Radiotherapy for locally-advanced prostate cancer
Radiotherapy for locally-advanced prostate cancer is usually given using a machine (external beam radiotherapy).
Radiotherapy treats cancer by using high-energy x-rays to destroy the cancer cells, while doing as little harm as possible to normal cells.
Radiotherapy for prostate cancer is usually given as external beam radiotherapy. There are other, newer types of external beam radiotherapy, but these aren’t available at every NHS hospital. These include conformal radiotherapy (CRT) and intensity-modulated radiation therapy (IMRT).
Some men can have brachytherapy (also called internal radiotherapy, see below). This is when small radioactive seeds are inserted into the tumour. It’s only suitable for a small number of men with locally advanced prostate cancer. Whether it’s given or not depends on how much the cancer may have spread beyond the prostate gland. Brachytherapy is usually given in combination with external radiotherapy.
Depending on your situation, your doctor may suggest you have hormonal therapy before or after your radiotherapy.
External radiotherapy is given in the hospital radiotherapy department, usually as daily sessions from Monday-Friday, with a rest at the weekend. For locally advanced prostate cancer, the course of treatment may last up to seven weeks.
Planning external radiotherapy
External radiotherapy is planned by a cancer specialist (clinical oncologist). Planning is a very important part of radiotherapy and may take one or two visits to hospital. The treatment has to be carefully planned to make sure it’s as effective as possible. You’ll be asked to have a CT scan, which takes x-rays of the area to be treated. You can read more about what a CT scan involves in our booklet Having tests for prostate cancer.
Tiny tattoos or permanent marks may be drawn on your skin. These show where the radiotherapy is to be given, and help the radiographers position you accurately when they give you your treatment. The marks are usually permanent because they must remain visible throughout your treatment, but they are the size of pinpoints and will only be done with your permission. Having the tattoos done can be a little uncomfortable, but they can help to make sure that treatment is directed accurately. You’ll be given advice about how to look after your skin during your treatment.
Some radiotherapy departments may ask you to follow a special diet before planning treatment. Occasionally, you may be asked to have an enema. This involves having liquid passed into your rectum via a small tube. The liquid will help you to empty your bowel before the scans are taken. Having an empty bowel can help make sure radiographers have as clear a picture as possible when planning your treatment.
At the beginning of each session of external radiotherapy, the radiographer will position you carefully on the couch and make sure you’re comfortable. During your treatment, you will be left alone in the room but you’ll be able to talk to the radiographer, who will watch you from another room. Radiotherapy isn’t painful but you do have to lie still for a few minutes during the treatment.
Conformal radiotherapy (CRT) and intensity-modulated radiation therapy (IMRT)
In CRT, a special attachment to the radiotherapy machine carefully shapes the radiation beams to match the shape of the prostate gland. Shaping the radiotherapy beams reduces the radiation received by the healthy cells in nearby organs such as the bladder and rectum. This reduces the side effects of radiotherapy and may allow higher doses to be given, which could be more effective.
IMRT is a more complex type of conformal radiotherapy that allows the specialist radiotherapy doctor (oncologist) to vary the dose of radiation given to different parts of the tumour and surrounding tissue. It‘s not yet known whether IMRT is a more effective treatment than CRT.
Planning and treatment sessions of CRT and IMRT are carried out in the same way as standard external beam radiotherapy.
Short-term side effects
Most of the side effects of radiotherapy gradually disappear once the treatment has finished. Your cancer specialist, nurse or radiographer can tell you what to expect. Let them know what side effects you have, as there’s usually something that can be done to help.
Radiotherapy causes tiredness, especially if you’re travelling a long way for treatment each day. It’s important to get enough rest, but try to balance this with regular, gentle exercise, which will give you more energy.
We have more information about coping with tiredness.
Radiotherapy to the prostate area may irritate the rectum, cause soreness around the anus, and cause diarrhoea. Your doctor can prescribe medicines to reduce these effects and you may be advised to make some changes to your diet.
Radiotherapy can also cause inflammation of the bladder (cystitis), which can make you want to pass urine more often or cause a burning feeling when you pass urine. Your doctor can prescribe medicines to reduce this. It’s important to make sure you drink plenty of fluids. These effects usually disappear gradually a few weeks after the treatment has finished.
A small number of men may have difficulty passing urine. In this situation, it may be necessary to have a urinary catheter put in. This is a tube that is placed inside the bladder to help the urine drain out of the body. Rarely, some men may experience leakage or incontinence of urine.
Radiotherapy to the pelvis may make some of your pubic hair fall out. When you’ve finished the course of treatment, the hair will grow back. However, it may be thinner or finer than before.
External radiotherapy doesn’t make you radioactive and it’s perfectly safe for you to be with other people, including children, throughout your treatment. .
Possible long-term side effects
Some men may have side effects that don’t improve, or may develop side effects many months or years after radiotherapy. These are known as long term or late effects.
Our section on pelvic radiotherapy in men describes these late effects in greater detail.
Radiotherapy for prostate cancer can cause the inability to have an erection (impotence) in about 3-5 in 10 men (30-50%) who have this treatment. The risk may be higher if you’re having hormonal therapy as well. After radiotherapy, men might not experience erection problems straight away, but it can sometimes develop over a period of 2-5 years. There are various treatments that can help; some of which are discussed ways in our section on coping with erection problems.
This side effect of treatment can be difficult to deal with, and can affect your sex life and your relationship with your partner. Whether you develop erection problems or not will depend on your age and whether you're being treated with hormonal therapy as well.
You may find it helpful to read our section on Sexuality and cancer.
Our database lists many helpful organisations that offer counselling for sexual or relationship problems.
Radiotherapy to the prostate can cause permanent infertility.
Some men find this very difficult to cope with. If you want to father children after your treatment, it may be possible to store sperm before treatment starts.
Bowel or bladder problems
Some men may have bowel or bladder changes as a result of radiotherapy. The blood vessels in the bowel and bladder can become more fragile, which can make blood appear in your urine or bowel motions. This can take many months or years to occur and can sometimes be a long-term effect. If you notice any bleeding, it’s important to let your doctor know so tests can be carried out and appropriate treatment given.
Occasionally, bowel movements may be more urgent after radiotherapy, and very rarely some men experience difficulty controlling their bowels (faecal incontinence). Let someone from your healthcare team know if this happens. Although it may feel embarrassing to talk about, they can give you practical advice.
Often, radiotherapy can improve problems with passing urine. But for a small number of men, it can lead to leakage of urine (urinary incontinence) due to damage to the nerves that control the bladder muscles. However, this is unlikely unless you’ve had a TURP or prostatectomy, as well as radiotherapy.
If this side effect occurs, it’s important to discuss it with your doctor, who can arrange for you to see a specialist continence nurse. You may also find it helpful to contact the Bowel and Bladder Foundation.
If radiotherapy has been given to the lymph nodes in the pelvic area as well as to the prostate, it can cause some swelling of the legs and genitals. This is known as lymphoedema.
We more information in our lymphoedema section.
Advantages and disadvantages
External radiotherapy can help control locally advanced prostate cancer for many years and may lead to a cure for some men. Giving hormonal therapy before and during the radiotherapy may improve the results.
For a small number of men, external radiotherapy to the prostate can cause long-term bowel problems such as loose or more frequent bowel motions or bleeding from the back passage. Occasionally, a small number of men will develop urinary leakage or incontinence. Some men will develop erection problems, and radiotherapy to the prostate can cause infertility.
This type of radiotherapy is available in some hospitals in the UK. Brachytherapy is also sometimes called internal radiotherapy, implant therapy or seed implantation.
It can be carried out under a general anaesthetic or a spinal anaesthetic (epidural).
There are two ways of giving brachytherapy:
High-dose rate (HDR) brachytherapy This involves placing tiny plastic tubes (catheters) into your prostate gland. Radioactive seeds are inserted into the catheters for a set period of time, and then withdrawn. After the treatment, the catheters are easily removed and no radioactive material is left in the prostate gland. You’ll usually have this along with external beam radiotherapy and hormonal therapy.
Low-dose rate (LDR) brachytherapy or permanent seed implantation This uses small, radioactive metal ‘seeds’ that are inserted into the tumour so that radiation is released slowly. The seeds are not removed but the radiation gradually fades away over about six months. There is no risk of it affecting other people. This type of brachytherapy isn’t commonly used to treat locally advanced prostate cancer.
Brachytherapy is a simpler procedure than external beam radiotherapy, as it usually only involves one planning and one treatment session. It’s usually done under general anaesthetic and you may be able to go home the same day. Occasionally, a hospital stay of one or two days is necessary.
Before the seeds are put into the prostate, a study of the prostate gland will be done. This is called a volume study. It’s done to confirm the exact size and position of the prostate gland.
Brachytherapy may not be suitable if you have a very large prostate. However, in some situations hormonal therapy can be given to reduce the size of the prostate before brachytherapy is given.
An ultrasound probe is passed into your rectum to take pictures of the prostate. These provide a three-dimensional model, which is then used to decide the number of seeds needed for treatment, and exactly where they should be placed.
For 24 hours before the volume study you may be asked to follow a special diet to make sure your bowel is empty. You may also be given an enema to empty your bowel so that the ultrasound picture is as clear as possible.
The volume study can be done under local anaesthetic, but occasionally some men may need to go to an operating theatre and have a general anaesthetic.
The procedure is carried out under general anaesthetic and usually takes about an hour. An ultrasound probe is inserted into the rectum to show the prostate. The radioactive seeds are inserted through the skin between your prostate and anus, and guided into your prostate gland.
If you’re having HDR brachytherapy, the radioactive seeds will be inserted into fine plastic tubes (catheters). These tubes are then guided into your prostate. A computer will monitor the length of time the tubes stay in place for, and when the treatment is finished, the tubes are removed with the radioactive seeds inside.
If you are having permanent seed implantation (LDR brachytherapy), the seeds are passed into your prostate using a needle. The needle is removed and the seeds are left inside the prostate gland.
A catheter is sometimes inserted into the bladder to drain urine during the treatment session. This is because the procedure may cause some swelling of the prostate, which can lead to blockage of the urethra (the tube that drains urine from the bladder). The catheter may be removed after a couple of hours or will be left in place overnight.
You’ll be given antibiotics after the treatment to prevent infection, as well as medicine (Flomax®) to help improve the flow of urine. Most men go home on the same day as soon as they’ve recovered from the anaesthetic and are able to pass urine normally. Occasionally, some men may have to stay overnight. After treatment, it’s best to avoid heavy lifting or strenuous physical activity for 2–3 days.
All the radioactivity is absorbed within the prostate, so it’s completely safe for you to be around other people. However, if you’ve had permanent seed implantation, as a precaution, you should avoid long periods of close contact with women who are (or could be) pregnant, and children. You shouldn’t let children sit on your lap, but you can hold or cuddle them for a few minutes each day. It’s safe for them to be in the same room as you. Your specialist can give you more information about the precautions you should take.
The seeds stay permanently embedded in your prostate gland, but there is a tiny chance of a single seed being passed in the semen during sex. So it’s advisable to use a condom for the first few weeks after the implant.
During this time the semen may look black or brown. This is normal and is due to bleeding that may have occurred during the procedure. Double-wrap used condoms and dispose of them in a dustbin.
Side effects of brachytherapy
Brachytherapy causes similar side effects to external beam radiotherapy. It’s also common to feel mild soreness, and to have some bruising and discoloration between the legs for a few days after the procedure. Your doctor can prescribe painkillers to relieve this.
You may also notice some blood in your urine and semen. This is normal at first but if it becomes severe or there are large clots present, let your doctor know immediately. It’s important to drink plenty of water to help prevent blood clots and to flush the bladder.
Around 3-4% of men may not be able to pass urine immediately after the procedure and may need to have a catheter inserted for a while. Some men may develop narrowing of the urethra weeks or months after the treatment, which may cause problems with passing urine.
As with external radiotherapy, erection problems develop in 3-5 out of 10 men (30-50%), usually over a period of 2–5 years after the treatment. This may be higher if you’re having external beam radiotherapy or hormonal therapy as well. Brachytherapy may also cause infertility in some men.
Brachytherapy may be less likely to affect the bowel than external beam radiotherapy, although the risk of urinary problems (such as narrowing of the urethra) is higher. However, as mentioned earlier, men with locally advanced prostate cancer often have these two treatments together.
Around 1 in 100 men (1%) experience leakage of urine after brachytherapy. Some men find they have pain or discomfort when they pass urine, need to pass urine more often, or have a weaker urine stream. This is usually due to the radiation from the seeds in the prostate and improves over 3-12 months as the seeds lose some of their radioactivity. Drinking plenty of fluids and avoiding caffeine may help reduce these effects.
Most men will be able to return to their normal activities within 1-2 weeks after this treatment. This is likely to take longer if you have external beam radiotherapy as well.
Advantages and disadvantages
Brachytherapy combined with external beam radiotherapy can help control locally advanced prostate cancer for many years and may lead to a cure for some men. Brachytherapy usually only involves one treatment session and one planning session.
Brachytherapy is usually given in combination with external beam radiotherapy, so it may not be possible to avoid frequent visits to hospital for treatment. It may also cause problems with erection difficulties, difficulty passing urine and urine leakage. Brachytherapy can also cause infertility.