External Beam Radiotherapy
The information on this page comes from our Tool Kit fact sheet on radiotherapy. To order your own tailored copy of the Tool Kit, visit our publications page. You can also download and print a PDF version of this fact sheet.
This page is for men who are thinking about having radiotherapy to treat their prostate cancer. It describes how prostate cancer is treated using radiation directed at the prostate gland from outside the body. 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 internal radiation treatment, where radioactive seeds are implanted into the prostate. For information on this treatment, please read our page on Brachytherapy. This sheet does not cover the use of radiotherapy for pain relief in advanced prostate cancer. You can contact our confidential Helpline for more information on this.
- Who can have radiotherapy?
- How does radiotherapy 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 specialist team?
- Links
Who can have radiotherapy?
Radiotherapy is one of the treatments that can be used to treat cancer that has not spread outside the prostate gland (localised). Radiotherapy may also be suitable for a small number of men whose cancer has spread to the area just outside the gland (locally advanced). You may be offered hormone therapy before you start radiotherapy to reduce the size of the prostate. You may also have hormone therapy during your course of radiotherapy, and sometimes for a period of time afterwards, to increase the chance of controlling the cancer. You can read more about this in our page on Hormone Therapy.
Radiotherapy is a suitable treatment for men of any age and is as effective as surgery (radical prostatectomy) at treating localised prostate cancer 1. Which treatment you choose will depend on the discussions you have with your specialist team and your feelings about the side effects of each treatment. You can read the other pages in this section of the website and call our confidential Helpline for information on other treatments and their side effects.
Radiotherapy can also be used after surgery if the PSA starts to rise or if it is not possible to remove all of the cancer with surgery.
How does radiotherapy treat prostate cancer?
The aim of radiotherapy treatment is to destroy cancer cells in the treated area, while limiting any damage to normal cells. High energy X-ray beams are directed at the prostate from outside the body. These beams damage the cells and stop them from dividing and growing. Cancer cells are not able to recover from this damage and die, but normal healthy cells can repair themselves more easily. The whole prostate gland is treated, including the area surrounding the gland to make sure that any stray cancer cells are treated.
The treatment is completely painless but there are some side effects, which are described on this page.
There are two types of external beam radiotherapy available: 3D conformal and intensity-modulated. Both types aim to reduce the amount of radiation given to normal tissue around the prostate gland. This reduces the risk of side effects and allows higher doses of radiation to be given.
3D conformal radiotherapy is widely available across the UK. The radiotherapy machine shapes the beams to fit the size and shape of your prostate.
Intensity-modulated radiotherapy (IMRT) is a newer technique that is not yet available in all treatment centres and may be offered as part of a clinical trial. The radiation beam can be adjusted to give different doses to different parts of the treatment area. This reduces the amount of radiation given to the bowel, reducing the risk of bleeding from the back passage 2,3 (see side effects on this page). The results of IMRT have so far been promising 4, however, only a relatively small number of men have been treated using this technique, and more research is needed.
What are the advantages and disadvantages?
The advantages and disadvantages of radiotherapy depend on your age, health and stage of disease. Your specialist team will discuss your individual situation and options with you.
Advantages
- It has none of the risks associated with surgery and a general anaesthetic
- You do not need to stay in hospital overnight
- You can carry on with many of your usual activities while you are having treatment
Disadvantages
- Possible damage to the bladder and back passage (rectum)
- There is a risk of erectile dysfunction and infertility
- As with other treatments for prostate cancer, it is possible that some cancer cells may be outside the treatment area and it is difficult to tell straight away whether the treatment has worked
What does treatment involve?
Before treatment
If you are thinking about having radiotherapy you will be referred to a specialist who treats cancer with radiotherapy, known as a clinical oncologist or radiotherapist.
You may be offered hormone therapy for three to six months before you begin radiotherapy. This shrinks the prostate and makes the cancer easier to treat. You may also have further hormone therapy throughout your course of radiotherapy. Some men, who are at a higher risk of their cancer spreading, will continue to have hormone therapy for between one and three years afterwards.
Before starting radiotherapy treatment you will be invited to a planning session. This may sometimes involve more than one visit. You will have a CT scan to find the exact location of your prostate and to measure its size. Your lower body will then be marked with three small permanent marks (tattoos). They are barely visible but they help the staff to position you correctly on the radiotherapy machine each time you are treated.
A small number of treatment centres use image guided radiotherapy. If you have this type of radiotherapy, your specialist will use a special radiotherapy machine to take a scan immediately before each treatment. An advantage to this method is that your specialist can check the position of the prostate gland before each treatment is given, but each treatment will take longer. Image guided radiotherapy is a new type of radiotherapy and researchers are looking into how well it works.
When you come for each treatment you will be asked to have a comfortably full bladder and to have an empty bowel. This helps the specialist to target the treatment area more accurately.
Tell your specialist team about any medication you are taking before you start treatment.
Treatment
You will be treated at your hospital radiotherapy unit, as an outpatient. You will have one treatment (known as a fraction) each day from Monday to Friday, with a rest over the weekend to help your normal cells recover. Treatment normally lasts for between seven and eight weeks, although some hospitals may offer a shorter course of treatment which will last for about four weeks. But the overall amount of radiotherapy you have will be the same.
When you arrive at the radiotherapy unit, you will be asked to lie on your back underneath the radiotherapy machine, as shown below.
You will be moved into the right position, using the small tattoos that you were given at the planning session as a guide. This can take a little while but it is important to get right. The staff then leave the room but they will be able to see and hear you at all times. The treatment starts and the machine will move around your body. The machine will make a slight noise but it does not touch you and you will not feel anything. You will need to keep still but the treatment only lasts a few minutes.
It is perfectly safe for you to be around other people, including children, during your course of radiotherapy. You will not give off any of the radiation you have been given. If you have any questions about your treatment, speak to the radiographers who give you your treatment or the nurses who work in the radiotherapy unit. They can also give you advice on coping with side effects. You can also speak to one of our specialist nurses by calling our confidential Helpline.
What happens afterwards?
Your follow-up appointment
Your PSA level will be checked six to twelve weeks after your treatment finishes, and then two or three times a year for several years. You will also be asked about any side effects that you may have. Your specialist team will tell you how often your PSA level will be tested and whether your appointments will be at the hospital or at your GP surgery.
If your treatment has been successful your PSA level should start to fall. This can take a few months so do not worry if you do not see a change in your PSA straight away. Your PSA will fall to its lowest level (nadir) 18 months to two years after treatment. Ask your specialist what your lowest level is likely to be.
Hormone therapy also lowers your PSA so you will need to wait until your course of hormone therapy is finished before you can see the effect of the radiotherapy on your PSA level.
The rate at which your PSA level falls is not related to the success of the treatment 5 and you may find that your PSA never drops to zero. This is because your prostate gland is still there in your body and will always produce some PSA.
Although your PSA will usually fall after treatment, it is possible that it might start to rise again at some point in the future. If so, you may need further treatment such as hormone therapy. Some centres may offer newer treatments such as HIFU or cryotherapy. A few specialists may offer surgery, but this is rarely possible due to the scarring caused by radiotherapy. However, the benefits of each of these treatments to treat prostate cancer after radiotherapy are not clear, and all treatments carry the risk of side effects. As there may be some clinical trials available for these newer treatments, ask your specialist team what is available. You can also read the other pages in this section of the website or call our confidential Helpline for information on these treatments or for more information about clinical trials.
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 can also speak to one of our specialist nurses by calling our confidential Helpline.
What are the side effects?
Side effects are caused by radiation of the normal healthy cells near the prostate gland. Many of these healthy cells are able to recover and so any side effects will only last a few weeks or months. However, some side effects can take longer to develop and can become long term problems. The latest treatment methods have reduced the risks but most men will still have some side effects.
The most common side effects are described here but there is no way of knowing which of these you will 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 to put you in touch with other men who have had the treatment. Alternatively, there may be a local support group you can contact to speak to other men who have experienced the treatment. You can also call our confidential Helpline.
Short term side effects?
These can develop during, or shortly after your treatment.
Bowel problems
The bowel and back passage are exposed to radiation because they are close to the area being treated. This may not cause any problems, but in most men it causes the lining of the bowel to become inflamed (proctitis) which then leads to symptoms. These symptoms usually start during the second or third week of treatment, but may develop earlier. Symptoms usually start to settle down a few weeks after you have finished your treatment, but you may find that some of the symptoms become permanent.
Before you start radiotherapy, tell your specialist team if you have ever had any problems with your bowels because this may increase your risk of further bowel symptoms.
Symptoms vary from man to man. Many men will notice that their stools become loose and watery, they pass a lot more wind and they have to open their bowels more often. Some men find they need to rush to the toilet or feel the need to have a bowel movement, but then find that nothing has passed.
You may feel pain around your back passage or stomach, or feel that you have not emptied your bowels properly. You may also pass some mucus or blood.
You should tell your specialist, the radiographer or the nurses about any changes in your bowel habits. Ask your specialist team before taking any medication for your symptoms. They may give you creams or drugs to help. Your specialist team may also give you advice on your diet but usually you should follow a normal diet and drink plenty of fluids.
Urinary symptoms
Radiotherapy can irritate the lining of the bladder. This can cause a burning feeling when you pass urine, difficulty passing urine, a need to pass urine more often and sometimes blood in the urine. This is known as radiation cystitis. Symptoms may appear within a week or two of starting treatment but these usually start to improve once your course of treatment is finished.
My experience: “I had no side effects for the first few days but then there was a gradual increase in the frequency of needing to pass urine. Towards the end of treatment it became a case of when I had to go, I needed to go straight away”
Tell your radiotherapy team if you develop any urinary symptoms. They will check whether the symptoms are being caused by the radiotherapy or by a treatable infection. Drink plenty of fluids but try to reduce coffee, tea and alcohol.
Some men find that drinking lemon barley or cranberry juice helps. If you are taking the drug warfarin to thin your blood, avoid cranberry juice because it can increase the effect of the drug. 6
Tiredness
Towards the end of your treatment, you may feel more tired than usual. Regular gentle exercise, such as walking, can help to prevent and improve tiredness 7. Many men continue to work throughout their treatment but if tiredness becomes a problem you may need to take some time off work. Most men recover completely from their tiredness within a couple of months of finishing treatment.
My experience: “One invaluable tip was to take a short rest each day when I got back home after having treatment”
Skin irritation and hair loss
This is less common than it used to be as radiotherapy techniques have improved. Towards the end of treatment, the skin between your legs and around your back passage may become a bit darker in colour and sore, like sunburn. Tell your specialist team if you have any of these symptoms. Avoid using any creams, lotions or soaps unless you are advised to do so by your specialist, nurse or radiographer. Wear loose, cotton clothes and try to keep the area cool. Avoid hot baths.
You may also notice that you lose some hair in the area that has been treated. This usually grows back but hair loss can be permanent in some men.
Painful ejaculation
The tube that you pass urine and semen through (urethra) can become inflamed. This may make ejaculation uncomfortable during your course of radiotherapy, but should improve after you finish treatment.
Long term side effects?
Most side effects will settle down after your course of radiotherapy treatment has finished. However some side effects can become long term or permanent. These can start to appear three months or more after you complete your treatment.
Older age, diabetes, previous bowel or prostate surgery, and previous bladder and bowel problems can all increase your risk of getting long term side effects 8. Speak to your specialist team about your individual risk.
Bowel problems
Short term bowel problems usually start to settle once your treatment is finished. This can take anything from a few weeks to six months or more. However, some men will find that their bowel habits change permanently. This may be a minor change, such as having to open your bowels twice a day instead of your usual once a day, or it can be a bigger change that affects your everyday life.
Symptoms may start during the course of radiotherapy and never improve, or they may improve after treatment only to reappear months or years later. These can include passing lots of wind, loose stools and light bleeding from the back passage.
Some men get a straining feeling as if they need to empty their bowels. You may need to rush to the toilet and you may sometimes leak loose stools or mucus from the back passage.
Do not be embarrassed to tell your specialist or your GP about any new or existing bowel problems. There are often simple treatments available that can help. Bowel problems are common in older men, so it is possible that they are the result of something other than the radiotherapy. Your cancer specialist or your GP can arrange simple tests to find out the cause of your symptoms, or they may recommend that you are referred to a bowel specialist.
Bladder problems
Radiotherapy can cause you to pass urine more often and you may get a burning sensation (radiation cystitis). A few men get a narrowing of the urethra (stricture) which makes it difficult to pass urine. This can be treated with surgery.
In rare cases (around one in 100 men 9), radiotherapy can cause you to leak urine. This is more likely if you have previously had prostate surgery such as TURP or radical prostatectomy. If this becomes a problem, you can speak to your specialist or read our page on Urinary continence and prostate cancer.
Erectile dysfunction
Radiotherapy can damage the blood vessels and nerves that control erections and so can affect your ability to achieve and maintain an erection. It can take up to two years for these symptoms to appear fully. Some men notice a reduced volume or force when they ejaculate and some will have a ‘dry’ orgasm where they do not ejaculate any semen.
Erectile dysfunction (ED) affects one in three men 10 treated with radiotherapy. You are at greater risk if you had erection problems before treatment or if you have hormone therapy together with radiotherapy 11. The stress of dealing with a cancer diagnosis, and tiredness caused by your treatment, can also affect the quality of your sex life.
If ED becomes a problem, ask your specialist to refer you to an ED nurse who can discuss treatment options with you. You can also read our page on Sexuality and prostate cancer for more information, or call our confidential Helpline.
Infertility
Radiotherapy can damage the cells that produce semen. If you are planning on having children you may be able to store your sperm before you start treatment, to use later in IVF (In Vitro Fertilisation). If this is important to you, ask your specialist team if this option is available locally.
Radiotherapy can harm a developing baby, so use condoms if there is a risk of your partner becoming pregnant. You should not father children for two years after your treatment has finished.
Questions to ask your specialist team
Which type of radiotherapy will I have? 3D conformal or IMRT?
When will the treatment start?
How long will it last (how many sessions?)
Will I have hormone treatment? Will this continue after the radiotherapy? How long for?
What are the likely side effects?
Will I be able to continue as normal during the treatment (go to work etc)?
How will we know how successful it has been? How soon will my PSA be checked after the radiotherapy finishes and what level would you expect it to drop to?
How often will I be followed-up? How long for?
If the radiotherapy is not successful, which other treatments can I have?
Who should I contact if I have any questions at any point during my treatment? How do I contact them?
Links
The following organisations provide further information relevant to this page.
Dipex
www.dipex.org.uk/
Watch, listen to, or read personal experiences of cancer diagnosis and treatment. Includes interviews with men who have had radiotherapy 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.
Sexual Dysfunction Association
www.sda.uk.net/
For information on treatments for erectile dysfunction.
Reviewed by:
- Jervoise Andreyev, Consultant Gastroenterologist in pelvic radiation disease, Royal Marsden Hospital
- Mo Beange, Treatment Review Radiographer, Department of Clinical Oncology, Raigmore Hospital
- Jane Booker, Macmillan Urology Nurse Specialist, Christie Hospital NHS Trust
- Dr P Kirkbride, Consultant Clinical Oncologist, Sheffield Teaching Hospitals FT
- Jeanette Lyons, Nurse Clinician, Clinical Oncology, Christie Hospital NHS Trust
- Phil Reynolds, Treatment Support Radiographer, Guy’s and St. Thomas’
- Cathy Taylor, Superintendent Radiographer, Christie Hospital NHS Trust
- Jo Treeby, Radiographer, Advanced Practitioner Urology, Addenbrooke’s Hospital, Cambridge
- Linda Welsh, Prostate Specialist and Clinical Trials Radiographer, Torbay Hospital, South Devon NHS Healthcare Trust
- The Prostate Cancer Charity Information Volunteers
- The Prostate Cancer Charity Support & Information Specialist Nurses
Written and edited by: The Prostate Cancer Charity Information Team
Sources used in the compilation of this page
1 Kupelian PA 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
2 O’Connor KM, Fitzpatrick JM. Side effects of treatments for locally advanced prostate cancer. BJU International (2005) 97, 22-28
3 Hong TS, Ritter MA, Tome WA, Harari PM. Intensity modulated radiation therapy: emerging cancer treatment technology. British Journal of Cancer (2005) 92, 1819-1824
4 Hong TS, Ritter MA, Tome WA, Harari PM. Intensity modulated radiation therapy: emerging cancer treatment technology. British Journal of Cancer (2005) 92, 1819-1824
5 Royal College of Radiologists Clinical Oncology Information Network, British Association of Urological Surgeons. Guidelines on the management of prostate cancer: a document for local expert groups preparing prostate cancer management policy documents. 1999.
6 British National Formulary 51 (2006) 2.8.2 Oral anticoagulants.
7 Windsor P M, Nichol K F, Potter J. A randomized, controlled trial of aerobic exercise for treatment-related fatigue in men receiving radical external beam radiotherapy for localised prostate carcinoma. Cancer (2004) 101 (3), 550-7.
8 O’Connor KM, Fitzpatrick JM. Side effects of treatments for locally advanced prostate cancer. BJU International (2005) 97, 22-28.
9 Royal College of Radiologists Clinical Oncology Information Network, British Association of Urological Surgeons. Guidelines on the management of prostate cancer: a document for local expert groups preparing prostate cancer management policy documents. 1999.
10 Wilt T. Prostate Cancer (non-metastatic). In: Clinical Evidence. BMJ Publishing Group. 2003
11 Ataman F et al. Late toxicity following conventional radiotherapy for prostate cancer: analysis of the EORTC trial 22863.Eur J Cancer 2004; 40:1674-81.