How We Treat Prostate Cancer
The prognosis for metastatic prostate cancer can be discouraging, but some treatment centerslike the Johns Hopkins Precision Medicine Center of Excellence for Prostate Cancerspecialize in innovative, individualized therapy with the potential to improve outcomes.
Why Do You Need Imrt And Igrt When Treating Prostate Cancer
To understand the benefits of IMRT and IGRT for prostate cancer treatment, we must first understand how radiation therapy works. Radiation is a highly effective treatment that kills cancer cells by damaging their genetic structure to prevent the tissue from growing. The problem, however, is that the radiation can also damage surrounding healthy tissue.
Steven G. Lester, M.D., F.A.C.R.O., board-certified radiation oncologist at Central Florida Cancer Care, describes how this affected prostate cancer treatments, In the past, before the technology improved, we had to take about a two-centimeter margin around the prostate to make sure we didnt miss it.
The problem is that its common for the prostate to shift. This happens throughout the day, in part, because your rectum is located behind the prostate. If the rectum is distended with gas or stool, it will push the prostate in one direction. If the rectum is empty, the prostate will drop in a different direction.
The prostate also moves depending upon how full your bladder is. Doctors generally tried to tread patients when their bladders were full, but there are variables related to how much fluid is in the bladder, which could cause the prostate to shift.
These variables made radiation oncologists strive for more innovative and accurate techniques to protect the surrounding tissue while fully treating the prostate cancer. They found innovation in IMRT and IGRT.
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.
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Are There Side Effects Of The Combination Approach To Prostate Cancer Radiation Therapy
When it comes to early stages of disease, patients very frequently do well with either brachytherapy or external beam radiation. Success rates of around 90% or higher can be achieved with either approach. When the disease is somewhat more advanced based on the PSA level, Gleason score, extent of visible disease on magnetic resonance imaging we have learned over the years that higher doses of radiation are critical to achieving better results. Some evidence, including a large trial, suggests that for patients with intermediate- or high-risk prostate cancer, a combined approach using brachytherapy along with external beam radiation may be best compared to standard dose external beam radiation therapy alone.
Biochemical Control And Survival Outcome
In the IG-IMRT group, 35 patients developed biochemical failure, compared with 20 in the LDR-BT group. The actuarial five-year biochemical failure-free survival rate was 88.7% and 96.7% in IG-IMRT and LDR-BT, respectively it was 88.2% for the high-risk group, 95.2% for the intermediate IG-IMRT, and 96.8% for the low-risk group. There is a significant difference in the biochemical control rate among those three risk groups . As shown in Table , the predictors of biochemical control on univariate analysis included treatment , T classification , Gleason score , and a higher baseline PSA . On multivariate Cox regression analysis, the use of LDR-BT and T classification remained significant for improving PSA control . As we found a borderline significance in the high-risk group, we also compared PSA control rate in the high-risk group excluding T3b and T4 diseases or iPSA 50ng/ml or more , which also showed superior tendency in LDR-BT than IG-IMRT groups. IPTW involving propensity scores was used to reduce background selection bias. IPTW showed a statistically significant difference between LDR-BT and IG-IMRT in total population , high risk , and high risk excluding T3-4 or initial PSA> 50ng/ml group .
Figure 1
As there is no prostate-cancer-related death in this cohort, the five-year cause-specific survival rates were 100% in all groups.
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Faq: Radiation Therapy For Prostate Cancer
Why would I choose radiation therapy?
Radiation therapy, including external beam radiation therapy and brachytherapy, is an alternative form of treatment for prostate cancer. EBRT may be used after other treatments, such as surgery, to manage cancer that has recurred or is at high risk of recurrence. Radiation therapy has an excellent record of success, providing long-term disease control and survival rates equivalent to other treatments, including surgery.
How should I expect to feel during radiation therapy?
Undergoing external beam radiation therapy is similar to having a routine X-ray. Radiation cannot be seen, smelled or felt. Generally, side effects don’t appear until the second or third week of treatment. Because radiation therapy is a local treatment, only the areas of the body where it is directed will experience side effects. Most patients will experience some or all of the following:
- Increase in the frequency of urination
- Urinary urgency
- Softer and smaller volume bowel movements
- Increased frequency of bowel movements
- Worsening of hemorrhoids or rectal irritation with occasional scant blood and fatigue
Many questions may arise during radiation therapy treatment. Your doctors will be available to answer questions throughout your treatment.
How should I expect to feel after radiation therapy?
What Should Patients Know About Msks Approach To Treating Prostate Cancer
At MSK, we manage prostate cancer in a very comprehensive way, tailored to each patients disease. There is no one specific therapy that is best for everyone.
Our initial assessment includes a carefully evaluated biopsy and a very detailed MRI to show the location of the disease, the integrity or soundness of the capsule surrounding the prostate, and the amount of disease. We will often obtain next-generation imaging and do genomic testing. Then, based on that information and with input from the urologist, the radiation oncologist, and the medical oncologist we can provide a comprehensive recommendation.
The radiotherapy we do here at MSK is state-of-the-art and unparalleled. We are one of the few centers in the world to do MRI-based treatment planning and one of the few centers in the US to offer MRI-guided treatment. When we give brachytherapy, we use computer software that provides us with real-time information about the quality and accuracy of the seed implant during the procedure. It requires a great deal of collaboration with our medical physics team to try to get the most accurate positioning of the prostate during the actual three or four minutes of the treatment.
We make adjustments while the patient is still under anesthesia, so that when the procedure is completed, we have been able to achieve ideal placement of the radiation seeds. This translates into improved outcomes.
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What Will Happen During My Daily Imrt Treatments
You and your doctors will take several preparatory steps at each treatment session. You may get medication to ensure your bowel is empty before the actual treatment. Your radiographer will help you position before starting the machine. Although post-treatment effects of radiation defer across individuals, most men can continue with their daily activities. You may need to take time off work if the treatment is making you tired.
What Is Stereotactic Body Radiation Therapy And What Advantages Does It Offer
Stereotactic body radiation therapy, or SBRT, involves the use of sophisticated image guidance that pinpoints the exact three-dimensional location of a tumor so the radiation can be more precisely delivered to cancer cells. Traditionally, external beam radiation has been delivered in anywhere from 45-48 sessions over multiple weeks. But large, randomized studies have shown that shorter courses of radiation are just as safe and effective. Therefore, at MSK, we have shortened all our radiation courses.
There is increasing interest in giving this radiation in very short courses of treatment using intense radiation doses, called hypofractionated radiation therapy. Many of the people we care for have a type of radiation therapy called MSK PreciseTM. This is a hypofractionated form of SBRT that can be given in five sessions. MSK has been doing this for the past 20 years, and the results in the several hundred people whove been treated have been excellent so far. The treatment is very well tolerated and quite effective
Because of its superior precision, MSK Precise can have fewer side effects than more conventional radiation techniques, with extremely low rates of incontinence and rectal problems. The sexual side effects are low, similar to what is experienced with more extended external radiation techniques. And of course, its much more convenient for patients.
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Are There Side Effects Of The Combination Approach
There is a slightly higher chance that patients who receive the combined therapy will have rectal irritation or urinary side effects. This is common with prostate cancer radiation therapy because the radiation can damage cells in the tissues surrounding the prostate. But at MSK, we routinely use sophisticated computer-based planning techniques that help us reduce the dose given to normal tissues such as the rectum, bladder, and urethra, lessening the chances of side effects and complications. We have also found that, when treating with the combined approach, using the high-dose-rate brachytherapy compared to low-dose-rate brachytherapy may have less in the way of side effects.
In addition, at MSK, we routinely use a rectal spacer gel, which we inject between the prostate and the rectum while the patient is under mild anesthesia, to create a buffer between these two tissues. By creating this space, we can further reduce the dose of radiation the rectum is exposed to. This leads to fewer side effects for the patient. The rectal spacer gel is biodegradable and dissolves on its own within the body after a few months.
Biochemical Control/overall Survival/distant Metastasis
Of the 324 patients treated: 35 were low risk, 201 were intermediate risk, and 87 were high risk. Patient characteristics are presented in Table 1. The average age at diagnosis was 70 years old . The 3-year PSA relapse free survival rates were 95% , 99% , and 83.4% for low, intermediate, and high risk patients respectively. PSA relapse free survival by NCCN risk group is presented in Figure 1. Median follow-up for the whole group was 31 months.
Table 1Figure 1
There were no distant metastasis developments in the low or intermediate risk groups. There were five distant metastasis observed in the high risk group. The mean time to development of metastasis was 48 months with a range of 5128 months.
Five-year overall survival for the whole cohort was 94% . Multivariate analysis showed that age , PSA , and Gleason scores were predictive of decreased biochemical control.
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Do We Know Which Treatment Is Best For Prostate Cancer Brachytherapy Or External Beam Radiation
Its not a question of which type of radiation therapy is best in general, but rather which therapy is best for the patients specific disease and quality-of-life concerns. We want to use the most tailored, pinpointed radiation to treat the prostate tumor effectively while minimizing side effects. This can depend on the tumors size and stage as well as other patient characteristics and even a patients individual preferences.
Will My Diet Affect My Treatment
Yes. Good nutrition is an important part of recovering from the side effects of radiation therapy.
When you eat well, you have the energy to do the activities you want to do, and your body is able to heal and fight infection. Most importantly, good nutrition can give you a sense of well-being.
Since eating when you don’t feel well can be hard, let your treatment team know if youâre having trouble. You could also consider working with a dietitian. They can help make sure that youâre getting enough nutrition during your radiation therapy.
These tips might help while youâre going through treatment:
Try new foods. Things that you havenât liked in the past may taste better to you during treatment.
Power up with plant-based foods. They can be healthy and tasty substitutes for meat. So for instance, swap out a burger or chicken for beans and peas at a few meals each week.
Eat a rainbow of fruit and vegetables. Get your fill of these healthy powerhouses every day. Good options include spinach, raspberries, yellow peppers, carrots, and cauliflower.
Limit or avoid unhealthy choices. That includes red or processed meats, sugary foods and drinks, and processed foods.
Aim to stay at a healthy weight during treatment. You can ask your doctor what your ideal range on the scale should be. Itâs normal to have small weight changes while you go through treatment.
Try to stay physically active. If youâre not active now, you can ask your doctor how to move more and exercise safely.
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What Is A 5
A relative survival rate compares people with the same type and stage of cancer to people in the overall population. For example, if the 5-year relative survival rate for a specific stage of prostate cancer is 90%, it means that men who have that cancer are, on average, about 90% as likely as men who dont have that cancer to live for at least 5 years after being diagnosed.
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.
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What Is Proton Beam Radiation Therapy
This type of therapy treats tumors with protons instead of X-ray radiation. It may be able to deliver more radiation specifically to a prostate cancer tumor with less damage to normal tissue.
Proton beam therapy might be a safe treatment option when a doctor decides that using X-rays could be risky for a patient. But so far, research hasnât shown that it works better than traditional radiation therapy against solid cancers in adults.
The side effects of proton beam therapy are similar to the ones that other types of radiation treatment bring on. But since proton therapy may be less damaging to normal tissue, the side effects might be milder.
After treatment, you may gradually have ones like:
- Fatigue or low energy
- Sore, reddened skin around the area where you got treated
- Hair loss around the treatment spot
One of the disadvantages of proton therapy is that it might not be covered by all insurance companies. Youâd need to check with your health plan to find out.
Proton therapy also isnât widely available. You can get it only at certain centers in the U.S.
Prostate Cancer: Radiation Therapy
Radiation therapy, also called X-ray therapy, uses high levels of radiation to kill prostate cancer cells or keep them from growing and dividing while minimizing damage to healthy cells.
Radiation can be given from a machine outside the body and directed at the prostate . Or a surgeon can place radioactive materials into the tumor . These radioactive materials can be temporary or permanent.
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Radiopharmaceuticals That Target Psma
Prostate-specific membrane antigen is a protein that is often found in large amounts on prostate cancer cells.
Lutetium Lu 177 vipivotide tetraxetan is a radiopharmaceutical that attaches to PSMA, bringing radiation directly to the prostate cancer cells.
This drug can be used to treat prostate cancer that has spread and that has already been treated with hormone therapy and chemotherapy. The cancer cells must also have the PSMA protein. Your doctor will order a PSMA PET scan before you get this drug to make sure the cancer cells have PSMA.
This drug is given as an injection or infusion into a vein , typically once every 6 weeks for up to 6 doses.
Possible side effects
Some of the more common side effects of this drug include:
- Feeling tired
- Constipation
This drug can lower blood cell counts:
- A low red blood cell count can cause tiredness, weakness, pale skin, or shortness of breath.
- A low blood platelet count can lead to bleeding or bruising more easily than normal, or bleeding that is hard to stop.
- A low white blood cell count can lead to an increased risk of infections, which might show as a fever, chills, sore throat, or mouth sores.
This drug might damage the kidneys. Your doctor or nurse will likely advise you to drink plenty of fluids and to urinate often before and after getting this drug, to help protect the kidneys. Tell your doctor or nurse if you start to pass less urine than is normal for you.