Let’s talk about radiation treatment. There are many different aspects to understanding this as a treatment choice. To review surgical management, click here. Please note, that this again is a discussion for localized prostate cancer, or prostate cancer that has not spread.
How does radiation work?
Radiation therapy uses radiation (duh) or high-energy rays to preferentially kill prostate cancer cells. These effects happen over time. With radiation treatment, the prostate isn’t removed so there will see be living prostate cells that are left in place but those are cells of normal prostate tissue. This is in contrast to a prostatectomy in which the prostate is surgically removed.
Another key aspect of this treatment is that it will be done under the direction of a Radiation Oncologist. This is a physician who specializes in using radiation treatments to manage cancer. His or her focus will be determining the right dose of radiation to deliver, in this case to the prostate, while also trying to minimize the collateral damage or effects of the radiation on surrounding tissues.
Are there different kinds of radiation therapy?
For prostate cancer, there are two different ways that radiation can be delivered.
External beam radiotherapy
For external beam radiotherapy (EBRT), you will come to the radiation center 5 days a week (Monday through Friday) and a radiation dose will be given. It’s almost like getting a CT scan for those who have had that done before. You will lie down on the table and sometimes the technologist will put something on you to help keep your body still during the treatment. Once you are in position, x-rays will be taken to get the exact location of the prostate. Lastly, a machine called a linear accelerator will go around the body and actually deliver the radiation. Each treatment is called a fraction and the number of fraction will vary based on the protocol determined by the radiation oncologist. Each treatment is pretty short and usually is done in around 30 minutes.
Brachytherapy (internal radiation)
This is when the radiation is physically delivered inside the body. For this technique, you will be taken to the operating room and be put to sleep. In this instance, an ultrasound is used to guide either seeds or needles directly into the prostate and these will be the means to deliver radiation directly to the prostate. A catheter will be left in place overnight and this will be removed the next day in the office.
There are two forms of brachytherapy–low-dose rate and high-dose rate. Low-dose rate (LDR) brachytherapy is what people refer to as seeds. This is where needles are guided into the prostate and radiation seeds are left inside the prostate that will deliver radiation. High-dose rate (HDR) brachytherapy is where needles are inserted into the prostate and through these needles, radiation is delivered. This is usually done in two sessions about two weeks apart. After each session a catheter will be left in place overnight and removed the next day in the office.
Combination brachytherapy and external beam radiotherapy
For some men, they will be given the combination of both brachytherapy and EBRT. There are certain instances that according to the stage of the cancer, the radiation oncologist will recommend a combination of both treatments. This combination is usually reserved for higher risk cancers and you really should press the doc in this setting as to why both are needed because there are some instances when I have seen people get the full combination without great data to support that treatment plan.
What are the risks of radiation treatment?
As with any treatment, there are potential risks or side effects. For radiation, there are immediate side effects as well as delayed side effects. This doesn’t mean that you will get all these side effects, it just means that it is possible.
Let’s go over potential immediate Side Effects
Fatigue
This is the most common complaint my patients will give me. People will feel tired and not have the same energy that they normal have. Oftentimes patients will tell me that they have to take a nap when they don’t normally need to do that
Bowel problems
Radiation can irritate the rectum and this can lead to blood in your stool. Sometimes you may even develop fecal incontinence in which poop will leak out. Lastly people can sometimes have pain with bowel movements or urgency in which they have the feeling that they have to rush to the bathroom.
Bladder problems
Similar to the bowel problems above, patients will notice bladder changes. It is common to have urinary problems which leads increased urgency, which means that you will feel like you have to run to the bathroom and feel like you gotta go real bad. This can sometimes lead to leaking of urine as well. As the prostate swells during treatment, some men will notice that it is harder to urinate and take longer to pee. Sometimes people will noticed pain with urination.
Sexual problems
This usually happens slowly over time in that you can develop erectile dysfunction. This effect is more pronounced in older patients as well as those who already suffer ED. This is a big difference between radiation and surgery. With surgery, the sexual side effects happen much faster whereas with radiation, these potential changes happen more slowly.
Skin changes
With external beam radiation therapy there can be skin changes during treatment kinda like a sunburn. The skin may become red, warm and sensitive to the touch. After the treatment is done, this will usually get better.
Let’s go over potential delayed side effects
This is sometimes really confusing for patients when this happens. The fact that you get radiation treatment can potentially have lingering effects over the course of your lifetime and there are some side effects that can happen months to even years later. This is why your age will sometimes play a factor when we decide on treatment choice. The frequency of delayed side effects are much less common overall though.
Sexual side effects
Now to be clear, erectile dysfunction is something that is really common and effects men as they get older over time. However, with radiation, the loss of erection function happens faster and over the course of 2-3 years many men will experience difficulty with penis hardnness and penetration.
Gastrointestinal problems
You gotta think about what are the neighbors to the prostate and these include the intestines as well. Just like the bladder can get affected, the bowels can too and similar symptoms that happen in the bladder can happen in the rectum as well.
Bladder problems
Men can sometimes develop radiation cystitis or radiation changes in the bladder. This can lead to irritative urinary symptoms like going frequently to the bathroom or rushing to the bathroom. It can also lead to troublesome bleeding called hematuria. In some instances, this bleeding can be difficulty to stop.
Development of other cancers
Very very rarely people can develop a cancer due to the fact that they had radiation. This can include bladder, colon or leukemias. The likelihood of developing these cancers are low.
How do I know if the radiation worked?
For prostate cancer, we follow your blood test to determine if the treatment was successful. Over time, the PSA will drift down. We will ideally hope that the PSA settles below 0.5-1. Where the PSA ends up is different for every patient and the lowest that the PSA gets is an important number called the PSA nadir.
The PSA nadir is the key number that we will focus on when following your cancer. We will define recurrence, or something called biochemical recurrence, if the PSA goes 2 points higher than the nadir. This is when we will investigate to see if the cancer has come back.
For example, let’s say that John Doe had a PSA of 5.42 before treatment started. After he received radiation, the lowest the PSA got was 0.4, which is his PSA nadir. So when we see him back and his PSA goes up to 0.9, we don’t get worked up over this. Now, if his PSA goes up to 2.4, now the value is 2 points higher than his nadir and we call this biochemical recurrence.
Do I need any other treatments alongside the radiation therapy?
Maybe. Depending on the level of your cancer, the urologist may recommend hormone therapy, or Lupron as an example, with the radiation. The reason for this is that for certain levels of prostate cancer, the addition of hormone shots can prolong your lifespan. The length of treatment for his can vary between 6 months to a couple years. For more about hormone therapy, click here.
Wrap Up
So this post gives a broad overview on radiation therapy for prostate cancer. Please note that for many men, this can be an excellent treatment option and people can do great. The hard part with prostate cancer treatment is choosing between the various choices, but rest assured, in general all choices are appropriate and oftentimes very successful.