Intact Prostate Cancer Discussion - SBRT, Brachytherapy, EBRT, SpaceOAR, Margins

[seper]

Promoting prostate HDR in US would not be bad.

In theory based on this chart could single fraction prostate HDR pay $23K global? If so look out for a prostate HDR renaissance in the US. CMS is, wittingly or unwittingly, massively incentivizing (and disincentivizing) certain treatment paradigms with this new model. For better or worse!

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[RickyScott]

Promoting prostate HDR in US would not be bad.

this would accelerate stereo. Feel if you do enough hdr you will inevitably encounter a bad complication?

 

[seper]

Are you thinking head-to-head SBRT vs. HDR monotherapy comparison? Actually, I'm not sure which would win.

this would accelerate stereo. Feel if you do enough hdr you will inevitably encounter a bad complication?

 

[RickyScott]

Or 60 gy in 20 fractions which has surprising amount of good data.

 

[deleted1002574]

I can’t imagine with today’s technology that SBRT can equal or better HDR ? It’s such a good technique in the right hands (I don’t own said hands).

 

[RickyScott]

I can’t imagine with today’s technology that SBRT can equal or better HDR ? It’s such a good technique in the right hands (I don’t own said hands).

Know very little about hdr, but fractionation w/5-10 fractions may offset better dose distribution and multilple needle placements? Wasn’t recent article from Europe on phase III trial with 7 fraction regimen?

 

[scarbrtj]

Why not single shot 19 Gy SBRT? On paper it could be equal LC and less complications than 19 Gy HDR x1.
“Cure your prostate cancer with a single outpatient clinic visit in 20 minutes or less.”

 

[RickyScott]

Race to the bottom here. Don’t want to even calculate predicted on treats and what time I will be getting out in afternoon.

 

[RickyScott]

Also my department will be a Lot more valuable to nearby NCCN center than my own hospital!
Would make a lot of sense for them to take us over/ buy us etc to spread financial toxicity. Paradoxically this inteases rates!

 

[taserlaser]

We’ve done a few 19 Gy single shot SBRT on trial here, patients tolerate it excellently.

My concern with that is the Toronto data showing worrying failures with single shot 19 Gy HDR as opposed to 2 fraction HDR. I think it’s still unclear to as what effect is causing that, whether it is:
a) biology resistant to single shot
b) 19 Gy not enough
c) multifraction allows for better coverage per RickyScott

Due to the above, I think there is appetite here to try and escalate to 21 Gy in a single shot shot with external beam. But I think multifraction, either with linac or HDR will probably end up being more robust.

Edit: here is the paper - https://www.redjournal.org/article/S0360-3016(19)31327-6/fulltext

I forgot this too - MRI fusion with DIL boost may be another acceptable strategy, but will have to wait for that one.

 

[medgator]

Would much rather do 5 fx sbrt with spaceOAR than be a shish kebab (sans biryani).

 

[scarbrtj]

Why not single shot 19 Gy SBRT? On paper it could be equal LC and less complications than 19 Gy HDR x1.

We’ve done a few 19 Gy single shot SBRT on trial here, patients tolerate it excellently.

My concern with that is the Toronto data showing worrying failures with single shot 19 Gy HDR as opposed to 2 fraction HDR. I think it’s still unclear to as what effect is causing that, whether it is:
a) biology resistant to single shot
b) 19 Gy not enough
c) multifraction allows for better coverage per RickyScott

Due to the above, I think there is appetite here to try and escalate to 21 Gy in a single shot shot with external beam. But I think multifraction, either with linac or HDR will probably end up being more robust.

i think it was Rod Withers who used to say “show me something that you can treat in one fraction and I’ll show you how it can be better treated in five.” So maybe. But I like the 21Gy idea too.
This is neat stuff.
Here’s how it would work. Consult 9AM. Sim and plan 10AM. Treat 11AM. Do same thing on patient #2 in afternoon. A center can make almost $50K a day w just two patients a day doing this. Crazy. You could literally make 12 million a year with just two patients under beam daily.

 

[RickyScott]

We’ve done a few 19 Gy single shot SBRT on trial here, patients tolerate it excellently.

My concern with that is the Toronto data showing worrying failures with single shot 19 Gy HDR as opposed to 2 fraction HDR. I think it’s still unclear to as what effect is causing that, whether it is:
a) biology resistant to single shot
b) 19 Gy not enough
c) multifraction allows for better coverage per RickyScott

Due to the above, I think there is appetite here to try and escalate to 21 Gy in a single shot shot with external beam. But I think multifraction, either with linac or HDR will probably end up being more robust.

Edit: here is the paper - https://www.redjournal.org/article/S0360-3016(19)31327-6/fulltext

I forgot this too - MRI fusion with DIL boost may be another acceptable strategy, but will have to wait for that one.

I just don’t understand research of 1 vs 2-5 fraction srt. What is the goal?

 

[medgator]

I just don’t understand research of 1 vs 2-5 fraction srt. What is the goal?

Optimizing the bundle/APM.

It's a chicken and egg scenario though.... Did that come about because of the research?

 

[scarbrtj]

I just don’t understand research of 1 vs 2-5 fraction srt. What is the goal?

Unless I’m brain farting this morning when the alpha beta of a tumor is lower than the alpha beta of surrounding healthy tissue you can show mathematically how single fraction is the optimal treatment choice maximizing LC and minimizing late effects.

 

[evilbooyaa]

We’ve done a few 19 Gy single shot SBRT on trial here, patients tolerate it excellently.

My concern with that is the Toronto data showing worrying failures with single shot 19 Gy HDR as opposed to 2 fraction HDR. I think it’s still unclear to as what effect is causing that, whether it is:
a) biology resistant to single shot
b) 19 Gy not enough
c) multifraction allows for better coverage per RickyScott

Due to the above, I think there is appetite here to try and escalate to 21 Gy in a single shot shot with external beam. But I think multifraction, either with linac or HDR will probably end up being more robust.

Edit: here is the paper - https://www.redjournal.org/article/S0360-3016(19)31327-6/fulltext

I forgot this too - MRI fusion with DIL boost may be another acceptable strategy, but will have to wait for that one.

Wouldn't do 19Gy - Prospective data from Beaumont shows poor oncologic control: https://www.redjournal.org/article/S0360-3016(19)30205-6/abstract

I heard at ABS maybe a year or two ago (when Krauss from paper above was presenting poor outcomes data as well) that 21Gy single fraction HDR had unacceptable toxicity, but can't find the supporting data currently.

I'm still skeptical on whether SBRT can have less toxicity than HDR. If so, how?

WUSTL evaluating 23Gy single fraction HDR - Safety and Efficacy of 23 Gy for High Dose Rate (HDR) Prostate Brachytherapy - Full Text View - ClinicalTrials.gov

 

[RickyScott]

FYI https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(19)30652-7/fulltext

 

[taserlaser]

Wouldn't do 19Gy - Prospective data from Beaumont shows poor oncologic control: https://www.redjournal.org/article/S0360-3016(19)30205-6/abstract

I heard at ABS maybe a year or two ago (when Krauss from paper above was presenting poor outcomes data as well) that 21Gy single fraction HDR had unacceptable toxicity, but can't find the supporting data currently.

I'm still skeptical on whether SBRT can have less toxicity than HDR. If so, how?

WUSTL evaluating 23Gy single fraction HDR - Safety and Efficacy of 23 Gy for High Dose Rate (HDR) Prostate Brachytherapy - Full Text View - ClinicalTrials.gov

Agree regarding 19x1. Patients were enrolled on study prior to these reports.

 

[RickyScott]

Agree regarding 19x1. Patients were enrolled on study prior to these reports.

I guess space oar, which I used to dismiss is going to really take off?

 

[scarbrtj]

I'm still skeptical on whether SBRT can have less toxicity than HDR. If so, how?

I guess one first way to attempt to answer your question is to ask how EBRT can have less toxicity than seed brachy. And I'm not just talking dosimetrically-related (although I think it would), I'm talking mechanically too. The doses can be quite inhomogenously high intratarget (a bug or a feature?) when the therapeia is brachy vs tele.

 

[deleted1002574]

I guess one first way to attempt to answer your question is to ask how EBRT can have less toxicity than seed brachy. And I'm not just talking dosimetrically-related (although I think it would), I'm talking mechanically too. The doses can be quite inhomogenously high intratarget (a bug or a feature?) when the therapeia is brachy vs tele.

Long term, I'd see LDR is less toxic than EBRT as monotherapy, in skilled hands.

 

[scarbrtj]

Long term, I'd see LDR is less toxic than EBRT as monotherapy, in skilled hands.

The endless debate. In my hands though, IG-IMRT has quite a bit more favorable toxicity profile than brachy. And clearly single shot EBRT would be a heck of a lot more convenient than brachy... taking away one of brachy's historical advantages.

 

[OTN]

I guess space oar, which I used to dismiss is going to really take off?

I do prostate SBRT without spaceOAR. 40 Gy in 5 fox is extremely well-tolerated in the short and long-term.

If we get data showing 50 in 5 has better control of high-risk disease, well then, now I’m 100% on board. Until then, it’s not saving enough rectal toxicity to be worth it, in my opinion.

 

[RadOncDoc21]

I do prostate SBRT without spaceOAR. 40 Gy in 5 fox is extremely well-tolerated in the short and long-term.

If we get data showing 50 in 5 has better control of high-risk disease, well then, now I’m 100% on board. Until then, it’s not saving enough rectal toxicity to be worth it, in my opinion.

SpaceOar has great reps!

 

[evilbooyaa]

Long term, I'd see LDR is less toxic than EBRT as monotherapy, in skilled hands.

Correct, but LDR is the most operator dependent thing we do, in the vein of 'surgical' quality. HDR prostate is much more forgiving. If you place a needle in a not great position, you can at least turn the dose down or compensate to avoid say urethral or rectal toxicity.

 

[medgator]

Correct, but LDR is the most operator dependent thing we do, in the vein of 'surgical' quality. HDR prostate is much more forgiving. If you place a needle in a not great position, you can at least turn the dose down or compensate to avoid say urethral or rectal toxicity.

Yup, just ask a vet in Philly....

NRC fines Phila. VA $227,500 over prostate care

The Philadelphia VA Medical Center was hit with a $227,500 fine by the Nuclear Regulatory Commission yesterday for poor care in a prostate cancer program that resulted in 97 veterans getting incorrect doses of radiation.

www.inquirer.com

 

[seper]

Yest, the Chair's career skyrocketed and he was recently endorsed by the ABS.

Yup, just ask a vet in Philly....

NRC fines Phila. VA $227,500 over prostate care

The Philadelphia VA Medical Center was hit with a $227,500 fine by the Nuclear Regulatory Commission yesterday for poor care in a prostate cancer program that resulted in 97 veterans getting incorrect doses of radiation.

www.inquirer.com

 

[RickyScott]

Seattle brachy group had handful of fistulas which I have never heard of in IGRT area w/ebrt

 

[w00tz]

Seattle brachy group had handful of fistulas which I have never heard of in IGRT area w/ebrt

There are more toxicities with LDR vs EBRT, but there is an increase in bPFS per ASCENDE-RT, so there is a trade off.

Would love to see results of SBRT vs brachy trial. My feeling is toxicities are higher with SBRT compared with brachy (in skilled hands), but wouldn't be practice changing unless you were good at brachy.

 

[SneakyBooger]

Ah yes, brachy for prostate...

Wallner also authored an article on "The Malpractice of Prostate Brachytherapy" or some title like that. What other procedure do we perform that has a publication title like that?

Seper, as I recall off top of my head there was a publication out of Seattle with a 1.7% fistula rate. I have the paper stored away somewhere and can probably find it.
...

 

[scarbrtj]

We’ve done a few 19 Gy single shot SBRT on trial here, patients tolerate it excellently.

My concern with that is the Toronto data showing worrying failures with single shot 19 Gy HDR as opposed to 2 fraction HDR. I think it’s still unclear to as what effect is causing that, whether it is:
a) biology resistant to single shot
b) 19 Gy not enough
c) multifraction allows for better coverage per RickyScott

Due to the above, I think there is appetite here to try and escalate to 21 Gy in a single shot shot with external beam. But I think multifraction, either with linac or HDR will probably end up being more robust.

Edit: here is the paper - https://www.redjournal.org/article/S0360-3016(19)31327-6/fulltext

I forgot this too - MRI fusion with DIL boost may be another acceptable strategy, but will have to wait for that one.

Can anyone speak to length of tx delivery for 19 Gy HDR. If one can give 19 Gy <10min via RapidARC vs >20min 19 Gy HDR, there is a theoretical oncologic benefit to EBRT (Hall). Also a lengthy HDR delivery could explain the unexpected failures w/ 19 Gy HDR that weren't predicted via a strict LQ formalism. (This effect gets small when dose rate >1 Gy min, granted.) With very low alpha betas LC is a little "brittle" to dose rate effects.
This is very "inside baseball" radiobiology but could be important. (No one really talks 'bout this.)

 

[Haybrant]

I guess space oar, which I used to dismiss is going to really take off?

You’re wrong to dismiss spaceoar.

 

[deleted1002574]

Yeah SpaceOAR really good actually.
After you do about 10 cases, it’s really hard to go back to not doing it, after you see some pretty amazing DVHs

 

[medgator]

You’re wrong to dismiss spaceoar.

Issue I have is the reimbursement if you have to rent the equipment.

Makes sense to partner with a urologist if they have the proper equipment imo

 

[PhotonBomb]

I think it's reasonable to think about the practical aspects - because not every patient needs it. I favor using it in SBRT and in non-SBRT patients on blood thinners.

 

[deleted1002574]

Issue I have is the reimbursement if you have to rent the equipment.

Makes sense to partner with a urologist if they have the proper equipment imo

No local urologists do it ? It’s real quick.
If you have a guy you do seeds with, can do the seeds first, and at that time put spacer in. I think once they get the hang of it, it’s a quick thing for them - fiducials + spacer.

 

[SneakyBooger]

Significant rectal toxicity is so rare nowadays do pts need SpaceOAR.

SpaceOAR itself has risks.

 

[deleted1002574]

Boogs, those data definitely should give everyone pause. I haven’t seen it. I know our institution does it a lot. Would love to see their data written up.

 

[medgator]

No local urologists do it ? It’s real quick.
If you have a guy you do seeds with, can do the seeds first, and at that time put spacer in. I think once they get the hang of it, it’s a quick thing for them - fiducials + spacer.

Requires more than your standard u/s setup as it is not done via the same approach as a biopsy (transperineal vs transrectal). Requires a stepper, similar to brachy setup. Paying for rental eats into reimbursement for the procedure

 

[Mandelin Rain]

Yeah the above quoted severe toxicity of spaceoar insertion is like 3x greater than of EBRT itself. It’s a nice marketing gimmick and can produce a great dvh, but it’s a solution to a non-problem that has problems itself.

 

[medgator]

Significant rectal toxicity is so rare nowadays do pts need SpaceOAR.

SpaceOAR itself has risks.

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Compelling links. My personal observation of proctitis was fairly low before using it.

Complication rate almost seems equivalent. Definitely giving me pause to using outside of sbrt/hypofx, but the first article with the most of numbers of pts seems to indicate the balloon is the problem not spaceOAR gel?

 

[deleted1002574]

Yeah the above quoted severe toxicity of spaceoar insertion is like 3x greater than of EBRT itself. It’s a nice marketing gimmick and can produce a great dvh, but it’s a solution to a non-problem that has problems itself.

Okay so you don’t use it. People do and have good results. In a disease where majority of people literally live their life expectancy without dying of disease, reduction of toxicity is a worthwhile endeavor. Im tellin’ ya, “Mans Best Cancer Hospital” uses it and you can call it a marketing gimmick, but truly, do 10 cases and get back to me. I was a naysayer, initially.

 

[medgator]

Okay so you don’t use it. People do and have good results. In a disease where majority of people literally live their life expectancy without dying of disease, reduction of toxicity is a worthwhile endeavor. Im tellin’ ya, “Mans Best Cancer Hospital” uses it and you can call it a marketing gimmick, but truly, do 10 cases and get back to me. I was a naysayer, initially.

To be fair, before using it, how much rectal toxicity were you seeing in your patients, esp long term? I've followed several of my prostate pts out past 2-3 years (77.4-79.2 typically) and I can't remember the last time I saw xrt proctitis

 

[Chartreuse Wombat]

I suggest the moderators move the SpaceOAR discussion to a separate thread. Little to do with the original post.

 

[Mandelin Rain]

The reps will self assuredly tell you you’re seeing 10% proctitis and rectal bleeding. They’ll become incredulous when you tell them you haven’t seen one in 10 years. I follow my guys at least 5 years.

 

[Krukenberg]

To be fair, before using it, how much rectal toxicity were you seeing in your patients, esp long term? I've followed several of my prostate pts out past 2-3 years (77.4-79.2 typically) and I can't remember the last time I saw xrt proctitis

late RT toxicities don’t plateau. The longer you follow the more you’ll see

 

[PhotonBomb]

Again - there is no need to do this in your standard patient, for those who are still doing conventional fractionation.

There is rationale for it in SBRT patients as well as patients who are on anti-coagulation, even if nine-weekers, because they are at higher risk of bleeding.

 

[BobbyHeenan]

Thanks for those papers.

I'm diving into the spaceOAR game, starting now for just SBRT patients, and it's obviously good to know the toxicities because the randomized trial had ZERO of those events...but I had talked to a guy that had a peri prostatic abscess on one of his cases that was a disaster and another guy that had a rectal wall injury.

However, have spoken with other colleagues that swear by it.

I enroll on NRG GU-005 and it is optional on trial.

I did have my first proctitis (bleeding as only symptom; no diarhea, no rectal pain) I've seen in years recently (70 Gy in 28 fractions; V70 Gy was < 2 cc), though the guy was taking meloxicam, aspirin, and then excedrin migraine (with aspirin in it) as well. AFter stopping those and using carafate suppositories his bleeding stopped. Awaiting GI scope to just make sure nothing more significant going on.

 

[Mandelin Rain]

Late grade 3 or greater toxicity in prostate cancer is what? <0.5%? Let’s say SpaceOAR reduces this to 0%. If the complication rate of SpaceOAR is 1% you’re still coming out behind.

 

[PhotonBomb]

Thanks for those papers.

I'm diving into the spaceOAR game, starting now for just SBRT patients, and it's obviously good to know the toxicities because the randomized trial had ZERO of those events...but I had talked to a guy that had a peri prostatic abscess on one of his cases that was a disaster and another guy that had a rectal wall injury.

However, have spoken with other colleagues that swear by it.

I enroll on NRG GU-005 and it is optional on trial.

I did have my first proctitis I've seen in years recently (70 Gy in 28 fractions; V70 Gy was < 2 cc), though the guy was taking meloxicam, aspirin, and then excedrin migraine as well. AFter stopping those and using carafate suppositories his bleeding stopped. Awaiting GI scope to just make sure nothing more significant going on.

I really appreciate your posts, you have a strong general clinical experience and it shows.