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Thanks Jim, the added information helps. It seems like there is a lot of promotion of proton which makes me think they may be trying to pay for the expensive facility needed for proton radiation. I know photon radiation and specifically IMRT is getting better at consolidating the higher radiation in the target area. Any input is appreciated and especially from men who have had salvage radiation.
Bruce, I find myself largely in agreement with Jim's explanation of proton beam therapy (PBT). In October 2011, I completed first-line PBT treatment at MD Anderson in Houston. I'm in my 40s and presented with Gleason 6, T1C disease with a PSA = 7.2, which is generally regarded as "low risk" disease. My urologist said that if I was age 70+, he would have strongly recommended AS rather than immediate treatment.
Upon diagnosis, I spent weeks thoroughly researching all treatment alternatives. I'm fortunate to have a health care and statistical background, which helped immensely in reading all those PubMed journal articles. Simply put, I ruled out surgery fairly quickly -- too barbaric and "over the top" for what is likely organ-confined disease. EBRT appealed to me due to the cure rates (comparable to surgery) and the side effects (seemingly far fewer than surgery). Within EBRT, I looked closely at IMRT versus PBT, concluding that PBT was superior for the theoretical reasons you noted, as well as for the overall outcomes I was learning about. PBT (protons) is simply more precise than any IMRT (photons) due to the respective characteristics of the beams. As you remarked, photons shoot right through you, entering at their highest dose, hitting their target, and then exiting at a lower dose. Protons, on the other hand, are akin to guided missiles, entering low before "exploding" directly on their target and then immediately dying down to nothing (i.e., no exit dose). The practical effect is that the target gets the same amount of Grays (Gy) but surrounding tissue is largely spared. Radiation oncologists call this a lower "integral dose" to the body -- and it can be substantial.
With respect, I think the Dattoli reference you cite is mostly bunk. Yes, typical PBT is "scattered" onto its target, but this description is actually less scary than it first may appear. MD Anderson customizes bronze and lucite templates to the shape of your prostate and pelvic anatomy, effectively focusing and pinpointing the beam with surprising precision. MDA even has two different types of PBT devices: fixed (scattered) beam and pencil beam. The latter is the most precise, although for the vast majority of patients there is no material difference in outcomes. I was treated on the fixed (scattered) beam equipment and am doing just great so far. Pencil beam is generally reserved for cancers other than prostate, though a few higher Gleasons did get assigned pencil beam while I was there for my care.
Best of luck in your research and ultimate decision. Admittedly, my experience is first-line, versus salvage, treatment but I believe the main principles are readily transferrable to your situation. There were a few men in Houston for salvage PBT while I was there, so I know they do that work at MDA.
R Scott Thank you for that input. I have decided to go with IMRT at UCLA. My reasoning is as follows:
Doctors at UCLA have always been open with me and I don't get the feeling they are selling me. Blogs and people at Lome Linda give me a sense they are pushing their product. For salvage radiation pin point accuracy does not come into play as much. Radiation Oncologist at UCLA said that Lome Linda's technology is very old and IMRT at UCLA is state of the art. He did mention there are 3 new facilities in US that are offering newest generation proton therapy that may be better than IMRT but it is to soon to tell. They are on the other side of the country. At some time a person needs to make a decision and for better or worse I have made mine. I do feel in good hands at UCLA. Again thanks for the input. Bruce
Proton will definately work for low and intermediate grade cancers. For the higher grades sometimes a Photon boost is added, this means that they are still unable to get the higher doses normally delivered by IMRT. Higher dose equals better cancer control. The biggest disadvantage of Proton is the cost and the travel normaly associated with it. I have never seen any evidence that the side effects are better than IMRT, which is the major selling point. There has been ample time to generate quality of life data as there are hundreds of QOL studies for Brachy and IMRT, but I have never seen one on Proton so you just have to rely on anactodal information. The only two head to head studies I have seen on radiation are the ACER 2009 and the Prostate Cancer Study Group in which Proton did not fair very well. In light of all the information that seems to indicate that it is not better than IMRT and may be worse in cancer control than the other radiation options one would have to justify the additional cost and effort and I just have not seen this done satisfactorly up to this point in time.
Bruce,
It sounds like you have decided on photon radiation (that's good) and this is in no way an effort to change your mind, but I thought I would give my 2 cents. I just finished 9 weeks of proton therapy at UFPTI in Dec. I had Stage 2B GS8 organ-confined PCa. Most guys I met there had GS6 or GS7 (3+4) and their treatments were a "walk in the park" like you have heard. I agree all the stuff I have heard about proton is anecdotal but I've heard some rumors that UFPTI will publish some 5-year results later this year (they only started treatments in 2006) and reports I've heard are quite amazing.
I did actually meet a guy down there who was having proton therapy for failed RP. He was just starting his "work-up" and wouldn't start therapy until this month. I considered Loma Linda, but I liked the protocol they used at UFPTI better. Yes, it is expensive, and takes a couple of months, and yes I had to travel over 600 miles from home, but I had gotten my fill of "anecdotal" stores at my local UsToo monthly meetings. Their post photon treatment stories varied from "sorry" to "grim." Each one had QOL issues. (In my group of about 60 guys, about 50% got surgury, 25% got "seeds" and 25% got some form of EBRT/IMRT.) In fairness-- no one other than me has had proton therapy in our UsToo group and most guys there didn't know the difference between a photon and a proton when I talked about my treatment.
I think this has been a good exchange about the relative benefits of photon and proton radiation bearing in mind the lack of definitive studies.
I see that the Dattoli site was mentioned. I believe that some of the material on that site is misleading and if SOME is misleading, then it might be an idea to be somewaht wary of other information.
In particular I was interested in a statement made to a young man who consulted the good doctor. He was told in writing that prostate cancer in young men was more aggressive (he had a diagnosis what was Low Risk in terms of current definitions). This intrigued me because it is a subject I am personally interested in, having being diagnosed as a 'young man'. So I mailed the organisation and asked if I could be directed to the data or studies supporting this statement. The response I got was from the Marketing Department saying that the statement was based on their observed experience.
In another section of the site, the various options were listed and mainly dismissed. In this section references were given to studies that it is implied support the statements made. Very few do that.
I took this matter up in a discussion with a vehement PCa activist, suggesting that it might be in the interestes of men to campaign against the posting of informaiton that might be misleading. His response was that in a commercial world such statements were acceptable; the importnat point being that all men diagnosed with PCa be treated.
John, since I'm a "graduate" of the MD Anderson PBT treatment protocol, I feel I must respectfully challenge some of the misinformation that your post on the subject contains. First, MDA's PBT regimen treats the full range of localized PCa without the need for any photon boosts at the higher risk levels. Most men with a Gleason score >= 4+3 are also on Lupron to help knock down their tumor. PBT generates dosage levels to the target area at least equal to IMRT, if not slightly greater (according to my MDA doc).
Second, and perhaps because of your first erroneous point, you suggest that cancer control with PBT might not be as good as it is with IMRT. This is simply baseless. I will grant that the precision of PBT requires excellent dosimietry and treatment planning by your radiation oncologist (i.e., to ensure proper coverage of the gland, with a small 4-5mm margin), but once that is accomplished, the outcomes are at least equal. For an outstanding overview of PBT in the Journal of Oncology (June 2011), please see --
http://floridaproton.org/pdf/1106ONCHoppe.pdf
In particular, take a look at the stunning comparative illustrations on the bottom of p.645 and then tell me whether you'd prefer your pelvis baked "medium" (proton) or "extra well done" (photon). The answer is fairly obvious to most of us. This graphically depicts why the so-called "integral dose" of radiation to the body is substantially lower with PBT, while at the same time not compromising the dose reaching the all-important target area (your prostate).
Now, not surprisingly, with less total dosage being absorbed by the body and pelvic region, there do tend to be side effect advantages, which are beginning to be documented. Here's a persuasive link in that regard, although I will concede more research must continue to be done --
The sexual function scores are particularly gratifying for many of us who wish to continue activity in that area. I'm several months post-PBT at this point and am running at "full steam" in that department so far (i.e., no change from prior to treatment).
