Please weigh in on the differences between Cyberknife and Proton Therapy. Why is one better than the other, or not?
Cyberknife may turn out to be an excellent choice, but there is much less data and even a pros and cons section on a Cyberknife site says that the long-term curative potential of CyberKnife remains to be defined. If you want to explore Cyberknife, there was quite a bit of discussion on this board a couple months ago, and a search using that as a keyword can probably help.
The books that have been recommended to you have discussions and comparisons on all the treatments. It might be helpful if you use these and then supplement the information, or try to get clarification, on this board.
The books are often written by doctors, and we're not, although there's a lot of collective experience by many on this board.
I can't give you an absolute answer on that one, but here's what I know from my research-and if anyone has more info, please jump in:
The benefit to proton therapy is that there is no exit of the beam as the proton beam dies on the intended target and there is less scatter radiation to deal with, and that's a good thing. For example if you targeting the prostate from above, the bowl below is spared because the beam doesn't exit through it. The results are a high cure rate as well as lower side effects from IMRT or other forms of traditional radiation therapy. SBRT (Cyberknife) takes a different approach but with conventional radiation, by placing the radiation source on an arm that can rotate in an almost 360% sphere around the body as opposed to the stationary arc found in proton and IMRT machines. Entry and exit plans for the radiation can be tailored to keep from dosing the same healthy tissue over and over again and concentrate the cumulative effect on the prostate. What makes this possible is that gold markers or fiducials are permanently placed in the prostate and become reference points for the equipment to lock onto and track in real time so that the accuracy of the beam is controlled to 0.5mm. My Cyberknife treatment plan uses over 300 different points of entry/exit compared to less than a dozen for an IMRT or proton therapy plan. The "high rent" areas (nerve bundles, etc.) will have less trauma if you don't have to repeatedly dose the same cells.
So, proton therapy gets its benefit from a more "friendly" beam that does less damage by not scattering or exiting the body, Cyberknife gets its benefits from using a conventional beam with a highly refined targeting system that greatly limits the exposure of any one non-targeted body entry/exit point while delivering the needed dose to the target. By the way, both proton and SBRT are coming up with about the same cure rate/side effects statistics.
Given the accuracy of Cyberknife and the benefits of proton beam therapy you would think that at some point that the next logical step would be to marry the two. Maybe it will be done at some point, but real the end game is high cure rate with low side effects and both seem to have the same edge over conventional IMRT therapy right now.
Personally, I chose the Cyberknife option over proton therapy which I very heavily considered because the treatment time required and the distance to a facility was much better for me with Cyberknife. I haven't stopped running my company and as of this moment no one in the company even knows that I have PC and am undergoing treatment-I am just out the first part of the day at "meetings". If I do get tired, I'll take a vacation day or two. I don't think that I will ever tell them as I really don't see myself missing a beat. Try that with the surgical option!
First, don't buy the HIFU baloney. It is all testimonial BS by the HIFU business to lure
unsuspecting clients. Proton Therapy is better than Cyberknife - but you are in California, and Loma Linda's Proton Therapy uses a balloon inserted up the anus, and pressurized with water to keep the prostate lock in position before every therapy session. That pressured stretch of the colon results in chronic constipation - according
to a report by the Chairman of that Department which is posted somewhere online.
University of Florida Proton Therapy doesn't use the balloon, but I don't know if you have that option. My medical group in the Chicago didn't approve my request, and I had to have IMRT radiation locally. If I were you, I would chose Cyberknife over Proton with the baloon.
After looking at all the options, I have decided to have the sugery after all. Having talked to a radiation oncologist I have found that the side effects and results are almost the same whether one has radiation or the surgery. The difference is that with radiation the side effects occur a couple years later. IMRT is as good as Proton Therapy. The technology for targeting specific areas has improved vastly over the last few years and they are now able to target within a milimeter. Since, in my case, my age, gleason scores, and psa numbers, the cancer is not percieved to have left the prostate capsule. I feel removal is the best way to go for me. That said, I am now searching for the best surgeon local to my area as well as looking at all the insurance related issues.
Jake, I know that you feel a level of relief having made a treatment decision. It feels like a step forward after getting knocked back several steps, doesn't it? Also glad you looked hard at the options, perhaps sorted through the riff-raff that one is bound to run across on the internet, and decided on something that is right for you.
Your next milestone is selecting a surgeon. Once again, take your time and look far and wide. I'm from outside of Chicago, and from a very large number of surgeons available in this metropolitan region, when I looked deeper I felt that I had a choice of several outstanding surgeons. I also gave consideration to going outside the area (Henry Ford Hospital in Detroit). Although I don't have specific knowledge, I'm confident the LA metropolitan area also has more than one outstanding surgeon just waiting to be identified by YOU!
"Networking" will be an important step for you now. Talk to friends, because they will know somebody else who had a friend who had prostate surgery. That friend would probably willingly talk to you about their first hand experiences with their doctor. Do this enough, and you will start to get familiar with the doctor names in your area, and start to hear overlapping stories. Maybe someone else with familiarity with LA-area will chime-in here with a name(s). Networking takes on many forms, and sometimes takes unexpected turns to take you to the path you eventually follow.
best wishes, and do continue to keep us informed...
If you have the option to go either way, you might want to reconsider radiation. While surgery does have the psychological advantage of knowing that the prostate is gone, if your stage is like mine, you would probably do better with radiation from a side effects standpoint. My surgeon (head of Univ of PS Urology) leveled with me and said that all surgical patients experience incontinence, etc., and that once the nerve bundles are disturbed, it's completely dependent on your body's ability to recover. The question is how long it lasts. With today's IMRT and SBRT radiology being so much better targeted to spare these parts than even a few years ago I would think that going forward you will see a much lower percentage of patients with side effects. My research, not what any particular doctor has told me, has led me to the opinion that the best way to treat contained early PC is with radiation. I would NOT opt for robotic surgery as very recent studies show that patients are less satisfied with the outcome than traditional open surgery when the surgeon is not seasoned in this technique, and today very few surgeons are. So if you want surgery, go open, not robotic.
As a follow up to my own CyberKnife experience, it is now 8 days past my last treatment and all symptoms are gone. You won't get that with surgery.
Having talked to a radiation oncologist I have found that the side effects and results are almost the same whether one has radiation or the surgery. The difference is that with radiation the side effects occur a couple years later.
Jake, as you can see, some people have a "live for today" approach to life, and some people are thinking about tomorrow. This statement is not judgemental, but different people internalize the same information differently. It's a mixed blessing just to have a number of choices in treatments for PC.
Personally, if I was in my 60's or 70's, the decision between radiation or surgery would have been a lot tougher. Heck, if I was in my 70's and was concerned about undergoing major surgery, I might even have considered Cyberknife.
I hope that you continue to get good, positive support from this site.
Last edited by kcon; 02-14-2010 at 06:49 AM.
...After looking at all the options, I have decided to have the sugery after all... I feel removal is the best way to go for me. ...
Congratulations on having made a decision that feels right for you. It's great that you spent an appropriate amount of time getting educated. As we've discussed, this is a highly personal choice and it's difficult to say what's right for one person is what another should choose. You've researched and talked to others, so at this point, don't look back. Just find that great surgeon and you'll soon have all this behind you!
Thank you for sharing your information on HIFU. I think that it is important that people keep sharing their information and experiences. The advancement of medicine is only achieved by trying and today's gold standard becomes the barbaric treatment of the past. Personally I think that in the next several years that surgery will be looked on as overkill for treating the very early level of PC that is now being detected. It's too invasive and radical a procedure for something that targeted, non-invasive therapies can handle easily with the same cure rate. But, as long as a hospital stay and surgeon's fees are the cheapest economic choice, I am sure that insurance companies will still approve the cut and sew option.
Why do PC patients shun new treatments? It's the fear that they won't be cured.
That is the fear that I had to face head-on, overcome and put behind me before I could make ANY intelligent decision. Prostate cancer, until the recent advent of the PSA test was like pancreatic cancer in that it can remain silent long after it metastasizes, and that silent course of progression strikes fear into the heart. I don't blame anyone who chooses surgery out of fear, after all, they aren't the expert. I do think that the medical community sometimes does patients a disservice by not insisting that the patient educate themselves.
I had that exact experience with the Urologist who did my biopsy. When I went back to him for the results he never discussed my options with me and within less than five minutes of giving me the diagnosis, wanted to schedule me for surgery, stating that he though that this was the "best" option for me and ruled everything else out. Of course, the surgery would be with his partnership which recently had gotten into robotics.
Fortunately I have had a very good GP for may years now plus a lot of close friends who are docs. They helped me sort things out. In the end, the decision put to me was that at this stage in my PC's growth that the decision was mine as to whether I wanted surgery or radiation. Pretty much verbatim the conversation went like this: "Some people want to die with all of their body parts intact, and some want that offending part in a bottle on the shelf". That's a far cry from: "Surgery is your only option."
It's natural for people to think that surgery controls cancer like nothing else because there was a time when that was true. More importantly, my generation grew up with a fear of cancer. A fear that only a trip to the O.R would calm-or so we believed. But even then as now, no surgeon would give you a 100% guarantee of cure because they know that they can't. Today we know so much more about cancers in general and prostate cancer in specific. We can treat it effectively in a variety of ways because we can now find it very early and monitor it so well. But that finding and monitoring has only come about in the last 20 or so years. As proof of that, please note that the Gleason score, while it was invented in the 60's, didn't become the de facto standard until the late '80's. PSA screening for early PC has only come about because of a randomized study done in the early '90's. Our fear comes from our parents, who rightly knew of only one "real" cure-and that's to cut whatever it is, out.
Of course Proton, CyberKnife, HiFU, Cryo and all the rest are long-term untested treatments. We are just now treating early stage PC aggressively with all forms of procedures, including surgery. We are ALL part of the long-term study.
The ability to do with sub-mm accurately non-surgical procedures may be a very recent advent (brought about by the incredible advances in computing) but these procedures are built on the shoulders of long established medical knowledge, knowledge waiting for the opportune time to be implemented. In short, we are seeing therapies that were dreamed of but impractical until the technology made them possible. The principals of HIFU isn't anything new, but like CyberKnife, delivering it with efficacy without harming the patient, is. It's a brave new world.
Actually, there are clinical trials going on right now for HIFU for PC in the USA. Currently HIFU is approved for use with uterine firboids by the FDA, as of '04. HIFU is also used to treat BPH in the USA which is non-cancerous.
The problem with PC is, of course, that the prostate is buried in the body and PC can remain and metastasize if the prostate is not completely ablated. Not so with BPH, so if you leave something microscopically, there is no harm. Unfortunately, other than removing the prostate and dissect the entire organ to check for PC, the only way to confirm that the treatment had met its intended goal is a long-term study. The trials are not designed to prove the efficacy of HIFU, that's not in question. But, rather to insure that a proper protocol (how much/long treatment, what areas, what strength, etc.) is developed so that the treatment is effective long term. The fact that it is in trials right now in the USA is very promising and when approved, it will be a welcome non-surgical addition to the cancer-fighting arsenal.
I'm glad that your husband's experience was so positive. I hope that his quality of life remains good and that his future remains PC free.
Don't know where you got the idea that the Proton Beam causes constipation! I was a Loma Linda patient in 2005 and am a member of the brotherhood of the balloon (over 4,000 members... all previous Proton beam prostate cancer patients). I haven't heard any mention of constipation, although I'm sure it's a possible side effect.
Here's my understanding of the differences between Proton and Photon (standard radiation) therapy. Far less likelihood of side effects when treated by the Proton beam. With photon radiation, the particles go completely through the body causing damage to cells other than the targeted cancer. The Proton beam uses a heavier particle (Hydrogen proton), has a Braggs Peak (stops at the programed depth), and does not continue on through the body. It also delays giving off it's energy until the programed depth is reached.
Results?... higher cure rate than either surgery (including robotic) or Photon radiation with about a 1/3 less likelihood of impotency or incontinence. One of your big questions should be "what's the recurrence rate for the various therapies?" Answer; Surgery... 30%, Proton bean... 11%.
A new Proton center is being built in Long Beach, CA and should be opening in late 2011.
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I had a long discussion with my radiologist about photon vs proton and she laid out the pros and cons of both for me. Based on our conversation, if I had to choose between standard IMRT and Proton, I would choose Proton. They are both delivered in a single plane, which is the reason that both take place over a series of very low doses. The same healthy tissue in between the beam and the target is still bombarded every time and needs to recover. That radiation of any kind passes through the body is a problem for the most sensitive tissue in its path, the intestines. Dosing can only be done at the rate that the most sensitive tissue can withstand. The problem with both standard IMRT and Proton is that the equipment can only deliver the beam in an arc and the beam is constantly dosing that same sensitive tissues. By the way, Univ of PA uses the rectal balloon to stabilize the prostate for their IMRT therapy-it's a good idea no mater which way you go-and they have no problems with bowl complications for using it. Here is something to note; while Proton might not continue past the target very far, scatter on impact is very much an issue, and that scatter has to be taken into account as it can scatter into the bowl.
If the only means of delivery available is the standard arc setup, well from a possible side effect standpoint, I'd take the Proton setup as that has a better chance of not irritating the bowl....but, I didn't take either one. I chose the CyberKnife approach fundamentally because it avoids dosing the same tissues over and over again during the treatments. The numbers tell all: IMRT (and Proton) both dose at about 1.8Gy per session, about the maximum the same healthy tissue in its path can handle. CyberKnife does 7.25 Gy per session. Do the math, that's almost 4 times as much! But, because PC dies at a much faster rate with the higher dose over a short period of time (read about HDR Brachy), the treatment has a lower cap on radiation at 36.25 Gy vs. 80 Gy for IMRT and Proton. My personal experience bears out the value of the CyberKnife approach. I had mild urethral irritation (to be expected-it was in the path part of the time) plus some very mild bowl irritation (see my posts on the subject) both of which were completely-and I mean completely-gone in about 15 days. At no time did I feel overly tired or unable to do anything that I normally would. It was no worse than feeling like I had a mild urethral infection and a little bit of mild food poisoning. I've gotten worse upset from eating jalapeno peppers! I am only a little over a month from finishing my treatment and I feel as if it were all a dream from 20 years ago-and yes, I am looking forward to putting this behind me forever.