(1) Hormone therapy is not indicated.
(2) SBRT is extreme hypofractionation — like HDR brachytherapy except with advanced dose control and outpatient external beam delivery.

There is nothing proven to be better for low-risk cure and ease of therapy for the patient.

Many naysayers … all with conflicts of interest!

The immediate use of adjuvant hormone therapy in a case like yours would seem very odd to me. However, I am not a doctor, just a well-informed layman. If your CyberKnife therapy has worked well, then there is a good chance that this therapy is curative. If it has not been curative, there are other forms of second-line therapy that might be considered prior to initiation of hormone therapy. You are correct when you state that you are “borderline intermediate” risk.

I would suggest two things: (1) Waiting until you have got a clear indication of how low your PSA goes before you accept further treatment AND (2) getting a second opinion from another prostate cancer specialist to be sure that this is a good decision. Having said that, if your current physician can give you some really good reason why he believes that adjuvant hormone therapy is a good idea for you, then you should be listening to him. All I can really tell you at this point in time is that I am not hearing any really good reason for such a management strategy … but your doctor has examined and treated you. Only he can possibly explain to you at this point in time why he considers that adjuvant hormone therapy is a good idea.

I am borderline intermediate. Would you suggest hormones?

Please read the clinical studies related to prostate cancer and the use of CyberKnife. High-risk patients are treated with a combination of IMRT and three Cyberknife sessions as a boost (without hormone therapy).

The first study (by Dr King) has 5-year biological control rate of 95% without the use of hormones. The study by Alan Katz has a 5-year biological control rate of 98%.

Hormones after Cyberknife make no sense. As someone posted earlier, some have used hormones before IMRT, but from my reading this is after the prostate cancer has left the barn following surgery.

There are no studies that I have read in which hormone therapy has been used in conjunction with CyberKnife. Talk to your doctor and ask him for the published data showing use of hormones after CyberKnife. May be a good time for another urologist.

I am a patient, not a doctor; however I am well informed when comes to prostate cancer treatment with SBRT/CyberKnife.

Good Luck!

The 95% success rate for CyberKnife therapy (at 5 years of follow-up) is only applicable to men who are diagnosed with low- and very low-risk disease. Thus, if you have a higher risk level (e.g., localized disease but a Gleason score of 7 and/or a PSA level > 10 ng/ml), some form of hormone therapy for a period of time may be sensible (maybe a year or so). However, what I find puzzling about your comment is that it would be much more common to start such hormone therapy before the radiation therapy in order to optimize the long-term outcome. Clearly this was not done in your case.

Thank you very much for your comments. I am 69 years old and am presently undergoing the CyberKnife. My urologist is encouraging the hormone treatments after the five fraction procedures. What I have read about the effects of Hormone treatment on one’s quality of life is something that I do not want to have invade what life I have left.

My doctor has said that hormone therapy increases the success of the CyrerKnife treatment. A 95% success rate without hormones from the limited studies that are available is good enough for me.

Please comment

Age is not a consideration for the Cyberknife because of low risk from treatment and side effects. Life expectancy is a consideration for any treatment. Hormone therapy is not common with Cyberknife treatment for prostate cancer.

There is a lot of false information about every treatment option. Every man with prostate cancer will benefit if they take time to understand each option.

The use of hormone therapy in combination with CyberKnife therapy is rare.

I was treated with the CyberKnife in 2008. I have had zero side effects and am biologically disease free.

First, let me be very clear that CyberKnife therapy is not surgery. It is radiation therapy. The idea that is is “surgical” in any way is pure marketing hype.

Second, if one was to have hormone therapy in association with CyberKnife radiation therapy, it would be normal to initiate this at least a few months prior to the actual radiation. This is called “neoadjuvant” hormone therapy.

Third, there are several possible reasons why neoadjuvant hormone therapy might be used in conjunction with CyberKnife therapy. They include reduction in the size of the prostate prior to the actual radiation therapy and reduction of any possible risk from cancer that may have escaped from the prostate itself. If your doctor is recommending this for you, you need to talk to him or her about exactly why this is being recommended for you.

I’m sorry. I have no idea. That’s a question you need to ask Kaiser (or a California-based provider of CyberKnife radiation therapy).

Thank you.

First and most importantly, please understand that I am not a doctor and I am in no position to make any individual recommendation about an individual patient. What I was trying to say to Raj, and I believe that the same information is relevant to the care of your father (based on the data you have provided), is that in older men with a diagnosis of prostate cancer and one or more other co-morbid conditions (such as a history of heart disease) one needs to be careful to balance the risk of the prostate cancer against risk of death from all other causes. In particular, in the case of older men with Gleason 9 diease, there is a significant risk for micrometastatic prostate cancer — even when MRIs, CT scans, bone scans, and PET scans are all negative.

It is important in such cases to have a serious discussion with one’s doctors about what can be expected from localized treatment, and whether such treatment can really be given with curative intent or whether what is really being done is attempting to delay the progression of the disease. While surgery (and other localized therapies such as various forms of radiation therapy) for men with Gleason 9 disease can most certainly be curative, it is customary in many younger men with Gleason 9 disease for surgery to be followed by adjuvant radiation therapy with or without hormone therapy. That is a very aggressive form of treatment for someone in their 70s whose life expectancy may only be another 5 to 10 years, and whose symptoms of prostate cancer (if any) can be managed with hormone therapy and radiation therapy as and when they occur, and who may never die from his prostate cancer.

But then there are “young” 70-year-olds and not so young ones. Some 70-year-olds (even some with a co-morbid condition) may be good candidates for surgery. Others clearly aren’t. Such other patients may be better managed with some form of radiation therapy with or without adjuvant hormone therapy.

What I am trying to tell you (and Raj) is that everyone’s expectations need to be carefully assessed. No one lives for ever. All treatments for prostate cancer come with significant risks for adverse effects. Some of those adverse effects can be highly debilitating for older men, and life without quality of life is surely not what you are likely to want for your father or what he is going to want for himself. The doctors need to be encouraged to think about treating the whole patient, not just the cancer in his prostate (and very possibly outside it too). Unfortunately, all too often, the prostate cancer surgeon (and the radiation oncologist) can over-estimate his or her ability to eliminate the cancer and under-estimate the impact of treatment on the quality of life of the patient. The older the patient, the more important it becomes to look really hard at the potential risks and benefits of every type of treatment.

Now having said that, it is very likely that your and Raj’s fathers will need and should have some form of treatment to address the fact that they bnoth have high-risk disease. The much harder question is what form of treatment is appropriate and what expectations everyone has from such treatment. Is CyberKnife therapy a possibility? Certainly. Should you ex[pect that to be curative? That is not a question I can answer, although your doctors might be able to give you estimates of probabilities based on all of the data available to them. What I can tell you is the following:

Based on the Kattan pre-treatment nomogram, a 70-year-old man with 4/12 positive biopsy cores, a PSA of 7, clinical stage T2b disease (i.e., significant cancer that can be felt or observed on an ultrasound), and a Gleason score of 4 + 5 = 9 and who had his prostate surgically removed by a skilled surgeon has the following probabilities:

– Probability of organ-confined disease = 27%
– Probability of extracapsular extension = 66%
– Probability of seminal vesicle invasion = 42%
– Probability of positive lymph nodes = 13%

In other words, the probability is very high that such a man has cancer that has already escaped from his prostate into the surrounding tissues. The ability of any form of localized treatment to cure such a patient on its own is limited. He is highly likely to need some form of adjuvant or follow-up therapy if he is to be cured, and his risk for side effects of treatment are significant over time. In such a man, the longer his real lif expectancy and the greater his desire to live to the full extent of his life expectancy, the more reasonable it becomes to consider aggressive, early treatment — but there will be some associated cost in terms of quality of life in the majority of such patients.

– Sextant trucut biopsies from prostate – prostatic adenocarinoma, composite Gleason score 4 + 5 = 9.
– Present in nearly all the cores that were submitted
– Occupying about 70% of the areas of the cores

Thank you in advance for your recommendation. Appreciate it.

The importance of the Gleason score is not limited to CyberKnife radiation. The Gleason score is important when assessing the potential value of any form of treatment for potentially localized prostate cancer, along with several other factors, including the patient’s age, his PSA level, and the amount of cancer in the prostate (based on number of positive biopsy cores and amount of cancer in each core).

Your father has high-risk prostate cancer because he has Gleason 9, regardless of any other information. While it is possible that he can be cured of his prostate cancer by CyberKnife radiation, there are few data to support this possibility based on the use of CyberKnife radiation in the treatment of prostate cancer to date. We are aware of only one published study that included data (from 29 men) on the use of CyberKnife radiation in the treatment of high-risk prostate cancer assumed to be localized to the prostate. That study only has 5-year follow-up data.

Futhermore, in a man with high-risk (Gleason 9) prostate cancer, the fact that his MRI, PET scan, and bone scan are all negative means only that these scans are not showing gross signs of extraprostatic cancer. These scans are not capable of showing early stage, micrometastatic prostate cancer that could already have escaped from the prostate into his seminal vesicles, his lymph nodes, and even his bone marrow. There are no available tests today that can clearly and accurately identify the presence of such very small (micrometastatic) foci of prostate cancer outside the prostate, but such foci are relatively common among men who have Gleason 9 disease at the time of diagnosis.

Finally, given your father’s prior CABG in 2002, and depending upon his age and other health factors, there are serious questions about whether treatment will have any impact on his life expectancy because he may well be at higher risk of death from cardiovascular disease than he is at risk from his prostate cancer. Certainly if he is 70 or more years of age, the value of interventional treatment is open to considerable question, because the complications of treatment may come at higher risk than any risk of death from prostate cancer. These are all factors that need careful discussion between your father, your family, and his doctors.