Overview: What is brachytherapy?

Patient Evaluation: How will I know if I’m a good candidate for brachytherapy?

Receiving Brachytherapy Treatment: What is involved in the procedure?

Combined Treatments and Therapies:

• Brachytheraphy and Hormone Therapy
• Brachytherapy and External Radiation

Follow-up Care: What can I expect following the procedure?

Side Effects: What are the risks and side effects associated with brachytherapy?

Brachytherapy Overview

Radiation is the oldest form of treatment for prostate cancer. Since Dr. Hans Holm’s pioneering efforts in 1983 in Copenhagen, Denmark, radiation treatment has changed radically. Known as brachytherapy, this ultrasound-guided implantation procedure places radioactive seeds directly  into the prostate. These tiny sources of radiation arestrategically placed inside the prostate gland allowing additional radiation delivery to the tumor itself and less to the surrounding tissues.

First performed in Minnesota by Dr. Doug Olson in 1988, brachytherapy involves placement of 70-120 tiny ‘seeds’ into the gland under ultrasound guidance. The titanium seeds are about the thickness of a pencil lead and just over 1/8 inch long.

Patient Evaluation

A number of factors are considered when evaluating patients for brachytherapy:

• The size of the prostate gland;
• The amount of tumor in the prostate gland (the stage);
• And measurements of aggressiveness (PSA level and the Gleason score).

All of these elements help to determine evidence of spread beyond the prostate capsule. These factors are very important in helping determine the type of seed required and whether a short course of external beam radiation is necessary in addition to the seed implant.

The Brachytherapy Procedure


Prostate brachytherapy, like any surgical procedure, requires a careful evaluation of the patient’s complete medical history, medications, and allergies. An examination, appropriate blood tests, and an EKG are completed in advance. Patients are given a laxative to cleanse the bowel the day before the procedure.

The seed placement procedure is performed in a specially-equipped operating room in tandem by the radiation therapist and an urologist. Working closely together, the team uses ultrasound to guide long thin metal tubes into the gland through which the seeds are placed. After placement, the tubes are removed. The patient is asleep under general anesthesia or occasionally spinal anesthesia if he is unable to tolerate general anesthesia.

On average, the seed placement takes from 45 minutes to one hour. The urologist will place a catheter in the bladder to ensure normal urine flow in the event of temporary swelling of the prostate.

Although the internal seeds emit a low energy radiation with trace amounts of radiation leaving the patient’s body, all facilities performing brachytherapy recommend patients avoid close contact with children and pregnant women for a short time following seed placement. As the radiation decreases over time, the seeds become inactive and no longer give off radiation. They can be safely left in place indefinitely.


Combined Treatments and Therapies


Brachytherapy and Hormone Therapy

In cases where the prostate is too large for immediate seed placement, brachytherapy is still possible after hormone therapy to shrink the gland. This is normally accomplished by using medications that block production and action of the male hormone testosterone.

• Injectable medications (Lupron or Zolodex) are most typically used with an occasional oral drug added (Casodex or Eulexin). 
• After three to six months of therapy, the prostate size is remeasured by ultrasound.
• While on hormone therapy the tumor typically shrinks in size along with the rest of the gland.

Brachytherapy and External Radiation

Even patients where there is concern that the tumor has extended beyond the capsule surrounding the prostate may still be eligible for brachytherapy. In these cases, brachytherapy is frequently followed by a shortened course of external radiation to treat areas not adequately treated by the seeds. This combined approach allows for many of the benefits of brachytherapy and is associated with fewer side effects than external beam therapy alone. This is because the amount and duration of external therapy is reduced compared to external therapy alone.

For patients who require combined brachytherapy and external beam radiation, there is normally a delay of about six to eight weeks after the seed implants before external radiation is begun.


Follow-up Care

• The catheter, which was placed during the procedure, is removed the following day in the urologist’s office.
• An x-ray and CT scan confirm seed location, and permit the physicist to calculate the dose and exact location of the radiation received.
• Patients continue seeing their urologist for periodic follow-up care.
  

Side effects

Side effects of brachytherapy are usually mild and brief, and may include the following:

• Slight bleeding in the urine and/or bruising in the groin and scrotal areas.
  • Cause: Needle insertion for seed placement
  • Recovery time: A few days
• Weakening of the urinary stream, leading to frequent urination
  • Cause: Prostate swelling
  • Recovery time: A few weeks

All treatments for prostate cancer carry with them some risk of erectile dysfunction. Although this risk is lower for brachytherapy than for other treatments – such as surgery – it nevertheless can occur. The risk depends to some extent on the patient’s overall health and co-existing medical conditions.