Possible Long Term Side Effects
Most side effects gradually go away in the weeks or months after treatment. But some side effects can continue or might start some months or years later. This includes problems getting an erection.
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Prostate cancer: diagnosis and managementNational Institute for Health and Care Excellence , 2019. Last updated December 2021
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Cancer: Principles and Practice of Oncology VT DeVita, TS Lawrence, SA RosenbergWolters Kluwer, 2019
How Does Sbrt Work
Although “surgery is a part of the acronym, SBRT is a noninvasive treatment. During the procedure, doctors simply ask that a patient lie quietly and breathe normally.
The first part of treatment involves a consultation with one of our radiation oncologists, followed by a discussion of treatment options. Yale Medicine takes a multidisciplinary approach to treatment. In the case of lung cancer, radiation and thoracic oncologists will discuss the course of treatment. For spine cases, they work as a team with a neurosurgeon.
Once a plan is in place, you’ll next have an hour-long simulation, during which Yale Medicine places you in an immobilization device and measures the motion your organs. We have to account for motion of the tumor, that can be up to several centimeters, Dr. Decker says. After all, lungs move when you breathe.
A week or two later, doctors begin the radiation, and, depending on the size of the tumor, its location and diagnosis, the process continues for up to five treatments, each lasting about half an hour.
How Is Sbrt Delivered What Technology Is Used
SBRT consists of a much shorter course of radiotherapy than the conventional approaches, with only five treatment sessions. This is accomplished by delivering a higher dose per day, which requires significant precision and accuracy with expertise from the treating radiation oncologist as well as a team of medical physicists, medical dosimetrists, and radiation therapists. Modern and advanced linear accelerator technology is also required. Overall, SBRT planning and treatment delivery requires six visits to the department .
Because the prostate can move due to filling up and emptying of the bladder and rectum, pinpoint accuracy is required for SBRT. There are two ways to achieve this level of accuracy:
CT-guidance: In order to make sure that the prostate is accurately targeted and tracked, we place 3 implanted markers into the prostate. All of our treatment devices are equipped with onboard X-ray imagers or cone-beam CT technology that allow us to triangulate these markers . Also, prior to each treatment session, a cone-beam CT is obtained in order to make sure the anatomy is stable for treatment. This generally means having a full bladder and an empty rectum. We do provide detailed instructions on preparation for treatment to each patient.
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What Is Involved In Cyberknife Treatment
CyberKnife® Machine
You will see a urologist a week or two before treatment. This doctor will place gold markers, known as âfiducialsâ, in your prostate as a way of marking the target. This is done under ultrasound guidance, similar to the procedure for prostate biopsy. The tumor position will be tracked during the Cyberknife treatment using the fiducials.
After the gold markers have been placed, a CT simulation is performed. During this CT scan, you will be positioned in the same way you will be positioned during the actual treatments. The physician uses this scan to outline the treatment area and organs or tissues to be avoided. This information is used to create the treatment plan.
The number of treatments and the amount of radiation per fraction can vary. Each fraction is a higher radiation dose than is used with traditional radiation, but fewer fractions are given. Typically, treatments include:
- Four or five fractions .
- Treatment is given over 1-2 weeks.
- The total dose in the mid to high 30 Gray range.
- Each treatment session is 30 to 90 minutes .
While you are being treated, the machine takes pictures of the tumor, which are compared in real-time to the images from the CT simulation. The CyberKnife robot moves around you to deliver precise treatment that can be adjusted as the prostate moves when you breathe.
Can I Get Sbrt For High
Yes, as of 2020, SBRT is considered a standard of care option for patients with high-risk and very-high risk prostate cancer. Dr. Kishan led the largest study of SBRT for high-risk prostate cancer, which was published in early 2021 and pooled data from seven trials from across the world . This study showed extremely favorable outcomes for SBRT for high- and very-high risk prostate cancer in a group of 344 patients.
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How Stereotactic Body Radiation Therapy Works
Stereotactic body radiation works similarly to other forms of radiation treatment. The radiation does not actually remove the tumor, but rather causes it to shrink -when the DNA of tumor cells is damaged, the cells are unable to reproduce. Malignant and metastatic tumors may shrink more rapidly, even within a couple of months.
SBRT treatment requires specific, 3D-imaging technology. This imaging is used to locate the tumor within the body and define the exact size and shape as well as guide the treatment plan and positioning of the patient for treatment. Treatment is delivered with a linear accelerator.
SBRT may be used to deliver a single high dose of radiation, or several separate radiation doses .
If This Uncertainty Would Bother You So Much That It Would Affect Your Quality Of Life Surgery May Be A Better Option For You Phuoc Tran Md Phd
However, if youre okay with waiting for the PSA nadir, and if you dont mind getting treatment over the course of a few weeks instead of in one operation, then radiation may be ideal for you.
What are my options?
Conventional external-beam radiation therapy is given in little doses, a few minutes a day, five days a week, for seven or eight weeks. These small doses minimize the injury risk for the healthy tissue near the tumor. Scientists measure radiation in units called Gy . Most men get a minimum total dose of 75.6 Gy, but could get as much as 81 Gy this works out to 2 Gy or less per day.
The treatment itself is painless just like getting an x-ray at the dentists office. But one big challenge with getting repeated treatments is making sure youre always in the exact same position, so the radiation can hit the target the way its supposed to. Thus, you will be custom-fitted with your own pelvic immobilization device, which will not only keep you from fidgeting, but will make sure youre not slightly higher and to the right on the table one day, and slightly lower and to the left the next.
When you get fitted for your device, you will have a CT scan, so doctors can get a 3D look at your prostate. Then, when you get the radiation, you wont just get it from one side, but from multiple directions, and each beam of radiation will be individually shaped to target the cancer and a 5- to 10-millimeter margin of healthy tissue around the prostate.
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Patient Liable For Cyberknife Treatment For Prostate Cancer
Cyberknife is typically used for patients with
- Early-stage disease.
- A prostate volume of less than 80-100 cm
- A lesion or tumor that is untreatable by surgery or other radiation modalities.
Most people with enlarged prostates may be given hormone therapy and try to shrink the prostate to be able to get cyberknife treatment for prostate cancer. Patients who are considered high risk for spread to the lymph nodes or have cancer in the lymph nodes are not good candidates for cyberknife treatment for prostate cancer.
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Prostate Stereotactic Body Radiation Therapy Program
Prostate cancer that is confined to the prostate gland can be treated by removal of the prostate or radiotherapy. Radiotherapy can be given either by directing x-ray beams from outside the body to the prostate or by inserting radioactive seeds that release localised radiation from within the prostate.
What is Stereotactic Body Radiotherapy ?
SBRT refers to an advanced form of external beam radiotherapy. The aim is to deliver high doses of radiation to a target within the body in either one or up to five treatment sessions. A specialised co-ordinate system allows multiple, sharply focussed x-ray beams to hit small targets in the body.
What are the advantages of SBRT for the prostate?
SBRT is a completely painless and non-invasive technique that is done in the outpatient setting. This is an advantage over brachytherapy which involves a hospital stay, use of urine catheter and needles. There is also risk of bleeding, infection and general anaesthesia with brachytherapy.
Unlike conventional EBRT which needs 37-39 daily treatments in 7-8 weeks, SBRT is completed in 5 sessions every other weekday over 1 and a half weeks. The amount of rectum and bladder radiated in SBRT is less than with conventional EBRT because the beams are more focussed.
What are the main features of SBRT to the prostate?
Left CT simulation scan of the prostate outlined with aid of MRI scan which shows with much greater clarity prostate gland
What are the results with SBRT to the Prostate?
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Technical Aspects Of Sbrt
Stereotactic body radiotherapy uses a 3-dimensional co-ordinate system utilizing internal fiducials or image guidance for tumour tracking and treatment delivery. Cyberknife has the advantage over other SBRT systems in that it is capable of tracking the co-ordinates in real time while the head of the accelerator re-aligns itself to accommodate fluctuations in target position. The delivery of SBRT generally utilizes multiple noncoplanar arcing fields directed at the radiation target. As a result, the dose gradient is much deeper than conventional radiation and irregularly shaped. The dose with SBRT is generally prescribed to the isodose line encompassing the target which allows for an inhomogenous dose delivery in which the core of the target receives a much higher dose. This may be especially advantageous when anticipating a hypoxic core that may harbour resistant clonogens. Stereotactic body radiation fractionation uses doses that may range from 5 to 30 Gy/fraction and often takes into consideration the BED offered by dose escalation.
Stereotactic body radiotherapy is the best tool for sparing parallel normal tissue, abutting planned large volumes. Even several tissues like lung, liver and kidney may benefit when functional subunits are maximally preserved by the deep dose gradients.
Frequent Urination Burning With Urination And Difficulty Urinating
These are the most common complaints. Occasionally the urinary stream will weaken. Generally these symptoms are managed with medications to help the bladder function better or eliminate burning. Rarely, your doctor may order a urine test. Symptoms will resolve after the end of treatment. Contact your doctor if you see blood in your urine or if you are unable to urinate.
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Candidates For Cyberknife Radiotherapy Treatment
CyberKnife is suitable for all patients with a small or medium-sized prostate those with localised T1 or T2 stage prostate cancer, have a Gleason score of seven or lower, or a PSA score below twenty are also appropriate candidates. Claustrophobic patients can usually be accommodated, due to the free, open design of the machinery used.
Due to its use of MRI scanning, unsuitable candidates also include patients with implants such as pacemakers or metal plating patients who have had both hips replaced are also unsuitable candidates . CyberKnife is also unsuitable for severe urinary symptoms.
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Why You Should Consider Sbrt Over Other Treatment Options
There are many treatment options for prostate cancer. In expert hands, they all tend to have a good cure rate. It is important to research your options, see what treatments you are eligible for, and see what makes sense to you. I like SBRT because it is a relatively short treatment with little recovery time, an excellent cure rate, and typically mild side effects.
If you visit with many different doctors you may discover that they all recommend a different treatment. Surgeons will recommend surgery, and radiation oncologists will recommend radiation. There are many approved treatment options for prostate cancer, and there is not simply one was to treat it.
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How Does Sbrt Compare With Longer Courses Of Radiation
As of 2020, SBRT is considered a standard of care option for any patient with low through very-high risk prostate cancer who is considering radiation therapy. The first patient to be treated with modern prostate SBRT was treated in December 2000. Since then, a large amount of data and evidence have amassed demonstrating the safety and efficacy of SBRT. UCLA investigators have played a leading role in accumulating and publishing these data. To date, the best data available to support SBRT for prostate cancer are:
A study led by Dr. Amar Kishan that compiled the outcomes of 2142 men treated with SBRT between 2000-2012, showing low rates of toxicity and high efficacy with a median follow-up of nearly 7 years. The article can be found here:
The HYPO-RT-PC randomized trial, which directly compared conventional radiation against a high-dose-per-day treatment across seven sessions in 1200 Swedish men. Importantly, this trial used older radiation planning techniques and did not deliver modern SBRT. Regardless, the efficacy and long-term side effects were equivalent in both arms of the trial. The article can be found here:
Treatment Steps And Schedule
There are multiple steps to preparing for and performing the SBRT treatment. Typically, during the first week we place the gold markers seeds and SpaceOAR hydrogel. During the second week we do the mapping and computer planning. During weeks 3 and 4 we do the actual SBRT treatments, which occur every second weekday. The fastest all of this can be scheduled is a 15 day period, from the day you have the marker seeds placed, until the day of the final treatment.
The first step of course is to do a consultation, then complete any scans or staging tests that are required. Once we decide on SBRT as a treatment we need to get approval from your insurance company.
Next we place the 3 4 gold marker seeds into the prostate gland under ultrasound guidance, while you are under sedation. These seeds are not radioactive. They stay in the prostate gland permanently. They are used to help the SBRT machine lock onto the prostate gland during treatment. We do not try to place the marker seeds where the cancer is, they simply are placed inside the prostate gland. We will also usually do a SpaceOAR procedure at the same time, where a gel is injected in between the prostate and the rectum and it pushes these two organs apart. This will result in less radiation dose reaching the rectum. The gel is broken down by the body after 3 months.
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Possible Side Effects Of Ebrt
Some of the side effects from EBRT are the same as those from surgery, while others are different.
Bowel problems: Radiation can irritate the rectum and cause a condition called radiation proctitis. This can lead to diarrhea, sometimes with blood in the stool, and rectal leakage. Most of these problems go away over time, but in rare cases normal bowel function does not return. To help lessen bowel problems, you may be told to follow a special diet during radiation therapy to help limit bowel movement during treatment. Sometimes a balloon-like device or gel is put between the rectum and the prostate before treatment to act like a spacer to lessen the amount of radiation that reaches the rectum.
Urinary problems: Radiation can irritate the bladder and lead to a condition called radiation cystitis. You might need to urinate more often, have a burning sensation while you urinate, and/or find blood in your urine. Urinary problems usually improve over time, but in some men they never go away.
Some men develop urinary incontinence after treatment, which means they cant control their urine or have leakage or dribbling. As described in the surgery section, there are different levels and types of incontinence. Overall, this side effect occurs less often with radiation therapy than after surgery. The risk is low at first, but it goes up each year for several years after treatment.
What Is Stereotactic Body Radiation Therapy And What Advantages Does It Offer
Stereotactic body radiation therapy, or SBRT, involves the use of sophisticated image guidance that pinpoints the exact three-dimensional location of a tumor so the radiation can be more precisely delivered to cancer cells. Traditionally, external beam radiation has been delivered in anywhere from 45-48 sessions over multiple weeks. But large, randomized studies have shown that shorter courses of radiation are just as safe and effective. Therefore, at MSK, we have shortened all our radiation courses.
There is increasing interest in giving this radiation in very short courses of treatment using intense radiation doses, called hypofractionated radiation therapy. Many of the people we care for have a type of radiation therapy called MSK PreciseTM. This is a hypofractionated form of SBRT that can be given in five sessions. MSK has been doing this for the past 20 years, and the results in the several hundred people whove been treated have been excellent so far. The treatment is very well tolerated and quite effective
Because of its superior precision, MSK Precise can have fewer side effects than more conventional radiation techniques, with extremely low rates of incontinence and rectal problems. The sexual side effects are low, similar to what is experienced with more extended external radiation techniques. And of course, its much more convenient for patients.
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