, it is just as good as other IMRTs cancer killing wise. I wanted the higher does killing method, without any physical intrusions (porcupine like needles to insert radioactive pellets or surgery) into the prostate, and SBRT did that for me.

Remember that when IMRT became widely used, it was targeting for 68-70 Gy and I believe nowadays (2008/2009) they are going for 74-80 Gy because the long term data showed that there were more bio-chemical failures on the lower dose. In my case, I know one hypo-fractionated RT study that did a 36 Gy total, and the RT investigator at Virginia Mason I talked to said that the results were not as good, and the next one she planned will be closer to the one I had. Chris King in Seattle is also doing a hypo-fractionated study but not as high as mine. I think that the 5-8 hypo-fractionated treatment with cyberknife type equipment will be the new RT standard once long term data become a fruition. The present IMRT equipment cannot do with precision to deliver the high dose beams.

 
Old 02-14-2009, 11:44 AM   #14
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

[QUOTE=viperfred;3884899]
...
I considered all options including proton therapy. Targeting is getting better for localized PCa and delivery of Radiation is improving as a result. The only system that offers real time tracking is the CyberKnife. Unless you have access to the planning system that produces the dose prescription you can not appreciate the benefit of the CyberKnifes many beam angles and the resulting dose to target and step drop of dose to the surrounding tissue.

I have not seen any published data from Proton therapy that shows a better result cure or side effects than IMRT or CyberKnife or Brachrtherapy or surgery....
[QUOTE]

I must admit I'm intrigued by the Cyberknife, and probably would have considered it seriously had I known more about it when I was reviewing options. That said, I cannot say whether I would have chosen it over proton beam therapy, because I had so much positive feedback from patients, and with higher, well-tolerated dosages being given more recently, I was very
comfortable with the decision. I do think there needs to be more reporting of these results, and that will probably happen, as it will with Cyberknife.

My belief is that the side effects after proton are less than with other forms of radiation and surgery, but I wouldn't expect the cure rate to be dramatically different (although the more precise the targeting, the better
things should turn out). So we can all get to the same place using varying
treatments. Guess it's a comfort level with the number of patients treated
an important consideration as is the facility and/or doctors involved. For me, proton came out way ahead, but as I say, Cyberknife certainly looks like an interesting approach. I had heard, but don't know for sure, that
there is a group now receiving proton therapy at the Univ of Florida Proton Therapy Institute which involves fewer treatments and higher dose per treatment. With enough time, many more answers will be known, but unfortunately we all have to make our decisions on what's available today and how each one of us reacts to the choices. (Of course, there are still those that don't want to look beyond the initial doctor's recommendation for surgery- certainly still a choice many prefer, but I wonder if there would be as many if they knew that results are not guaranteed, the cancer can come back, and the side effects for some at least, can be severe.)

I think your results have been great-- PSAs have come down dramatically and I know you are pleased with that.

 
Old 02-15-2009, 07:30 AM   #15
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Re: CyberKnife with Stereotactic Body Radio Therapy (SBRT): Promise & Not Yet Proven

Does anyone here have access to Timmerman and Madsen study reports/papers with regard to SBRT for PCa? Both of them have done Phase I and I believe Timmerman is about to go into Phase II. Thanks.

 
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