Patient Selection And Technical Description
Successful implementation of HDR brachytherapy for prostate cancer begins with appropriate patient selection. Anatomic factors lending to successful HDR treatment are as follows: prostate volume of approximately 20-60 cc a central/straight urethral position that can be adequately avoided during transperineal needle implant absence of significant benign prostatic hypertrophy/median lobe or transurethral resection of the prostate defect at the prostate base adequate spacing between the prostate and rectum and adequate pubic arch width to avoid interference with needle placement. Clinical factors include general risks of both anesthesia and elective surgical procedures . Careful attention must be paid to baseline urinary function. Brachytherapy is not a good treatment option for patients with significant baseline obstructive uropathy. Risks for significant obstructive complications of brachytherapy increase substantially in such patients, and our practice typically will exclude patients with a baseline American Urologic Association symptom score > 15 if already on medication, or > 20 if previously untreated for obstructive symptoms.3 Any of these factors are relative contraindications to performing HDR brachytherapy and the treating physician should consider them on a patient-by-patient basis, weighing risks and benefits.
When Can Hdr Brachytherapy Be Used
HDR brachytherapy is primarily used to enhance external prostate cancer radiotherapy, but it is also used as the monotherapy for prostate cancer.
HDR brachytherapy can be used as monotherapy for local low-risk prostate cancers. When it comes to medium-high-risk and high-risk cancers as well as locally advanced prostate cancers, the combination of external radiotherapy and HDR therapy appears to be particularly effective, while the recurrence of cancer in the prostate gland is considerably less likely and the probable appearance of metastases is smaller compared with mere external radiotherapy or surgery.
Even though the radiation dose level in HDR brachytherapy is very high, the external healthy tissues, such as the bladder or the rectum, will be spared from adversely high doses of radiation, as it is possible to deliver the high radiation dose directly to the prostate area only. Consequently, it is possible to minimise the adverse effects. This also explains why there is hardly any reason for active follow-up for low-risk prostate cancer.
HDR brachytherapy may also be combined with other treatments for metastatic prostate cancer.
How To Decide Between Radiation And Surgery For Localized Prostate Cancer
If youre like most men whove been diagnosed with prostate cancer, youve been told you have early-stage, localized prostate cancer, meaning the disease hasnt spread beyond the prostate. You may have also been told that you have choices about what you want to do next.
Unless your cancer is aggressive, youve probably been presented with three treatment options: active surveillance, radiation therapy or surgery. If you arent comfortable with active surveillance, or if its not an advisable option for you, you may have to decide between radiation therapy and surgery to treat your cancer.
Many men want to know whats the best treatment for their localized prostate cancer. But its a misconception that you have only one better or safer choice. In most cases, either radiation therapy or surgery is an equally good choice when we look at long-term survival.
Weve heard of some physicians telling men of their prostate cancer diagnosis and asking them to make a treatment decision at the same appointment. But prostate cancer progresses slowly, so most men have time to think about their options and shouldnt feel pressured into making an immediate decision.
How you feel about the big three possible side effects of treatmenturinary incontinence, sexual dysfunction and bowel healthmay be the deciding factor for you.
To help you through the process of making this decision, this article covers:
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How Do Doctors Perform Brachytherapy
Brachytherapy implants are inserted through a small catheter or a larger device called an applicator. The procedure is generally performed in a hospital setting where the radiation is kept inside the room.
The patient receives anesthesia of some sort and the catheter or applicator is moved into position. Once the catheter or applicator is in place, the radiation source is positioned and may be kept in place for minutes, days, or permanently. The length of the placement depends on the type of radiation source, the type of cancer being treated, the location of the cancer in the body, the patients health, and other cancer treatments that may have been used.
Techniques for placing brachytherapy include:
- Interstitial brachytherapy
- The radiation source is placed in or near the tumor, but not in a body cavity
- This technique is often used for prostate cancer
What Are The Advantages And Disadvantages
An advantage for one person might not be for someone else. If you are offered HDR brachytherapy, speak to your doctor or nurse before deciding whether to have it. They can help you think about which treatment to have. Theres a list of questions on below which you might find helpful. Give yourself time to think about whether HDR brachytherapy is right for you.
Advantages
- HDR brachytherapy delivers a high dose of radiation directly into the prostate. This means healthy tissue nearby only gets a small dose of radiation and is less likely to be damaged and cause side effects.
- You will be in hospital for just one or two days for treatment.
- Recovery is quick, which means you can usually return to your normal activities within a week.
- If your cancer comes back, you may be able to have further treatment with hormone therapy.
Disadvantages
- It can cause side effects such as urinary, bowel and erection problems.
- You will need an anaesthetic.
- At some hospitals, you may need more than one radiation treatment. You may need to stay in the same position between treatments, with the tubes still in your prostate. Some men find this uncomfortable.
- It may be some time before you will know whether the treatment has been successful.
If you are having external beam radiotherapy as well as HDR brachytherapy, think about the advantages and disadvantages of both treatments. You may have more side effects if you have HDR brachytherapy and external beam radiotherapy.
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Follow Your Healthcare Providers Instructions For Taking Aspirin
If you take aspirin or a medication that contains aspirin, you may need to change your dose or stop taking it 7 days before your procedure. Aspirin can cause bleeding.
Follow your healthcare providers instructions. Dont stop taking aspirin unless they tell you to. For more information, read the resource Common Medications Containing Aspirin, Other Nonsteroidal Anti-inflammatory Drugs , or Vitamin E.
Type : High Dose Rate Brachytherapy
HDR brachytherapy involves inserting a radioactive âseedâ into the prostate using a number of thin hollow tubes. The seed is attached to a wire which is controlled by a machine which moves the seed in and out of each tube. The seed delivers a dose of radiation directly to the prostate while minimising dose to the bladder, urethra and rectum.
How does it work?
HDR brachytherapy can be done using different types of anaesthesia. You might be given a spinal or epidural anaesthetic, where youâll stay awake during the treatment but wonât feel anything. Or, you may be given a general anaesthetic and be put into a deep sleep while the treatment takes place.
The radiation oncologist will insert thin hollow tubes multiple tubes into the prostate gland. The position of the tubes are checked using a CT scan, MRI or ultrasound scan and a radiation plan is made. The tubes are then attached to the afterloader and the treatment is delivered in a short period of time . The prostate then gets a highly targeted dose of radiation to try to kill the cancer cells.
The tubes will be removed once the treatment is finished. After the treatment, the HDR seed and tubes are removed so you are not radioactive after treatment. Your doctor may advise having more than one treatment, but they can give you more details. You will also have a catheter placed into your bladder to help drain your urine during treatment.
How long will I be in the hospital?
Follow-up care
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What Is Hdr Prostate Brachytherapy
It is a cancer treatment that allows the patient to have improvement day by day during the treatment. The radiation affects as little as possible, leading to fewer side effects than other treatments. In addition, the high risk that this treatment poses in other areas of the body has been reduced thanks to new technologies. More health and more safety for the patient during his/her treatment.
Surgery For Prostate Cancer
A radical prostatectomy is the surgical removal of the prostate. This procedure may be performed through traditional open surgery, which involves one large incision in the abdomen. Laparoscopic surgery using the robotic daVinci® Surgical System is a minimally invasive alternative. Robotic surgery only requires a few small incisions in the abdomen, which may result in reduced pain, lower risk of infection and a shorter hospital stay after surgery.
The technology associated with the robotic surgical system is designed to give the surgeon greater precision and control, which may help spare healthy tissue and one or two of the nerve bundles on the sides of the prostate. This often allows the patient to have better erectile functionin both the short term and long term.
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Hdr In Conjunction With External Beam
When first used for prostate cancer, HDR brachytherapy was predominantly implemented to boost the prostate as an adjunct to pelvic EBRT. This was considered particularly advantageous when first being used given the contemporary EBRT doses of 66-70 Gy that were considered standard at the time. Several single-institution experiences reported on the safety and efficacy of such treatment, and a prospective, randomized trial published by Hoskin et al6 demonstrated superior biochemical control in patients receiving HDR brachytherapy boost treatment relative to those patients treated with EBRT alone.
Biological analyses of responses to changes in HDR dosing/fractionation suggested a high sensitivity of prostate cancer cells to increasing fractional doses. That is, prostate cancer has a low alpha-beta ratio, and biologically equivalent dose , it was found, could be dramatically increased through relatively small increases in HDR fraction size. In fact, evidence of dose response in terms of enhanced biochemical control was demonstrated across a range of HDR fractionation regimens increasing progressively from as low as 550 cGy x 3 fractions up to 1150 cGy x 2 fractions.7 More recently, HDR boost regimens given in a single fraction of 1500 cGy 8,9 has gained favor and is the recommended dosing in the most recent open Radiation Therapy Oncology Group protocol to allow HDR brachytherapy as a boost.
What Is Brachytherapy For Prostate Cancer
Brachytherapy is a form of radiation treatment. During brachytherapy, doctors take small particles or seeds that contain a source of radiation and place them inside the body in or near a tumor.
The radioactive material only affects the tissue very close to it, so it tackles the tumor but doesnt harm the rest of the body.
According to the American College of Surgeons , healthcare professionals may recommend brachytherapy as a stand-alone treatment if you have very low- or low-risk prostate cancer or favorable intermediate-risk prostate cancer.
If you have a higher-risk case, healthcare professionals might use brachytherapy in addition to external beam radiation therapy .
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Adverse Effects Of Radiotherapy Are Milder Than Those After Prostatectomy
According to our experience, the side effects of both external and internal radiation therapy of prostate cancer are considerably milder than those of prostatectomy. The reason for this is the fact that in modern radiotherapy, high doses of radiation can be directed at the cancer area only, sparing the healthy tissues from high doses of radiation.
As it is possible to target the radiation dose to the tumor precisely, for example urinary incontinence and impotence occur less frequently than after surgery.
At Docrates Cancer Clinic, another way to minimise such side effects is to use SpaceOAR hydrogel as part of the standard treatment for all prostate cancer patients prior to radiation therapy. SpaceOAR hydrogel is injected into the space between the prostate and the rectum during prostate radiotherapy. The procedure is done to push the rectum away from the prostate. It will significantly reduce the rectal radiation dose, thanks to which the patients will not suffer from persistent diarrhea, which previously used to be a rather common side effect.
Thanks to SpaceOAR, the radiation dose to be directed at the prostate can be safely increased, thus intensifying the treatment among high-risk prostate cancer patients. SpaceOAR also enables so-called salvage radiation therapy after prior external beam radiotherapy in the event of recurrence of the disease.
Inflammation Of The Back Passage
Inflammation of the back passage is a long term side effect. Proctitis can cause a feeling of wanting to strain whether or not you actually need to pass a bowel movement. You might also have bleeding from your back passage or a slimy mucous discharge.
Bleeding is usually slight but can be more severe for some people. Talk to your radiographer or nurse if you have proctitis. They might suggest you use treatments such as steroid suppositories for a short time. This might reduce the inflammation.
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What Should I Look Out For After Treatment
Your doctor or nurse will give you a telephone number to call if you have any questions or concerns. Contact them or go to your local accident and emergency department if any of the following happen.
- If your urine is very bloody or has clots in it, this could mean you have bleeding in your prostate. This may need treatment as soon as possible.
- If you are suddenly not able to urinate, this could be acute urinary retention. This will need treatment as soon as possible.
- If you have a high temperature with or without chills, this may be a sign of infection.
Prepare Your Nulytely Bowel Preparation Solution
On the morning of the day before your procedure, add lukewarm water to the NuLYTELY, filling it to the top of the line on the bottle. Add a flavor pack, if you choose. Use only a flavor pack that was provided with your NuLYTELY.
With the cap on, shake the NuLYTELY bottle until the powder is dissolved. The mixture will be clear, even if you used a flavor pack. If you prefer, you can place the bottle in the refrigerator to chill it. Many people have told us that NuLYTELY tastes better cold. Dont mix the NuLYTELY earlier than the morning before your procedure.
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What Is A Radiation Oncologist
If a patient is undergoing radiation, the cancer treatment plan may be managed by a radiation oncologist who carefully monitors the persons overall health and well-being through the process.
With advanced cancer, a patient may also be referred to a medical oncologist. This specialized doctor uses medicines such as chemotherapy and hormone therapy to treat cancers. Its common for several medical specialists to work together on a treatment plantheyre known as a cancer care team.
Side Effects Of Ebrt For Prostate Cancer
Many of the possible side effects of radiation therapy for prostate cancer involve the bladder and bowelthe prostate is very close to both. Although the goal is to target only the prostate with radiation, sometimes small amounts may cause problems to nearby areas of the body.
Some of the potential side effects from EBRT include:
- Bowel problems, including diarrhea, leakage or rectal bleeding
- Urinary symptoms, such as a need to urinate more frequently, incontinence or a burning sensation during urination
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What Are The Side Effects
Like all treatments, HDR brachytherapy can cause side effects. These will affect each man differently, and you may not get all the possible side effects. Before you start treatment, talk to your doctor, nurse or radiographer about the side effects. Knowing what to expect can help you deal with them.
You may have more side effects if you have HDR brachytherapy and external beam radiotherapy together although this doesnt always happen. External beam radiotherapy can cause side effects months or even years after treatment.
You might also get more side effects if you had problems before treatment. For example, if you already had urinary, erection or bowel problems, you may find these are worse after HDR brachytherapy.
Tiredness and fatigue
You may feel tired for the first few days after treatment as you recover from the anaesthetic. The effect of radiation on the body may make you feel tired for longer, especially if you are on hormone therapy as well. If you are getting up a lot during the night to urinate, this can also make you feel tired in the day.
Fatigue is extreme tiredness that can affect your everyday life. It can affect your energy levels, your motivation and your emotions.Fatigue can continue after the treatment has finished and may last several months.
If you are also having external beam radiotherapy, this can also cause tiredness.
There are things you can do to help manage fatigue. Read more about fatigue and managing fatigue. Or contact our Specialist Nurses.
Compared To Ldr Brachytherapy Hdr Brachytherapy Offers Significant Advantages
There are two types of brachytherapy: LDR and HDR internal radiotherapy. Finnish operators are discontinuing LDR brachytherapy to replace it with high dose rate brachytherapy or HDR brachytherapy, which uses a highly active iridium isotope as a radiation source.
HDR brachytherapy offers significant benefits compared with the LDR brachytherapy previously used at Docrates Cancer Center, too. Unlike LDR brachytherapy , HDR brachytherapy can be used to treat prostate cancer that has spread beyond the prostatic capsule. In HDR brachytherapy, the momentary dose of radiation is computationally up to tens of thousands of times larger than the dose given in LDR brachytherapy, meaning that it kills cancer cells more effectively.
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