Questions to ask a high dose rate (temporary implant) brachytherapist

HDR Brachy monotherapies doctor questions

1.        I assume we are talking about monotherapy only, without external beam radiation or hormone therapy – is that correct for my case?

2.       How many monotherapies have you performed? How many combined with external beam?

3.       How has your practice of HDR brachy changed over the years?

4.       What is your 5-yr freedom from recurrence rate for patients at my risk level? What proportion of your recurrences were local?

5.       What kind of urinary and rectal reactions can I expect? How long can I expect them to last? What medications or interventions do you typically give for that? Should I expect those symptoms to recur later?

6.       What is your rate of serious (Grade 3) adverse events? Do you see urinary strictures? Urinary retention requiring catheterization? Fistulas? Rectal bleeding requiring argon plasma or other interventions?

7.       What is the margin you will treat around the prostate? Is it less on the rectal side?

8.       What is the prescribed dose to the planned target volume?

9.       What is your treatment protocol? Number of insertions? Number of fractions? Dose per fraction? Can we vary those for convenience?

10.    What kind of imaging do you use for planning? MRI? CT? US?

11.      Do you increase dwell times in areas of known cancer?

12.    Do you use fiducials or Calypso transponders?

13.    In my treatment plan, what do you identify as “organs at risk” and what dose constraints do you put on them?

o    What dose will my penile bulb receive?

o    How do you limit urethral dose? (e.g., catheter)

14.    How long does each treatment take?

15.     How will I be immobilized/anesthetized during each treatment? What kind of analgesia is used?

16.    Are there any bowel prep or dietary requirements?

17.     Should I avoid taking antioxidant supplements?

18.    In your practice, among men who were fully potent, what percent remained fully potent 3-5 years later?

o    Have any men retained some ability to produce semen?

o    What is your opinion of taking Viagra preventatively?

19.    Do you monitor side effects with the EPIC questionnaire?

o    In your practice, what percent of men experience acute urinary side effects?

o    In your practice, what percent of men experience acute rectal side effects?

o    In your practice, what percent of men experience late term urinary side effects?

o    In your practice, what percent of men experience late term rectal side effects?

20.   What kind of PSA pattern should I expect following treatment?

21.    What is the median PSA nadir you are seeing in your practice, and how long does it take to reach that, on the average?

22.   In your practice, what percent of men experience biochemical recurrence?

o    What % of those have been local?

o    If there should be a biochemical (PSA) recurrence, what would the next steps be?

o    Have you ever used SBRT, brachy, or cryo for salvage after a local HDR brachy failure, and was that focal or whole gland?

23.   Are you open to email communications between us?

Questions to ask a low dose rate (seeds) brachytherapist

Questions for LDR brachytherapists

1.     How many have you performed?

2.     How has your practice of brachytherapy changed over the years?

3.     What is your 5-yr freedom from recurrence rate for patients at my risk level? What proportion of your recurrences were local?

4.     What kind of urinary and rectal reactions can I expect? How long can I expect them to last? What medications or interventions do you typically give for that? Should I expect those symptoms to recur later?

5.     What is your rate of serious (Grade 3) adverse events? Do you see urinary strictures? Urinary retention requiring catheterization? Fistulas? Rectal bleeding requiring argon plasma or other interventions?

6.     For how long should I refrain from sex with a partner?

7.     For how long should I refrain from close contact with people and pets?

8.     Among men who are previously potent, what percent of your patients return to baseline?

9.     Do you recommend ED meds as protective?

10. What kind of dose with which isotope do you use? Would adjuvant IMRT be given with that? Would hormone therapy be given with that?

11. How do you prevent seed migration?

12. Do you use “intra-operative planning” or some other technique to guide placement and assure adequate seed distribution? Do you use a template with ultrasound guidance, cone-beam CT or some other method?

13. What do you set as dose limits for organs at risk? How do you assure that urinary sphincters, the urethra, and the rectum are spared?

14. Do you do a follow-up CT or MRI after a month?  How often do you find you have to go in again to treat cold spots?

15. How will we monitor PSA? What kind of PSA pattern can I expect?

16.  What kind of aftercare (including sexual rehab) will you provide, and how will we monitor side effects, and for how long? Will you regularly monitor my urinary and erectile recovery progress with validated questionnaires like EPIC and IPSS?

17.  In your practice, what percent of men experience biochemical recurrence?
    • What % of those have been local?
    • If there should be a biochemical (PSA) recurrence, what would the next steps be?
    • Have you ever used SBRT, brachy, or cryo for salvage after a local LDR brachy failure, and was that focal or whole gland?

18.  Are you open to email communications between us?

Questions to ask on a first visit for primary radiation therapy (IGRT/IMRT)

IGRT/IMRT Questions for Doctors

1. How many have you planned? 
2. How has your practice of IMRT changed over the years? 
3. What is your 5-yr freedom from recurrence rate for patients at my risk level? 
4. What proportion of your recurrences were local? (see this link) 
5. What kind of urinary and rectal reactions can I expect? 
• How long can I expect them to last? 
• What medications or interventions do you typically give for that? 
• Should I expect those symptoms to recur later? 
6. What is your rate of serious (Grade 3) adverse events? 
7. Do you see urinary strictures? 
8. Urinary retention requiring catheterization? Fistulas? 
9. Rectal bleeding requiring argon plasma or other interventions? 
10. What is the margin you will treat around the prostate? 
• Is it less on the rectal side? 
11. Will you include the pelvic lymph nodes? 
12. What about the seminal vesicles -proximal or entire? 
13. What are the prescribed doses to the planned target volumes? 
14. If applicable, in light of my unfavorable risk cancer: 
• do you think I need a brachytherapy boost to the prostate? (see this link) 
• do you think I need hormone therapy? For what duration?
15. In light of the 8 major randomized clinical trials on hypofractionation reported in the last year (see this link), do you recommend hypofractionation (fewer treatments) for me? 
16. Does your hospital do SBRT monotherapy for patients like me? Why not? 
17. Do you work off a fused MRI/CT scan for the plan? 
18. What machine do you use? (any brand of VMAT or Tomotherapy are good) 
19. Do you use fiducials or Calypso transponders? 
• Do you do transperineal placement of them? 
20. What system do you use for inter-fractional tracking? (cone beam CT or stereoscopic X-ray, probably) 
21. Is the alignment automated? 
22. In my treatment plan, what do you identify as “organs at risk” and what dose constraints do you put on them? 
• What dose will my penile bulb receive? 
23. Do you use angiography to locate and spare the pudendal artery? (see this link) 
24. How long does each treatment take? 
25. How will I be immobilized during each treatment? 
26. Are there any bowel prep or dietary requirements? 
27. Should I avoid taking antioxidant supplements during treatment? 
28. In your practice, among men who were fully potent, what percent remained fully potent 3-5 years later? 
29. Have any men retained some ability to produce semen? 
30. What is your opinion of taking Viagra preventatively? (see this link) 
31. Do you monitor side effects with the EPIC questionnaire? 
32. In your practice, what percent of men experience acute urinary side effects? 
33. In your practice, what percent of men experience acute rectal side effects? 
34. In your practice, what percent of men experience late term urinary side effects? 
35. In your practice, what percent of men experience late term rectal side effects? 
36. What kind of PSA pattern should I expect following treatment? 
37. What is the median PSA nadir you are seeing in your practice, and how long does it take to reach that, on the average?
38. If there should be a biochemical (PSA) recurrence, what would the next steps be? (they have to prove it’s local but not distant) 
39. Have you ever used SBRT, brachy, or cryo for salvage after a local IMRT failure, and was that focal or whole gland? 
40. Are you open to email communications between us?

Questions to ask (and not ask) on a first urologist visit after a biopsy

1. Am I a good candidate for surgery? What about anatomic abnormalities, previous hernia, effects of anesthesia, cardiovascular disease, diabetes or other comorbidities?


2. I would like to get a second opinion on my biopsy slides from Epstein's lab at Johns Hopkins. (Here's the link.)


3. What is my highest Gleason score? How many cores were positive? What was the highest percent of cancer in any core?


4. What is my stage, and risk level? (You should  know your PSA – if you don’t, ask). How big is my prostate, and what is my prostate density?


• If stage is T3 or T4: How can surgery be a good option if only the prostate capsule is taken out, leaving the rest behind? Aren’t the side effects of adjuvant radiation worse than if I had radiation at the start? (he may not know this.)


5. Am I a candidate for active surveillance (why, why not), and if so, what are your Active Surveillance criteria and protocol? Why those and not something more or less stringent? Should I get a genetic test before deciding? Will that be covered by insurance?


6. How many of the surgery technique you practice (whether robotic, laparoscopic or open) have you performed? (1000+ would be a good answer)


7. Are you going to be doing all of the really important parts of my procedure yourself? (You need to be particularly careful about this at major training institutions where residents may be doing some parts of the surgery, or even the whole operation, while “your” surgeon is overseeing it.)


8. In the last year, what was your positive surgical margin rate? (Should be less than 10% among men with stage pT2)


9. What is your "trifecta" rate? (tricky because you don't want cherry-picked patients)


10. What is your estimate of my risk for lasting incontinence; i.e., a pad or more after a year?


11. What about lasting stress incontinence? climacturia? penile shrinkage? inguinal hernia? Peyronie’s? orgasmic pain or dysfunction?


12. What kind of anastomosis technique do you use? (total - not just anterior)


13. Will the bladder neck be spared? How will you maximize the urethral sparing?


14. If you have positive biopsy cores near the apex: How will you ensure that all cancerous tissue is removed there?


15. Will you take frozen sections and have a pathologist standing by to determine margins and how much of neurovascular bundles can be spared?


16. What measures will you take to assure the integrity of the neurovascular bundles?


17. What kind of penile rehab do you suggest?


18. What kind of imaging (Bone scan, CT or MRI) is necessary for men at my risk level?


19. Will you sample lymph nodes (PLND) or take extended lymph nodes (ePLND), or does it seem unnecessary for my risk level? If so, how will you find them (fluorescent dye)? How will you minimize risk of lymphocele and lymphedema?


20. What kind of aftercare (including sexual rehab) will you provide, and how will we monitor side effects, and for how long? Will you regularly monitor my urinary and erectile recovery progress with validated questionnaires like EPIC and IPSS?


21. How will I be monitored for recurrence? Will I get an ultrasensitive PSA test? How will you decide the point at which you would recommend I see a radiation oncologist? Do you use the Decipher test?

Questions not to ask:

1. Is my age a factor in whether active surveillance is right for me? (only you can decide whether you are willing to live more years with the side effects of treatment, or whether you prefer to be treated while younger when side effects are apt to be less - see this link)


2. What treatments should I consider and which is the best for me? (this would be asking your doctor to be an expert in treatments outside of his specialty, and also to know which benefits and risks are most important to you – he doesn’t have time or inclination to be expert in all therapies, and he’s not a mind reader.)


3. If I were your father, what would you recommend? (You don’t know how he feels about his father (lol), and more importantly, what he would feel most comfortable with is not necessarily what you would feel most comfortable with. This is your decision to make and live with – don’t give up your power!)

When is whole pelvic radiation needed for salvage?

Patients who elect to have post-prostatectomy radiation for recurrent prostate cancer face a couple of important decisions:

(1) Should the radiation be limited to the prostate bed (PBRT)? OR
(2) Should one treat all the pelvic lymph nodes at the same time (whole pelvic radiation - WPRT)? And if so, is the oncological outcome likely to be better if one has androgen deprivation therapy (ADT) along with it?

There is an ongoing prospective randomized clinical trial (RTOG 0534) to help answer these questions. But results are not expected until the end of 2020. Meanwhile, the best we can do is look at how patients have done in the past. Ramey et al. conducted a retrospective analysis of 1861 patients treated at 10 academic institutions between 1987 and 2013. The treatments and patient characteristics were as follows:

• All had post-prostatectomy PSA> 0.01 ng/ml (Median was 0.5 ng/ml)
• All had post-prostatectomy Gleason scores ≥ 7
• None had detected positive lymph nodes
• 1366 had PBRT without ADT,  250 with ADT
• 176 had WPRT without ADT, 69 with ADT
• Median salvage radiation dose was 66 Gy
• More than half of GS 8-10 patients got ADT, whereas most GS 7 patients did not
• 60% had extraprostatic extension
• 21% had seminal vesicle invasion
• 60% had positive surgical margins

After a median follow-up of 51 months, the 5-year freedom from biochemical failure outcomes are shown in the following table.

             5-Year Freedom from Biochemical Failure

	PBRT	WPRT	TOTAL
With ADT	51%	66%	55%
Without ADT	48%	60%	50%
TOTAL	49%	62%	51%
Among GS 7:
With ADT	56%	70%	59%
Without ADT	52%	66%	54%
TOTAL	53%	67%	56%
Among GS 8-10:
With ADT	45%	64%	49%
Without ADT	34%	44%	35%
TOTAL	37%	53%	44%

WPRT with ADT had the best outcomes in total and in each Gleason score category. Two-thirds of salvage patients had 5-year cancer control with the combination, whereas only about half had oncological control without them. The differences were especially marked among those with GS 8-10. There was significant improvement even in men with GS 7; however, they did not have the data to ascertain whether they were GS 3+4 or GS 4+3. Adjuvant ADT improved outcomes whether it was used in conjunction with WPRT or PBRT. On multivariate analysis, both WPRT and ADT independently increased freedom from biochemical failure. Higher radiation dose, lower PSA, lower Gleason score, Stage T2, and positive surgical margins decreased the risk of failure.

Neither WPRT nor ADT made any difference in the rate of metastases, which were low at 5 years post-prostatectomy.

Toxicity and quality of life, which would be the only reasons not to give WPRT and ADT to all salvage radiation patients, were not evaluated in this study. Also lacking were data on duration and type of adjuvant ADT

This study is congruent with a couple of retrospective studies (see this link and this one), but incongruent with a couple of other retrospective studies (see this link and this one). The present study is the largest and most recent dataset of them, and corrects for the effects of other variables in a way that the two opposing studies did not.

We saw previously that adjuvant ADT has been proven in a randomized clinical trial to improve oncological outcomes of salvage radiation after prostatectomy (see this link).

While we await the more definitive data from RTOG 0534, this builds the case that both WPRT and ADT should be included in the salvage radiation treatment of men with prostatectomy-diagnosed Gleason scores of 8-10, and at least some of those with Gleason score of 7. There are several open questions:

• Is there a benefit for GS 3+4, or only for GS 4+3 or higher?
• Is there a benefit when higher salvage radiation doses (70-72 Gy) are used, or with hypofractionated protocols that raise the biologically effective dose?
• What is the optimal duration of adjuvant ADT?
• Would any of the newer hormonal therapies (e.g., Zytiga or Xtandi) or other systemic therapies improve outcomes?
• What are the trade-offs with toxicity and quality of life?
• What is the optimal treatment field for WPRT, and should it vary with individual anatomy and comorbidities, given its potential toxicity?
• Can we use the newer PET scans or USPIO MRI to help decide if WPRT is necessary?
• Can we identify any subsets (e.g., low PSA, stage T2, GS 3+4) that would not benefit from the additional treatment?