Brachytherapy

From Kidney Cancer Resource

Contents 1 Overview 2 Details 2.1 Who can have Brachytherapy? 2.2 Stage and grade of the cancer 2.2.1 Size of the prostate gland 2.2.2 Ordinary symptoms 2.2.3 TURP 2.3 How does Brachytherapy treat Prostate Cancer? 2.3.1 There are two main treatment methods: 2.4 What are the advantages and disadvantages? 2.4.1 Advantages 2.4.2 Disadvantages 2.4.3 Planning session 2.5 The Brachytherapy team includes: 2.6 Seed implant 2.7 After the procedure 2.7.1 What happens afterwards? 2.7.1.1 Your follow-up appointment 2.7.1.2 After treatment 2.7.2 Precautions to take 2.7.3 Going back to work 2.7.4 Travel 2.7.5 Sexual activity 2.8 Where to get help 2.9 What are the side effects? 2.10 Problems passing urine 2.11 Erectile dysfunction 2.12 Bowel problems 2.13 Tiredness 2.14 Questions to ask your doctor 2.15 Sources 2.16 Reviewed By 2.17 Edited By 2.17.1 Comments 3 References 4 Disclaimer 5 E&OE - Errors & Omissions Excepted

Overview

This page is for men who are thinking about having Brachytherapy to treat their Prostate Cancer. It describes how Prostate Cancer is treated using radioactive seeds implanted in the Prostate Gland. Each hospital and specialist team will do things slightly differently so use this page as a general guide to what to expect and ask your specialist team for more details about the treatment you will have. This page does not describe high dose rate Brachytherapy or external beam Radiotherapy. The Prostate Cancer Charity offers a Helpline for more information on these treatments Details can be found if you Click Here.

Details

Who can have Brachytherapy?

KCR would like to thank The Prostate Cancer Charity for the basic document utilised below - we hope that by publishing it here it will give help to more people involved in the Challenges of Prostate Cancer.

If you want more details on The Prostate Cancer Charity, including their help line data Click Here

Brachytherapy is used to treat Cancer that has NOT spread outside the Prostate Gland. It is most commonly used on its own but if there is a higher risk of the Cancer spreading, it can be used together with a shortened course of external beam Radiotherapy.

Brachytherapy appears to be as effective as radical Prostatectomy or external beam Radiotherapy in men who are suitable for the treatment1 2. Alternative treatments include radical Prostatectomy, external beam Radiotherapy, Cryotherapy, HIFU and active surveillance. The Prostate Cancer Charity offers a Helpline for more information on these treatments Details can be found if you Click Here.

If you choose Brachytherapy as a treatment option, your specialist team will look at the following factors to find out if you are suitable for the treatment.

Stage and grade of the cancer

The Cancer must be contained within the Prostate Gland (localised cancer). Brachytherapy is generally suitable for men with a PSA of less than 20, a Gleason score of 7 or less and a cancer stage of T1 or T2. However, different treatment centres will set their own criteria so check with your specialist team. Read our pages on How prostate cancer is diagnosed and Prostate Specific Antigen testing for an explanation of cancer staging and grading.

Size of the prostate gland

Brachytherapy is normally used to treat men with Prostate Glands of 60cc or less. If the gland is larger than this, some treatment centres will try to shrink the Prostate with three to six months of Hormone Therapy before treatment. Other centres will treat larger glands without hormones as long as the bone that sits in front of the prostate (pubic bone) is not in the way of the Brachytherapy needles.

Ordinary symptoms

Brachytherapy is not suitable for men who have severe problems passing urine because the treatment can make the symptoms worse. Your specialist team will ask you to fill out a questionnaire about your symptoms and you may have a urine flow test and Bladder scan. You may be offered Surgery or Laser treatment three to six months before Brachytherapy to treat any urinary symptoms.

TURP

If you have had surgery to treat a non-cancerous enlargement of the Prostate, called a Trans Urethral Resection of the Prostate (TURP), you may not be suitable for Brachytherapy. This may depend on how long ago you had the TURP and how much Prostate tissue was removed. Ask your specialist team for advice on your individual situation.

How does Brachytherapy treat Prostate Cancer?

The Prostate Gland is implanted with tiny radioactive seeds, each the size and shape of a small grain of rice. These seeds can be implanted individually or as part of a strand of seeds. Sometimes the specialist will use both individual seeds and strands of seeds to make sure the whole prostate is treated.

Because the seeds are concentrated inside the Prostate, they give a higher dose of radiation than is possible with external beam Radiotherapy, while limiting damage to the surrounding tissues. The seeds give off radiation over several months, with most of the radiation being released in the first three months after having the implant. After around ten to 12 months, almost all of the radiation has been released and the seeds are no longer active.

There are two main treatment methods:

The two-stage procedure (Seattle) and the one stage procedure (Potters). Both methods use similar doses of radiation and are equally successful at treating the cancer. Ask your specialist team which method they use at their centre.

The Seattle procedure is the most common method and has been used in the United Kingdom and United States for the last 15 to 20 years. The treatment is given in two stages and commonly involves two hospital visits and two anaesthetics. The first stage is the pre-implant planning session, known as a ‘volume study’, where the specialist team measure your Prostate and calculate how many seeds they will need. Two to four weeks later, you go back to hospital for the second stage when the seeds are implanted.

Currently, only one treatment centre in the UK offers the Potters method, which combines the planning session and the implant. You visit the hospital just once for treatment and you do not need to stay in hospital overnight. Slightly larger Prostate Glands (up to 90 cc) can be treated using this method, without the need for hormones.

What are the advantages and disadvantages?

Advantages

Treatment takes just one or two days. Recovery is quick so you can return to your normal activities soon after treatment. Can usually be used without Hormone Treatment. The radiation is targeted to the gland, giving high doses to the Prostate while minimising damage to the Urethra, Bladder and Rectum. Suitable for men who have bowel problems such as inflammatory bowel disease.

Disadvantages

Commonly causes urinary symptoms. Requires one or two general or spinal anaesthetics depending on the method used. Can take up to two years after treatment for the PSA to fall to its lowest level.

What does treatment involve?

Planning session

You will visit the hospital for a planning session (also called a ‘volume study’) to measure the size and position of the Prostate and to work out how many seeds will be used in the implant. If you are having the Seattle technique, this will take place two to four weeks before you have your treatment. If you are having the Potters technique the planning is done at the same time as the treatment so you will only visit the hospital once.

The Brachytherapy team includes:

• An Oncologist or Urologist

Doctors who specialise in treating Prostate Cancer

• Physicists

Responsible for the Brachytherapy equipment and planning of the seed implantation

• Radiographers

Specialists in using Radiotherapy to treat Prostate Cancer

• Specialist nurses

Assist with the treatment and are responsible for your care before and after the treatment.

The team will explain the procedure to you and tell you if you need to change any of your regular medicines, such as warfarin, before having the treatment. Do not stop taking any medicines without speaking to your specialist team. You may need to take a laxative the day before the planning session to clear your bowels.

You will be given a general or spinal anaesthetic. An Ultrasound probe is then gently placed in the back passage (Rectum). The computer makes a three dimensional image of the Prostate, which the physicist uses to work out how many seeds to implant and where to place them. The process only takes a few minutes and you can go home the same day if you are not having the implant straight away. Ask a friend or family member to take you home, as you will not be able to drive for 24 hours after a general anaesthetic.

Seed implant

You may need to take another laxative at home the day before the implant to clear your bowels. You will be given a general or spinal anaesthetic for the seed implant. An ultrasound probe is placed into the back passage so that the specialist can see where the seeds are to be implanted. Thin needles are placed into the prostate through the area of skin between the testicles and the back passage Rectum called the Perineum. The specialist then passes the seeds through the needles into the Prostate, following the plan that was put together at the planning session.

Between 60 and 120 seeds are implanted into the Prostate. Some seeds are implanted individually in the middle of the gland. Others are placed around the edges of the gland as part of a strand that holds the seeds together.

The seed implant takes 30 to 45 minutes using the Seattle method, or one and a half to two hours if you are having the planning session at the same time (Potters method). Depending on what time of day you have your treatment, you may need to stay in hospital for one night or you may be able to go home the same day.

After the procedure

You will come round from the anaesthetic in the recovery room, before going back to the ward. Your specialist team will give you any medicines that you may need at home. These may include painkillers, drugs to help prevent urinary problems (such as Tamsulosin) and antibiotics to prevent infection.

If you are having the Seattle method, you are likely to have a catheter for a few hours but this will be taken out before you go home. A small number of men (around one in 20) are unable to completely empty their bladders immediately after the treatment. If this happens you may need to have a temporary Catheter. Alternatively, you may be shown how to use a fine Catheter yourself to regularly drain urine from your Bladder.

What happens afterwards?

Your follow-up appointment

Four to six weeks after the treatment, the specialist team will invite you back to the hospital for a CT or MRI scan to check the position of the seeds (called a dosimetric analysis). Some teams do this shortly after the treatment instead. Use this opportunity to tell the team if you are having any bowel symptoms, sexual problems or difficulty passing urine.

After treatment

Your PSA level and any symptoms will be checked regularly either at the hospital or at the GP surgery. It can take two years for the PSA to reach its lowest level (nadir) and you may find that your PSA level falls and rises (PSA bounce) during this time. PSA bounce is not related to the success of the treatment but speak to your specialist nurse or doctor if you are worried about your PSA level.

Brachytherapy appears to be as effective as radical Prostatectomy or external beam Radiotherapy at successfully treating Prostate Cancer. However if your PSA level continues to rise, you may need to have further treatment such as cryotherapy or, less commonly, radical prostatectomy. Contact our confidential Helpline for more information on these treatments.

The months following treatment can be a stressful time while you wait for the results of PSA tests and the outcome of your treatment. Family and friends can be very supportive during this time. You may also find it helpful to speak to someone who has been through the same experience. The Prostate Cancer Charity offers a Helpline for more information on these treatments Details can be found if you Click Here.

Precautions to take

It is perfectly safe for you to be around other people. However, as a precaution, you should avoid close contact with pregnant women or children under the age of two for the first three months after treatment. Your specialist team will give you advice on this.

It is possible, but rare, for you to pass a seed in your urine. Ask your specialist team for advice on what to do if this happens. Some hospitals advise you to flush the toilet twice if you think you have passed a seed.

Contact your Brachytherapy team if you need unrelated Surgery to your Abdomen or Bowel within a year of having Brachytherapy. They will advise your medical team on the risk of being exposed to the radiation from the seeds. You will be given an advice card to carry at all times, which explains the treatment you have had.

Going back to work

You should be able to return to your normal activities within a few days. You can go back to work as soon as you feel able, but this will depend on how much physical effort your work involves.

Travel

If you have had a general anaesthetic, you should not drive a vehicle for 24 hours after treatment.

You will be given an advice card which states that you have had treatment with internal radiation. Take this card with you whenever you travel by air, as the radiation in the brachytherapy seeds will set off the airport radiation sensors.

Sexual activity

It is rare for any seeds to be passed in your ejaculate but, as a precaution, you should use a condom for the first six months after treatment.

We do not yet fully understand how Brachytherapy affects fertility. You may notice that you produce less ejaculate but it is possible that you are still fertile. You should avoid fathering children for two years because the radiation may harm an unborn child.

Where to get help

Your specialist team will give you a telephone number to call if you have any questions or worries. Contact your team or visit your hospital’s Accident and Emergency department if:

Your urine is very bloody, has clots in it or you are having difficulty passing urine.

You get a fever of more than 38°c or 101°f, or chills with a raised temperature. This may be a sign of infection.

What are the side effects?

You may not have any side effects for several days until the radiation from the seeds begins to take effect. Side effects are generally at their worst a few weeks after treatment, when the radiation dose is at its peak, but should then improve over the following months as the seeds lose their radiation.

The most common side effects are described here but you may not get all of these. Ask your specialist team for more information on the risk of side effects. They should be willing to show you their results and put you in touch with other men who have had the treatment.

In the first two to three days after the implant, you may have:

Blood-stained urine. This usually clears up in a few days.

Discoloured semen. This is caused by bleeding from the treated area and can last for a few weeks.

Bruising in the area between your testicles and back passage (Perineum) which can spread to your inner thighs and penis. This will disappear in a week or two.

Pain or discomfort spreading to the tip of the penis.

Discomfort when you pass urine and needing to pass urine more often, especially at night. Some side effects may take several weeks to develop and are likely to be longer lasting. These may include problems passing urine, erectile dysfunction, bowel problems and tiredness.

Problems passing urine

Brachytherapy causes inflammation of the tube that you pass urine through (Urethra). This leads to symptoms such as needing to pass small amounts of urine frequently, needing to go urgently, hesitating before starting to urinate and poor flow. These symptoms can get worse in the first few weeks after treatment but usually start to improve after a few months 6 7 .

Sometimes the inflammation can cause the Urethra to narrow so that urine cannot pass easily out of the body. This is called urinary retention and it can affect up to one in ten men. If this happens you should contact your specialist team at the hospital or go to your local Accident and Emergency department. A Catheter will be inserted to drain the urine away and you may be shown how to use a temporary Catheter yourself. The inflammation normally goes down after four to 12 weeks.

Urinary incontinence is rare in men treated with Brachytherapy but you may be at greater risk if you have previously had surgery to treat urinary problems. Up to four out of every ten men who have had a major TURP operation to treat BPH (Benign Prostate Hyperplasia) experience stress incontinence after Brachytherapy. This is the leakage of urine caused by coughing, sneezing or sudden movement.

You are more likely to have problems passing urine if you have a large Prostate or if you had urinary symptoms before treatment. Your risk is also increased if you are having external beam radiotherapy together with Brachytherapy.

You may be given drugs, called alpha blockers and non-steroidal anti-inflammatories, to help with problems passing urine. Drink plenty of fluid (one and a half to two litres a day) but avoid drinks containing caffeine, such as tea and coffee, and fizzy drinks which can irritate the bladder. It is safe to drink alcohol in moderation. Try drinking less fluid in the evening to reduce the number of times you have to get up during the night. One or two glasses of cranberry juice each day may help to relieve some symptoms. However, if you are taking the drug warfarin to thin your blood, avoid cranberry juice because it can increase the effect of the drug.

Erectile dysfunction

Brachytherapy can damage the nerves and blood vessels needed for erections. This damage may gradually worsen over several years. This leads to an inability to get an erection strong enough for sexual intercourse.

The risk of long-term erectile dysfunction (ED) after Brachytherapy is similar to external beam Radiotherapy and lower than after radical Prostatectomy. Your risk will increase if you had any problems getting and maintaining an erection before treatment or if you are also having Hormone Therapy or external beam Radiotherapy.

Reported rates of ED vary a great deal but up to half of men treated with Brachytherapy may be affected. This lack of certainty is due to the way that researchers collect the data, how they define ED and how long after treatment they measure the number of men with ED. Ask your specialist team for their ED rates. There are several treatments available to help improve erectile function.

You may find that you ejaculate less fluid than before the treatment. This is a permanent side effect of Brachytherapy. Alpha blocker drugs, taken to help urinary symptoms, may also temporarily reduce the amount of fluid you ejaculate.

Bowel problems

Mild bowel problems affect less than one in five men in the first year after Brachytherapy. However, some symptoms can start as late as two to three years after treatment. Inflammation of the back passage (proctitis) can cause some bleeding and needing to empty your bowels more often. If you are also having external beam Radiotherapy you are more likely to experience bowel problems. Tell your specialist team about any symptoms as there are treatments available that can help.

Tiredness

The Brachytherapy seeds will continue to release radiation for several months so you may find that you continue to feel tired after the seeds have been implanted. Your sleep may also be interrupted if you need to get up to go to the toilet during the night.

Questions to ask your doctor

• Which type of Brachytherapy will I have? The one day (Potters) or two day (Seattle) procedure?

• Will I have external beam Radiotherapy as well as Brachytherapy? Will I have this before or after the implant?

• What are the chances of short term and/or long term side effects with this treatment?

• Do I need Hormone Treatment before Brachytherapy?

• How will we know if the treatment has worked?

• What should my PSA level be after treatment and when will you be checking it again?

• If my PSA continues to rise, what other treatments are available?

Sources

This document is largely as supplied by The Prostate Cancer Charity and their sources were declared as:

1 Kupelian PA, Potters L, Khuntia D et al. Radical prostatectomy, external beam radiotherapy <72 Gy, external beam radiotherapy > or =72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1-T2 prostate cancer. International Journal of Radiation Oncology, Biology, Physics 2004; 58(1):25-33.

2 Potters L, Klein E, Kattan M et al. Monotherapy fostage T1-T2 prostate cancer: radical prostatectomy, external beam radiotherapy, permanent seed implantation. Radiotherapy & Oncology 2004; 71:29-33.

3 Langley SEM, Laing R. Prostate brachytherapy has come of age: a review of the technique and results. BJU International 2002; 89:241-249.

4 The Prostate Cancer Centre [page on the Internet]. Surrey: The Prostate Cancer Centre; 2005. [cited 2006 Nov 1].

5 Stock RG, Stone NN, Cesaretti JA. Prostate-specific antigen bounce after prostate seed implantation for localized prostate cancer: descriptions and implications. International Journal of Radiation Oncology Biology Physics 2003; 56:448 – 453.

6 Langley SEM, Laing RW. Iodine seed prostate brachytherapy: an alternative first-line choice for early prostate cancer. Prostate Cancer & Prostatic Diseases 2004; 7:201-207.

7 Miller NL, Theodorescu D. Health-related quality of life after prostate brachytherapy. BJU International 2004; 94:487-491.

8 Bhatnagar V, Stewart ST, Huynh V et al. Estimating the risk of long-term erectile, urinary and bowel symptoms resulting from prostate cancer treatment. Prostate Cancer and Prostatic Diseases 2006; 1-11.

Reviewed By

The original document by The Prostate Cancer Charity was reviewed by:

Peter Acher, Research Fellow, Guy’s and St Thomas’ NHS Foundation Trust

Jane Booker, Macmillan Urology Nurse Specialist, Christie Hospital NHS Trust

Donna Higgins, Lead Urology / Brachytherapy Nurse Specialist, Royal Surrey County Hospital

Professor Stephen Langley, Professor of Urology, Royal Surrey County Hospital

Janette Nichol, Prostate Clinical Nurse Specialist, Guy’s and St Thomas’ NHS Foundation Trust

Ingrid Spickett, Support & Information Specialist Nurse, The Prostate Cancer Charity

Cathy Wilkinson, Specialist Radiographer & Brachytherapy Co-ordinator, Christie Hospital NHS Trust

The Prostate Cancer Charity Information Volunteers

Edited By

The Original Document Was Edited by Debbie Clayton, Information Manager, The Prostate Cancer Charity

The Prostate Cancer Charity makes every effort to make sure that its services provide up-to-date, unbiased and accurate facts about Prostate Cancer. We hope that these will add to the medical advice you have had and will help you to make any decisions you may face. Please do continue to talk to your doctor if you are worried about any medical issues.

Further cross referencing, linking and editing has been done by KCR User: Greg L-W.

To view the original of the article on which this is based Click Here

Comments

Hi, for the benefit of those reading this from South Wales may I reassure you that Brachytherapy is not something unmentionable you do with icecream at the back of a cafe! If you need a translation ....!! User: Greg L-W.

References

Disclaimer

E&OE - Errors & Omissions Excepted