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Internal radiotherapy (brachytherapy) for prostate cancer

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This page is about brachytherapy (a type of internal radiotherapy) for localised prostate cancer. There is information about

 

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Brachytherapy (internal radiotherapy) for prostate cancer

Brachytherapy is radiotherapy treatment given from inside the prostate gland. It is a treatment to try to cure early prostate cancer. There are 2 different types of internal radiotherapy for prostate cancer. 

If you have seed implantation brachytherapy, your doctor puts small radioactive seeds into your prostate gland. These are put in place using a fine needle inserted through the area of skin between the scrotum and the anus (the perineum). The seeds stay in and give a dose of radiation to the prostate over a few months. It is also called low dose rate brachytherapy (LDR). The radiation does not travel very far in the body. So, the surrounding healthy tissue receives a much smaller dose than the prostate gland.

If you have high dose rate brachytherapy, your doctor puts thin tubes through the skin behind your testicles and into position inside the prostate. The thin tubes connect to a special machine which contains a radioactive material. This gives a dose of radiotherapy to the prostate gland. When the correct dose has been reached the doctor removes the tubes. You then have no radiation left in your prostate.

Internal brachytherapy for prostate cancer usually involves one planning session and one treatment session.

Side effects of brachytherapy

The most common side effect with brachytherapy is difficulty passing urine. This may last for a few months. Some men have long term problems with passing urine after this type of treatment. About 2 in 100 men (2%) have a straining feeling in the back passage, called proctitis. And some men have problems getting and keeping an erection after brachytherapy.

 

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What brachytherapy (internal radiotherapy) is

Your specialist may suggest that you have radiotherapy given from inside the prostate gland. This is to try to cure prostate cancer that is completely contained within the prostate (localised prostate cancer). This treatment is called brachytherapy. 

Your doctor may recommend it on its own if your cancer is at low risk or intermediate risk of developing within a few years. If your cancer is at high risk of developing your doctor will recommend that you also have external radiotherapy. 

There are two types of brachytherapy – seed implantation (low dose rate therapy - LDR)) and high dose rate therapy (HDR). Both types treat prostate cancer with radiation from inside the prostate gland. But there are differences in the way you have the treatment.

Some men prefer to have brachytherapy instead of external radiotherapy because with brachytherapy they only need to go to the hospital once or twice. But check with your specialist about that, because some men need to have some external radiotherapy as well as brachytherapy.

 

When brachytherapy is used

You can have brachytherapy on its own if your prostate cancer is contained within the prostate gland and is not high risk. The radiation does not travel very far, so your prostate cancer must not have grown more than a millimetre or two past the outer covering (capsule) of the prostate. It must be a stage T1 or T2 cancer.

If your prostate is quite large, you may need to have 3 months of hormone treatment to shrink it before you have your brachytherapy.

If your PSA reading is high (over 20) brachytherapy will not be suitable for you. A high PSA reading shows that your cancer is not likely to be localised, even if your scans show that it is.

If you have had a TURP operation you will be more likely to have urine leakage (incontinence) after this treatment. So it may not be the best choice for you.

 

Seed implantation brachytherapy

Before Treatment

Seed implantation is when your doctor puts between 80 to 120 very small radioactive seeds into your prostate gland. You go into hospital the night before the treatment and have an examination to check that you are fine for the procedure. 

During Treatment

The next day you go to theatre and have a general anaesthetic which makes you feel very sleepy. Or you have a spinal epidural so you feel nothing from below the waist.  

The doctor puts an ultrasound probe into your back passage. This gives a clear picture of your prostate, which the doctor uses to position the seeds. The Doctor then puts between 80 and 120 small gold, radioactive seeds into your prostate. A fine needle is used to insert the seeds through the area of skin between the scrotum and anus (the perineum).

The doctor takes out the ultra sound probe. You go back to the ward once you have woken up from the anaesthetic.

For the first day you are alone in a room, on the ward, because the seeds give out radiation. However after a day, the radiation levels go down so you can go home. The seeds stay in the prostate forever. They slowly release a low level of radiation into the area of the prostate, over a few months.

Diagram showing how you have radioactive seed implants as a treatment for prostate cancer

After Treatment

When you go home, your doctor gives you a card. You need to keep the card on you at all times for 2 years.

This card has your personal details including the details of your consultant. It says what procedure you have had. This should be shown in case of an emergency. If you go to a hospital for any reason you should show the staff your card. Also let your next of kin know, so that they can tell staff on your behalf.

Safety Precautions

Some doctors advise that you don’t spend a long time with children or pregnant women for 2 months after treatment. After 2 months the radiation is almost gone. After 4 to 6 months, the radiation level falls very low. It is barely there at all and cannot even be measured on a scan.

The seeds may come out when you go to the toilet. It is unlikely. If a seed does come out, do not touch it. Pick it up using tweezers or tongs and flush it down the toilet. Contact your consultant to let them know.

It is safe to have sex and sleep in the same bed as your partner after treatment. For a few months, when having sex you should wear a condom. This is in case a seed comes out.

There is a very small risk that one or more seeds may work their way out of the prostate gland. There have been reports of seed moving into the bladder or lung. This hardly ever happens. When a seed has moved to another part of the body, it does no harm. The seeds are tiny and each one carries a tiny amount of radiation.  

Around 6 weeks after the treatment you have a CT scan to check all the seeds are in the right place.

 

High dose rate brachytherapy

You have high dose rate brachytherapy (HDR) by itself or alongside external beam radiotherapy. With HDR brachytherapy your doctor puts thin tubes into your prostate. These tubes are the connected to the brachytherapy machine. A radioactive metal comes out from the machines and enters the tubes giving off a dose radiation to the prostate.

Preparing for treatment

You go into hospital the night before the treatment. You have an examination to check that you are fine for the procedure the next day.

Having the tubes fitted

The next day you go to theatre and have a general anaesthetic which makes you feel sleepy. Or you have a spinal epidural so you feel nothing from below the waist.  

The doctor puts an ultrasound probe into your back passage. This gives a clear picture of your prostate which the doctor uses to position the tubes. The doctor positions between 10 and 35 thin tubes into your prostate. The doctor uses a fine needle to insert the tubes through the area of skin between the scrotum and anus (the perineum). The tubes are fixed into place so they won’t move. At the same time a tube called a catheter is put into your bladder.

The doctor takes out the ultra sound probe when the procedure has finished. When you wake up you will be lying on a trolley. You need to stay still and not move until the treatment is over. You have to stay lying flat. It is very important you don’t move otherwise the position of the needles can change or they can come out.

Diagram showing how you have high dose brachytherapy for prostate cancer-

Planning for the treatment

You have a CT and MRI scans. This checks the position of the tubes as well as your organs inside. The radiographers then take you back to the ward where you can rest and have something to eat and drink.

The treatment team create a treatment plan using the images from the scans. Once the treatment plan is complete you may have another CT scan. This checks that the tubes have not moved.

Treatment

The radiographers take you to the treatment room. They connect the tubes to the brachytherapy machine. They leave the room and watch you from outside on a closed circuit screen.

The radioactive metal ball leaves the machine and travels into the tubes in the prostate. This gives a radiation dose to the prostate. It takes about 15 to 40 minutes. You won’t feel anything during the treatment.

After treatment

The radiographers come back into the room and disconnect the tubes from the machines. They then take out the tubes. This can be painful but you have pain medicine, and gas and air to take. The catheter stays in overnight.

You stay on the ward overnight and are free to move as normal.

Your urine may have blood in it after the procedure, so do not be worried if the catheter bag is red. If everything is fine overnight, the nurse takes out the catheter and you are free to go home.

There are no radiation risks after your treatment, as all the radioactive material is removed after treatment.

 

Side effects of brachytherapy

For a few days you will have some soreness and bruising between the legs where the needles or thin tubes went through. 

The most common side effect with brachytherapy is difficulty or discomfort when passing urine. Up to 15 out of 100 men (15%) can't pass urine at all and have to have a tube into the bladder (catheter) put in for a few days. This side effect can last for up to a month or so.

The diagram below shows a tube (catheter) into the bladder to drain urine.

Diagram showing a urinary catheter in a man

Often, men have few problems during the first couple of weeks after brachytherapy. If symptoms occur they may peak at around 4 to 6 weeks after treatment because the radiation causes swelling. The symptoms then usually improve over the following months. 

Possible symptoms include the following

  • Blood in the urine and semen
  • A feeling of constipation due to swelling of the prostate
  • A feeling that you need to open your bowels more often than usual

The radiation dose with this treatment is localised to the prostate. So the other common side effects of external radiotherapy (such as diarrhoea or erection problems) are less likely to happen.

 

Possible brachytherapy long term side effects

This treatment can have side effects that last for longer than a few weeks. For most men, these symptoms settle gradually, but for some they are permanent. Possible permanent side effects include the following

  • Inflammation of the back passage (proctitis)
  • Difficulty passing urine
  • Erection problems (impotence)

Unfortunately, your doctor can't tell before your treatment whether these permanent side effects are likely to happen to you. Permanent side effects seem to be less common with brachytherapy than with other prostate cancer treatments.

Inflammation of the back passage (proctitis)

Rectal straining and bleeding (proctitis) occur in about 2 out of 100 men (2%).

Difficulty passing urine

After this treatment some men develop a narrowing of the tube that carries urine from the bladder to the penis (the urethra). The narrowing is called a stricture and can cause difficulty in passing urine. Having no control over passing urine (incontinence) is not common unless you have already had a TURP

With high dose rate brachytherapy, studies have reported that between 1 and 14 men in every 100 treated (1 to 14%) have some problem with urine leakage at 3 to 5 years after treatment.

Erection problems (impotence)

Whether you have problems getting and keeping an erection after brachytherapy depends on your age. It is difficult to say exactly how common this is after brachytherapy. The risk varies with age. If you are under 65 when you are treated, erection problems are less likely than if you are over 70. If you have other health conditions this may also increase your likelihood of impotence after treatment.

With seed implantation brachytherapy, research studies have shown that in men who could have erections before treatment, between 15 and 40 out of 100 (15 to 40%) have erection problems after treatment. The studies showing the higher levels of erection problems probably included a higher proportion of older men.

For combined high dose rate brachytherapy and external beam radiotherapy, the figures on erection problems from research vary a great deal. One difficulty is that the studies don't all use the same definition of erection difficulty or impotence. The studies report that between 14 and 45 men in every 100 treated have some degree of problem. In older men, up to 76 out of every 100 had erection problems 7 years after treatment (76%).

 

Follow up

Following your treatment your PSA should be checked within the first 6 weeks. Then it will be checked at least every 6 months for the first 2 years. Then yearly after that. If you experience any problems in between appointments it is important to let your doctor know. 

 

More about prostate cancer brachytherapy

Find out about

Stages of prostate cancer

External radiotherapy for prostate cancer

Hormone treatment

Internal radiotherapy

TURP operation

Long radiotherapy side effects

Coping with radiotherapy side effects

Other treatments for prostate cancer

Prostate cancer organisations

Prostate cancer reading list

UK Prostate Link can direct you to information about brachytherapy to treat prostate cancer

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Updated: 25 February 2014