Who can have brachytherapy?
Brachytherapy is a treatment for cancer that is thought to be contained within the prostate gland (localized prostate cancer). 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. Studies show that brachytherapy is as effective at treating prostate cancer as radical prostatectomy or external beam radiotherapy in men who are suitable for the treatment. Other treatment options for cancer that has not spread outside the prostate gland (localized cancer) may include: • radical prostatectomy • external beam radiotherapy • active surveillance • watchful waiting You may also be offered HIFU (High Intensity Focused Ultrasound) or cryotherapy as part of a clinical trial or through private healthcare. These treatments are not used very often in the NHS as a first treatment because we do not know enough about their long term benefits and risks. 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 thought to be contained within the prostate gland (localized cancer). Brachytherapy is generally suitable for men with a PSA of less than 10, a Gleason score of 6 or less and a cancer stage of T1 or T2. However, if you have a PSA of between 10 and 20, and a Gleason score of 7, brachytherapy may still be an option for you because different treatment centers will set their own criteria.
Size of the prostate gland
Your prostate gland will normally need to be 60cc or less in size. If your prostate is larger than this, some treatment centers will try to shrink it with three to six months of hormone therapy before treatment.
Brachytherapy may not be 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 any urinary problems and you may have a urine flow test and bladder scan to assess the flow of your urine stream. Your specialist will work with you to try to reduce any urinary problems you may have. Changing your drinking habits or taking medication may help. If not you may be offered surgery (TURP) or laser treatment. This would be done at least three months before starting brachytherapy.
A Trans Urethral Resection of the Prostate (TURP) is a minor operation to treat a noncancerous (benign) enlargement of the prostate (Benign Prostatic Hyperplasia). This is carried out in order to help relieve any urinary problems you may have. If you have had TURP surgery you may have to wait three to six months before brachytherapy treatment can begin. Ask your specialist team for advice about your individual situation. If you would like to speak to a brachytherapy specialist before deciding on a course of treatment, please call our free and confidential Helpline for details of your local brachytherapy center.
How does brachytherapy treat prostate cancer?
Tiny radioactive seeds are placed directly into the prostate gland using thin needles. They are inserted through the area of skin between the testicles and back passage (perineum). There is no cut (incision) but there are small puncture wounds which heal quickly. Each radioactive seed is 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 of treatment. The seeds are permanent but 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 ways to implant the seeds into the prostate; either as a one stage or two-stage procedure.
Your hospital may offer their own variation of one of these procedures so ask your specialist team for details of the treatment you will receive. Both the one-stage and two-stage methods use similar doses of radiation and are equally successful at treating the cancer. The two-stage procedure is the most common method and has been used in the United Kingdom and United States for the last 20 years. The treatment commonly involves two hospital visits and two anesthetics. The first stage is the pre-implant planning session, known as a ‘volume study’. During this procedure the specialist team measure your prostate using an ultrasound probe and then calculate how many seeds they will need to implant. Two to four weeks later, you go back to hospital for the second stage when the seeds are implanted. The one-stage technique has been used for 12 years in the USA and six years in the UK. The technique combines the planning session and the implant into a one day procedure. You visit the hospital just once for treatment and you may not need to stay in hospital overnight.
What are the advantages and disadvantages?
• Treatment takes just one or two days
• Recovery is quick so you can return to your normal activities soon after treatment • The radiation is targeted to the gland, giving high doses to the prostate while minimizing damage to the urethra, bladder and rectum
• Suitable for men who have bowel problems such as inflammatory bowel disease
• Can cause problems passing urine
• Requires one or two anesthetics depending on the method used
• Can take up to two years after treatment for the PSA to fall to its lowest level
• Surgery after brachytherapy is rarely possible if the treatment fails to treat the cancer successfully
What does treatment involve?
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 two-stage technique, this will take place two to four weeks before you have your treatment. If you are having the one-stage technique the planning is done at the same time as the treatment so you will only visit the hospital once.
The brachytherapy team includes: • A Clinical Oncologist and/or Urologist Doctors who specialize in treating prostate cancer • Physicists Responsible for the brachytherapy equipment and planning of the seed implantation • Radiologist Specialist in ultrasound • Radiographers Specialists in delivering radiotherapy to treat prostate cancer • Specialist nurses 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 have an an aesthetic so that you do not feel any pain during the procedure. You may be asleep during the procedure (general an aesthetic) or you may be awake and not able to feel anything (spinal or epidural an aesthetic). An ultrasound probe is then gently inserted into the back passage (rectum). The computer makes a three dimensional image of the prostate, which the physicist uses to work out how many seeds are required 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 an aesthetic.
You may need to take another laxative at home the day before the implant to clear your bowels or you may be given an enema just before the procedure. You will be given a general, epidural or spinal an aesthetic 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 (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, as shown in the picture below. 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. Where the seeds go in the prostate radioactive seed tumor The seed implant takes 30 to 45 minutes using the two-stage method, or one and a half to two hours if you are having the planning session at the same time (one-stage 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 aesthetic in the recovery room, before going back to the ward or discharge area. 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 two-stage 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 (urinary retention) immediately after the treatment. You may need to take a drug called tamsulosin which helps to prevent this from happening. If you are not able to empty your bladder 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. If you are unable to empty your bladder after you have gone home you should contact your hospital straight away for advice.
What happens afterwards?
Your follow-up appointment
Four to six weeks after the treatment, your 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.
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 external beam radiotherapy, cryotherapy or, less commonly, radical prostatectomy or hormone treatment. Contact our free and 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.
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. For example, avoid letting young children sit on your lap for long periods of time. 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 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.
If you have had a general an aesthetic, 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, especially by air, as the radiation in the brachytherapy seeds can set off the airport radiation sensors. Ask your specialist team if you have any concerns about holidays and travel plans.
It is rare for any seeds to be passed in your ejaculate but, as a precaution, you should use a condom the first few times you have sex after treatment. We do not yet fully understand how brachytherapy affects fertility. You may notice that you produce less fluid when you 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. Contact your Doctor or visit your hospital’s Emergency Room 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 there is no way of telling which of these you may get or how bad they will be. 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. • Discolored 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 prostate, which can constrict the tube that you pass urine through (urethra) and may also irritate the bladder. 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. 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 doctor or your hospital emergency room. A catheter is inserted to drain the urine away.
Your doctor may advise you to keep the catheter in for a few weeks until the inflammation reduces. Alternatively you may be shown how to use a temporary catheter yourself to drain off any excess urine. 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 (40 per cent) who have had a major TURP (Trans Urethral Resection of the Prostate) operation to treat BPH (Benign Prostatic 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 ease problems with passing urine. Drink plenty of fluid (one and a half to two liters 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.
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 (50 per cent) 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 or any prostate cancer treatment. Alpha blocker drugs, taken to help urinary symptoms, may also temporarily reduce the amount of fluid you ejaculate.
Mild bowel problems such as inflammation, bleeding or change in bowel habit affect less than one in five men (20 per cent) 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. Tell your brachytherapy specialist team if you need any treatment to your bowel after brachytherapy for prostate cancer. This is because the tissue of the bowel has been affected by the brachytherapy making further investigations or treatment in that area more difficult than usual.
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.