So, radiation—we talked about the salvage treatments that HIFU could be. With radiation, can you
re-irradiate the prostate and is that an acceptable form? Or is it one-and-done?
So, one of the problems with early radiation (say 10-15 years ago) they didn't have the
targeting that they have today and so they had to dial the dose down because there was
a lot of overspray and a lot of damage to the surrounding structures. That meant that
the cure rates weren't as good and so people could develop a recurrence of cancer right
in the very spot where the radiation was given previously. In the old days, we thought that
meant no further radiation was possible, but modern radiation is so targeted that they
can ensure that all the radiation goes into the prostate, which can be sacrificed, and
so, in particular, salvage seed implant radiation is being used more and more frequently for
some men that have had these older radiation treatments that didn't get the job done. So,
the answer is yes. You can give radiation therapy a second time, in many cases to the
men that have had older type radiation and who are now developing a problem in their
prostate again. Now, the other issue, of course, is that if the cancer comes back in another
part of the body, not where the prostate is, but let's say in the lymph node (in an area
of the body that was never treated in the first place), it's quite simple with modern
targeted radiation to treat those other spots, and so giving radiation a second time to those
people doesn't represent any problem at all.
Okay, and when you mention the seeds, does it have to be like temporary or, you know,
permanent, or is it for both it'll have the same effect?
Either one. Of course, this is another skill procedure and you need to go to the people
that have dedicated themselves to doing seed implants, and I wouldn't have a seed implant
from a doctor that says, "Well," they tell me, "I can do this, do you want to be my first
patient?" But there are a number of centers that have had a series of people that they've
treated with salvage seed implants with good outcomes, and so it's always important to
be selective of the doctor.
So, are there further side effects if you re-irradiate some tissue that has already
been irradiated? Is there an expectation that there may be more extensive side effects because
of that?
Well, that's the risk and the risks of radiation, whether it's the first time or second time,
we're all familiar with: urinary problems, erectile dysfunction, rectal problems in some
cases. So, those risks are there doing it again, but studies in the hands of experts
show that those risks seem to be occurring or those problems are occurring at a relatively
low rate.
So, speaking of, you know, re-irradiating the prostate tissue, what actually happens
to the tissue once it has been irradiated?
So, the typical treatments like freezing and laser and HIFU, the tissue is completely destroyed
and it's replaced by scar tissue. The example may be easier to understand is when a woman
undergoes radiation for breast cancer, her breast doesn't disappear, it doesn't turn
into scar tissue. So, what happens is the normal cells are able to repair themselves
better from radiation than cancer cells. So, when radiation is administered, the prostate
cancer cells die, but the normal prostate cancer gland cells continue although they
may be impaired and they may not be able to make as much fluid as semen as the original
gland did. So, the prostate may be a little bit smaller, there may be a reduction in the
number of original cells, but there still is a prostate there after radiation.
So, is there a certain time frame where those prostate cells, you know, after they kind
of come back and heal that a man can produce more semen and will heal from some of these
side effects over time.
It depends on the intensity of the radiation. Seed implant dosages are higher, but I have
had patients get their wives pregnant after previous prostate radiation. So, there can
be functionality of the prostate after radiation, although most men won't be able to do that,
of course.
Okay, and was that in like 6 months or a 2 year time frame?
In that particular case?
Yeah.
Probably about 2 years after treatment.
Oh okay, wow.
The next question I would like to ask is—I think I get asked this question extremely
often—and that men who are calling our Helpline and they've had prostate surgery and they
want to know if they need radiation, and so how often, what Gleason score, what stage
do they need to be in?
Yeah, there have been quite a few studies looking at this question. So, if someone has
a positive margin or if it was a big cancer or a high Gleason, it's the safest thing to
just go ahead and give radiation. The studies seem to be indicating that if the PSA is undetectable,
in the majority of cases, if you watch it really closely and start radiation at the
very first sign of an increase in PSA that you'll do just as well as if you just go ahead
and do the radiation right after the operation. And, of course, waiting is advantageous because
if you do radiation right after the operation you have a higher incidence of incontinence
and impotence and other problems. So, that's a general rule of thumb. Of course, this whole
space is changing quickly due to the advent of new PSMA/PET scans and that can be done
at the time of relapse or it could be done at the time of surgery. But I always have
to throw in my own little pet peeve about doing surgery in the first place. So, if you're
thinking you might have to do radiation right after the surgery, why not start with the
radiation and skip the surgery? The cure rates are just as good. This is just one more reason
I'm not a big fan of surgery.
Okay, and when we talk about radiation is that just like IMRT or Cyberknife or does
it matter what type if they do have to have it?
So, Cyberknife and SBRT are more convenient because they can be given quickly. IMRT may
take 5-8 weeks and lots of visits and travel time. The studies are ongoing right now to
see if short-term radiation would work just as well and be just as safe as giving it over
5-7 weeks. The preliminary indications are that it may be safe, but most of the men that
are getting treatment like that are having it done on a clinical trial because it's not
100% sure that giving it real fast like that is 100% safe, though most people think it's
going to turn out to be safe.
Well, thank you so much for answering our questions once again. I love sitting here
with you because it totally expands my own personal, you know, thought process when it
comes to how we should all think about prostate cancer, and I feel like I get to experience
it with the patients.
If you would like to have me ask Dr. Scholz a question in the future, you can go ahead
and leave your questions int he comments below and our team will pick them up, and for more
information about prostate cancer, if you would like to talk to somebody, we do have
a Helpline so you can go ahead and call us, and find our number on our website at PCRI.ORG,
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hope you have a great week.