Prostate Patients Urinary Symptoms

[Haybrant]

We all know urologists love to send the less than healthy prostate cancer patient for RT. Ive been getting a good number of older pts with obstructive symptoms recently and I want to ask some strategies you guys have been using.

My question is, are there patients that you deny RT (IPSS > 20?). If they have hormone indications I have been putting them on hormones and see if they improve. Usually they have mild improvements. Otherwise I counsel the heck out of them that they have a small chance of obstructing or being left with significantly worse urinary symptoms intermediate or long term.

Do you have strategies for the patients that do develop bad function? I mean Flomax bid only will do so much. Will urology consider TURPS for such patients, at what point is that reasonable? Thank you!

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[seper]

how about Flomax and Avodart?


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[medgator]

Could talk with urology about turping them before xrt. Hormones is another option but usually it ends up shrinking the prostate without really helping the actual sx much as you stated.

I've had some luck with NSAIDs as well

 

[Haybrant]

Could talk with urology about turping them before xrt. Hormones is another option but usually it ends up shrinking the prostate without really helping the actual sx much as you stated.

I've had some luck with NSAIDs as well

In my mind I always thought TURP was pretty discouraged if the patient has prostate cancer; anyone ever sent a patient or seen a patient that had this? I can think of a couple guys I would like to TURP right now prior to their RT

 

[medgator]

In my mind I always thought TURP was pretty discouraged if the patient has prostate cancer; anyone ever sent a patient or seen a patient that had this? I can think of a couple guys I would like to TURP right now prior to their RT

Before brachy, yes not good, but before EBRT, don't see why not.

 

[Haybrant]

Before brachy, yes not good, but before EBRT, don't see why not.

How long would you wait before starting RT then if you did a TURP? How about TURP after RT if pts symptoms are so significant? I feel like there is a risk to the sphincter as well if turp'ing and RT

 

[Reaganite]

If my patient is having significant urinary issues during RT, I'll usually refer back to my urology colleagues (thankfully we are on good terms and they actually want to see these patients). Urinary symptoms during XRT are multifactorial and are often a combination of obstruction and overactivity. I find uros are better able to tease out these details and have more than just flomax at their disposal.

 

[medgator]

How long would you wait before starting RT then if you did a TURP? How about TURP after RT if pts symptoms are so significant? I feel like there is a risk to the sphincter as well if turp'ing and RT

I've heard people waiting a few months without a problem, the risk isn't bad if it's EBRT. Haven't dealt with this personally myself

 

[Haybrant]

Simple question: I had someone cover a prostate sim for me when I was away, there is a reasonable about of air in the rectum. Brings up a few questions:

Just curious what your thresholds are regarding rectal air in prostate treatment. During sim what are your best strategies to improve this; if you cant improve it much during sim do you have them come back a different day with a more aggressive prep? We do an enema day of sim for all patients. Thanks

 

[scarbrtj]

We all know urologists love to send the less than healthy prostate cancer patient for RT. Ive been getting a good number of older pts with obstructive symptoms recently and I want to ask some strategies you guys have been using.

My question is, are there patients that you deny RT (IPSS > 20?). If they have hormone indications I have been putting them on hormones and see if they improve. Usually they have mild improvements. Otherwise I counsel the heck out of them that they have a small chance of obstructing or being left with significantly worse urinary symptoms intermediate or long term.

Do you have strategies for the patients that do develop bad function? I mean Flomax bid only will do so much. Will urology consider TURPS for such patients, at what point is that reasonable? Thank you!

Radiation has a significant IPSS-improving effect on the IPSS>20 subgroup; almost no one with IPSS>20 has significant long-term worsening. Your experience may differ but mine has not, and I've measured it pretty assiduously in the past. So I often counsel these patients that a great treatment for their bad IPSS is radiation. Generally, as you can see, the change in IPSS after radiation is roughly 6-(0.8*pre-IPSS)... the implication being there's more chance for worsening with a lower pre-tx IPSS.

Don't know if that directly answers your question.

 

[scarbrtj]

Simple question: I had someone cover a prostate sim for me when I was away, there is a reasonable about of air in the rectum. Brings up a few questions:

Just curious what your thresholds are regarding rectal air in prostate treatment. During sim what are your best strategies to improve this; if you cant improve it much during sim do you have them come back a different day with a more aggressive prep? We do an enema day of sim for all patients. Thanks

It has never seemed sensible to me, and at best unreasonably rectally optimistic, to enema-ize at simulation but then not to do so for the daily treatment.

I keep my friends close and my enemas out of the clinic.

 

[Haybrant]

It has never seemed sensible to me, and at best unreasonably rectally optimistic, to enema-ize at simulation but then not to do so for the daily treatment.

I keep my friends close and my enemas out of the clinic.

Usually we get guys hyped up on some bowel regimen before they start. Ideally they would be on it prior to sim but given the layover often for ADT and other apts (fiducials etc) there compliance with it is poor by the time they come to sim. Once they're in our hands they do much better with it and there's a good chance much more complaint. Usually this improves issues of rectal air/stool as seen on igrt/fiducial shifts

 

[Haybrant]

Radiation has a significant IPSS-improving effect on the IPSS>20 subgroup; almost no one with IPSS>20 has significant long-term worsening. Your experience may differ but mine has not, and I've measured it pretty assiduously in the past. So I often counsel these patients that a great treatment for their bad IPSS is radiation. Generally, as you can see, the change in IPSS after radiation is roughly 6-(0.8*pre-IPSS)... the implication being there's more chance for worsening with a lower pre-tx IPSS.

Don't know if that directly answers your question.

Thanks I was unaware of this, I'm pretty sure many people use IPSS score as a reason to determine RT candidacy. Was looking for references but didn't see any, do you know if this has been replicated in any other studies? Are you the only one who has looked at it? Do other people know this correlation, I was always taught the higher the IPSS the poorer the candidacy for RT and often we'd push toward surgery in this case.Thanks

 

[scarbrtj]

I'm pretty sure many people use IPSS score as a reason to determine RT candidacy

If so, based on rad onc urban legends and not any hard data AFAIK.

do you know if this has been replicated in any other studies? Are you the only one who has looked at it?

You'd think someone would've, but I don't know. I don't think anyone has evaluated it quite as in-depth as me.

Do other people know this correlation

It was a top 10 ASTRO abstract '08. I should've written it up for thorough publication as it was a pretty respectably-sized dataset. Unfortunately never got around to it.

 

[Palex80]

I wouldn't risk treating anyone with a high IPSS score. I have seen a couple of patients who got into serious trouble because of this.
You could try hormones, they sometimes work.
TUR-P is a good option. I would wait 4-6 months after TUR-P before irradiating.

 

[Haybrant]

I wouldn't risk treating anyone with a high IPSS score. I have seen a couple of patients who got into serious trouble because of this.
You could try hormones, they sometimes work.
TUR-P is a good option. I would wait 4-6 months after TUR-P before irradiating.

Ya I wouldn't change practice based on this but it is interesting, hope someone else looks into it. It was stated here as if it was fact though which confused me but it was an abstract from 2008. Ive only had a couple patients that ended up with intermittent caths and they were in the IPSS 15-20 range. Try to avoid 20+ when possible but the couple I had still standout as having a good # of urinary sxs 3+ months in follow up but by IPSS % were not terribly worse. Probably hard to go from a 25 to a 30 than from a 12 to a 15. But if there IPSS is really decreasing that would be very interesting

Palex when it comes to TURP I was also trained that we should not disrupt the disease but this may be folklore too. Have you done it?

 

[scarbrtj]

I wouldn't risk treating anyone with a high IPSS score. I have seen a couple of patients who got into serious trouble because of this.
You could try hormones, they sometimes work.
TUR-P is a good option. I would wait 4-6 months after TUR-P before irradiating.

To each his own. But if "serious trouble" is urinary toxicity, I found that patients with IPSS 0-6 were MUCH more likely to have serious trouble after high dose XRT than patients who started out with serious trouble in the first place. Out of 81 IPSS>20 patients, 2 had IPSS worsening; that worsening was 5 points or less. Out of 400+ IPSS 0-6 patients, a good 300 patients as I recall had worsening with many getting bumped up over 20. If you have treated hundreds of prostate patients and remember a "couple" high IPSS patients who got into serious trouble, in reality how rational is it to start making a cause/effect argument? I'm sure there is the phenomenon of the symptomatic prostate patient; i.e., a prostate cancer patient whose prostate cancer is giving them prostate problems. We don't talk about it much. We look at the IPSS as some sort of stand-alone thing apart from the patient's prostate cancer. Surely radiation must help prostate patients, sometimes. Could one not make the argument that urging non-treatment of a high IPSS prostate cancer patient is somewhat akin to urging non-treatment of a painful bony metastatic site? Again, I'm just saying this is an alternative viewpoint. Alternative fact? You decide!

 

[Haybrant]

To each his own. But if "serious trouble" is urinary toxicity, I found that patients with IPSS 0-6 were MUCH more likely to have serious trouble after high dose XRT than patients who started out with serious trouble in the first place. Out of 81 IPSS>20 patients, 2 had IPSS worsening; that worsening was 5 points or less. Out of 400+ IPSS 0-6 patients, a good 300 patients as I recall had worsening with many getting bumped up over 20. If you have treated hundreds of prostate patients and remember a "couple" high IPSS patients who got into serious trouble, in reality how rational is it to start making a cause/effect argument? I'm sure there is the phenomenon of the symptomatic prostate patient; i.e., a prostate cancer patient whose prostate cancer is giving them prostate problems. We don't talk about it much. We look at the IPSS as some sort of stand-alone thing apart from the patient's prostate cancer. Surely radiation must help prostate patients, sometimes. Could one not make the argument that urging non-treatment of a high IPSS prostate cancer patient is somewhat akin to urging non-treatment of a painful bony metastatic site? Again, I'm just saying this is an alternative viewpoint. Alternative fact? You decide!

I don't think anyone would argue it's not interesting. But you're stating it like its a fact based on a patient reported endpoint in a retrospective abstract from 9 years ago. It may well be that there are actual peer reviewed publications about this since then and if so would be great to see them so we stop referring these guys away.

 

[scarbrtj]

I don't think anyone would argue it's not interesting. But you're stating it like its a fact based on a patient reported endpoint in a retrospective abstract from 9 years ago. It may well be that there are actual peer reviewed publications about this since then and if so would be great to see them so we stop referring these guys away.

The Red Journal accepted almost anything back in those days, and peer review ain't all it's cracked up to be as the number of peer reviewers for a manuscript vs an abstract is about 3 or 4 vs 1 or 2. That data has less relevance or "factuality" as a peer-reviewed abstract versus a peer-reviewed paper is possibly argumentum ad verucundiam. Data is data--veracity or "truth" is a moving target and requires an act of faith on the data receiver's/practitioner's part in all cases unless you were personally present for all aspects of the study. And even then when I'm personally doing the study I don't claim it to be a "fact" or "true." It is what it is ("I report, you decide" in the parlance of Fox News) subject to all possible human foibles etc. I have made practice-changing decisions based on abstract publications in the past; have you not? For example, when the SWOG postop prostate data appeared at ASTRO or the FIT Zevalin data at ASH or when the Temodar data for GBM came out in abstract form. (I'm not saying this abstract is "up there"... only that acting on published data in abstract form after measuring risks/benefits is not crazy.)

 

[Palex80]

To each his own. But if "serious trouble" is urinary toxicity, I found that patients with IPSS 0-6 were MUCH more likely to have serious trouble after high dose XRT than patients who started out with serious trouble in the first place. Out of 81 IPSS>20 patients, 2 had IPSS worsening; that worsening was 5 points or less. Out of 400+ IPSS 0-6 patients, a good 300 patients as I recall had worsening with many getting bumped up over 20. If you have treated hundreds of prostate patients and remember a "couple" high IPSS patients who got into serious trouble, in reality how rational is it to start making a cause/effect argument? I'm sure there is the phenomenon of the symptomatic prostate patient; i.e., a prostate cancer patient whose prostate cancer is giving them prostate problems. We don't talk about it much. We look at the IPSS as some sort of stand-alone thing apart from the patient's prostate cancer. Surely radiation must help prostate patients, sometimes. Could one not make the argument that urging non-treatment of a high IPSS prostate cancer patient is somewhat akin to urging non-treatment of a painful bony metastatic site? Again, I'm just saying this is an alternative viewpoint. Alternative fact? You decide!

"Serious trouble" were urinary catheters needed around 50 Gy into treatment, alter converted to suprapubic catheters. It took months to get them off the catheter. That's not pleasant...

 

[Palex80]

Palex when it comes to TURP I was also trained that we should not disrupt the disease but this may be folklore too. Have you done it?

I am not sure what you mean by "disrupt the disease"?

I have sent patients back to the urologist for TUR-P, then waited for 4 months, then treated.
You can use the time window between TUR-P and RT to do your ADT.
Pretty much every patient going to primary RT needs ADT nowadays, or as a colleague of mine says "If your patient is ineligible for ADT, he is also ineligible for RT". Which is more or less true, since you can do AS for almost all those who don't need ADT parallel to RT.

 

[evilbooyaa]

Pretty much every patient going to primary RT needs ADT nowadays, or as a colleague of mine says "If your patient is ineligible for ADT, he is also ineligible for RT". Which is more or less true, since you can do AS for almost all those who don't need ADT parallel to RT.

Disagree with that. It's certainly an option if you want to be like that in your practice, but doing definitive RT without ADT isn't some sort of super rare unicorn.

The NCCN Guidelines for Prostate are essentially "do whatever you want" for low and intermediate risk (and even high risk).

 

[Haybrant]

And even then when I'm personally doing the study I don't claim it to be a "fact" or "true." It is what it is ("I report, you decide" in the parlance of Fox News) subject to all possible human foibles etc. I have made practice-changing decisions based on abstract publications in the past; have you not? For example, when the SWOG postop prostate data appeared at ASTRO or the FIT Zevalin data at ASH or when the Temodar data for GBM came out in abstract form. (I'm not saying this abstract is "up there"... only that acting on published data in abstract form after measuring risks/benefits is not crazy.)

you're equating results of a massive swog study and a randomized trial in GBM to your abstract. Just publish it, it's interesting. Anyway, palex I also had to get SPTs on a couple guys after a few months of intermittent cath'ing, its a terrible situation for someone with low intermediate risk disease. By disruption I mean, are there any other situations that you are going and morselating tumors up; I may just not understand the turp procedure. Caused my attendings in training some concern so they didn't do it, but ya if they are on hormones probably not a big deal.

 

[w00tz]

It has never seemed sensible to me, and at best unreasonably rectally optimistic, to enema-ize at simulation but then not to do so for the daily treatment.

I keep my friends close and my enemas out of the clinic.

It has never seemed sensible to me, and at best unreasonably rectally optimistic, to enema-ize at simulation but then not to do so for the daily treatment.

I keep my friends close and my enemas out of the clinic.

I think in terms of patient setup, I do agree that it is not reproducible, but felt like daily CBCT helped overcome that. Where I am training, the enema on day of simulation is to get the rectal volume as low as possible, thus making the rectal constraint more difficult to achieve compared an overly large rectum where the V70 can be "diluted". I also understand there are other ways to determine conformality/unnecessary rectal dose when evaluating a plan. Our patients are generally good sports when it comes to the enemas. We also give our patients some perspective/consolation when we tell them that "across the street" they are doing daily rectal balloons.

We also shy away from XRT from patients with high IPSS if possible, but will justify treatment knowing that patients can get urethral dilation or TURP afterwards if there is worsening.

 

[Haybrant]

Somewhat interesting situation. Was referred a 62 yo guy with intermediate risk prostate cancer Gleason 3+4 in 3 cores and PSA is 13 ng/ml (its been pretty steady bt 12-13 for 2 yrs). He had a cysto for hematuria and resection of a bladder lesion turned out to be High Grade TCC noninvasive. They plan to re-scope him and offer BCG. Hes a pretty poor surgical candidate and wants definitive RT

What the appropriate thing to do? If re-cysto is clear offer RT now. Is there any issue with doing RT at the same time that BCG is being given? thanks

 

[RadOncDoc21]

Somewhat interesting situation. Was referred a 62 yo guy with intermediate risk prostate cancer Gleason 3+4 in 3 cores and PSA is 13 ng/ml (its been pretty steady bt 12-13 for 2 yrs). He had a cysto for hematuria and resection of a bladder lesion turned out to be High Grade TCC noninvasive. They plan to re-scope him and offer BCG. Hes a pretty poor surgical candidate and wants definitive RT

What the appropriate thing to do? If re-cysto is clear offer RT now. Is there any issue with doing RT at the same time that BCG is being given? thanks

I don't think it would be a problem but not aware of any data. He may have a higher risk of cystitis and hematuria short-term. Is the lesion near the target volume?

 

[Palex80]

Give him hormones for 6 months and treat with RT afterwards?
By then, the BCG reaction may be less prominent?

 

[Mandelin Rain]

Anyone suggest 800mg Ibuprofen for acute change in LUTS during beam?

 

[medgator]

Anyone suggest 800mg Ibuprofen for acute change in LUTS during beam?

Learned about it in practice. Seems to help some pts, watch out if they are on other NSAIDS, have kidney/bp issues and/or are on blood thinners

 

[Haybrant]

finally happened, got a young guy 60 yo w intermediate risk prostate cancer post RRP with persistent positive PSA, positive margin, ECE, negative nodes (hooray they took 3 nodes out), gleason is 4+3 (6 positive cores prior to resection). Really bad incontinence, tried sim'ing him at 3 months but no ability to fill bladder. Started him on ADT. Waited another 2 months, still no improvement 100% of the bladder would be in field

What to do? Is this a guy that will need cath to fill his bladder? Has anyone had to do this - Do you usually have the patient do the cath himself during treatment or the tech's? How do you decide how much saline to infuse in the bladder? Thanks.

 

[Chartreuse Wombat]

finally happened, got a young guy 60 yo w intermediate risk prostate cancer post RRP with persistent positive PSA, positive margin, ECE, negative nodes (hooray they took 3 nodes out), gleason is 4+3 (6 positive cores prior to resection). Really bad incontinence, tried sim'ing him at 3 months but no ability to fill bladder. Started him on ADT. Waited another 2 months, still no improvement 100% of the bladder would be in field

What to do? Is this a guy that will need cath to fill his bladder? Has anyone had to do this - Do you usually have the patient do the cath himself during treatment or the tech's? How do you decide how much saline to infuse in the bladder? Thanks.

Ask patient to clamp penis for 1-2 hours prior to treatment and allow bladder to fill. Several simple and easy penile clamps available.

 

[Haybrant]

Ask patient to clamp penis for 1-2 hours prior to treatment and allow bladder to fill. Several simple and easy penile clamps available.

Thanks chartreuse, do you usually have them drink as a normal prostate patient would (x glasses of water prior to sim) as well or do you do it different. thanks

 

[Chartreuse Wombat]

Thanks chartreuse, do you usually have them drink as a normal prostate patient would (x glasses of water prior to sim) as well or do you do it different. thanks

Yes. Comfortably full bladder..whatever that means

 

[nkmiami]

Have suggested Quercetin (whole foods/vitamin store) if flomax not working and found it helpful- it is an anti-inflammatory flavanoid taken from strawberries and onions. There is actually some literature on it for prostatitis/bph. If someone suggests it to patient- please post if it works.

Quercetin for chronic prostatitis/chronic pelvic pain syndrome. - PubMed - NCBI