video of Dr.Shasha talk about what prostate cancer is and how it is diagnosed
The Department of Radiation Oncology offers state-of-the-art care with
Intensity Modulated Radiotherapy (IMRT). This sophisticated computer-based
treatment modality combines the accuracy of CT scans with the precision
of computerized treatment planning to target the prostate with pinpoint
accuracy, allowing escalation of the radiation doses while minimizing
side effects. These approaches are designed to maximize the radiation
dose to the prostate, minimize the side effects and spare normal tissues.
Radioactive seed implants are also offered. This treatment provides patients
with early-stage, localized disease a therapy which is completed in one
day without compromising safety or cure, enabling them to return to their
normal routine with minimal disruption in their schedules, lifestyles
and quality of life.
Modulated Radiation Therapy (IMRT) for Prostate Cancer
Simulation is the first and most important step to ensuring that the patient's
treatment takes place accurately and reproducibly for each of his daily
treatments. This requires one to two visits to the department before the
actual treatment begins. Information gathered, measurements taken, and
procedures performed will ensure the highest degree of precision in the
delivery of the treatments. This information is used to develp an individualized
treatment plan for each patient. This plan includes how many beams should
be used, their shape and intensity, all devised with the goal of accurately
treating the prostate while minimizing side effects.
Treatment is not begun until the simulation is completed, and all aspects
of the plan have been reviewed by the doctors, physicists, and radiation
Treatment is delivered daily, Monday through Friday, for roughly eight
weeks. The patient will undress and wear a hospital gown for each of his
treatments. Once in the treatment room, he will be positioned on his stomach
in the customized mold by the radiation technologists. Although he will
be alone in the room during the treatment, the therapists will be monitoring
him at all times through a video and intercom system. The patient will
not feel anything during the treatment, but he may hear the treatment
machine turn on and off. The time of each treatment lasts only two to
three minutes, but he will be in the room for about 15-20 minutes to allow
for accurate positioning each day.
Once per week of treatment, the patient will be seen by his radiation oncologist
and a nurse, during which time he will have the opportunity to ask any questions
and discuss any concerns. He may also see his doctor or nurse at any time
between these weekly visits by asking his radiation therapist to contact
There are no restrictions placed on activity during treatment, except to
follow a low-fiber diet during therapy. The patient should maintain his
usual daily routine as much as possible, including working and exercising.
The patient's response to treatment will be measured at regular intervals
by his radiation oncologist and urologist. At the completion of therapy,
he will return to the clinic to see the radiation oncologist after one
month. Thereafter, he will be seen approximately every three months for
the next two years by his urologist and radiation oncologist. During each
of these visits, a physical examination and blood tests (including PSA)
will be performed. These visits present a good opportunity for the patient
to ask any questions or to discuss any concerns with the physician.
Side Effects of Treatment
IMRT techniques are designed to minimize the amount of radiation that
normal surrounding structures receive, while ensuring the accurate, pinpoint
delivery of radiation to the prostate gland. As a result of the small
amounts of radiation that the normal surrounding structures (bladder and
rectum) receive, the patient will likely experience side effects. Side
effects typically do not begin until two to three weeks of treatment have
passed, and they generally resolve by four to six weeks after therapy
is completed. Rarely do these problems persist and become chronic problems.
Most often, the side effects are mild and transient.
Side effects most commonly experienced are caused by irritation of the
lining of the bladder and the rectum. The patient may describe an increased
urge to urinate, and a sense of incomplete evacuation. This may appear
as increased frequency of urination during the day or the night. Occasionally,
the patient experiences a mild burning sensation with urination. Similarly,
an increased urge to defecate and an increased frequency of defecation
may also occur. Mild rectal discomfort, hemorrhoidal irritation, or mucous
discharge may also occur. Diarrhea, occurs occasionally with with IMRT,
and nausea or vomiting never occurs. Some patients experience mild fatigue
towards the end of therapy.
For most patients, these side effects are generally mild and do not require
any intervention. However, if a patient becomes uncomfortable, his physician
can prescribe medications to minimize or relieve the symptoms.
Late side effects of radiation therapy may occur between four months and
two years after treatment is completed. These side effects, while rare,
may include persistent bladder or rectal irritation, including rectal
bleeding as described above. Sexual impotency, defined as a difficulty
or inability to obtain or maintain an erection, is another possible side
effect. A change in the consistency or volume of ejaculate may also be
noted. If impotence does occur, a number of medical and surgical treatment
options exist, and the appropriate referral to a physician who treats
these problems will be made upon request.
Seed Implants for Prostate Cancer
In order for the cancer cells to be killed, the physician will implant radioactive
seeds into the prostate. The two types of seeds used for prostate cancer
are Iodine 125 or Palladium 103. These seeds give low energy X-rays which
are designed to destroy the cancer in the prostate without affecting the
rest of the body.
Iodine 125 (also known as I-125) and Palladium (also known as Pd 103) give
up to 90% of their radioactivity within a two- to six-month period. After
one year, the radioactivity can be considered minimal. A radiation oncologist
choose the isotope that is best for each patient's condition.
The radioactive seeds are about the length of a grain of rice but thinner.
The physician places approximately 50 to 150 seeds into the prostate gland.
Because there may be microscopic amounts of cancer throughout the prostate,
the entire gland is treated.
Before, during and after the Procedure
Some preparation is required before performing a seed implant. One or
two days before the implant, the patient will be given instructions
on diet changes and use of an enema. This will help remove fecal material
from the lower bowel and rectum in order for the ultrasound picture
of the prostate to come in clearly. The patient will not be able to
eat or drink anything after midnight the night before the procedure.
After the implant is completed, he will be able to resume normal food
and beverage intake.
Approximately one week prior to the implant, the patient will have a
series of tests done, including a blood test, urine test and possibly
an electrocardiogram (EKG) and chest X-ray. The doctor will determine
which tests are necessary and they will help inform the anesthesiologist
of a patient's ability to tolerate anesthesia. The procedure is done
as outpatient surgery with the patient returning home after the procedure
Before the radiation oncologist begins the implant procedure, a map
of the patient's prostate will be made from a prostate ultrasound. This
procedure is called a volume study. Radiation physicists and dosimetrists,
aided by sophisticated computers, will use the volume study to determine
the number of seeds needed to treat the cancer, their strength, and
exactly where in the prostate the seeds should be placed.
The implant procedure does not require open surgery. Instead, a small
round ultrasound probe is placed in the patient's rectum, which provides
the physician with a picture of the gland on a screen. Needles are then
passed through the patch of skin between the rectum and scrotum and
are guided into the correct position in the prostate. The seeds are
then implanted into the prostate. After the implant is completed, the
probe and the needles are removed. The seeds remain in the prostate
The implant procedure lasts about one to two hours and is done in the
operating room. The patient will usually receive spinal anesthesia,
which will leave him numb from the waist down. Medication is also administered
through an intravenous (IV), and will leave the patient feeling drowsy.
The patient usually does not remember anything from the procedure. A
catheter may be placed temporarily in the bladder to drain urine. The
patient will then go to the recovery room for about two hours, until
he has regained feeling down in his legs. The urinary catheter ofen
will be removed after the patient has fully regained feelings in his
legs. This procedure involves very little discomfort, however pain medication
will be available if needed.
A patient's urine may contain blood. This occurrence is normal and should
subside within approximately 24 hours. If, after 24 hours, visible blood
persists or if the patient begins to pass blood clots, he should contact
The patient should avoid heavy lifting, bicycle riding, or strenuous
physical activity for the first two days. After that, he may return
to his normal activity level.
Radiation safety is a concern of many of our patients. I-125 and Pd-103
are low-energy radioactive materials and lose their activity quickly.
Low energy simply means that the radiation travels a short distance
and is mostly contained within the prostate. Some radiation is given
off to structures very close to the prostate, such as the rectum and
bladder. A very small amount is present outside the body. Objects that
the patient touches or items that he uses are not radioactive, and his
bodily wastes (urine and stools) are not radioactive.
The patient may resume sexual intercourse anytime he wishes after the
implant. The first time he ejaculates he should use a condom, just in
case a seed is discharged. After this, there are no restrictions. His
semen may be discolored dark brown to black, which is a normal result
of bleeding that may have occurred during the implant and is not being
released into the ejaculate. If he passes a seed in his urine, or in
ejaculation he should follow the directions given to him.
The patient will have a few mild urinary side effects after the implant
procedure. Though these side effects are minimal, he may experience
minor burning during urination, more frequent urination, mild pain or
the inability to pass urine freely. These symptoms are common and ordinarily
stop in one to four months.However, if the patient experiences extreme
discomfort, especially the inability to urinate,he should contact his
physician. Rectal bleeding or diarrhea are rare. Sexual impotence is
less likely to occur after seed implant compared with the other treatments
for prostate cancer.
One to two weeks after the implant, the patient will return to the radiation
oncology department for a brief exam, X-rays and a CT scan. These tests
will enable the physicians to count the exact number of seeds in the
prostate and document their exact location. This is necessary to determine
whether the prostate gland is receiving the proper amount of radiation.
Occasionally, it is necessary to give an additional amount of radiation
with either external radiation or another implant.
Follow-up with the urologist and radiation oncologist is done on a regular
basis, usually every three months. Physical examination and blood tests
will be done at certain intervals as part of follow-up visits.