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Brachy Therapy For Prostate Cancer

Treatment For A Rising Psa After Brachytherapy

Update on Brachytherapy for Prostate Cancer 2020

A PSA test measures prostate-specific antigen levels in the blood. Benign enlargement of the prostate, inflammation of the prostate, and prostate cancer can all cause a high PSA.

PSA levels sometimes rise after brachytherapy. However, your doctor wont recommend further cancer treatment based on this test alone. Theyll look for a rising trend in PSA over time and consider other factors, such as imaging tests, before recommending further treatment.

Even if your doctor cant see cancer cells with imaging, they may recommend you undergo treatment again based on a risk-benefit analysis. The benefit of catching all the cancer may outweigh the risk of additional treatment.

Possible Side Effects Of Ebrt

Some of the side effects from EBRT are the same as those from surgery, while others are different.

Bowel problems: Radiation can irritate the rectum and cause a condition called radiation proctitis. This can lead to diarrhea, sometimes with blood in the stool, and rectal leakage. Most of these problems go away over time, but in rare cases normal bowel function does not return. To help lessen bowel problems, you may be told to follow a special diet during radiation therapy to help limit bowel movement during treatment. Sometimes a balloon-like device or gel is put between the rectum and the prostate before treatment to act like a spacer to lessen the amount of radiation that reaches the rectum.

Urinary problems: Radiation can irritate the bladder and lead to a condition called radiation cystitis. You might need to urinate more often, have a burning sensation while you urinate, and/or find blood in your urine. Urinary problems usually improve over time, but in some men they never go away.

Some men develop urinary incontinence after treatment, which means they cant control their urine or have leakage or dribbling. As described in the surgery section, there are different levels and types of incontinence. Overall, this side effect occurs less often with radiation therapy than after surgery. The risk is low at first, but it goes up each year for several years after treatment.

How Effective Is Brachytherapy

A large study from Germany including 718 patients reported that HDR brachytherapy ensures a great outcome: biochemical control in prostate cancer after 8 years 90%, and metastasis-free survival 97% .1 Biochemical control means that 90% of patients were free from an increase of PSA after 8 years. Metastasis-free survival means that 97% of patients had no metastases after 8 years.

Picture 1. Biochemical control and survival in patients with prostate cancer treated with HDR brachytherapy2

Results of the UK trial comparing external beam radiation therapy alone and EBRT + high dose rate brachytherapy shows advantages in relapse free survival when brachytherapy is added to the treatment 2: 55% and 71% at 6 years and 27% and 48% at 12 years.

It means that when brachytherapy was added to the treatment, 71% of patients didnât experience cancer in the next 6 years and 48% didn’t experience cancer in the next 12 years.

Picture 2. Relapse-free survival in patients with prostate cancer treated with EBRT + HDR brachytherapy and only EBRT2

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Proton Beam Radiation Therapy

Proton beam therapy focuses beams of protons instead of x-rays on the cancer. Unlike x-rays, which release energy both before and after they hit their target, protons cause little damage to tissues they pass through and release their energy only after traveling a certain distance. This means that proton beam radiation can, in theory, deliver more radiation to the prostate while doing less damage to nearby normal tissues. Proton beam radiation can be aimed with techniques similar to 3D-CRT and IMRT.

Although in theory proton beam therapy might be more effective than using x-rays, so far studies have not shown if this is true. Right now, proton beam therapy is not widely available. The machines needed to make protons are very expensive, and they arent available in many centers in the United States. Proton beam radiation might not be covered by all insurance companies at this time.

Side Effects Of Brachytherapy For Prostate Cancer


Brachytherapy causes similar side effects to external beam radiotherapy. If you have brachytherapy on its own, some side effects may be less severe. If you have it with external beam radiotherapy, they may be more severe.

Brachytherapy causes similar side effects to external beam radiotherapy. Having brachytherapy with external beam radiotherapy may make some side effects more severe. Some side effects may take several weeks to develop and may last for longer.

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What Can I Expect After Prostate Seed Implantation Surgery

There is generally little discomfort after the implant, except for some mild soreness in the perineal area, typically lasting for one to two days.

You may experience mild rectal bleeding or spotting, for about 24 hours, in the area where the oncologist inserted the needles. There may be a small amount of blood in your urine.

These side effects are normal and should stop in one to two days.

Your doctor may instruct you to use an antibiotic cream on the surgical site for a few days following surgery.

You should avoid:

  • Heavy lifting or hard physical activity for the first two days after the implant. You can return to your normal activity level after that.
  • Exposing children and pregnant women to the radiation from the prostate seeds for several months after implantation. Your doctor will inform you of the specific precautions.

Between four and six weeks after implant surgery, you will have a follow-up appointment.

It will include x-rays and a CT scan of the pelvis to indicate the positioning of the seeds and help determine the dose of radiation the prostate is receiving.

When Should You Call For Help

  • You passed out .

or seek immediate medical care if:

  • You have a fever.
  • You have bleeding from your rectum.
  • You have new or worse pain.
  • You think you have an infection.
  • You have new symptoms, such as a cough, belly pain, vomiting, diarrhea, or a rash.
  • You can’t pass urine.
  • You have new or more blood clots in your urine.

Watch closely for changes in your health, and be sure to contact your doctor if:

  • You do not get better as expected.

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Brachytherapy Will Make You Give Off Radiation

With brachytherapy, the radiation source in your body will give off radiation for a while. If the radiation you receive is a very high dose, you may need to follow some safety measures.

  • Staying in a private hospital room to protect others from radiation coming from your body.
  • Being treated quickly by nurses and other hospital staff. They will provide all the care you need but may stand at a distance, talk with you from the doorway of your room, and wear protective clothing.

Your visitors will also need to follow safety measures, which may include

  • not being allowed to visit when the radiation is first put in
  • needing to check with the hospital staff before they go to your room
  • standing by the doorway rather than going into your hospital room
  • keeping visits short, about 30 minutes or less each day
  • not having visits from pregnant women and children younger than a year old

You may also need to follow safety measures once you leave the hospital, such as not spending much time with other people. Your doctor or nurse will talk with you about any safety measures you should follow when you go home.

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Prostate Cancer Risk Groups

HDR Brachytherapy for Prostate Cancer

Prostate cancer can be categorised into one of 5 risk groups in the Cambridge Prognostic Group .

Doctors will look at the Grade Group , prostate specific antigen level and tumour stage to decide which CPG group the prostate cancer is.

The risk group of the cancer will help determine which types of treatments will be necessary.

If prostate cancer is diagnosed at an early stage, the chances of survival are generally good.

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What Are The Pros And Cons Of Brachytherapy

Brachytherapy is highly effective at treating prostate cancer. But its main benefit is that it limits radiation exposure to the surrounding areas. The normal structures around the prostate get close to no radiation, which is really dramatic, and that’s why people tolerate these treatments so well, Horwitz said.

Good Prostate Cancer Care

Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.

You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.

You should also be told about any clinical trials you may be eligible for.

If you have side effects from treatment, you should be referred to specialist services to help stop or ease these side effects.

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Who Is Eligible For Brachytherapy

Brachytherapy is widely used to treat men with all different stages of prostate cancer. Brachytherapy alone is used for men with early-stage and some intermediate risk prostate cancers and in combination with intensity modulated radiation therapy for men with larger prostate cancers. All men should be evaluated to see if it is a good treatment option for them. However, it may not be ideal for men who already have significant urinary issues such as frequency, urgency, or incomplete emptying, since those may be exacerbated by brachytherapy treatments. For patients with larger prostate glands, it can also be harder to accurately place the radiation.

According to Horwitz, there are some instances where traditional, noninvasive radiation therapies may be preferable.

The brachytherapy implant is a small surgical procedure, but it does involve anesthesia, he said. So for people who have a cardiac history, it may not be as safe for them. In addition, people using blood thinners may want to opt for a less invasive treatment.

But if a person is relatively healthy and it’s safe for them to have anesthesia, then they can do either.

Salvage For Local Recurrence After Ebrt

Focal low

Brachytherapy with either LDR-BT or HDR-BT monotherapy are possible treatments for local recurrence after EBRT or LDR-BT.230234 Salvage brachytherapy is a promising option, particularly for patients who are not deemed fit for salvage prostatectomy. The NCCN guidelines include few recommendations regarding the approach 3 thus, referral to a specialty centre with salvage experience is recommended.

Nguyen et al.235 published a prospective phase II study of MRI-guided salvage brachytherapy for 24 men with a rising serum PSA and biopsy-proven, intraprostatic cancer at least 2 years after initial radiotherapy , who had favourable clinical features: Gleason score < 8, serum PSA < 0 ng/ml, and negative pelvic and bone imaging studies. They achieved biochemical control in 70% of patients at 4 years after the salvage procedure. The 4-year estimate of grade 3+ gastrointestinal or genitourinary toxicity was 30% and 13 patients required a colostomy and/or urostomy to repair a fistula.

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High Dose Rate Brachytherapy

How it works

This is a form of brachytherapy using a single high energy radioactive source to deliver a high dose to the prostate over a short time. It is nearly always used in addition to external beam radiotherapy as a boost, enabling a higher dose to be delivered to the prostate cancer.

Who is suitable?

This treatment may be used for men with higher risk prostate cancers.

What are the benefits and side effects?

The main advantage of HDR brachytherapy is that it delivers a higher dose directly inside the prostate than can typically be delivered with external beam radiation therapy alone. It is usually part of a package of treatment that includes external beam radiation therapy.

The side effects include temporary bladder irritation and bruising from the needles. In the long term the treatment risks are similar to external beam radiotherapy. There is a slightly higher risk of urethral scarring and bladder irritation in the long term.

What is the procedure for treatment?

This procedure requires patients to have either a spinal or general anaesthetic and spend up to 24 hours in hospital without getting out of bed.

Results of HDR brachytherapy

Results of HDR brachytherapy in terms of long-term cure/control of prostate cancer are at least as favourable as external beam radiation therapy or surgery .

Benefits And Disadvantages Of Brachytherapy For Early Prostate Cancer

If you have a low-risk cancer, you may be asked to decide between external beam radiotherapy and brachytherapy. This is because your doctor thinks they are both effective treatments for you. It is important to talk about the possible advantages and disadvantages of each treatment with your doctor or nurse. You can then decide with them which treatment is right for you.

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Radiation Therapy For Prostate Cancer

Radiation therapy uses high-energy rays or particles to kill cancer cells. Depending on the stage of the prostate cancer and other factors, radiation therapy might be used:

  • As the first treatment for cancer that is still just in the prostate gland and is low grade. Cure rates for men with these types of cancers are about the same as those for men treated with radical prostatectomy.
  • As part of the first treatment for cancers that have grown outside the prostate gland and into nearby tissues.
  • If the cancer is not removed completely or comes back in the area of the prostate after surgery.
  • If the cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.

Comparison Of Dosimetry Among Ebrt Ldr

Prostate Cancer Radiation Fiducial Marker and SpaceOAR Gel Procedure ABS Virtual Reality (360 VR)

Both LDR-BT and HDR-BT have favourable dosimetry compared with EBRT. The majority of prostate cancers develop in the peripheral zone of the gland, and brachytherapy plans can be tailored to deposit the highest dose in this zone .40 Furthermore, several caveats to dose prescriptions differentiate EBRT from brachytherapy.

Dosimetric comparison of LDR-BT versus HDR-BT

a The prostate gland is composed of a peripheral zone, central zone, transitional zone, and an anterior fibromuscular layer. The majority of prostate cancers develop in the peripheral zone. 40

b Relative dose versus position in tissue. With 3D-CRT, the maximal point dose is towards the centre of the prostate, near the urethra the dose decreases gradually toward the periphery of the prostate. IMRT ensures coverage of the entire prostate gland with dose and minimizes hotspots within the gland. Nonetheless, with IMRT, the prescription dose must be delivered to the PTV, which expands outside of the prostate. With SBRT, radiotherapy is prescribed to an isodose line to cover the PTV. Furthermore, the hotspot is again in the centre of the prostate toward the urethra although protocols include a urethra dose constraint,101, 102 the higher dose toward the centre of the gland with SBRT is sometimes unavoidable.74, 75

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What Are The Side Effects

Like all treatments, permanent seed brachytherapy can cause side effects. These will affect each man differently, and you may not get all the possible side effects.

Side effects usually start to appear about a week after treatment, when radiation from the seeds starts to have an effect. They are generally at their worst a few weeks or months after treatment, when the swelling is at its worst and the radiation dose is strongest. They are often worse in men with a large prostate, as more seeds and needles are used during their treatment. Side effects should improve over the following months as the seeds lose their radiation and the swelling goes down.

You might have worse side effects if you have permanent seed brachytherapy together with external beam radiotherapy and hormone therapy.

You might also get more side effects if you had problems before the treatment. For example, if you already had urinary, erection or bowel problems, these may get worse after permanent seed brachytherapy.

After the treatment, you might get some of the following:

  • discomfort when you urinate and a need to urinate more often, especially at night, and more urgently.

Some side effects may take several weeks to develop and may last for longer. These may include problems urinating, erection problems, bowel problems and tiredness.

Sometimes bowel, urinary and sexual problems after radiotherapy treatment are called pelvic radiation disease. The Pelvic Radiation Disease Association has more information.

What To Expect When The Catheter Is Removed

Once you finish treatment with LDR or HDR implants, the catheter will be removed. Here are some things to expect:

  • You will get medicine for pain before the catheter or applicator is removed.
  • The area where the catheter or applicator was might be tender for a few months.
  • There is no radiation in your body after the catheter or applicator is removed. It is safe for people to be near youâeven young children and pregnant women.

For a week or two, you may need to limit activities that take a lot of effort. Ask your doctor what kinds of activities are safe for you and which ones you should avoid.

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Surgically Removing The Prostate Gland

A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.

Like any operation, this surgery carries some risks, such as urinary incontinence and erectile dysfunction.

In extremely rare cases, problems arising after surgery can be fatal.

It’s possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.

Studies have shown that radiotherapy after prostate removal surgery may increase the chances of a cure, although research is still being carried out into when it should be used after surgery.

You may want to ask your doctors about storing a sperm sample before the operation so it can be used later for in vitro fertilisation .


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