Radiation therapy

Homme étendu prêt pour la radiothérapie de son cancer de la prostate

Overview

Radiation therapy is one of the main treatment options for men with localized prostate cancer. It is used to potentially cure the cancer or to relieve pain or other symptoms (palliative care).

Why and for whom

Radiotherapy uses high-energy rays or particles to destroy cancer cells. Radiation can be used for prostate cancer:

  • as the primary treatment to destroy cancer cells.
  • after surgery to destroy cancer cells left behind and to reduce the risk of recurrence (adjuvant radiation therapy).
  • after surgery if the cancer recurs in the area where the prostate gland was (salvage radiation therapy).
  • to relieve pain or manage symptoms of advanced prostate cancer (palliative radiation therapy).

The amount of radiation given during treatment, as well as when and how it is given, is different for each person.

Types of radiation therapy

External beam radiation therapy

Prostate cancer is usually treated with external beam radiation therapy. A machine emits radiation directed at your tumour and some of the surrounding tissue.

  • External beam radiation therapy may be offered as the primary treatment.
  • It is given after surgery (adjuvant radiation therapy) if the tumour has spread close to or into the prostate’s outer covering.
  • It may be given for stage 4 prostate cancers to relieve urinary symptoms caused by the tumour or to relieve pain caused by bone metastases.

Brachytherapy

Brachytherapy is internal radiation therapy. For this treatment, a radioactive material (radioactive isotope) is implanted directly into the tumour. The radiation destroys cancer cells over time.

Brachytherapy is administered in two ways:

  1. High dose rate brachytherapy: a source of high dose-rate radiation is inserted into the prostate gland for 20 minutes. Temporary implants are removed once the desired dose of radiation is delivered.
  2. Low dose rate brachytherapy: the radiation dosage for this treatment is very low, but permanent. Permanent implants, like radioactive seeds, are not removed. They release radiation over several weeks or months.

Brachytherapy is usually used to treat low- and intermediate-risk prostate cancer. Combined external beam radiation therapy and brachytherapy may be used for cases of high-risk prostate cancer.

Systemic radiation therapy

Systemic radiation therapy is a type of radiation therapy in which radioactive material travels through the bloodstream to reach cells all over the body.

Radium RA 223 dichloride (Xofigo) is a systemic radiation therapy drug, which may be used for castrate-resistant prostate cancer that causes pain and has spread only to the bone.

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Is it for you

Maybe

discussion avec son urologue pour une radiothérapie du cancer prostate

External beam radiation therapy is used to treat prostate cancer using high intensity radiation beams. More precisely, it is the emission of radiation from an external source directed at the tumour and some of the normal surrounding tissue.

This treatment destroys cancer cells and prevents them from dividing and growing.

The benefits of ionizing radiation are not immediate but gradual as they depend on the cumulative effect of treatment sessions. Since cellular death continues for several months after radiation therapy has been completed, it is often necessary to wait a year after the start of treatment to assess the results.

Sources of external beam radiation therapy are X-rays and gamma rays, electron, proton, and neutron particles.

Method

Since radiation therapy also reaches healthy cells, radiation oncologists generally divide the treatment into small doses administered 5 times a week.

With this type of treatment schedule, healthy cells have time to heal over the weekend since cancer cells do not regenerate as easily as healthy cells.

Each session lasts between 15–30 minutes and the full treatment program can take 6–8 weeks.

External beam radiation therapy…

  • does not hurt.
  • does not make the person radioactive.
  • cannot be seen, felt, or smelled.
  • does not require hospitalization or anesthesia.

This treatment can lead to recovery if your cancer does not spread to other parts of your body.

Radiation therapy can be used alone or in combination with other treatments, including chemotherapy, surgery, or hormone therapy.

Who can have external radiation therapy?

  • Men with a low- or medium-grade cancer who are not good candidates for surgery because of other health problems.
  • Men in whom the cancer has not been completely eliminated or in whom the cancer has reappeared after surgery.
  • Men whose cancer has spread beyond the prostate and into the surrounding tissues. The treatment is combined with hormone therapy before and after radiation therapy.
  • Men with advanced cancer; in order to get a handle on the cancer and manage symptoms.
  • Men whose cancer has spread to the bones. Used in order to reduce the size of the tumour, relieve urinary symptoms brought on by the tumour, and alleviate pain caused by metastases in the bone.

Reasons for choosing radiation therapy

For many men with localized prostate cancer, radiation provides an effective treatment without the risks and recovery time associated with surgery.

For men with a 7–10 year life expectancy, radiation therapy appears to have the same success rate as surgery. The long-term effectiveness—7–10 years after —of this treatment in comparison to surgery, however, has been the subject of much debate.

Types of external radiation therapy

Radiation therapy has become much more precise over the past few years. The standard treatment now used in most radiology departments is known as “3‑D conformal radiation therapy” or “intensity‑modulated radiation therapy (IMRT)”.

Powerful computers and tomographic scans (CT or CAT scans) generate a more exact, three-dimensional picture of the prostate. These images enable increased precision when administering radiation which maximizes the impact on cancer cells. This in turn reduces the negative effects of radiation exposure on healthy surrounding tissues which then reduces the risk of side effects.

Advantages and limitations

Advantages of radiation therapy

  • Radiation therapy may be an option if you are not fit or well enough for surgery.
  • Many men are able to continue their normal activities during treatment.
  • You avoid surgery, general anesthesia, and all associated complications.
  • Sessions last about 20 minutes; this includes the time it takes to get you in position.
  • You do not need to stay in the hospital and the treatment is painless.

Limitations of radiation therapy

  • You need to go to the radiotherapy department every day for several weeks.
  • It may be some time before you know whether the treatment has been successful.
  • Failures cannot be surgically treated, which eliminates an important treatment option.
  • Early and late side effects, appearing 2 years after treatment, affecting bowel, urinary, and erectile functions.
  • Sterility: you will no longer be able to have children after surgery.

Risks and complications

Radiation therapy damages cancer cells. Healthy cells in the treatment area can also be damaged, even if precautions are taking to protect normal tissue as much as possible. Side effects are caused by damage to healthy cells. However, external beam radiation therapy does not affect all men in the same way.

Short term

Short-term risks and complications can appear several weeks after starting radiation therapy and will slowly go away within a year of finishing treatment. You may have one of the following side effects:

  • Fatigue: lack of energy, weight loss, or changes in your appetite.
  • Gastro-intestinal or rectal problems: diarrhea, stomach cramps, painful bowel movements, rectal bleeding, anal irritation.
  • Urinary problems: burning feeling during urination, frequent urination, difficulty urinating, blood in the urine, and urinary incontinence (leakage).
  • Skin reactions: redness, itching, dry skin, and hair loss only in the area being treated with radiation. You will not lose the hair on your head or elsewhere.

Medium–long term

Some side effects, however, may continue after treatment is over because it takes time for healthy cells to recover from the effects of radiation therapy. Late side effects can occur months or years after treatment.

Side effects may vary:

  • Scar tissue in the urinary passage slows urinary flow
  • Permanent changes to the frequency of your bowel movements
  • Blood in your stool or urine
  • Significant decrease in fluid ejaculation and loss of fertility
  • Erectile dysfunction

It is important to report any side effects to your radiotherapy team. Most side effects can be alleviated with medication, dietary changes, or other measures.

What to expect

Your doctor has recommended radiation therapy to treat your prostate cancer. This section explains the treatment and precautions to take so that everything goes as smoothly as possible.

Terminology

Illustration de l’appareil de l’homme pour un cancer prostate

To familiarize you with medical language, here is a brief description of structures that make up the male reproductive system.

Bladder: The muscular sac-like organ in which urine is collected and stored in the body.

Prostate: The gland located just below the bladder that surrounds the urethra. It secretes fluids that mix with sperm cells to form semen. These secretions make the environment alkaline and promote sperm mobility.

Rectum: The terminal section of the large intestine.

Sphincter: The muscle located at the opening between the bladder and the prostate. The sphincter prevents urine from leaking out of the bladder—controlling urinary continence.

Seminal vesicles: Small pouches alongside the prostate that store the sperm cells produced by the testicles.

Urethra: The tube that carries urine from the bladder and sperm secreted by the genital glands out through the penis.

Testicles: The two glands located inside the scrotum that form sperm cells and produce testosterone (male hormone).

Modalities for external radiotherapy

préparation et simulation à une radiothérapie du cancer prostate

Pre-treatment visits

Shortly before starting your treatment, you will meet with your medical team in order to prepare you for it.

Simulation

The simulation is a planning session that happens before the first external beam radiation therapy session. It ensures that the radiation will be directed to exactly the same spot every session.

Duration of the intervention

Treatments usually take 38 weeks. It is possible that your treatment is shorter, if you are part of a research group or if you also receive a high dose rate brachytherapy (another type of radiation therapy).

Your PSA level

With radiation therapy, PSA levels will generally not fall all the way down to 0 ng/mL because it is almost impossible to destroy 100% of prostate cells. In general, the PSA level will drop to less than 1 ng/mL and remain stable.

Before treatment

implication avant chirurgie cancer prostate

Before your radiation therapy

Your Prostate

Some men who have a large prostate can receive hormone therapy for 3–6 months in order to shrink it before starting radiation therapy. This makes the cancer easier to treat.

Be active

It is important to move to stay healthy, even if you have prostate cancer. Consequently, if you’re already practicing a regular activity, you should continue doing it. If this is not the case, it’s never too late to add exercising to your daily routine; even if it’s at a lower intensity.

Even taking a short 15–30 minute walk can be beneficial.

Planning your time off with your employer

If your treatment takes place in another neighbourhood, you won’t have any choice but to tell your employer. Planning your time off and your return to work is important for both your recovery and peace of mind. If you work, you should address the subject as soon as possible.

If you have private insurance, talk to your insurance provider or your company’s human resources department to plan for your absence and minimize your stress.

Are your treatments far from home?

If necessary, contact the Quebec Cancer Foundation for accommodation. The QCF offers accommodation that is affordable, comfortable, and safe near major radiation oncology centres. Their Lodges in Montreal, Gatineau, Sherbrooke, and Trois- Rivières will welcome you along with a companion for the entire duration of your treatments.

Try to stop smoking

Even if it’s stressful, it is recommended that you stop smoking 6 weeks before your surgery in order to reduce the risks of lung, healing, and infection problems. If needed, your doctor may prescribe medication to help you.

Reduce your alcohol consumption

Alcohol can also interact with medication. This is why it is recommended to reduce its consumption and not drink in the 24 hours before surgery.

Adopt good eating habits

A healthy and balanced diet will also help you to recover quickly after the surgery and prevent a recurrence of prostate cancer. Energy, proteins, vitamins, and minerals that you get from your food can help fight against these infections and help contribute to your healing.

Basic advice for you

  • Have 3 meals a day and snacks when you need them.
  • Eat food from all four of Canada’s Food Guide (low-fat dairy products, fruits and vegetables, grain products, lean meat, skinless poultry, fish, and other alternatives) in order to ensure you get your daily intake of various nutrients.
  • Have at least one meal day that consists of lean meat, skinless poultry, or fish in order to ensure you get your daily intake of various nutrients.
  • Fruits and vegetables are an excellent and important source of vitamins and minerals.
  • Drink enough water—at least 1 500 mL a day or 6–8 glasses.

Your medication

Ask your doctor what to do before you stop taking your medication.

Avoid natural products

If needed, discuss it with your urologist first.

Arrange transportation

If you live in an urban area, close to the hospital centre where the procedure will take place, getting there will not be a problem. However, distance and repeat visits can be problematic—transportation and accommodation support becomes necessary for the success of the whole treatment. 

The hospital where your treatment takes place is responsible for helping you with your travel and accommodation needs. 

The Ministry of Health And Social Services has revised its Déplacement des usagers Policy and forwarded it to the Directors of all Health and Social Services Institutions and to the Presidents or CEOs of all Health and Social Service Agencies. 

In its introduction, the document states: Travel for a user residing in Quebec requiring transportation to an institution in the Health and Social Services network is not covered by the Régie de l’assurance maladie du Québec. Initially, all transportation to an affiliated Institution was the responsibility of the person being transported unless eligible for the free government program.

In general, it is the job of the social worker assigned by the referent Institution to aid you in finding transportation or accommodation and in providing you with the rules and details of the transportation program that are applicable to your case.

illustration ou photo d'une radiothérapie du cancer prostate

Before starting your treatment

Shortly before starting your treatment, you will meet with your medical team in order to prepare you for it.

First visit: Implanting gold or platinum pellets

In some treatment centres, 3–4 gold or platinum pellets are implanted during the radiotherapy treatment to increase the precision of the localization. The pellets allow the radiotherapist to see the prostate, which can slightly shift between sessions, more clearly and aim the beam with precision. 

During your first visit, the medical team will implant 3–4 pellets into your prostate with the help of an ultrasound machine inserted into your rectum. This procedure is very similar to that used during your biopsy.

These pellets are reference markers that will permanently stay in your prostate but will have no side effects.

  • Antibiotics will be prescribed to prevent infection. You will need to take them the night before your visit, the day of your visit, and the day after your visit.
  • In preparation, you should also perform a Fleet enema the morning of the visit.

Second visit: Simulating a radiation therapy session

The CT simulation is a planning session that happens before the first external beam radiation therapy session. The scans ensure that the radiation will be directed to exactly the same spot every session.

Treatment plan: During the second visit, the medical team will examine the inside of your body using an imaging machine known as a CT scanner. This exam, called a CT scan or a computerized axial tomography (CAT scan), precisely defines the area of your body that will be treated while steering clear, as much as possible, of parts that are not sick. This is what we call a “treatment plan”.

For this visit, you will need to do a Fleet enema the morning of the simulation and your bladder should be satiated. You will be given instructions to guide you.

Positioning: A technologist will determine exactly what position you should be in for all of your treatments. If necessary, the radiotherapy technologists may use special equipment to help keep you in the desired position. Immobilizers are specially designed to fit the shape of a person.

The prostate can shift slightly inside the pelvis depending on the volume of fecal matter or urine contained in the bladder and rectum. Your healthcare team will endeavour to reduce prostate movement by asking you to follow the same daily schedule for filling your bladder and clearing your rectum. If everything meets the standards, the plan will be approved and your treatment can start.

Skin markings: The technologist will then mark your skin with small tattooed dots that will serve as reference points throughout the treatment.

Third visit: Verification and first treatment

You will first meet with the radiation oncology technologists to discuss your treatment steps. Do not hesitate to ask them YOUR questions.

The third visit will be to check if the treatment area is consistent with the treatment plan. You will need to get into the same position that you will be in for all your treatments—you will have the required accessories to keep you in position.

Then you will receive your first treatment immediately.

During treatment

image irm sur moniteur radiothérapie du cancer de la prostate

During your radiation therapy

You will always be in the same position for each treatment.

During each session, technologists will make sure that everything is working well from a technical standpoint. They will also take pictures to locate the prostate through the platinum pellets. After checking that you’re in the right position, they leave the room. An intercom and cameras will keep you in contact with them—they can see you, hear you, and speak to you.

After your treatment, a technologist will give you the date and time of your next appointment.

During the treatment, you will have regular appointments with your radiation oncologist to monitor side effects and check on your progress.

Each session lasts for about 20 minutes.

Treatments usually take 8 weeks. It is possible that your treatment is shorter, if you are part of a research group or if you also receive brachytherapy (another type of radiation therapy). If this is the case, you will receive a document explaining the subject. You will meet with your doctor on a regular basis in order to check that your treatments are running smoothly.

Will I feel pain?

You will feel no pain during the treatment. However, you will probably develop side effects after several treatments.

Safety measures

External beam radiation therapy does not make a person radioactive. It is not dangerous to be around people, including children, right after treatment.

At home

Instructions

consigne à la maison radiothérapie cancer prostate

Take care of your skin

  • Wash the radiation-treated areas with mild unscented soap, without lanolin and of a neutral pH. If necessary, consult a pharmacist.
  • If needed, your doctor may prescribe a cream to use during treatment.
  • Do not use any product on the treated skin without first talking to your doctor.
  • Wear loose clothing to reduce irritating treated areas. Choose cotton or natural fabrics.
  • Cover the treated area to protect it from the sun.
  • Do not apply heat or cold directly to the treated area.
  • Do not wash off the marks the team draws on your skin

Avoid foods that increase intestinal activity

  • Whole-grain bread, prunes, dried fruits, cucumbers, corn, leeks, fermented cheese (brie, Oka), legumes, a lot of juice, ice cream, etc.
  • Reduce your consumption of coffee and milk. A nutritionist will answer YOUR questions.

Drink lots of water

Activities during treatment

Some people can continue to work and perform their regular recreational activities while undergoing radiation therapy. Others note that they tire easily and need to rest more. Take naps when you need them.

Physical contact and sexual activity are safe after external beam radiation therapy. It is possible that after treatment is over, some people need to take better care of their skin for a while.

Medical follow-up

The importance of follow-ups

suivi médical de l'effet de l'hormonothérapie pour un cancer prostate

Medical certificate

If you need a medical certificate, don’t forget to ask your radiation oncologist.

Results

As with radical prostatectomies, it is impossible to estimate the average success rate of radiation therapy.

  • Success will vary from person to person because of individual differences in the grade of the tumour, the degree to which the cancer has spread, and the PSA level before treatment.
  • The less severe these three factors are, the better the patient’s chances are of being in the clear.

PSA tests

Every three to six months, a digital rectal exam is performed and your prostate‑specific antigen (PSA) level is measured to monitor the patient’s status.

  • PSA levels should begin to drop in the months following the start of treatment.
  • PSA levels may continue to drop for as long as year after treatment ends. The lower they fall, the greater the chances that the cancer is fully under control.

Your PSA level

With radiation therapy, PSA levels will generally not fall all the way down to 0 ng/mL because it is almost impossible to destroy 100% of prostate cells. In general, the PSA level will drop to less than 1 ng/mL and remain stable.

Recurrence

At every appointment, a new blood sample is taken so that your doctor can monitor your PSA level.

  • If the PSA level starts to climb, the doctor will monitor how much time it takes to double. The shorter this period is, the greater the risk of recurrence and the more aggressive the recurrence will be. In some cases, chemotherapy and/or hormone therapy may be prescribed.

Remission

You will be monitored for at least five years after your radiation therapy treatment. If everything goes well, after seven to ten years without recurrence, the risk of recurrence is very low.

Side effects

effets secondaires radiothérapie cancer prostate

The most common problems associated with brachytherapy are urinary, gastro-intestinal, and erectile functional problems.

Intestinal and urinary functions

Sometimes intestinal and urinary functions do not return to normal after treatment is complete. This happens to 5–10% of men.

  • Some medications (such as cortisone that reduces rectal inflammation) and muscle relaxants can sometimes help alleviate these symptoms.
  • Make an appointment with a nutritionist or dietician for your intestinal problems.
  • Discuss your urinary problems with your doctor. Urinary problems can often be easily corrected with medication or a procedure

Blood in your urine or stool

  • The presence of blood in the urine (microscopic haematuria) is sometimes observed. If you see blood in your urine, tell your urologist.
  • You may also notice blood in your stool. Most often, this is a problem that will disappear quickly at the end of your treatment. However, you should talk to your doctor who may want a consultation with a specialist who will be able to assess the bleeding area.

Your ejaculations and loss of fertility

Radiation therapy “dries out” your prostate, so you can expect a significant decrease in ejaculate. Seminal liquid, that you will no longer produce, keeps your sperm cells healthy, which is why you usually become infertile.

If you wanted to have children, you will need to call a sperm bank. Discuss it with both your doctor and partner. This is a decision that should not be taken lightly or made alone. You should make this decision with the person you share your life with, especially if you are young and old enough to procreate.

Erectile Dysfunction (ED)

In about 20 to 50% of men, ionizing radiation can result in permanent erectile dysfunction. However, unlike other side effects, erectile disorders continue to occur several months and sometimes even up to 2 years after treatment.

  • As cellular death happens gradually, you will still be able to have an erection at first, but will slowly lose the ability with time.
  • You erectile capacity depends on your sexual function before treatment, your age, your general state of health, and the preservation of your erectile nerves during radiation therapy.

To learn more about incontinence or erectile dysfunction, take a look at our section on side effects.

ED treatments

When you start experiencing erectile dysfunction, your doctor will prescribe medication that will help you regain your erectile capacity and a satisfying sex life.

Treatments include: oral medication such as Cialis, Levitra, and Viagra; the MUSE pellet; penile injections; vacuum pumps; or surgical penile implants.

Your libido and orgasms

Your libido and ability to have orgasms remains intact. It should be stressed that your orgasm (feelings of enjoyment) is not affected since it is controlled by other nerves located far from your prostate. Your sex drive (libido) will also remain intact, unless you undergo hormone therapy.  

Suggestions and advice

pour vous et cancer prostate

Give yourself time

  • There is a lot of information to retain. Don’t try to learn it all in one day.
  • You will have questions. Write them down and bring them with you to your next appointment.
  • Your body needs time to recover during treatment.

A healthy lifestyle will help you feel better

  • Eat healthy
  • Sleep a lot
  • Do activities that you enjoy and that relax you
  • Socialize

Accept help from others, they want what is best for you

  • Practical help
  • Emotional support
  • Delegate tasks if you need to
  • Do not be embarrassed to ask for help

Spend time with others and give them your attention

  • Your friends and family also need comfort
  • Keep a good line of communication open
  • Resolve problems when they happen

Questions to my doctor

Here is a list of questions about radiation therapy for you to ask your doctor and healthcare team.

Read more…

  • What type of radiation therapy is used for this cancer?
  • How is radiation therapy given? How often? Over what period of time?
  • Does radiation therapy require a hospital stay? If so, for how long?
  • What are the chances it will be successful? When will we know?
  • What tests are done during radiation therapy?
  • What are possible side effects of radiation therapy? When would they start? How long do they usually last?
  • What side effects should I report right away? Who do I call?
  • Are there special things that I should or should not do during and after radiation therapy?
  • Will there be other treatments after radiation therapy? If so, what kind?
  • When are follow-up visits scheduled? Who is responsible for follow-up after radiation therapy?

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