ALL ABOUT BRACHYTHERAPY FOR PROSTATE CANCER
Brachytherapy for prostate cancer is one of the best treatment options available today. Over 95% of patients have shown excellent results at an early stage of the disease.
WHAT IS BRACHYTHERAPY FOR PROSTATE CANCER?
Brachytherapy, also known as internal or interstitial radiotherapy, is a subtype of radiotherapy where the radiation dose is delivered inside the prostate gland.
Radiation, a powerful form of X-rays, causes great damage to the cancer cells and stops them from growing. The tumor cells can’t recover from this and die. However, healthy cells can quickly repair themselves.
The main advantage is that brachytherapy delivers radiation right into the prostate so that the surrounding healthy tissues may receive less radiation, with a lower risk of some side effects.
There are two types of prostate brachytherapy. Both are performed in the operating room and last 1-2 hours.
You will receive either spinal anaesthesia (you will be numbed from the waist down) or general anaesthetic (where you are completely asleep). Also, you might need to stay in the hospital overnight, but most commonly, it is an outpatient procedure.
The team in charge will be made up of anesthesiologists, urologists, physicists, therapy radiographers, and sometimes, a specialist nurse.
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BEFORE HAVING BRACHYTHERAPY: THE PLANNING SESSION
You will have an appointment scheduled one or two weeks before starting the protocol (two-stage procedure) to ensure no contraindication. Or, the planning session and the treatment itself may be performed on the same day (one-stage procedure).
At this first appointment, you’ll have had an ultrasound scan to evaluate the size of your prostate and decide how many seeds you will need.
If your prostate is too large, your doctor will likely offer hormone therapy for up to six months to shrink it. Then, you’ll have another planning session before the seeds are implanted.
Bear in mind that before the procedure, a thin tube (catheter) will be passed up through your penis right into your bladder to help drain urine. Also, your bowel must be empty beforehand so that the scan images are accurate. Hence, you may need to have an enema in the hospital or take a laxative the day prior to the planning session.
The planning session usually lasts about half an hour plus the time it takes to recover from the anaesthesia. This is an outpatient procedure, so you can go home later that same day if you aren’t having the treatment straight away.
Low-Dose Rate Brachytherapy (LDRB)
Low-dose rate brachytherapy uses several small radioactive pellets or “seeds,” each about the size of a grain of rice, to deliver the radiation. They contain iodine-125 or palladium-103 and are surgically implanted into the tumor using very thin needles.
The seeds go in the area between the scrotum and anus, known as the perineum. They are left in place (aka forever) and give off low doses of radiation for weeks or months.
Usually, you will need around 100 seeds, but it will depend on the size of your prostate. You can have loose individual seeds or linked together in a chain using material that slowly dissolves.
Treatment can take between 45 to 90 minutes.
Even though the radiation doesn’t travel far, your doctor may advise you to stay away from pregnant women and small children during the first two months after treatment.
Also, you shouldn’t cuddle children or pets on your lap for the first two months after treatment. But, after 8 to 10 months, almost all the radiation will have faded.
Like surgery or external beam radiotherapy, permanent seed brachytherapy is the go-to option for treating low-risk localized prostate cancer.
Also, a relapsed prostate cancer patient can undergo lifesaving therapy using this modality with excellent results.
High-Dose Rate Brachytherapy (HDRB)
The radiation can be delivered through thin tubes (catheters) placed inside the prostate. This is called high-dose-rate brachytherapy.
The tubes are placed through the skin between the scrotum and anus. They are connected to an HDRB machine that delivers radioactive iridium-192 or cesium-137 that stays in place for 5 to 15 minutes.
Having the tubes can be uncomfortable, and you must stay still, lying down while they are in place. If you need more than one treatment, the tubes remain put between treatments.
Some men need 2 or 3 treatments over 24 hours. Or, you may receive 1 to 4 sessions over two days, with the radioactive material being removed each time, so no radiation is left in your body. After the last treatment, the catheters are extracted.
Recovery is quick, which means you will be able to return to your everyday activities within a week.
However, you may experience discomfort, slight pain, or bleeding from the area where the needles entered. But, you can take OTC painkillers such as paracetamol for the first few days if you need them.
With HDRB, you receive a high dose of radiation to the prostate while slightly minimizing the risk of bowel problems. However, the risk of urinary problems is higher than with external beam radiotherapy. The probability of sexual dysfunction is the same.
IS BRACHYTHERAPY FOR PROSTATE CANCER RIGHT FOR ME?
This procedure is not for everyone. First, permanent seed brachytherapy (LDRB) or HDRB alone won’t be suitable if you have advanced prostate cancer. But, there are other limiting factors.
For example, brachytherapy is less than ideal if you have ulcerative colitis or Crohn’s disease. This is because it could worsen your bowel problems. Moreover, men who have had a transurethral resection of the prostate (TURP) or with pre-existing urinary problems have a higher risk of urinary side effects.
And, if you’ve recently had surgery to treat an enlarged prostate, you have to wait between three to six months before having treatment.
Also, brachytherapy might not yield great results in men with large prostate glands because it is technically difficult to place the radioactive seeds into the correct locations.
One way to get around this limitation is putting you on a few months of hormone therapy to shrink the prostate. Also, transrectal ultrasounds, CT scans, or MRIs can help guide the correct placement of the radioactive pellets.
However, very occasionally, imaging may show that brachytherapy is impossible due to the position of your prostate and pelvic bones. If this happens, your doctor will discuss other options with you.
Finally, this treatment won’t be suitable if you’ve had previous surgery to remove your back passage (rectum). After all, brachytherapy involves using an ultrasound probe in the back passage to ensure the seeds are in the right place.
CAN I HAVE BOTH EXTERNAL RADIOTHERAPY AND BRACHYTHERAPY FOR PROSTATE CANCER?
Brachytherapy alone is generally used only in low-grade, early-stage prostate cancer patients.
Actually, low-dose seed is as good at treating low-risk localized prostate cancer as external beam radiotherapy or even surgery.
But suppose there’s a risk that your cancer could spread outside the prostate. In that case, your doctor will prescribe you high dose-rate brachytherapy alongside a short course of external radiotherapy, plus hormone therapy. This is called brachytherapy boost.
Of course, having both types of radiotherapy can help make treatment more effective. However, it might also increase side effects.
ARE THERE ANY SIDE EFFECTS IN BRACHYTHERAPY FOR PROSTATE CANCER ?
Right after treatment, you may present:
- Blood-stained urine or brown-colored semen.
- Swelling, bruises, and pain in the area between your testicles and back passage, your inner thighs, and your penis. These will improve in a week or two.
- Pain or slight discomfort when you urinate or the need to do it more often, especially at night.
Other side effects may appear after several weeks and be long-lasting. These may include tiredness and urinary, erection, and bowel problems. These side-effects that often appear after radiotherapy treatment are known as pelvic radiation disease.
Side effects usually begin about a week after finishing the protocol. In the case of LRDB, they are generally at their worst a couple of few weeks or months after, when the radiation dose is strongest. They are often worse in patients with large prostates, as more needles and seeds are needed for the treatment.
However, side effects usually improve over the following months. Although, you might present more side effects if you had problems before the treatment. Or, these pre-existing conditions may get worse after brachytherapy.
You could present radiation cystitis with difficulty or slight discomfort when urinating. Luckily, bowel problems are usually mild and less common than external beam radiotherapy.
However, brachytherapy can cause erectile dysfunction due to damage to blood vessels and nerves that control erections. These erection problems may not present straight away but may develop some time afterward. You could end up producing less semen than before, or none at all. Your orgasms may feel different, or you may experience some pain when reaching climax.
Also, there is a chance that brachytherapy may make you infertile, so you may not be able to have children naturally.
SPECIAL CONSIDERATIONS WHEN HAVING LDRB
Even though the following are not side effects, take them as recommendations when having brachytherapy.
- Don’t have sex for a few days after treatment, and always use a condom the first five times. Also, double-wrap used condoms and properly dispose of them.
Even though the radioactive seeds usually stay in place, seeds can migrate and come out in your semen when ejaculating.
- Don’t pick up any seed that may come out in your urine. It is rare, but just flush it down the toilet if it happens.
But don’t worry, your treatment will still work. The remaining seeds provide enough radiation left in the prostate to treat your cancer effectively.
It is possible, although very rare, for a seed to migrate through your bloodstream and travel to another part of your body. This is harmless, and it will be detected when you have an image scan at your next follow-up appointment.
- Remember to take your advice card with you when you travel. The radiation in the seeds could set off radiation or metal sensors at the airport.
WHEN WILL PROSTATE CANCER BE ERADICATED AFTER BRACHYTHERAPY?
The treatment is effective from the first day it is applied. However, to check the effectiveness, the patient must wait maybe a year or more to know if the cancer is gone.
Your checkups will usually start two or three months after treatment. You will then have follow-up appointments every three to six months. After three years, they will be less frequent.
Periodic blood tests should be performed to determine the level of a protein called PSA (Prostate-Specific Antigen).
PSA values are an effective way of checking how well your treatment has worked. After finishing the protocol, your PSA levels should drop to their lowest level in 18 months to two years.
Actually, your PSA level may rise after your prostate cancer treatment is finished and then fall again. This is called ‘PSA bounce, ‘and it is normal. It could present up to three years after the procedure and doesn’t mean your cancer has returned.
However, if your PSA level rises by 2 ng/ml or more above its lowest level, or if it repeatedly rises for three or four PSA tests, this could mean that you have a cancer recurrence.
If this happens, talk to your doctor or nurse about what treatment option would be best for you.
IMOR HOSPITAL FACILITIES:
Center specializing exclusively in the care of the oncology patient.
The center area is 700 m2 distributed over four floors.
Latest technologies in radiotherapy and brachytherapy equipment.
Three-dimensional digital imagery.
Comfortable rooms with natural light.
Doctor Benjamín Guix Melcior
Specialist in Brachytherapy for Prostate Cancer
More than 35 years of experience in prostate cancer treatment.
Director of the IMOR Institute (Barcelona, Spain).
American Brachytherapy Society (ABS) Award 2009
Languages: Spanish, English, French
Bibliography – More recent publications:
Surgery Versus Radiotherapy for Clinically-localized Prostate Cancer: A Systematic Review and Meta-analysis. Wallis CJD, Saskin R, Choo R, Herschorn S, Kodama RT, Satkunasivam R, Shah PS, Danjoux C, Nam RK.Eur Urol. 2016
Advances in Radiotherapy for Prostate Cancer Treatment. Podder TK, Fredman ET, Ellis RJ.Adv Exp Med Biol. 2018
Radiation Therapy for Prostate Cancer. Kamran SC, D’Amico AV.Hematol Oncol Clin North Am. 2020
Information in radiotherapy for men with localised prostate cancer: An integrative review. Gordon L, Dickinson A, Offredy M.Eur J Cancer Care (Engl). 2019
WOULD YOU LIKE TO RECEIVE MORE INFORMATION ABOUT BRACHYTHERAPY FOR PROSTATE CANCER?
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Press Release 3 July 2013 (La Vanguardia, Spanish newspaper with a circulation of 230,000 copies per day)
Extract: Brachytherapy of the prostate has become one of the best treatment options for localized prostate cancer. Excellent results have been seen in over 95% of patients selected at an early stage of the disease. In most cases, it has been more effective than conventional prostate cancer surgery. The treatment is effective from the first day it is applied. In addition, patients who relapse can undergo, what is called rescue brachytherapy, with excellent results.
Press Release 11 February 2013 (La Vanguardia, Spanish newspaper with a circulation of 230,000 copies per day)
More than 1400 patients were treated with excellent results (IMOR Radiotherapy Hospital )
The IMOR Radiotherapy Hospital is a center of reference, not only in treatments carried out with radiotherapy but also in cancer treatment. The IMOR Radiotherapy Hospital in Barcelona is a pioneer center in Spain and one of the first centers internationally. It has extensive experience in brachytherapy applied to prostate cancer. A great expert from the country, Doctor Benjamí Guix, radiation oncologist and medical director of the IMOR Radiotherapy Hospital in Barcelona, reveals the successes achieved thanks to this innovative cancer treatment:
“Brachytherapy of the prostate involves irradiating the prostate directly inside. Since radiation affects a very localized area, it does not cause damage to the surrounding healthy tissue.
Normally, the age of the patient is between 50 and 88 years. One of the great benefits of this procedure is that it prevents urinary incontinence and preserves sexual function because it does not produce sexual impotence. “
IMOR Radiotherapy Hospital started to develop brachytherapy of the prostate in 1999. In the long term, more than 98% of patients are cured.
This procedure does not present the risks of traditional surgery and has the advantage of being a short treatment. It does not cause side effects, and the patient normally tolerates it well. In addition, it prevents urinary incontinence and does not produce sexual impotence. After a few days, the patient can continue his life normally.
IMOR RADIOTHERAPY HOSPITAL
C / Escuelas Pias nº 81 – 08017 Barcelona (Spain)
Closest metro stations: Sarrià / Les Tres Torres