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High-Dose Brachytherapy For Treating Prostate Cancer: Nursing Considerations Joan Colella Suzanne Scrofine P rostate cancer is the most common cancer, excluding skin cancers, in American men with the incidence higher in AfricanAmerican men (American Cancer Society [ACS], 2003). Survival rates are excellent when the cancer is detected in the early stages. In men, the digital rectal examination may be used to screen for prostate cancer. Often this is done in conjunction with a blood test, which measures the amount of the prostate-specific antigen (Aetna Intelihealth, 2001). If there is an abnormality in either of these exams, the patient is referred to the urologist who will perform a biopsy of the prostate tissue. Based upon the biopsy results, the tumor tissue samples will be graded on potential for aggressive growth and metastasis. The Gleason grading system (see Table 1), a method of classifying prostate cancer cells, provides a score or sum indicating the aggressiveness of the prostate tumor. The higher the score, the greater the biologic aggressiveness Joan Colella, MSN, RN, MPA, LNHA, ARNP-BC, NP-C, is an Advanced Practice Nurse, Prostate Cancer Institute of The Cancer Center, Hackensack University Medical Center, Hackensack, NJ. Suzanne Scrofine, BSN, BS, RN-BC, OCN, is a Clinical Nurse Coordinator, Radiation Oncology, The Prostate Cancer Institute of The Cancer Center, Hackensack University Medical Center, Hackensack, NJ. Radiation oncology nurses must be adequately educated on the care and management of patients and families undergoing high-dose rate brachytherapy for early-stage prostate cancer. The application of advanced assessment skills, while incorporating the treatment aspects of radiation, provides a framework for standards of nursing practice in this field. Current methodologies of radiation therapy are recommended for overall professional growth and improvement of patient care. of the tumor (American Urological Association Measurement Committee, 1999). Treatment of prostate cancer can include surveillance, “watchful waiting,” androgen hormone ablation, internal or external radiation, surgery, chemotherapy, or a combination of any of these modalities. Treatment decisions should consider the patient’s age, medical history, tumor stage, and contributing family medical history. The risk/benefit ratio of each treatment option should be considered and discussed thoroughly with the patient and his significant other(s) (see Table 2). The purpose of this article is to discuss the treatment of prostate cancer with external radiation 5040 cGy (cGy = centigray, Gy = Gray – reflecting measured amounts of radiation absorbed by the body) combined with internal radiation, specifically, high-dose rate brachytherapy (HDR), and the nursing management for this therapy. Since high-radiation doses cannot be sustained to kill the cancer without damaging other organs, a regular course of external beam radiation is administered prior to UROLOGIC NURSING / February 2004 / Volume 24 Number 1 HDR radiation. High-dose rate brachytherapy implant gives the advantage of applying a higher dose of radiation directly to the tumor while sparing healthy tissue and surrounding organs (Nucletron, 2000). Through the treatmentplanning computer, the position of the catheters is entered along with the location of the bladder and rectum. The computer calculates the radiation doses within and around the implant, and adjustments can be made to achieve the shape and doses that the physician wants to deliver to the tumor and nearby structures (California Endocurietherapy Cancer Center, 2003). High-Dose Rate Prostate Brachytherapy The term brachytherapy (short-distance therapy) refers to internal radiation and dates back to 1931. In the 1980s, improved imaging technology such as transrectal ultrasound (TRUS) and computerized tomography (CT) enhanced imaging of the prostate gland (Nag, 1997). Radiation therapy produces free radicals that severely damage the 39 Table 1. Gleason Grades: Histopathologic Grade G GX Grade cannot be assessed G1 Well differentiated (slight anaplasia) G2 Moderately differentiated (moderate anaplasia) G3-4 Poorly differentiated or undifferentiated (marked anaplasia) American Urological Association Measurement Committee (1999) Table 2. Benefits and Risks of HDR Benefits • • • • • • • Eliminates prolonged hospitalization No radiation precautions after treatment Minimal side effects to patient Less acute urethritis Dose optimization Treatment delivered within minutes No side effects associated to the treatment such as nausea or hair loss Risks • Physics intensive • Side effects such as rectal bleeding, urinary burning, frequency, urgency • Patient inconvenience (overnight hospitalization, positioning requires patient flat on back throughout hospitalization) • No long-term data on outcomes of treatment • Equipment is expensive Kelly (1998) DNA of cancer and normal cells resulting in cell death (ACS, 2000). High-dose rate therapy requires administering more than 600 cGy per hour or 10 Gy per minute to a particular site. It can be administered only by remote control due to the high-radiation exposure. High-dose rate radiation delivered over minutes is more potent than lower rates delivered over months (Kelly, 1998). Radiation most effectively attacks the reproducing cells. It is thought to work by damaging the DNA in the cells, which is responsible for the division and growth of the cells. High-dose rate radiation therapy allows a higher radiation dose to be given with greater precision in a small area than the normal tissues could otherwise tolerate (ACS, 2000). HDR is delivered by inserting multiple plastic flexible catheters interstitially through the perineal area into the prostate gland under trans-rectal ultrasound 40 guidance. The radiation oncologist places these flexible catheters strategically throughout the prostate gland to optimize radiation coverage into the prostate gland and seminal vesicles or around the pubic arch. The goal in radiation therapy is to deliver the highest possible dose to the tumor while minimizing morbidity in the normal tissue (Nag, 1997). Treatment planning (dose planning) occurs after the HDR catheters are placed in the operating room and the patient has completed a CT scan. During the CT scan, the radiation oncologist can adjust the catheters, if necessary, prior to beginning treatment. The CT scan information is entered into a computer-planning program that determines how much radiation will be given through each catheter. The catheters are divided into “dwell positions” every 0.5 cm and the computer determines the position and amount of dwell time for the radioactive seed in each catheter. An iridium-192 radioactive seed (gamma ray energy) is attached to a thin wire from the source machine, providing the radiation through transfer tubes, which are connected to the plastic catheters (Glasgow & Anderson, 1994). Dose adjustments can be made so the tumor receives the higher dose and surrounding organs receive lower doses. Iridium-192 is the radioactive source used since it delivers concentrated HDR with minimal exposure to surrounding tissue. In the combined therapy, the patient usually receives external beam radiation therapy prior to the interstitial brachytherapy (internal radiation) with HDR catheters. Indications for HDR radiation therapy are typically stage T1-2 tumors (clinically localized, low-risk disease), a prostate volume of 35 cc or greater, large TURP defect, and a pretreatment score of 8 or greater on the American Urological Association International Prostate Symptom Score Scale (I-PSS) (see Figure 1). The I-PSS is based on patient answers to seven questions concerning urinary symptoms. The higher the rating, the more severe the urinary symptoms (American Urological Association Measurement Committee, 1999). Usually patients with an I-PSS score of 8 or greater before treatment are at risk of developing urinary obstructive disease with permanent seed implants. This is due to the number of radioactive seeds required for effective radiation coverage in treating the cancer. Pre-Implant Phase Treatment planning begins with a volume study, done on an outpatient basis, about 1 to 2 weeks prior to the scheduled procedure date. The patient is given instructions for specific diet and bowel preparations for the procedure. The patient is placed in dorsal lithotomy position. It is important that the patient be positioned so that shoulders are in straight alignment with the buttocks to provide appropriate prostate imaging. Information from this proce- UROLOGIC NURSING / February 2004 / Volume 24 Number 1 Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always 0 1 2 3 4 5 Frequency Over the past month, how often have you had to urinate again less than 2 hours? After you finished urinating? 0 1 2 3 4 5 Intermittency Over the past month, how often have you found you stopped and started again? Several times when you urinated? 0 1 2 3 4 5 Urgency Over the past month, how often have you found it difficult to postpone urination? 0 1 2 3 4 5 Weak Stream Over the past month, how often have you had weak urine stream? 0 1 2 3 4 5 Straining Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4 5 1-Time Nocturia Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? 0 1 4-Times 5-Times or more Score 3-Times Date of Birth_____________ Date Completed __________ 2-Times Patient Name ______________________________________ Not at all Incomplete Emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? None Figure 1. International Prostate Symptom Score (I-PSS) (0-5 scoring) 2 3 4 5 Mostly Dissatisfied 1 2 3 4 5 Terrible Mixed 0 Unhappy Mostly Satisfied If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? Pleased Quality of Life Due to Urinary Symptoms Delighted Your Total I-PSS Score 6 American Urological Association Measurement Committee (1999) UROLOGIC NURSING / February 2004 / Volume 24 Number 1 41 Figure 2. Nucletron High-Dose Rate Radiation Equipment Table 3. Latent Side Effects of HDR Brachytherapy • • • • • • Irritative voiding symptoms Persistent urinary retention Rectal urgency Bowel frequency Rectal bleeding or ulceration Prostatorectal fistulas Source: DiBiase and Jacobs (2003) Figure 3. High-Dose Rate Catheters with Perineal Template Sutured in Place dure guides the radiation oncologist in making the final treatment decision whether to proceed with HDR catheters or permanent seed implants, depending on prostate volume. The HDR preparation and procedure, including pre-operative anesthesia requirements, are reviewed in detail with the patient and his significant other(s) at the time of the volume study Pre-admission. Testing depends upon physician preference or hospital protocol, and may include complete blood counts, bleeding times, blood chemistries, electrocardiogram, chest X-ray, and medical clearance. Intraoperative Phase Figure 4. Special Mattress for HDR Catheter Procedure General or spinal anesthesia is administered. An intravenous line is started and prophylactic antibiotics are given intraoperatively. Trans-rectal ultrasound guidance is used during the procedure for needle placement. Closed-end trochar pointed needles are inserted into the prostate according to a predetermined pattern. After all the steel needles are inserted, they are replaced with plastic hollow flexible catheters containing metal stylets. The radiation is delivered through the hollow plastic catheters (HDR catheters) after treatment planning is completed (see Figure 2). The number of catheters varies by the size (volume) of the gland; however, on average 15 to 24 catheters may be placed. Following catheter insertion, the detachable portion of the template is sutured to the perineum in order to hold the template and the catheters in position (see Figure 3). The patient is placed in a supine position on a special mattress (see Figure 4) and a flexible cystoscopy is performed to check HDR catheter positioning. Upon completion of the cystoscopy, the urologist inserts a three-way Foley catheter with continuous bladder irrigation. Possible immediate side effects after catheter implant include the possibility of perineal bleeding or discomfort, latent effects of anesthesia such as nausea/vomiting, urethral bleeding and bladder spasms due to the urinary catheter, and musculoskeletal discomfort due to required supine positioning (see Table 3). Postoperative/Treatment Phase Upon transfer to the radiation oncology department post implant, the radiation oncology nurse 42 UROLOGIC NURSING / February 2004 / Volume 24 Number 1 Table 4. Patient Education for High-Dose Rate Brachytherapy Volume Study Approximately 3 weeks before the implant procedure, your radiation oncologist will make a map of your prostate gland from a trans-rectal ultrasound (TRUS). This is called a volume study, which will determine the volume, size, and location of the prostate gland. A nursing staff member will escort you into the examination room, and you will be asked to change into a patient gown. You will be asked to lie down on the examination table, slide to the end of the table, and place your feet in stirrups or holders for your feet. Numbing jelly will be placed around and into the rectum prior to the insertion of the ultrasound probe. Images of your prostate, which look like underdeveloped pictures, will be projected onto the ultrasound screen. You may feel the probe moving and a clicking sound of the machine when the probe is adjusted to obtain different pictures of the prostate gland. The machine records and prints these pictures, which are used as part of your treatment chart. The procedure takes approximately 10 minutes. Procedure Day Before the Implant. You will take a bowel preparation drink to empty stool out of your intestines. This is called Golytely® and you will begin taking 8 ounces every 20 minutes, starting at 5 pm the evening before the procedure, until the gallon is finished. It is important that you take this so you will not experience abdominal bloating or stomach cramps during your hospital stay. You will be on a full liquid diet starting the day before your high-dose rate (HDR) procedure. No food, medication, or drink can be taken after midnight, unless you have been instructed differently by the urologist. Day of the Procedure. You will report to the admitting office and follow their directions to the Day Accommodation Area. You will be asked to undress, removing all clothes, jewelry, dentures, and removable teeth (such as bridges), hearing aides, and contact lenses. You will be dressed in a hospital gown and placed on a stretcher. Spinal anesthesia will be the anesthesia of choice and a small catheter will be placed in your back through which pain medication will be given. You will have an intravenous. A tiny machine with a push button will provide you with pain medication both automatically and as you need. This is called patient-controlled epidural analgesia or PCEA pump. This pain medication will be automatically administered or self-administered by pushing a button, as you need medication to relieve pain. You cannot overmedicate yourself since this pump is pre-set by the anesthesiologist, controlling doses and timing frequency of administration. Next, your skin will be cleaned with a special solution and your legs will be placed in stirrups or leg holders to position you for the procedure. A rectal ultrasound probe (same equipment used for your volume study) will be inserted into your rectum and an image of your prostate will be projected on a screen showing your bladder, prostate gland, seminal vesicles, urethra (urine passage tube), and rectum. This rectal probe will be attached to a stepping unit, which will hold the probe still for a good image and be moved in or out of the rectum by the physician turning a knob on this machine. The physician will place metal needles through the template, which is attached to your perineal area (skin under the scrotum). The metal needles will be removed and HDR catheters will be inserted into the prostate gland. The number of HDR catheters inserted for your radiation treatments depends on the size or volume of the gland. The template will be sutured, in each corner, to hold the plastic catheters so they cannot move. Your legs will be taken out of the stirrups and the urologist will then insert a flexible cystoscope (thin tube with a light) through the penis into the bladder to check the placement of the catheters. The cystoscope is then removed and a urinary catheter will be placed in your bladder. An irrigant (cleansing solution) will be attached to UROLOGIC NURSING / February 2004 / Volume 24 Number 1 the urinary catheter to keep the tube open and urine draining. You will then be transferred to the recovery room for a period of time until you are awake, or if you have spinal anesthesia, until you have movement in your legs. Special stockings called venodynes, will be placed over the support stockings on your lower legs to promote good circulation and prevent blood clots from developing. These stockings will be attached to a machine, which inflates and deflates on a timed basis, creating a feeling of tightness and looseness on your legs. After the recovery room, you will be brought by stretcher to the radiation oncology department and remain there for about 1.5 to 2 hours, until the treatment plan is completed. A CT scan will be done to check the HDR catheter placement and for radiation dose treatment planning. It takes about 1 hour to complete. At the time of the CT scan, you will be placed on a special blue mattress, which has a hole in the center for the HDR catheters, so there is no pressure on that area. You will remain on this mattress until the HDR catheters are removed and you should not be taken off the carrier with the blue mattress throughout your hospital stay. Once the dose planning CT scan is finished, the information is given to the physicist to plan and calculate the proper radiation dose through a special Nucletron treatment-planning computer. This produces a computerized plan for your treatments. The radiation oncologist will review, change if needed, and give the final approval of your treatment plan. You will receive one radiation treatment after the planning is completed and then return to your nursing unit. You will return in 6 hours for a second treatment, which is given on the first day. Once you return to the nursing unit, you will be given something to eat and begin receiving any medication your physician has ordered. The diet is a low-residue, low-fiber diet. You should try to drink fluids throughout your hospital stay and use the breathing machine (incentive spirometer) frequently to reexpand your lungs. You will be given a medication (Lomotil®), which will constipate you during the hospital stay. This will cause constipation that will be reversed the day after your last radiation treatment (treatment #4). You will have a total of four treatments during your overnight hospital stay (typically two on the day of the procedure and two the next day). During your radiation treatment, the catheters are attached to a special machine in the radiation room, which delivers the internal radiation (temporary seeds). The radiation unit pushes a single radioactive pellet into each catheter, one by one, for a precise amount of time and distance, determined by your treatment plan. The treatment does not cause pain and you will not feel anything. You will be asked to keep your legs in a bent position during the treatment, since the catheters are attached to tube-like wires, which deliver the radiation. The treatment time takes 15 to 20 minutes and you will need to lie still. You will be observed on a TV monitor outside the room and an intercom will be on so you can communicate with the physician, physicist, and nurse, as the need arises. After your last (4th) treatment, the HDR catheters will be removed. You will be brought into a treatment room and be given medication for pain to relax you and make you comfortable. The four sutures will be removed as well as the template and HDR catheters. You may have a small amount of bleeding from the HDR catheter site and a pressure dressing will be applied to the area. There will be no dressing to this site when you go home. After approximately 20 to 25 minutes, you will be taken off the special blue mattress. You can then turn, sit up, and move. Your urinary catheter will remain in place for at least 24 hours; therefore you will go home with a urinary catheter. In the nursing unit, instructions will be given to you related to the care of the urinary catheter before you are discharged. You will be given an appointment to return to the radiation oncology department to have the catheter removed by the nurse. 43 Table 4. (continued) Patient Education for High-Dose Rate Brachytherapy Discharge Instructions There is no radioactivity present; no radiation precautions need to be taken. • You will need to arrange transportation home, someone to drive you home. • Rest for the next 24 to 48 hours. • Apply ice to perineum as needed for discomfort. You may experience soreness, tenderness, or bruising at the site of the catheter insertion for the next 3 to 4 days. • Return for scheduled appointment 24 to 48 hours (1 to 2 days) after procedure for urinary catheter removal. • Take antibiotic prescribed until finished. • Take pain medication prescribed as needed for discomfort. Do not take blood thinners, aspirin, or ibuprofen products for 48 hours (2 days) unless your medical doctor has advised you to do so. • Return to normal activities (work and exercise) as tolerated. Heavy lifting (over 20 pounds) or strenuous activity should be avoided for 7 to 10 days following the procedure to allow healing. • Return to your normal diet. • You will be given Milk of Magnesia® to stimulate a bowel movement prior to leaving the hospital, and can repeat a dose the following day. You will be constipated initially due to anesthesia, pain medication, and antidiarrheal medication. Once urine catheter is removed: • Drink plenty of water for the next 24 hours (about 8 glasses), unless you are on a fluid restriction. • Expect to pass your urine within the next 2-hour period after the catheter is removed. If this does not happen, call the physician. • Urine may be blood tinged, brown tinged, or contain small clots due to the procedure. If you experience bright red blood or large blood clots, call the physician immediately. • Burning, pain, urgency, and frequency may occur when you urinate. This should end in a few days. • If you develop a fever or drainage (yellowish or bloody), redness, or swelling at the HDR catheter site call the physician. • Sexual activity can be resumed within 2 weeks. A condom should be used for 4 weeks. There may be old blood in the ejaculate initially. • Schedule a followup appointment with the radiation oncologist for 4 months after the procedure. • Schedule an appointment with your urologist. Reprinted with permission from The Prostate Cancer Institute of New Jersey of The Cancer Center, Hackensack University Medical Center, Hackensack, NJ. Table 4 may be photocopied for patient education purposes. assesses the patient for adequate pain control, patency of the intravenous and indwelling catheter, urine color and characteristics, operative site bleeding, and vital signs. Typically, routine postoperative orders include IV fluids, vital signs, progressive diet from clear liquids to a low-residue diet when tolerated, parenteral analgesics, antiemetics, antidiarrheals, antibiotics, and maintaining the continuous bladder irrigation with normal saline to keep the urine clear. Antidiarrheals are given to chemically constipate the patient while the catheters are in place. As an initial part of the treatment planning phase, a CT scan, with contrast of the prostate, is ordered to develop the radiation treatment plan. In addition, the radiation oncologist can better visualize the inferior border (apex) of the prostate to assure proper dose planning, thus avoiding underdosing the prostate gland (Mate, Kovacs, & Martinez, 1994). 44 The CT scan further identifies the margins of the gland in order to avoid excessive doses to the urethra and rectum. The HDR catheters and template grid are marked to assist with visual verification of catheter positioning during subsequent treatments. The metal stylets within the plastic catheters are removed once the CT scan positioning is completed. The lumens to the HDR perineal catheters must be dry for the highdose rate machine (Nucletron, 2000) to provide the treatment. If they become wet, the machine will default and not deliver radiation through the catheter lumens. The entire HDR treatment would need to be aborted if this occurs and the patient returned for re-implant of the HDR catheters. Upon completion and approval of the treatment plan, the patient is brought to the treatment room for the first of four treatments. Radiation treatment time takes approximately 20 to 25 minutes, depending on the number of catheters. The HDR catheters are connected to the remote after-loading machine, which is the radioactive source unit. The temporary radioactive seed placed into each catheter is iridium-192. By incorporating computer technology that controls both the position and time of the iridium-192 source, the target volume and dose distribution to each catheter can be tailored to the patient’s individual plan (Mate et al., 1994). While the treatment is in progress, monitoring by the nurse continues from outside the treatment room via cameras and an intercom system. When the treatment is completed, the physicist surveys the patient and room for potential levels of radioactivity by using a dosimeter. The physician disconnects the after-loading cables from the HDR catheters. Radioactivity is present only at the point of treatment, therefore the patient is not radioactive. Patients are typically treated twice on the first day and twice on continued on page 52 UROLOGIC NURSING / February 2004 / Volume 24 Number 1 High-Dose Brachytherapy continued from page 44 the second day of hospitalization. On each day, four treatments of 500 cGy for a total of 2,000 cGy are given 6 hours apart on each day for maximum effectiveness and tolerability. All catheters are removed simultaneously with the perineal template, and sterile abdominal pads are immediately applied to the perineum with manual pressure for hemostasis. Vital signs are immediately obtained and the bladder irrigation is titrated until the urine color is clear. A pressure dressing is maintained to the perineum for approximately 30 minutes. The urinary catheter remains in place post procedure for an additional 24 hours to prevent urinary obstruction resulting from inflammation of the urethra due to intra-operative manipulation of the prostate gland (Mate et al., 1994). The patient is discharged without a dressing to the perineum. Conclusion High-dose rate brachytherapy for early-stage prostate cancer is considered one of the most 52 advanced treatment technologies currently available. It was introduced at Kiel University in Germany in March 1986 (Nag, 1994). High-dose rate radiation treatment for prostate cancer is limited due to physician training required to perform the procedure. The advantage of this therapy is the ability to deliver high-dose radiation to a small area with no remaining radioactivity once the temporary radioactive source is removed. The disadvantage is that only a small volume of tissue can be treated. Longitudinal studies on quality of life related to urinary, bowel, and sexuality issues must be continued to evaluate the longterm effects of this treatment and its impact on the patient’s life. Comprehensive nursing management for patients before, during, and after the procedure is necessary to achieve high-quality outcomes and patient satisfaction (see Table 4). • References Aetna InteliHealth. (2001, May 05). Digital rectal exam. Retrieved April 24, 2002, from http://www.intelihealth.com American Cancer Society. (2003). Cancer facts and figures. Retrieved December 30, 2003, from http://www.cancer.org American Cancer Society, Inc., Cancer Resource Center. (2000). Radiation therapy principles. Retrieved April 16, 2002, from http://www3.cancer.org/ cancerinfo American Urological Association Measurement Committee. (1999). International prostate symptom score. Recommendations of the International Scientific Committee. Proceedings of the 4th International Consultation on BPH (pp. 3-6). Paris: Author. California Endocurietherapy Cancer Center. (2003). What is high dose rate (HDR) brachytherapy? Retrieved February 6, 2003, from http://www.cetmc.com DiBiase, S.J., & Jacobs, S.C. (2003). Brachytherapy for prostate cancer. In J.H. Mydlo & C.J. Godec (Eds.), Prostate cancer: Science and clinical practice (p. 406). New York: Academic Press. Glasgow, G.P., & Anderson, L.L. (1994). High dose rate remote afterloading equipment. In S. Nagy (Ed.), Principles and practice of brachytherapy. (pp. 41-54). New York: Futura Publishing Company. Kelly, D. (1998, January 22). Dr. Kelly’s response and explanation of HDR. Retrieved September 14, 2001, from http://www.brachytherapy.com/ Mate, T.P., Kovacs. G., & Martinez, A. (1994). High dose brachytherapy of the prostate. In S. Nag (Ed.), Principles and practice of brachytherapy (pp. 335-372). New York: Futura Publishing Company. Nag, S. (1997). Principles and practice of brachytherapy. New York: Futura Publishing Company. Nucletron. (2000). Questions and answers about high dose rate brachytherapy. Columbia, MD: Delft Instruments. UROLOGIC NURSING / February 2004 / Volume 24 Number 1