Hi, I’m Dr. Scholz. Let’s talk about prostate cancer.
In this video, we’re going to talk about five different types of radiation for men
with relapsed prostate cancer after previous surgery or previous radiation.
It’s always irresistible for me to at least talk about this myth that you have to do surgery
first to protect against the possibility of relapse so you can do radiation as salvage.
In this video, we’re going to talk about how radiation can be used as salvage for people
who’ve had previous radiation. So there was a time—when radiation was really, really
lame, and dangerous, and problematic—when you couldn’t do radiation after radiation.
But that has changed and we want to get the word out about that because the myth that
you can’t do radiation after radiation has been spread and repeated many times and honestly
it’s one of the last arguments used by surgeons to do surgery because all their other arguments
(like it cures you better or it has less side effects) have disappeared because radiation
has improved so much.
So the five types of radiation after surgery or radiation...
Let’s take the way we subdivide prostate cancer into the five stages, this being Indigo:
The relapse type of prostate cancer. If you don’t know if you are Indigo, you should
go to the PCRI website, take the quiz, and make sure that you really are Indigo stage.
Once you have confirmed that, then the determination as to whether you are in the Low, Basic, or
High Indigo status needs to be made. (And we’re not going through how to do that in
this video, but you can, again, look at the PCRI guide and determine whether you’re
in the Low, Basic, or High category.)
So let’s take men in the Low category first. This is where the cancer has come back, but
we believe that it is still in the area of the prostate (in men that have had previous
surgery they call it the “[prostate] fossa”) or inside the prostate itself in men that
have had previous radiation, and the conclusion is that there is very low possibility that
the cancer spread to the lymph nodes or around to the rest of the body. So it’s logical
that treatment to the prostate are alone will be sufficient.
So there’s basically three approaches—three different types of radiation—that could be
considered to treat someone that has locally relapsed or locally persistent prostate cancer.
The simple and obvious one, of course, is to give intensity modulated radiation called
IMRT to the prostate fossa in someone who had previous surgery, but the surgeon didn’t
get it all out. This type of treatment is usually administered over 7-9 weeks. It is
in some cases as little as five weeks, but the protocol involves daily visits to the
radiation therapy facility (Monday through Friday) for a brief treatment. The side effects,
while you’re going through the treatment, tend to be very mild. You might have a little
bit of discomfort with urination, a little soreness in the rectum that should dissipate
within 4-6 weeks. The main concern, of course, is that if after surgery a man is still getting
erections, the administration of radiation increases the chance of getting erectile dysfunction.
The chances are not entirely clear—the studies are not very clear—because people have variable
function after surgery to begin with, but I think one has to consider that there’s
about a 25% chance that—if you are functioning after surgery and getting erections—that
the addition of radiation will cause erectile dysfunction. And in the prostate cancer world,
that means the use of Viagra and Cialis are not going to save the situation; you’re
going to have to move onto something like injection therapy or possibly even a surgically
placed prosthesis. So radiation after surgery, the sort of classical type of salvage treatment—that
most people are familiar would be the first type of radiation that we’re going to cover
for the Low-Indigo category.
Now, what about men that have had previous IMRT and it appears that there’s still cancer
in the prostate and not anywhere else? This is also a Low-Indigo, but in a person that’s
had previous radiation. These situations more and more are being successfully treated with
salvage seed implantation. There are two types of seed implants: Permanent and temporary,
and both are on the table for consideration. If your situation calls for a salvage seed
implant such as this it is very important to get to a center that has a lot of experience
doing this sort of thing. It’s a skill procedure and there are greater risks in someone who
has had previous radiation.
The third type of salvage radiation for people that have had—in this case previous surgery—would
be very accelerated beam radiation called stereotactic body radiation or CyberKnife,
and preliminary studies recently published suggest that this is feasible without excessive
danger. We don’t have a super long follow-up, but the convenience of not having to take
a radiation salvage treatment over a 5-9 week period, and instead undergo the treatment
in a relatively short period such as less than a week or two is very attractive. So
stereotactic body radiation would be another consideration for someone with Low-Indigo
that’s had previous surgery. This has not been done for people who’ve had previous
radiation that I’m aware of.
Now let’s move on to talk about Basic and High-Indigo relapse. This is a situation where
men are presumed or actually is known to have spread into the pelvic lymph nodes (the small
nodes that surround the prostate area. This is a type of metastatic disease—early metastatic
disease—and now radiation is able to treat
this safely.
So when we’re talking about the two types of radiation for Basic-Indigo and for High-Indigo,
this can occur in people that have had original surgery and people that have had original
radiation. So radiating the lymph nodes—assuming the radiation to lymph nodes wasn’t administered
at initial treatment—is feasible with either approach, but as we talking about for Low-Indigo
(in other words treatment of the prostate area) men that have had previous surgery would
need IMRT whereas men that have had previous IMRT to the prostate, their salvage situation
would require a salvage seed implant. So you could see how it could be a consideration
for someone that is relapsing after radiation and has Basic or High-Indigo that they could
need a salvage seed implant to the prostate area, and then salvage IMRT to the surrounding
pelvic lymph nodes.
Are hormone treatments necessary when you’re doing salvage radiation?
My opinion for Low-Indigo: Hormone treatments may be unnecessary. But for men that are undergoing
IMRT on a salvage situation with Basic or High-Indigo (that is to the pelvic lymph nodes),
two studies now have shown that better cure rates can be achieved by adding hormone treatment.
In one study Casodex alone 50mg a day was used, and in another, a Lupron type drug was
administered. In these two studies, the treatment was continued for an average of 6-12 months.
Better cure rates were achieved. There are of course a variety of side effects from hormone
therapy which we’ve covered in another video and precautions always need to be implemented
when taking hormone blockade.
As you can see radiation is an essential component of managing Indigo. There are different types
of radiation and they can be used in different combinations with or without hormone treatment.
All of this is based on accurate staging ensuring that you know whether you’re in the Low,
Basic, or High subgroup.