Guest guest Posted September 29, 2011 Report Share Posted September 29, 2011 > I wrote about my husband's new diagnosis about 3 weeks ago; > and we both met with Dr. Walsh at Hopkins this > morning. Based on 's PSA of 4.3; Gleason of 4+3 > (7) and rectal exam he place the cancer at a T2a > stage. JOhn's age of 72; previous heart surgery; > diabetes; and obesity added greatly to Dr. Walsh's > recommendation. > > 3 mos. of Hormone therapy followed by image guided > radiation. Dr. Walsh literally wrote the book on prostate cancer. It's interesting that, although he's a surgeon and is the inventor of nerve sparing surgery, he's recommending radiation for your husband. It sounds to me like you got a very expert and very unbiased opinion. > Now to choose a center to have the therapy done. We > are leaning towards the Moffit Center in Tampa... any > suggestions? Naples is an hour further but shouldn't > be ruled out I guess. > > What does this learned group think? I can't count myself among the learned, but I do notice that the learned at the National Cancer Institute have identified the Moffit Center in Tampa as the only NCI Designated Cancer Center in Florida, and they've given it their highest rating as a " Comprehensive Cancer Center " . See: http://cancercenters.cancer.gov/cancer_centers/cancer-centers-list2.html#FL For info on what a comprehensive cancer center is, see: http://cancercenters.cancer.gov/about/our-history.html I believe that there are many fine doctors and clinics all around the country and there are surely a number of them in Florida. So Moffit is not the only fine place to get treatment. However I suspect that you won't go wrong by seeking treatment there. Some of the advantages of such a place are: They do research and teaching as well as treatment. Such hospitals are usually knowledgeable about the latest science and technology. The doctors are not going to be just technicians who know what buttons to push on the machines. They are typically less commercially oriented than the private clinics - which may be a benefit That's not to say that nothing can go wrong. Serious medical treatment is always subject to some vagaries of chance and luck. But, hopefully, a place like Moffit will maximize your chances of good luck. And of course we all wish you the best of luck. Alan Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2011 Report Share Posted September 29, 2011 Generally, it is my understanding that surgery for men over the age of 70 is considered somewhat risky. The hormone therapy, as I understand, works in synergy to increase the effectiveness of radiation therapy. Unfortunately, for Medicare patients, the cost is considerably higher than surgery alone. The best form of radiation treatment reportedly appears to be proton beam therapy because it has considerably less side effects than standard radiation, but the nearest center offering it is in ville, FL! Probably, Moffit is going to be your best bet. BTW, what does Dr. Walsh thinks of brachytherapy, because reportedly it has less long term delayed ED effects than standard radiation therapy. However, proton beam therapy has, by far, the least long term delayed ED effects of any radiation therapy. Louis. . . To: ProstateCancerSupport Sent: Thursday, September 29, 2011 3:52 PMSubject: Re: Hopkins Visit > I wrote about my husband's new diagnosis about 3 weeks ago; > and we both met with Dr. Walsh at Hopkins this > morning. Based on 's PSA of 4.3; Gleason of 4+3 > (7) and rectal exam he place the cancer at a T2a > stage. JOhn's age of 72; previous heart surgery; > diabetes; and obesity added greatly to Dr. Walsh's > recommendation. > > 3 mos. of Hormone therapy followed by image guided > radiation. Dr. Walsh literally wrote the book on prostate cancer. It's interesting that, although he's a surgeon and is the inventor of nerve sparing surgery, he's recommending radiation for your husband. It sounds to me like you got a very expert and very unbiased opinion. > Now to choose a center to have the therapy done. We > are leaning towards the Moffit Center in Tampa... any > suggestions? Naples is an hour further but shouldn't > be ruled out I guess. > > What does this learned group think? I can't count myself among the learned, but I do notice that the learned at the National Cancer Institute have identified the Moffit Center in Tampa as the only NCI Designated Cancer Center in Florida, and they've given it their highest rating as a "Comprehensive Cancer Center". See: http://cancercenters.cancer.gov/cancer_centers/cancer-centers-list2.html#FL For info on what a comprehensive cancer center is, see: http://cancercenters.cancer.gov/about/our-history.html I believe that there are many fine doctors and clinics all around the country and there are surely a number of them in Florida. So Moffit is not the only fine place to get treatment. However I suspect that you won't go wrong by seeking treatment there. Some of the advantages of such a place are: They do research and teaching as well as treatment. Such hospitals are usually knowledgeable about the latest science and technology. The doctors are not going to be just technicians who know what buttons to push on the machines. They are typically less commercially oriented than the private clinics - which may be a benefit That's not to say that nothing can go wrong. Serious medical treatment is always subject to some vagaries of chance and luck. But, hopefully, a place like Moffit will maximize your chances of good luck. And of course we all wish you the best of luck. Alan Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2011 Report Share Posted September 29, 2011 > ... The best form of radiation treatment reportedly appears to > be proton beam therapy because it has considerably less side > effects than standard radiation, but the nearest center > offering it is in ville, FL! Probably, Moffit is going > to be your best bet. BTW, what does Dr. Walsh thinks of > brachytherapy, because reportedly it has less long term delayed > ED effects than standard radiation therapy. However, proton > beam therapy has, by far, the least long term delayed ED > effects of any radiation therapy. Louis, Do you know of any studies showing that proton radiation has fewer side effects, sexual or otherwise, than x-radiation? I understand the theory of proton radiation. By accelerating protons to very precise speeds, it's possible to get them to deposit most of their energy in a small target area instead of ahead of or behind that area - which is not possible with x-rays. In practice however, I thought most of the side effects of radiation turn out to be caused by damage to the target area, not the area around it (with some caveats, see below). I had thought, for example, that a lot of the sexual and urinary side effects of radiation were due to damage in the prostate itself - which is the same for both proton and x-radiation, and probably very similar for both external beam and brachytherapy radiation. But the situation is unclear even for areas outside the prostate. Searching Pubmed I found this article published in 2009 by researchers at the Harvard Medical School: http://www.ncbi.nlm.nih.gov/pubmed/19672149 I located the full text of the article. Here are some excerpts from it. * * * .... > The physical characteristics of protons result in the majority > of energy being deposited at the end of a linear track, a sharp > maximum called the Bragg peak. Radiation dose then falls off > rapidly beyond the Bragg peak at the end of the particles' > range with essentially no exit dose, and a much reduced dose > proximal to the target volume. The position of the Bragg peak > for protons is determined by beam energy. An individual peak is > too narrow to cover any tumor of realistic dimensions, so often > beams of differing energies are combined and modulated to > broaden or spread out the Bragg peak so as to uniformly cover > the full extent of the target at depth. > Photons, on the other hand, lack mass and charge, and the x-ray > beams deposit dose in a continuous fashion such that there is > some dose received in the beam's path beyond the target (Fig. > 1). .... > The theoretical potential to precisely deliver high doses to a > tumor and increase the probability of tumor control, while > limiting collateral damage caused by scatter and exit dose to > surrounding normal tissue and reduce morbidity, is the promise > of protons. This promise of favorable dose distribution and the > ability to spare critical structures has proven safe and > successful in the management of rare malignancies, such as > ocular,8 base of skull,9 central nervous system, and pediatric > tumors.10 > The benefit in prostate cancer, however, remains unclear. > Protons' sharp distal falloff of dose is potentially a 2-edged > sword. On one hand, it allows the delivery of dose to the tumor > while sparing distal tissues. On the other hand, an > overestimate or underestimate of the path length for any reason > could cause undershooting or overshooting of the beam, > respectively, with consequent complete miss of a distal portion > of the tumor or high dose being delivered to adjacent normal > tissue. In fact, there can be some uncertainty about the > particle range in tissue and exact location of the steep fall > off because of sensitivity to tissue heterogeniety (ie, bone > and air). Such concerns are especially pertinent in the > delivery of PBT to deep-seated, mobile targets such as the > prostate, which is dependent on variations in bladder and > rectal filling, as well as bony-hip anatomy 11 (Fig. 2). Proton > beams also have a significant penumbra (ie, gradual dose fall > off at the lateral edge of the beam) at depth, compromising > their ability to spare adjacent tissues. > The uncertainties in proton-particle penetration in tissue > dictate certain beam configurations (different to IMRT > delivery). They also require the use of liberal proximal and > distal safety margins to ensure tumor coverage, at the expense > of irradiating uninvolved normal tissue, such as portions of > the bladder and rectum. Currently, given the range uncertainty > in the anterior and posterior directions and to safely > accommodate additional margins, opposed lateral proton beams > are used so as not to increase the volume of rectum receiving > high dose. This opposed lateral beam configuration travels > through both femoral heads perpendicular to the rectum on an > axial view. Such beam arrangement is associated with the > largest radiologic depth of the target leading to higher > scatter and wider-dose penumbra. Inevitably, this exposes the > anterior rectal wall to some of the high-dose region and leads > to not so insignificant hip dose. A range compensator, which is > used to conform the dose to the distal surface of the target, > needs to be modified ( " smeared " ) to counter the possible effect > of misalignment between bony anatomy and the prostate. In > addition, the prostate has been observed to move significantly, > not only from day-to-day treatment but also during a short > treatment. This necessitates the employment of even more > liberal safety planning margins to account for setup error as > well as inter and intrafractional motion and ensure complete > irradiation of the gland. Such insurance further dilutes any > theoretical advantage of protons. > Thus, the potential benefit of protons as currently delivered > is likely disease site specific and most readily realized when > treating more superficial tumors surrounded by homogeneous > tissue without any cavities, air pockets, or complex bones. > Reproducible immobilization and daily localization using image > guidance are key to exploiting the maximal precision of > protons. Because protons remain a limited resource, it will be > important to identify the sites in which PBT offers measurable > and clinically significant advantages over other more readily > available conformal treatments, such as IMRT or brachytherapy. > Although there are widespread reports of favorable clinical > experiences with PBT, there has been a paucity of randomized > studies and very few critical comparisons. This is largely > because of the fact that, until quite recently, only a few > centers have been engaged in PBT, and those that were had a > number of constraints including limited capacity, limited > energy, limited technology, and limited beam availability. > Furthermore, in certain disease sites where the initial > experience has been very favorable, subsequent randomized > trials have not been considered feasible based on ethical > grounds. > Although equipoise still exists, both by clinicians and > patients, it would clearly be desirable to test protons against > photons by means of an appropriately designed and powered > prospective randomized clinical trial with validated quality of > life endpoints for a commonly occurring tumor lying in close > proximity to critical structures known to benefit from dose > escalation, such as prostate cancer. * * * The hype surrounding proton treatment has been phenomenal. Prostate cancer patients and insurers have spent a fortune on proton therapy. Medical centers are incurring huge debts in order to install $150 million proton machines and are recruiting as many patients as they can get to pay off the loans. Is it justified? Are the outcomes actually better than for x-ray treatment? Are the real, actual side effects less? I don't know we really know that yet. Alan Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2011 Report Share Posted September 29, 2011 I still agree with Louis. I was dx 3 1/2 years ago with a psa of 20. Protons at Jax. Never any side affects. To me Protons wins the debate hands down. BTW psa is still < .1 d. On Thu, 9/29/11, Louis Carliner wrote: > ... The best form of radiation treatment reportedly appears to > be proton beam therapy because it has considerably less side > effects than standard radiation, but the nearest center > offering it is in ville, FL! Probably, Moffit is going > to be your best bet. BTW, what does Dr. Walsh thinks of > brachytherapy, because reportedly it has less long term delayed > ED effects than standard radiation therapy. However, proton > beam therapy has, by far, the least long term delayed ED > effects of any radiation therapy. Louis, Do you know of any studies showing that proton radiation has fewer side effects, sexual or otherwise, than x-radiation? I understand the theory of proton radiation. By accelerating protons to very precise speeds, it's possible to get them to deposit most of their energy in a small target area instead of ahead of or behind that area - which is not possible with x-rays. In practice however, I thought most of the side effects of radiation turn out to be caused by damage to the target area, not the area around it (with some caveats, see below). I had thought, for example, that a lot of the sexual and urinary side effects of radiation were due to damage in the prostate itself - which is the same for both proton and x-radiation, and probably very similar for both external beam and brachytherapy radiation. But the situation is unclear even for areas outside the prostate. Searching Pubmed I found this article published in 2009 by researchers at the Harvard Medical School: http://www.ncbi.nlm.nih.gov/pubmed/19672149 I located the full text of the article. Here are some excerpts from it. * * * .... > The physical characteristics of protons result in the majority > of energy being deposited at the end of a linear track, a sharp > maximum called the Bragg peak. Radiation dose then falls off > rapidly beyond the Bragg peak at the end of the particles' > range with essentially no exit dose, and a much reduced dose > proximal to the target volume. The position of the Bragg peak > for protons is determined by beam energy. An individual peak is > too narrow to cover any tumor of realistic dimensions, so often > beams of differing energies are combined and modulated to > broaden or spread out the Bragg peak so as to uniformly cover > the full extent of the target at depth. > Photons, on the other hand, lack mass and charge, and the x-ray > beams deposit dose in a continuous fashion such that there is > some dose received in the beam's path beyond the target (Fig. > 1). .... > The theoretical potential to precisely deliver high doses to a > tumor and increase the probability of tumor control, while > limiting collateral damage caused by scatter and exit dose to > surrounding normal tissue and reduce morbidity, is the promise > of protons. This promise of favorable dose distribution and the > ability to spare critical structures has proven safe and > successful in the management of rare malignancies, such as > ocular,8 base of skull,9 central nervous system, and pediatric > tumors.10 > The benefit in prostate cancer, however, remains unclear. > Protons' sharp distal falloff of dose is potentially a 2-edged > sword. On one hand, it allows the delivery of dose to the tumor > while sparing distal tissues. On the other hand, an > overestimate or underestimate of the path length for any reason > could cause undershooting or overshooting of the beam, > respectively, with consequent complete miss of a distal portion > of the tumor or high dose being delivered to adjacent normal > tissue. In fact, there can be some uncertainty about the > particle range in tissue and exact location of the steep fall > off because of sensitivity to tissue heterogeniety (ie, bone > and air). Such concerns are especially pertinent in the > delivery of PBT to deep-seated, mobile targets such as the > prostate, which is dependent on variations in bladder and > rectal filling, as well as bony-hip anatomy 11 (Fig. 2). Proton > beams also have a significant penumbra (ie, gradual dose fall > off at the lateral edge of the beam) at depth, compromising > their ability to spare adjacent tissues. > The uncertainties in proton-particle penetration in tissue > dictate certain beam configurations (different to IMRT > delivery). They also require the use of liberal proximal and > distal safety margins to ensure tumor coverage, at the expense > of irradiating uninvolved normal tissue, such as portions of > the bladder and rectum. Currently, given the range uncertainty > in the anterior and posterior directions and to safely > accommodate additional margins, opposed lateral proton beams > are used so as not to increase the volume of rectum receiving > high dose. This opposed lateral beam configuration travels > through both femoral heads perpendicular to the rectum on an > axial view. Such beam arrangement is associated with the > largest radiologic depth of the target leading to higher > scatter and wider-dose penumbra. Inevitably, this exposes the > anterior rectal wall to some of the high-dose region and leads > to not so insignificant hip dose. A range compensator, which is > used to conform the dose to the distal surface of the target, > needs to be modified ("smeared") to counter the possible effect > of misalignment between bony anatomy and the prostate. In > addition, the prostate has been observed to move significantly, > not only from day-to-day treatment but also during a short > treatment. This necessitates the employment of even more > liberal safety planning margins to account for setup error as > well as inter and intrafractional motion and ensure complete > irradiation of the gland. Such insurance further dilutes any > theoretical advantage of protons. > Thus, the potential benefit of protons as currently delivered > is likely disease site specific and most readily realized when > treating more superficial tumors surrounded by homogeneous > tissue without any cavities, air pockets, or complex bones. > Reproducible immobilization and daily localization using image > guidance are key to exploiting the maximal precision of > protons. Because protons remain a limited resource, it will be > important to identify the sites in which PBT offers measurable > and clinically significant advantages over other more readily > available conformal treatments, such as IMRT or brachytherapy. > Although there are widespread reports of favorable clinical > experiences with PBT, there has been a paucity of randomized > studies and very few critical comparisons. This is largely > because of the fact that, until quite recently, only a few > centers have been engaged in PBT, and those that were had a > number of constraints including limited capacity, limited > energy, limited technology, and limited beam availability. > Furthermore, in certain disease sites where the initial > experience has been very favorable, subsequent randomized > trials have not been considered feasible based on ethical > grounds. > Although equipoise still exists, both by clinicians and > patients, it would clearly be desirable to test protons against > photons by means of an appropriately designed and powered > prospective randomized clinical trial with validated quality of > life endpoints for a commonly occurring tumor lying in close > proximity to critical structures known to benefit from dose > escalation, such as prostate cancer. * * * The hype surrounding proton treatment has been phenomenal. Prostate cancer patients and insurers have spent a fortune on proton therapy. Medical centers are incurring huge debts in order to install $150 million proton machines and are recruiting as many patients as they can get to pay off the loans. Is it justified? Are the outcomes actually better than for x-ray treatment? Are the real, actual side effects less? I don't know we really know that yet. Alan No virus found in this message. Checked by AVG - www.avg.com Version: 10.0.1410 / Virus Database: 1520/3926 - Release Date: 09/29/11 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 30, 2011 Report Share Posted September 30, 2011 The problem with protons seems to be costs and limited availability, especially in Europe. Otherwise it seems a amongst the top choices, though I'm unsure how many folk have had the protons and had 15 years progression free. Re: Hopkins Visit I still agree with Louis.I was dx 3 1/2 years ago with a psa of 20. Protons at Jax. Never any side affects. To me Protons wins the debate hands down. BTW psa is still < .1 d. > ... The best form of radiation treatment reportedly appears to> be proton beam therapy because it has considerably less side> effects than standard radiation, but the nearest center> offering it is in ville, FL! Probably, Moffit is going> to be your best bet. BTW, what does Dr. Walsh thinks of> brachytherapy, because reportedly it has less long term delayed> ED effects than standard radiation therapy. However, proton> beam therapy has, by far, the least long term delayed ED> effects of any radiation therapy.Louis,Do you know of any studies showing that proton radiation hasfewer side effects, sexual or otherwise, than x-radiation?I understand the theory of proton radiation. By acceleratingprotons to very precise speeds, it's possible to get them todeposit most of their energy in a small target area instead ofahead of or behind that area - which is not possible with x-rays.In practice however, I thought most of the side effects ofradiation turn out to be caused by damage to the target area, notthe area around it (with some caveats, see below). I hadthought, for example, that a lot of the sexual and urinary sideeffects of radiation were due to damage in the prostate itself -which is the same for both proton and x-radiation, and probablyvery similar for both external beam and brachytherapy radiation.But the situation is unclear even for areas outside the prostate.Searching Pubmed I found this article published in 2009 byresearchers at the Harvard Medical School:http://www.ncbi.nlm.nih.gov/pubmed/19672149I located the full text of the article. Here are some excerptsfrom it.* * *...> The physical characteristics of protons result in the majority> of energy being deposited at the end of a linear track, a sharp> maximum called the Bragg peak. Radiation dose then falls off> rapidly beyond the Bragg peak at the end of the particles'> range with essentially no exit dose, and a much reduced dose> proximal to the target volume. The position of the Bragg peak> for protons is determined by beam energy. An individual peak is> too narrow to cover any tumor of realistic dimensions, so often> beams of differing energies are combined and modulated to> broaden or spread out the Bragg peak so as to uniformly cover> the full extent of the target at depth.> Photons, on the other hand, lack mass and charge, and the x-ray> beams deposit dose in a continuous fashion such that there is> some dose received in the beam's path beyond the target (Fig.> 1)....> The theoretical potential to precisely deliver high doses to a> tumor and increase the probability of tumor control, while> limiting collateral damage caused by scatter and exit dose to> surrounding normal tissue and reduce morbidity, is the promise> of protons. This promise of favorable dose distribution and the> ability to spare critical structures has proven safe and> successful in the management of rare malignancies, such as> ocular,8 base of skull,9 central nervous system, and pediatric> tumors.10> The benefit in prostate cancer, however, remains unclear.> Protons' sharp distal falloff of dose is potentially a 2-edged> sword. On one hand, it allows the delivery of dose to the tumor> while sparing distal tissues. On the other hand, an> overestimate or underestimate of the path length for any reason> could cause undershooting or overshooting of the beam,> respectively, with consequent complete miss of a distal portion> of the tumor or high dose being delivered to adjacent normal> tissue. In fact, there can be some uncertainty about the> particle range in tissue and exact location of the steep fall> off because of sensitivity to tissue heterogeniety (ie, bone> and air). Such concerns are especially pertinent in the> delivery of PBT to deep-seated, mobile targets such as the> prostate, which is dependent on variations in bladder and> rectal filling, as well as bony-hip anatomy 11 (Fig. 2). Proton> beams also have a significant penumbra (ie, gradual dose fall> off at the lateral edge of the beam) at depth, compromising> their ability to spare adjacent tissues.> The uncertainties in proton-particle penetration in tissue> dictate certain beam configurations (different to IMRT> delivery). They also require the use of liberal proximal and> distal safety margins to ensure tumor coverage, at the expense> of irradiating uninvolved normal tissue, such as portions of> the bladder and rectum. Currently, given the range uncertainty> in the anterior and posterior directions and to safely> accommodate additional margins, opposed lateral proton beams> are used so as not to increase the volume of rectum receiving> high dose. This opposed lateral beam configuration travels> through both femoral heads perpendicular to the rectum on an> axial view. Such beam arrangement is associated with the> largest radiologic depth of the target leading to higher> scatter and wider-dose penumbra. Inevitably, this exposes the> anterior rectal wall to some of the high-dose region and leads> to not so insignificant hip dose. A range compensator, which is> used to conform the dose to the distal surface of the target,> needs to be modified ("smeared") to counter the possible effect> of misalignment between bony anatomy and the prostate. In> addition, the prostate has been observed to move significantly,> not only from day-to-day treatment but also during a short> treatment. This necessitates the employment of even more> liberal safety planning margins to account for setup error as> well as inter and intrafractional motion and ensure complete> irradiation of the gland. Such insurance further dilutes any> theoretical advantage of protons.> Thus, the potential benefit of protons as currently delivered> is likely disease site specific and most readily realized when> treating more superficial tumors surrounded by homogeneous> tissue without any cavities, air pockets, or complex bones.> Reproducible immobilization and daily localization using image> guidance are key to exploiting the maximal precision of> protons. Because protons remain a limited resource, it will be> important to identify the sites in which PBT offers measurable> and clinically significant advantages over other more readily> available conformal treatments, such as IMRT or brachytherapy.> Although there are widespread reports of favorable clinical> experiences with PBT, there has been a paucity of randomized> studies and very few critical comparisons. This is largely> because of the fact that, until quite recently, only a few> centers have been engaged in PBT, and those that were had a> number of constraints including limited capacity, limited> energy, limited technology, and limited beam availability.> Furthermore, in certain disease sites where the initial> experience has been very favorable, subsequent randomized> trials have not been considered feasible based on ethical> grounds.> Although equipoise still exists, both by clinicians and> patients, it would clearly be desirable to test protons against> photons by means of an appropriately designed and powered> prospective randomized clinical trial with validated quality of> life endpoints for a commonly occurring tumor lying in close> proximity to critical structures known to benefit from dose> escalation, such as prostate cancer.* * *The hype surrounding proton treatment has been phenomenal.Prostate cancer patients and insurers have spent a fortune onproton therapy. Medical centers are incurring huge debts inorder to install $150 million proton machines and are recruitingas many patients as they can get to pay off the loans. Is itjustified? Are the outcomes actually better than for x-raytreatment? Are the real, actual side effects less?I don't know we really know that yet.Alan No virus found in this message.Checked by AVG - www.avg.comVersion: 10.0.1410 / Virus Database: 1520/3926 - Release Date: 09/29/11 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 30, 2011 Report Share Posted September 30, 2011 The problem, of course, is that you only had one treatment - protons - so you don't know what your outcome would have been with other treatments. So you can't really draw any conclusions about protons vs other treatments from your experience. In fact, it may be impossible to ever 'scientifically' demonstrate one treatment is better than another, given that you can't set up a study where you assign patients to different treatments. I was treated around the same time as you, and my psa is also <.1. And after the first few weeks (before I would have even finished proton therapy!), I have had no side effects other than reduced ejaculate, which is common to all radiation treatments. But I was treated by brachytherapy, not protons. My conclusion isn't that brachytherapy is the " best " treatment, but rather that I picked a good treatment for me given my age and health, I had great doctors, and my cancer was highly treatable. Whether surgery or a different radiation treatment would have been as successful, I will never know. I'm glad I didn't bother with the extra cost and time of proton radiation, but if someone feels more comfortable with that choice, for whatever reason, then they should go for it. > > > > > ... The best form of radiation treatment reportedly appears to > > > be proton beam therapy because it has considerably less side > > > effects than standard radiation, but the nearest center > > > offering it is in ville, FL! Probably, Moffit is going > > > to be your best bet. BTW, what does Dr. Walsh thinks of > > > brachytherapy, because reportedly it has less long term delayed > > > ED effects than standard radiation therapy. However, proton > > > beam therapy has, by far, the least long term delayed ED > > > effects of any radiation therapy. > > > > Louis, > > > > Do you know of any studies showing that proton radiation has > > fewer side effects, sexual or otherwise, than x-radiation? > > > > I understand the theory of proton radiation. By accelerating > > protons to very precise speeds, it's possible to get them to > > deposit most of their energy in a small target area instead of > > ahead of or behind that area - which is not possible with x-rays. > > > > In practice however, I thought most of the side effects of > > radiation turn out to be caused by damage to the target area, not > > the area around it (with some caveats, see below). I had > > thought, for example, that a lot of the sexual and urinary side > > effects of radiation were due to damage in the prostate itself - > > which is the same for both proton and x-radiation, and probably > > very similar for both external beam and brachytherapy radiation. > > > > But the situation is unclear even for areas outside the prostate. > > Searching Pubmed I found this article published in 2009 by > > researchers at the Harvard Medical School: > > > > http://www.ncbi.nlm.nih.gov/pubmed/19672149 > > > > I located the full text of the article. Here are some excerpts > > from it. > > > > * * * > > ... > > > The physical characteristics of protons result in the majority > > > of energy being deposited at the end of a linear track, a sharp > > > maximum called the Bragg peak. Radiation dose then falls off > > > rapidly beyond the Bragg peak at the end of the particles' > > > range with essentially no exit dose, and a much reduced dose > > > proximal to the target volume. The position of the Bragg peak > > > for protons is determined by beam energy. An individual peak is > > > too narrow to cover any tumor of realistic dimensions, so often > > > beams of differing energies are combined and modulated to > > > broaden or spread out the Bragg peak so as to uniformly cover > > > the full extent of the target at depth. > > > > > Photons, on the other hand, lack mass and charge, and the x-ray > > > beams deposit dose in a continuous fashion such that there is > > > some dose received in the beam's path beyond the target (Fig. > > > 1). > > > > ... > > > > > The theoretical potential to precisely deliver high doses to a > > > tumor and increase the probability of tumor control, while > > > limiting collateral damage caused by scatter and exit dose to > > > surrounding normal tissue and reduce morbidity, is the promise > > > of protons. This promise of favorable dose distribution and the > > > ability to spare critical structures has proven safe and > > > successful in the management of rare malignancies, such as > > > ocular,8 base of skull,9 central nervous system, and pediatric > > > tumors.10 > > > > > The benefit in prostate cancer, however, remains unclear. > > > Protons' sharp distal falloff of dose is potentially a 2-edged > > > sword. On one hand, it allows the delivery of dose to the tumor > > > while sparing distal tissues. On the other hand, an > > > overestimate or underestimate of the path length for any reason > > > could cause undershooting or overshooting of the beam, > > > respectively, with consequent complete miss of a distal portion > > > of the tumor or high dose being delivered to adjacent normal > > > tissue. In fact, there can be some uncertainty about the > > > particle range in tissue and exact location of the steep fall > > > off because of sensitivity to tissue heterogeniety (ie, bone > > > and air). Such concerns are especially pertinent in the > > > delivery of PBT to deep-seated, mobile targets such as the > > > prostate, which is dependent on variations in bladder and > > > rectal filling, as well as bony-hip anatomy 11 (Fig. 2). Proton > > > beams also have a significant penumbra (ie, gradual dose fall > > > off at the lateral edge of the beam) at depth, compromising > > > their ability to spare adjacent tissues. > > > > > The uncertainties in proton-particle penetration in tissue > > > dictate certain beam configurations (different to IMRT > > > delivery). They also require the use of liberal proximal and > > > distal safety margins to ensure tumor coverage, at the expense > > > of irradiating uninvolved normal tissue, such as portions of > > > the bladder and rectum. Currently, given the range uncertainty > > > in the anterior and posterior directions and to safely > > > accommodate additional margins, opposed lateral proton beams > > > are used so as not to increase the volume of rectum receiving > > > high dose. This opposed lateral beam configuration travels > > > through both femoral heads perpendicular to the rectum on an > > > axial view. Such beam arrangement is associated with the > > > largest radiologic depth of the target leading to higher > > > scatter and wider-dose penumbra. Inevitably, this exposes the > > > anterior rectal wall to some of the high-dose region and leads > > > to not so insignificant hip dose. A range compensator, which is > > > used to conform the dose to the distal surface of the target, > > > needs to be modified ( " smeared " ) to counter the possible effect > > > of misalignment between bony anatomy and the prostate. In > > > addition, the prostate has been observed to move significantly, > > > not only from day-to-day treatment but also during a short > > > treatment. This necessitates the employment of even more > > > liberal safety planning margins to account for setup error as > > > well as inter and intrafractional motion and ensure complete > > > irradiation of the gland. Such insurance further dilutes any > > > theoretical advantage of protons. > > > > > Thus, the potential benefit of protons as currently delivered > > > is likely disease site specific and most readily realized when > > > treating more superficial tumors surrounded by homogeneous > > > tissue without any cavities, air pockets, or complex bones. > > > Reproducible immobilization and daily localization using image > > > guidance are key to exploiting the maximal precision of > > > protons. Because protons remain a limited resource, it will be > > > important to identify the sites in which PBT offers measurable > > > and clinically significant advantages over other more readily > > > available conformal treatments, such as IMRT or brachytherapy. > > > > > Although there are widespread reports of favorable clinical > > > experiences with PBT, there has been a paucity of randomized > > > studies and very few critical comparisons. This is largely > > > because of the fact that, until quite recently, only a few > > > centers have been engaged in PBT, and those that were had a > > > number of constraints including limited capacity, limited > > > energy, limited technology, and limited beam availability. > > > Furthermore, in certain disease sites where the initial > > > experience has been very favorable, subsequent randomized > > > trials have not been considered feasible based on ethical > > > grounds. > > > > > Although equipoise still exists, both by clinicians and > > > patients, it would clearly be desirable to test protons against > > > photons by means of an appropriately designed and powered > > > prospective randomized clinical trial with validated quality of > > > life endpoints for a commonly occurring tumor lying in close > > > proximity to critical structures known to benefit from dose > > > escalation, such as prostate cancer. > > > > * * * > > > > The hype surrounding proton treatment has been phenomenal. > > Prostate cancer patients and insurers have spent a fortune on > > proton therapy. Medical centers are incurring huge debts in > > order to install $150 million proton machines and are recruiting > > as many patients as they can get to pay off the loans. Is it > > justified? Are the outcomes actually better than for x-ray > > treatment? Are the real, actual side effects less? > > > > I don't know we really know that yet. > > > > Alan > > > > > > > > No virus found in this message. > > Checked by AVG - www.avg.com <http://www.avg.com> > > Version: 10.0.1410 / Virus Database: 1520/3926 - Release Date: 09/29/11 > > > Quote Link to comment Share on other sites More sharing options...
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