Why Should You Have Sbrt Treatments At Ucla
At UCLA, we have unmatched clinical and technical expertise in performing SBRT that is done in a rational and meaningful manner. At the UCLA SBRT Center of Excellence, which is led by our expert Radiation Oncologists and Medical Physicists, you can expect only the best clinical care from the minute you walk into our clinic, until you have completed your SBRT treatments. We have the experience and track record to optimally deliver this type of highly specialized treatment. At UCLA, we have the technology to implement this potent, accurate, and precise radiation therapy. We utilize the state-of-the art radiation machines such as the to deliver SBRT. Here, we will follow your cancer care after your treatment in our SBRT follow-up clinic on a routine and as-needed basis, in order to assess treatment response, manage any and all potential side effects as well as offer any further treatments that may be beneficial. Furthermore, you can expect that our expert Radiation Oncologists and clinical supporting staff at UCLA will treat you with the utmost care and respect during this period of time.
Finally, we believe that you will get the best SBRT treatment and clinical care at UCLA compared to anywhere in the country as well as the world. Our promise to you is that we will deliver cancer care that is second to none. We hold ourselves to this standard each and every day with the goal of improving our patient’s treatment outcomes.
Do I Need To Come Back For Followup Visits And Psa Blood Tests
We usually do the first followup visit 3 months after the treatment. The PSA is typically down to 1 2 at that visit, but will eventually drop to 0.1 0.2 by the five year mark. After the first visit, PSAs can be checked every 6 months, provided the PSA is dropping like expected. If the PSA is not responding well or is rising then we may recommend you get the PSA checked every 3 months.
You can get your PSAs and followups done with your local family doctor or urologist if you wish to. You can also email me your PSA value anytime.
What Are The Benefits Of Sbrt
Conventional radiation is typically delivered in relatively small doses each day over several weeks. This can delay or interfere with other cancer treatments, such as chemotherapy. By contrast, SBRT can usually be given in five or fewer daily sessions and requires no anesthesia. SBRT also can lead to better outcomes and fewer side effects than conventional radiation therapy.
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Who Can Have Sbrt
Men with low-risk or intermediate-risk prostate cancer can be treated with SBRT alone.
For men with high-risk prostate cancer , it is not yet known if treating with SBRT alone is enough treatment. These men should perhaps have a combination of different treatments. One option for this is hormonal therapy for 6 36 months, SBRT boost for 2 3 treatments, and conventional radiation to the prostate and pelvic lymph nodes for 25 treatments.
Other limitations for SBRT are that the prostate gland should be small enough for SBRT, ideally less than 60cc, but occasionally up to 120cc. A normal prostate gland is about 30cc . Preferably there should not have been previous surgery on the prostate gland, i.e no prior TURP. It is preferable that there are no serious urinary symptoms before treatment starts. Patients also need to be able to tolerate having marker seeds inserted into prostate gland.
What Is Stereotactic Body Radiation Therapy
Stereotactic Body Radiation Therapy is a treatment procedure similar to central nervous system stereotactic radiosurgery, except that it deals with tumors outside of the CNS. A stereotactic radiation treatment for the body means that a specially designed coordinate-system is used for the exact
localization of the tumors in the body in order to treat it with limited but highly precise treatment fields. SBRT involves the delivery of a single high dose radiation treatment or a few fractionated radiation treatments . A high potent biological dose of radiation is delivered to the tumor, improving the cure rates for the tumor, in a manner previously not achievable by standard conventional radiation therapy .
Similarly, because this specialized form of radiation involves the use of multiple radiation beam angles, expert Radiation Oncologists specialized in this technique are able to safely deliver high doses of radiation, with very sharp dose gradient outside the tumor and into the surrounding normal tissue .
Figure 1.
External Beam Simulation and Treatment process
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Stereotactic Body Radiation Therapy Demonstrates Efficacy In Longer Follow
byElizabeth Hlavinka, Staff Writer, MedPage Today October 22, 2018
SAN ANTONIO — Fewer, higher-dose radiation treatments proved to be as effective as longer-course radiation treatments for men with prostate cancer, researchers said here.
In a sample of 1,641 low and intermediate-risk men treated with stereotactic body radiation therapy , 6% experienced biochemical recurrence and 0.6% experienced distant metastases, reported Amar U. Kishan, MD, of the University of California Los Angeles, at the American Society for Radiation Oncology meeting.
Action Points
- Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
Patients were divided into three groups: low-risk, favorable intermediate-risk, and unfavorable intermediate-risk, the most aggressive form observed in this study. After a 7-year follow-up, 95.5% of low-risk patients, 91.4% of favorable intermediate-risk patients, and 85.1% of unfavorable intermediate-risk patients were free of biochemical recurrence.
Overall survival rates were also high across groups: 91.4% for low-risk patients, 93.7% for favorable intermediate-risk patients, and 86.5% for unfavorable intermediate-risk patients, the Kishan’s group reported.
Overall, none of the patients observed in this study died from prostate cancer, the authors reported.
Disclosures
Translating The Biology Of Sbrt To The Clinic
SBRT is an increasingly used treatment modality for both localized and metastatic disease and multiple ongoing trials are now examining ways in which to achieve superior clinical outcomes through novel combinations of SBRT with systemic therapy.
Table 2. Ongoing SBRT trials combined with systemic therapy.
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What Are The Side Effects
During the 2 weeks of treatment there are minimal side effects. Once the treatment is finished, short term side effects may develop for the next 4 6 weeks with some urine burning / discomfort, a slower stream, and more frequent urination. We prescribe Flomax to help with these symptoms. There may also be some irritation of the rectum along with some mucous in the bowel movements. These short term side effects will usually go completely away.
In the long term, which sometimes takes years to develop, there may be weakening of the erections causing erectile dysfunction . Viagra or Cialis can help. There can be some scarring and narrowing of the urine passage where it passes through the prostate, resulting in a slower stream. Rarely / occasionally a dilatation or T.U.R.P. is required.
Stereotactic Body Radiation Therapy
Stereotactic body radiation therapy or radiotherapy and stereotactic ablative radiation therapy or radiotherapy both describe an advanced form of radiation therapy that is used to treat many different types of cancer. The two terms are interchangeable. It is used to treat both primary cancer , or where a cancer may have spread . Secondary cancers treated with SBRT include those in the bone, lung or liver.
This technique differs from other external beam radiation therapy as it involves the delivery of higher doses of radiation to the cancer. This is why the word ablative is part of the name sometimes given for this type of treatment. These higher doses are given to the patient from Xray beams directed from outside the body and using a small number of treatments . Typically, one to five treatments are used over a few days. The delivery technique is extremely precise which is what the term stereotactic refers to. There are several technologies available in Australia that can be used to deliver this technique including Linac based, Cyberknife, Tomotherapy and Gammaknife.
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What Happens To The Prostate Gland After Treatment
The prostate normally produces some of the fluid in the ejaculation. After radiation, the gland tissue in the prostate will mostly disappear and become replaced with fibrous scar tissue. The prostate will shrink. It will no longer produce fluid in the ejaculation, however the sensation may still be the same.
What Happens If The Cancer Comes Back
Usually the first sign of a problem is that the PSA begins to rise. PSA levels can bounce up and down a little day to day, so if it rises the first rule is to not panic and to simply recheck it in 3 months. If it rises on 3 consecutive occasions and/or if the PSA rises to 2 points above its post-treatment minimum value then there could be a cancer recurrence.
If the PSA trend is concerning then we will do CT scans and a bone scan to look for prostate cancer in the bones or lymph glands. If the cancer is coming back in the bones or lymph glands then it is usually no longer curable and the treatment will be long term hormone therapy such as Lupron. If the scans are normal we may do a biopsy of the prostate gland. If the cancer is found in the prostate gland and not in the bones or lymph glands, then you may be referred for cryotherapy or HIFU.
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How Is Sbrt Delivered
SBRT is delivered through devices called linear accelerators, which form beams of fast-moving subatomic particles.
At Memorial Sloan Kettering, doctors who specialize in radiation therapy, called radiation oncologists, use a computerized system to shape the radiation beams to match a three-dimensional outline of the tumor. This outline is generated by an MRI scan, which you will have before your procedure. Your radiation oncologist will collaborate with medical physicists to design a treatment plan that allows the delivery of radiation that conforms to the dimensions of your tumor.
SBRT is performed while you are lying on a table. Imaging technology on the linear accelerator helps ensure you are in the same position for every session and that the target area does not shift during treatment. You will be awake during the procedure, which usually takes between 30 minutes and an hour.
Response Evaluation And Follow
The patients prostate-specific antigen as well as the testosterone levels were checked every month. Biochemical progression was defined as PSA increased2 ng/mL from nadir . Biochemical progression-free survival was defined as the time from the date of SBRT delivery to the biochemical progression or the last follow-up. Local control was defined as local prostate lesions without progression. Overall survival was defined as the time from the beginning of radiation therapy to the last follow-up or death. Disease progression free survival was defined as the time from the date of the beginning of radiation therapy to any sites with clinical tumor progressions or death. Acute and late toxicity was scored according to CTCAE v 5.0.
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I Heard That You Cannot Have Surgery If The Cancer Returns After You Have Had Cyberknife
True. But, CyberKnife is very successful at controlling the cancer in the prostate gland so this is not something we usually need to worry about. According to Dr. Katzs 10 year results, 98% of the patients have the cancer controlled in the prostate. In the uncommon case where the cancer does come back in the prostate after CyberKnife then you may be referred for cryotherapy or HIFU of the prostate.
What Is The Success Rate Of Sbrt For Prostate Cancer
In some cases, SBRT can be a more effective form of treatment for prostate cancer than conventional radiation or surgery.
A 5-year study found that those who received SBRT for prostate cancer had a 94 percent survival rate at 3 years and 89.7 percent survival rate at 5 years. No deaths appeared to be related to prostate cancer.
That said, whether SBRT will be an effective treatment for you depends on your particular circumstances.
In one small observational study , people received SBRT to treat a reoccurrence of prostate cancer. At a follow-up period of 11.2 months after the SBRT, participants did not show any signs of prostate tumors.
These people had received conventional radiation therapy, not SBRT, as their first treatment before the prostate cancer came back.
There are several reasons you may not be a good candidate for SBRT, including the following:
- Your prostate cancer is still very mild, and your healthcare team opts to monitor it without treatment.
- Your doctor recommends a different treatment method based on the severity of your prostate cancer as well as other existing health conditions.
- You have high-risk prostate cancer that needs a different type of treatment.
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Psa Kinetics Following Prostate Sbrt
The PSA kinetics following prostate SBRT are distinct and may suggest a greater degree of efficacy when compared to those following treatment with CF-EBRT. One study from UCLA compared patterns of PSA response for 439 patients with low- or intermediate-risk prostate cancer following treatment with SBRT, high-dose-rate brachytherapy, or CF-intensity modulated radiation therapy . The authors found that significantly more patients treated with SBRT or HDR brachytherapy had PSA nadirs of < 0.5 ng/mL than those treated with IMRT and that overall, SBRT and HDR brachytherapy caused significantly larger PSA decay rates than IMRT, leading the authors to conclude that this difference in PSA kinetics may present a distinct radiobiological effect, and may be predictive of superior clinical outcomes. Other studies have confirmed that after one year of treatment, when compared to patients receiving treatment with CF-EBRT, the median PSA slope and nadir are lower for patients treated with SBRT .
Prostate Cancer Sbrt Offers Excellent Long
Stereotactic body radiation therapy for localized prostate cancer offers high rates of long-term oncologic control with mild toxicity, according to study results presented at the American Society for Radiation Oncology virtual annual meeting.
Alan J. Katz, MD, JD, of St Francis Hospital in Roslyn, New York, and Josephine Kang, MD, PhD, of New York-Presbyterian/Weill Cornell Medicine in New York, New York, reported findings of a 12-year study of 560 patients with organ-confined PCa treated with robotic SBRT between 2006 and 2009. Of these, 324, 154, and 82 patients had low-, intermediate-, and high-risk PCa, respectively, according to National Comprehensive Cancer Network criteria.
A total of 515 patients received a 35-36.25 Gy dose in 5 daily fractions and 45 received external beam radiation therapy followed by an SBRT boost .
Androgen deprivation therapy of up to 9 months was administered to 102 patients.
The 12-year biochemical disease-free survival was 92.0%, 79.1%, and 64.0% for the low-, intermediate-, and high-risk groups, respectively, according to the investigators. Local control rates were 97.0%, 91.7%, and 88.0%, respectively.
The 12-year bDFS rate did not differ significantly between the favorable intermediate-risk and low-risk patients . The unfavorable intermediate-risk patients had a 12-year bDFS rate similar to that of the high-risk group .
Reference
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Choosing Sbrt For Prostate Cancer
Your radiation oncologist at UCLA will review all of the treatment options with you, comparing the pros and cons of each in great detail. Often, there will be several equally good options, and together with your doctors you will be guided through the decision making process in order to arrive at a treatment that is the most appropriate for you and you feel most comfortable with.
All patients are eligible for prostate SBRT. UCLA has clinical protocols specifically designed for low/intermediate risk patients as well as high risk patients.
There are many good reasons to consider and choose SBRT over the other potential options, including:
- It is entirely non-invasive .
- It is a very short treatment course . SBRT is a total of 5 treatment sessions, each taking approximately 15 minutes, all as an outpatient.
- The cancer control rates of SBRT are equivalent to those of brachytherapy, conventional external beam radiotherapy, or surgery.
- Sparing of radiation exposure to the rectum and bladder is equal to or better than with brachytherapy.
Prostate Cancer Treatment Stereotactic Body Radiation Therapy
Overview by Dr Philip CamilleriConsultant Clinical Oncologist Oxford University Hospitals NHS Trustand Clinical Director Urological cancers and MR LinacGenesiscare UK
Key observation: SBRT delivers large doses of radiation per session with very great sub millimetre accuracy shortening treatment time to a few days
Other names for treatment using this technology include stereotactic ablative radiotherapy . The key difference between SBRT and Intensity Modulated Radiation Therapy , is that it delivers the radiation with very great, sub millimetre, accuracy. Consequently, very high doses of radiation can be delivered in each treatment session reducing the number of sessions to half a dozen that can be delivered over the course of a week or two in half hour sessions, rather than taking several weeks in the case of IMRT.
SBRT delivery of very large radiation doses is a form of what is known as ultrahypofractionation.
Within the UK, the PACE-B study looked at comparing 5 fractions of treatment for prostate cancer patients with conventional therapy over 20 fractions on a standard linac. Currently the results published only show that the side effects between the two forms of radiotherapy are about the same. There is no data yet on which treatment was better although this is awaited.
- Linac based using conebeam CT or fiducial markers
- Cyberknife using fiducial markers
- MR guided radiotherapy
Linac based SBRT
Cyberknife
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