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Brachytherapy

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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.

Who can have brachytherapy?

Brachytherapy is a treatment for cancer that is thought to be contained within the prostate gland (localised 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. 1, 2, 3, 4

Other treatment options for cancer that has not spread outside the prostate gland (localised cancer) may include:

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.

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Stage and grade of the cancer

The cancer must be thought to be contained within the prostate gland (localised 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 centres will set their own criteria. Check with your specialist team.

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 centres will try to shrink it 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) will not be in the way of the brachytherapy needles.

Urinary symptoms

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. You can read more about problems passing urine by reading our page on Urinary problems and prostate cancer.

TURP

A Trans Urethral Resection of the Prostate (TURP) is a minor operation to treat a non-cancerous (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 centre.

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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 ways to implant the seeds into the prostate; either as a one-stage or two-stage procedure. Your treatment centre 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 5.

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 anaesthetics. 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. Currently, very few NHS treatment centres in the UK offer the one-stage method although it is available in many private facilities. 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.

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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
  • 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

  • Can cause problems passing urine
  • Requires one or two anaesthetics 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

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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 11. 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 specialise in treating prostate cancer
  • Physicists
    Responsible for the brachytherapy equipment and planning of the seed implantation
  • Radiologist
    Specialist in ultrasound
  • Radiographers
    Specialists in using 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 anaesthetic so that you do not feel any pain during the procedure. You may be asleep during the procedure (general anaesthetic) or you may be awake and not able to feel anything (spinal or epidural anaesthetic). 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 anaesthetic.

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Seed implant

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 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 (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.

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.

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After the procedure

You will come round from the anaesthetic 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)6 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.

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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.

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 7. 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. You may also find it helpful to speak to someone who has been through the same experience. If you would like to be put in touch with someone who has had brachytherapy you can call our confidential Helpline on 0800 074 8383.

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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.

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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, 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.

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 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.

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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.

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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.
  • 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.

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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 8, 9.

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 8. If this happens you should contact your specialist team at the hospital or go to your local Accident and Emergency department. A catheter is inserted to drain the urine away. Your specialist team 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 8 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 8. This is the leakage of urine caused by coughing, sneezing or sudden movement. Read our page on Urinary problems and prostate cancer for more information.

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 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.

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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 10 and lower than after radical prostatectomy 10. 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 9.

Reported rates of ED vary a great deal but up to half (50 per cent) of men treated with brachytherapy may be affected 10. 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 9. Ask your specialist team for their ED rates. There are several treatments available to help improve erectile function. Read our page on Sex and prostate cancer for more information.

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.

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Bowel problems

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 10. 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.

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.

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Questions to ask your specialist team

  • Which type of brachytherapy will I have? The one day or two day procedure?
  • Will I have external beam radiotherapy as well as brachytherapy? Will I have this before or after the implant?
  • Do I need hormone treatment before brachytherapy?
  • What are the chances of short term and/or long term side effects with this treatment?
  • 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?

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Links

Bladder and Bowel Foundation
www.bladderandbowelfoundation.org
For support and information on continence problems.

Health Talk Online
www.healthtalkonline.org
Watch, listen to, or read personal experiences of cancer diagnosis and treatment. Includes interviews with men who have had brachytherapy for prostate cancer.

‘Going for a’ website
www.goingfora.com
Virtual hospital from the Royal College of Radiologists. Interactive information on cancer treatment and scans. Includes descriptions from both staff and patients.

National Institute for Health and Clinical Excellence (NICE)
www.nice.org.uk
NICE produces recommendations on whether a treatment is suitable for use in the NHS. Visit their website or phone their order line for information on brachytherapy (booklet number N0888).

Prostate Brachytherapy Advisory Group website
www.prostatebrachytherapyinfo.net
This website is written by health professionals and provides information about brachytherapy treatment.

Sexual Advice Association
www.sda.uk.net
For information on treatments for erectile dysfunction.

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
  • Cathy Taylor, Specialist Radiographer Prostate Brachytherapy, Christie Hospital NHS Trust
  • Linda Welsh, Prostate Specialist Radiographer / Clinical Research Radiographer, Torbay Hospital
  • The Prostate Cancer Charity Information Volunteers
  • The Prostate Cancer Charity Support and Information Specialist Nurses

Written and edited by:
The Prostate Cancer Charity Information Team

Sources used in the compilation of this page

1 Wilt TJ, MacDonald R, Rutks I, et al (2008) Systematic review: comparative effectiveness and harms of treatments for clinically localised prostate cancer, Annals of Internal Medicine, 148(6): 435-48.
2 Colberg JW, Decker RH, Khan AM, et al (2007) Surgery versus implant for early prostate cancer: results from a single institution, Cancer Journal, 13 (4): 229-32.
3 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.
4 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.
5 Langley SEM, Laing R. Prostate brachytherapy has come of age: a review of the technique and results. BJU International 2002; 89:241-249.
6 The Prostate Cancer Centre. Surrey: The Prostate Cancer Centre; 2005. [cited 2006 Nov 1].
7 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.
8 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.
9 Miller NL, Theodorescu D. Health-related quality of life after prostate brachytherapy. BJU International 2004; 94:487-491.
10 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.
11 Department of Health (2006). Advice on the development of low dose rate (permanent seed implant) brachytherapy services for localised prostate cancer in England. London: DoH; 2006

Page last updated: October 8th 2008