Radiotherapy

Radiation is used to treat localised prostate cancer with the intent to cure. In some cases, people may also be given radiotherapy with the intent to cure even if the cancer has spread to other parts of the prostate region (locally advanced prostate cancer).

Radiotherapy can be also given after surgery if:

  • There is a risk that your cancer might have spread after surgery – this is called adjuvant radiotherapy
  • Your PSA level started to rise – this is called ‘salvage’ radiotherapy.

There are two main types of radiotherapy – external beam radiotherapy (EBRT) and brachytherapy. The difference is whether radiotherapy is applied from outside the body (EBRT) or inserted directly into the prostate (brachytherapy). Hormone therapy or androgen deprivation therapy (ADT) is usually given before radiotherapy, called neo-adjuvant therapy, because this makes it a better treatment and improves treatment outcome. Evidence from research shows using hormone therapy* before and during radiotherapy can reduce the chance of the cancer spreading. For men with higher risk cancer, hormone therapy is also given after radiotherapy (adjuvant therapy) to improve treatment outcome and overall survival.

EBRT uses high energy x-ray beams that are directed at the prostate externally. Generally people are having this treatment in a hospital setting daily for 7 weeks. Usually the treatment does not greatly interfere with other day-to-day activities, although there are side effects. However, you may need to schedule multiple visits. EBRT may cause issues such as fatigue and skin discomfort around the area where the rays penetrated the skin, erectile problems and/or some urinary or bowel side effects. Radiotherapy may also mean you become infertile, so you may need to discuss alternatives such as sperm banking if you wish to have children in the future.

*Hormone therapy has been used as the only treatment for locally advanced prostate cancer but research has shown using it with radiotherapy improves treatment outcomes and overall survival.

 

Brachytherapy is when radioactive material is given directly into the prostate at either at a low dose rate (LDR) or high dose rate (HDR).

  • LDR: It is given by implanting permanent radioactive seeds directly into the prostate. The seeds give off a concentrated amount of radiation to the prostate with the aim of killing the cancer cells. LDR brachytherapy is used for localised prostate cancer with a curative intent. Placement requires surgery that may take a few hours but you will only need an overnight stay in a hospital.
  • HDR: It is also given by inserting radioactive material directly into the prostate but, unlike LDR seeds, the placement of the material is temporary and for shorter periods. The procedure takes place at a hospital but might require a longer stay than LDR brachytherapy. It is given in combination with EBRT for locally advanced disease, also with a curative intent.

Side effects after the brachytherapy procedure include soreness, frequent urination, difficulty or discomfort during urination, and bowel discomfort. You might be advised by the radiation oncologist to take temporary precautions after receiving seed implants because of radioactivity. Brachytherapy may not be available in your local public hospital.

Questions to ask:

The following could be useful for you to ask your healthcare team about the form of radiotherapy that is recommended to you:

  • Why are you recommending this form of radiotherapy and not surgery?
  • What are the advantages and disadvantages of this form of radiotherapy for my situation?

 

External beam radiation therapy (EBRT)

EBRT involves aiming a beam of radiation from a machine outside of the body at the prostate to kill or control the cancerous cells. This treatment extends over a period of seven weeks or more. The side effects from EBRT can be short-term, disappearing soon after treatment, or long-term, lasting for several months or permanently. The side effects include:

Bowel and urinary problems

Because the bowel and bladder are close to the prostate, the radiation can affect these organs and change your toileting routine (e.g. loose stools, needing to urinate more often). You might also have problems (e.g. blood in urine and faeces) and discomfort (e.g. painful urination) when going to the toilet.

Tips:

  • Talk with a continence nurse or physiotherapist for information on pelvic floor exercises. Use of pads could help with concerns you might have when in public. A continence nurse can offer suggestions about the best products for your needs.
  • Speak with a radiation oncologist, bowel continence nurse, or physiotherapist, who can provide you with advice to help manage the side effects.

Fatigue

EBRT can cause your energy level to drop during and shortly after your treatment.

Tips:

Talk with your healthcare team about developing a fatigue management plan to help you cope. Some things you can do include:

  • Make sure you get plenty of rest by having regular breaks during the day.
  • Do what you have to do when you have the most energy.
  • Plan ahead so you’re not rushed.
  • Prioritise activities so you only do those that are necessary.
  • Ask for help so you don’t feel you have to do everything.
  • Do some light exercise (e.g. short, easy walks) to help you feel less tired.

Skin changes

You might have temporary skin irritations between your legs and around your back passage when you receive treatment (e.g. skin becomes dry or itchy, and skin colour becomes darker).

Tips:

Your healthcare team can suggest suitable treatments to stop the irritation becoming worse. Some other ways that can help to manage skin irritations include:

  • When washing, use lukewarm water and non-perfumed soap
  • Keep skin clean and dry
  • Wear loose-fitting clothing
  • Check your skin regularly to look for any changes that could lead to infection.

Sexual difficulties

Your ability to have erections can be affected because of the damage the treatment can cause to nerves that control erections. It is also possible that ejaculation might become painful and you will notice less semen or no semen at all because of the effect the treatment has on the prostate. (Please see Section 4 for strategies)

Infertility

Radiotherapy can cause fertility problems because it damages the cells that make semen, and can affect your ability to have an erection. (Please see Section 4 for tips)

 


 

Brachytherapy

Brachytherapy is when radioactive material is given directly into the prostate at either at a low dose rate (LDR) or high dose rate (HDR).

  • LDR: given by implanting permanent radioactive seeds directly into the prostate. The seeds give off a concentrated amount of radiation to the prostate with the aim of killing the cancer cells. LDR brachytherapy is used with the aim of curing localised prostate cancer. Placement requires an operating room procedure that may take a few hours but only requires an overnight stay in hospital.
  • HDR: is given by inserting radioactive material directly into the prostate but unlike LDR seeds, the placement of the material is temporary and for shorter periods. The procedure takes place in hospital but might require a longer stay. It is usually provided in combination with EBRT with the aim of curing locally advanced disease, or localised disease with a higher Gleason score.

Similar to EBRT, the main side effects from brachytherapy include:

  • Bowel and urinary problems: Because the bowel and bladder are close to the prostate, the radiation can affect these organs and change your toileting routine (e.g. diarrhoea, needing to urinate more often). It can also cause problems (e.g. blood in urine and faeces) and discomfort (e.g. painful urination) when going to the toilet.
  • Fatigue: Your energy level will drop because of the effect the treatment has on the whole body.
  • Sexual difficulties: Your ability to have erections can be affected because of the damage the treatment can cause to nerves that control erections. It is also possible that when you ejaculate, there is less semen because of the effect the treatment has on the prostate.
  • Fertility issues: Because radiation can affect sperm production during treatment, and if parenthood is a concern for you, it is important that you speak with your healthcare team so you can find out about fertility preserving procedures.

For tips to manage these side effects, please see the EBRT section.

 

Use of hormone therapy with radiotherapy

Hormone therapy is usually offered with radiotherapy to improve treatment and overall survival. The more common side effects from hormone therapy include:

  • Loss of libido and erectile difficulties: Because testosterone is crucial in male sexual function, changing the level of testosterone means that this will reduce sexual interest, lead to loss of libido, and cause erectile difficulties.
  • Hot flushes: Changes in your hormone level can trigger sudden intense hot sensations in your upper body.
  • Tiredness (fatigue): Hormone therapy can make you feel tired because of what it is doing to your whole body. Also, the living with cancer itself can cause you to feel tired.
  • Weight gain: Changing the testosterone level can cause men to retain fluid and gain weight.
  • Loss of muscle mass and strength: Using hormone therapy can cause a decrease in muscle tissue or lean body mass, which can change the way your body looks and reduce your muscle strength.
  • Thinning of the bones (osteoporosis): Lowered testosterone could lead to a loss of calcium, needed for healthy bones.
  • Risk of heart disease: Some research has found that there is an increased risk of heart disease for men who are treated with hormone therapy.
  • Diabetes: Increased risk of developing diabetes or exacerbating existing diabetes.

Strategies to manage some of these side effects have been mentioned in earlier sections. To reduce risks of developing these side effects, it is important before you start hormone therapy that you find out if you have cardiovascular risk factors, including diabetes and hypertension. A regular exercise program should be followed to maintain muscle mass and strength as well as a healthy diet plan.