High dose rate brachytherapy
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This page is for men who are thinking about having high dose rate (HDR) brachytherapy to treat their prostate cancer. It describes how temporary sources of radiation are given directly to the prostate gland to treat the cancer. 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 permanent brachytherapy using seeds or external beam radiotherapy. Call our confidential Helpline for more information on these treatments.
- Who can have high dose rate brachytherapy?
- How does high dose rate brachytherapy treat prostate cancer?
- What are the advantages and disadvantages?
- What does treatment involve?
- What happens afterwards?
- What are the side effects?
- Questions to ask your doctor
Who can have high dose rate brachytherapy?
High dose rate (HDR) brachytherapy is suitable for men whose cancer has not spread outside the prostate gland (localised) or is beginning to spread through the wall of the prostate or into the seminal vesicles (locally advanced). This is known as T2 or T3 disease. Read our pages on How prostate cancer is diagnosed and Prostate Specific Antigen testing for an explanation of cancer staging and grading.
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The treatment is generally used to treat men with a Gleason score of more than 6 and a PSA of 10 or higher. However the cancer must not have spread to other parts of the body. There is no limit on the size of prostate gland that can be treated. Large glands are shrunk with three to six months of hormone therapy before treatment starts.
HDR brachytherapy is still being studied to find out how effective it is at treating prostate cancer and is currently only available in a few centres in the UK. Ask your treatment centre if they offer HDR brachytherapy and what their success rates are.
Alternative treatments include external beam radiotherapy in combination with hormone therapy, hormone therapy alone and watchful waiting. Contact our confidential Helpline for information on these treatments.
How does high dose rate brachytherapy treat prostate cancer?
HDR brachytherapy is sometimes used to treat cancers that have a high risk of spreading outside the prostate gland. It delivers short, high doses of radiation to the prostate, while limiting damage to the surrounding tissues.
HDR brachytherapy is used together with external beam radiotherapy to give higher doses of radiation to the whole gland as well as to the area just outside the gland.
What are the advantages and disadvantages?
Advantages
- Delivers a higher dose of radiation to the prostate gland.
- Limits damage to the surrounding normal tissues.
- Shorter course of external beam radiotherapy needed.
Disadvantages
- Requires a general anaesthetic.
- Two days confined to bed.
- Three to four days as an in-patient in hospital.
What does treatment involve?
You may have a shortened course (up to five weeks) of external beam radiotherapy together with HDR brachytherapy. Read our page on External beam radiotherapy for more information on this treatment.
Before the treatment
The brachytherapy team is made up of an oncologist, a urologist, a physicist, a radiographer and one or more nurses. They will discuss the treatment with you to make sure that you understand what is involved and that it is the right treatment for you. If you are happy to go ahead, you will go into hospital on the day of, or the day before, your treatment.
You will be given some medication (an enema) to clear your bowels, followed by a tablet to stop you needing to open your bowels when the implant tubes are in place.
In the operating theatre, you will be given a general anaesthetic. An ultrasound probe is then placed inside your back passage so that the specialist can see your prostate. Thin plastic tubes are inserted through the area of skin between your testicles and back passage (perineum) into the prostate gland and the surrounding tissues. Once these are in the right position, they are secured in place. A catheter is passed through the penis into the bladder so that urine can pass out easily and you will not have to get out of bed while the tubes are in place. The whole process takes about 45 minutes to an hour.
When you have woken up from the anaesthetic you will have a CT scan, which shows the outline of the prostate and the surrounding tissues. This is completely painless and takes about 20 minutes. The specialist team use the scan to plan the doses of radiation needed for your treatment. You will then have your first treatment.
Treatment
You will be taken to the brachytherapy room for each treatment. Flexible tubes from the brachytherapy machine are attached to each of the plastic tubes that are inside you. A high energy radioactive source travels down the tubes into the prostate. The radioactive source is programmed to give a measured dose to the prostate by spending an exact amount of time in each centimetre section of the plastic tubes. This way, a higher dose of radiation can be given to the tumour than to the normal surrounding tissues.
Treatment takes about ten minutes and is completely painless. You will have two or three treatments in total, with a gap of around six to eight hours between each one. You will need to stay in bed on the hospital ward until you have had the last treatment. The plastic tubes and catheter are then removed and you will be able to go home the next day. No radioactive material is left behind so it is perfectly safe for you to be around other people, including children.
What happens afterwards?
Your follow-up appointment
Four to six weeks after you finish your treatment, you will be invited back to the hospital for an appointment with the specialist team. They will monitor how well you are recovering from the treatment, check your PSA level and ask about any side effects.
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 to three 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 time1. 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.
If your PSA level continues to rise, you may need to have further treatment, such as cryotherapy. Contact our confidential Helpline for more information on this treatment.
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. Call our Helpline on 0800 074 8383 and ask to be put in touch with someone who has had brachytherapy.
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
You should not drive a vehicle for 24 hours after treatment to allow time for you to recover from the general anaesthetic.
Sexual activity
Some men notice a reduced volume or force when they ejaculate but most will have a ‘dry’ orgasm where they do not ejaculate any semen.
Radiation can harm a developing baby so avoid fathering children for two years after your treatment has finished.
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?
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.
Read our page on External Beam Radiotherapy for details of side effects associated with that treatment.
Problems passing urine
Brachytherapy causes inflammation of the tube that you pass urine through (urethra). This can lead to short-term symptoms such as needing to pass small amounts of urine frequently and pain when you pass urine2.
Sometimes the inflammation can cause narrowing of the urethra (known as a stricture) so that urine cannot pass easily out of the body. This is called urinary retention and it can affect up to one in ten men2. Symptoms caused by the inflammation can develop slowly over several months. If you find it difficult or impossible to pass urine, contact your specialist team at the hospital or go to your local Accident and Emergency department. The stricture may be stretched to allow urine to pass out more easily. 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 had an operation called a TURP (Trans-Urethral Resection of the Prostate) to treat urinary problems2.
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, coffee or 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.
Read our page on Continence Management for more information on managing urinary symptoms.
Erectile dysfunction
Brachytherapy can damage the nerves and blood vessels needed for erections. This damage may gradually worsen over several years3. 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 radiotherapy4. 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 radiotherapy5.
Reported rates of ED vary a great deal but up to half of men treated with brachytherapy may be affected5. 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 ED5. Ask your specialist team for their ED rates. There are several treatments available to help improve erectile function. Read our page on Sexuality and prostate cancer for more information.
You may find that there is less fluid when you ejaculate, or you may have a ‘dry’ orgasm where you do not ejaculate any semen. 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
The risk of bowel problems, such as inflammation of the back passage (proctitis) and bleeding, is low in men treated with HDR brachytherapy6. However you are more likely to have problems if you are also having external beam radiotherapy. Tell your specialist team if you have any symptoms as there are treatments available that can help.
Tiredness
You may feel tired for the first few days after treatment as you recover from the anaesthetic. 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
Will I have external beam radiotherapy before or after HDR brachytherapy?
What are the chances of short term and/or long term side effects with this treatment?
Do I need hormone treatment before and after HDR brachytherapy?
How long will I need to stay in hospital for the 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?
Sources used in the compilation of this page
1 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.
2 Morton GC. The emerging role of high-dose-rate brachytherapy for prostate cancer. Clinical Oncology. 2005; 17:219-227.
3 National Institute for Health and Clinical Excellence. Interventional procedures overview - High dose rate brachytherapy for localised prostate cancer. London: NICE; 2006 [cited 2006 Aug 17].
4 Al-Salihi O, Mitra A, Payne H. The challenge of dose escalation in locally advanced unfavourable prostate cancer using HDR brachytherapy. Prostate Cancer & Prostatic Diseases. In press 2006.
5 Miller NL, Theodorescu D. Health-related quality of life after prostate brachytherapy. BJU International 2004; 94:487-491.
6 O’Connor KM, Fitzpatrick JM. Side-effects of treatments for locally advanced prostate cancer. BJU International. 2005; 97:22-28.
Reviewed by:
- Dr Anna Lydon, Consultant Clinical Oncologist, Torbay Hospital
- Dr Heather Payne, Consultant Clinical Oncologist, UCL Middlesex Hospital
- Ingrid Spickett, Support & Information Specialist Nurse, The Prostate Cancer Charity
- The Prostate Cancer Charity Information Volunteers
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.
© The Prostate Cancer Charity September 2006 To be reviewed September 2008