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Radiation Therapy

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.


Intensity Modulated Radiation Therapy (IMRT) for Prostate Cancer

Simulation
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 technologists.

During Treatment
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 them.

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.

Follow-up
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.

The Implant: 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 is complete.

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 permanently.

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 his urologist.

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
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.

Precautions
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.

Side Effects
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.

Follow-up
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.