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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.

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.

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.

You may have HDR brachytherapy together with a few weeks of external beam radiotherapy. This will give a higher total dose of radiotherapy to the prostate and the surrounding tissues. You will also have hormone therapy before and after the radiotherapy. Ask your treatment centre if they offer HDR brachytherapy and what their success rates are.

Other treatment options may include:

You can call our free and confidential Helpline on 0800 074 8383 for more information on these treatments.

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How does high dose rate brachytherapy treat prostate cancer?

HDR brachytherapy is suitable for treating 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 prostate.

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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

  • You may need a general anaesthetic
  • You will need to stay in bed whilst the needles are in your prostate
  • You will need to spend three to four days as an in-patient in hospital

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What does treatment involve?

You may have a shortened course (up to five weeks) of external beam radiotherapy together with HDR brachytherapy.

Before the treatment

The brachytherapy team is made up of:

  • An oncologist
    Doctor who specialises in cancer treatment
  • A urologist
    Doctor who specialises in treating diseases of the urinary system including the prostate gland
  • A physicist
    Specialist in planning radiotherapy treatments
  • A radiologist
    Specialist in ultrasound
  • One or more specialist nurses
    Assist with the treatment and are responsible for your care before and after treatment

The team 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 have an anaesthetic so that you do not feel any pain. You may be asleep during the procedure (general anaesthetic) or you may be awake but unable to feel anything (spinal or epidural anaesthetic). An ultrasound probe is then gently inserted into your back passage so that the specialist can see your prostate.

The specialist will pass thin plastic tubes 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.

You will then have a CT scan or ultrasound scan, which shows the outline of the prostate and the surrounding tissues. This is 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.

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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 in the prostate 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. Hormone therapy will lower your PSA. Once you stop hormone therapy your PSA may rise a little 1. This is because some normal prostate cells may have recovered from the treatment and may release small amounts of PSA. If the treatment has been successful your PSA level should drop to less than 2ng/ml. 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.

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 a specialist nurse by calling our free and confidential Helpline on 0800 074 8383.

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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

If you have had a general anaesthetic you should not drive a vehicle for 24 hours after treatment.

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.

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What are the side effects?

Some of the possible side effects are listed below. There is no way of knowing which side effects 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 put you in touch with other men who have had the treatment.

You may also wish to read our pages on External beam radiotherapy and Hormone therapy for details of side effects associated with these treatments.

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 Urinary problems and prostate cancer for more information on managing urinary symptoms.

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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 Sex 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.

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Questions to ask your specialist team

  • Will I have external beam radiotherapy before or after HDR brachytherapy?
  • Do I need hormone treatment before and after HDR brachytherapy?
  • What are the chances of short term and/or long term side effects with this treatment?
  • 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?

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Links

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

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 high dose rate brachytherapy (booklet number N1040).

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


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Reviewed by:

  • Dr Anna Lydon, Consultant Clinical Oncologist, Torbay Hospital
  • Dr Heather Payne, Consultant Clinical Oncologist, UCL Middlesex Hospital
  • Linda Welsh, Prostate Specialist Radiographer / Clinical Research Radiographer, Torbay Hospital
  • The Prostate Cancer Charity Support & Information Specialist Nurses
  • The Prostate Cancer Charity Information Volunteers

Written and edited by:
The Prostate Cancer Charity Information Team


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.


Page last updated: October 8th 2008