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External Beam Radiation Therapy (EBRT) External beam radiation therapy (EBRT) involves precision delivery of high energy radiation beams to the tumor while sparing normal surrounding healthy tissue. EBRT has use as both primary definitive treatment with or without brachytherapy for prostate cancer that has not spread, as well as supplemental treatment after prostatectomy when PSA levels are higher than 0.2 ng/ml or when the pathology report after prostatectomy surgery identifies positive margins, or stage 3 cancer (extracapsular spread or spread to seminal vesicles) or when Gleason score 9 or 10 is identified. The goal of all radiation therapy technologies is to safely deliver the highest possible doses of radiation to the cancer and the lowest possible doses to normal structures, thereby achieving the highest possible cancer rates and the fewest possible side affects. Receiving external beam radiation is similar to having an X-ray taken. It is a painless, bloodless procedure that rarely causes side effects during or after treatment. On rare occasions, patients may experience mild increase in urinary frequency or mild fatigue, both of which are easily controllable with life-style changes or medications, and almost always resolve within a few weeks of completing treatments. In an effort to minimize side effects, the treatments are typically given daily Monday through Friday for a number of weeks. The radiation beam comes from a machine located outside of your body that does not touch your skin or the tumor. Using sophisticated treatment planning software, your radiation oncology treatment team of physicists and planners along with Dr. Shasha customizes the configuration and intensity of radiation beams to most effectively treat your tumor while sparing the normal surrounding organs (intestines and urinary bladder). Click here to view a comparison chart of treatment options and side effects between Brachytherapy (seeds) versus Radiation versus surgery (prostatectomy). Click here to see Patient Cure Rates with Brachytherapy ("Seeds"). EBRT involves using “beamlets” of high energy photons created by sophisticated computer controlled, robotic machines called linear accelerators (“linacs”) (Figure 7). Treatments with sculpted modulating energy beams are precisely delivered with the patient is comfortably lying still while the machine circumferentially rotates around. Depending on the technology employed, either a single circumferentially delivered continuous beam of radiation or several individual beams of radiation are delivered to converge on the prostate gland and seminal vesicles in the center of the patient like spokes on a wheel (Figure 8). The daily (Monday-Friday) treatment is delivered daily by staff called “radiation therapists” at approximately the same time on an outpatient basis for 5 to 9 weeks, although newer techniques are evolving to condense treatment time to 1 to 4 weeks. Therapists are responsible for positioning you and for delivering treatment with the linear accelerators. In order to maintain quality, therapists will verify your identification prior to each treatment and there will always be at least 2 therapists present at the linear accelerator for all of your treatments. Daily treatment time typically takes 2-3 minutes, with an addition 5-10 minutes for setting up, and 5-10 minutes for getting dressed and undressed – so that total time in the department is typically 30 minutes. You will be alone in the treatment room while treatment is being delivered, but will be able to communicate via video monitors and speakers with therapists who will be watching your treatment a few feet away at the treatment console. While the machine is rotating around, you will hear a ticking noise which is the sound of the lead shields moving in the machine in order to precisely target your prostate and avoid treating healthy tissues. Figure 7: Linear accelerator rotating around the patient while precisely delivering radiation to converge centrally on the prostate gland like spokes on a wheel. Change text in Figure 8: Computer-generated Image Guided Radiation Therapy plan demonstrating “spokes on wheel” radiation delivery to conformally target the prostate while sparing rectum and bladder. Figure 8: Computer-generated Image-G. Evolution of External Beam Radiation Therapy EBRT technologies o Three-dimensional Conformal Radiation Therapy (3dCRT) o First developed in the early 1990’s 3dCRT was the by-product of the technological revolution of that time that integrated newly invented radiation therapy high-energy linear accelerators (“linacs”), computed tomography (CT) scans and computer hardware and software. Consequently, for the first time ever, precise targeting was made possible, as well as safe escalation of radiation doses which resulted in improved cancer control rates and decreased toxicity compared to earlier treatments used prior to 3dCRT. o Intensity-Modulated Radiation Therapy (IMRT) o The realization that doses higher than safely achievable with 3dCRT were often needed to cure prostate cancer stimulated the rapid technologic evolution to develop the next generation of computer planning and controlled delivery of radiation treatments that would more precisely target the prostate and safely enable delivery of even higher doses of radiation, while further reducing radiation dose to normal surrounding tissues. This was accomplished in part by modulating the intensity of radiation being delivered (rather than the constant intensity of energy beams used by 3dCRT). Thus, the name “intensity-modulated” radiation therapy. o Image-Guided Radiation Therapy (IGRT) o IGRT is the newest technology,and was developed because patients commonly move during treatment, and because the prostate always moves with normal respiration, and because anatomy frequently varies with the fullness of urinary o o o o bladder and intestines. The goal of IGRT is to eliminate uncertainty daily just before each treatment is delivered by evaluating patient conditions at the time of treatment and either altering the patient position or adapting the treatment plan with respect to anatomical changes that occur during the course of treatment. Image guided radiation therapy (IGRT) signifies radiation therapy that uses image guidance with CT or x-rays for prostate localization before and after treatment to identify and correct problems arising before and during treatment from variation in patient setup and anatomy, including shapes and volumes of the treatment target(s), organs at risk, and surrounding normal tissues. Stereotactic Body Radiation Therapy (SBRT) SBRT is an emerging technology still under investigation with encouraging preliminary results for prostate cancer that takes advantage of millimeterprecision targeting now routinely possible with IGRT. SBRT delivers much higher doses for each daily treatment than IGRT. Consequently, the total number of daily treatments is reduced, enabling total treatment time to be condensed from 8-9 weeks with IGRT down to 1-4 weeks with SBRT. Safety and efficacy of SBRT and appropriate patient selection will be determined by results of ongoing studies in the near future. Cyberknife is a brand of SBRT that is frequently used by itself for patients with early stage prostate cancer confined to the prostate or in combination with another therapy, such as external beam radiation for patients with disease that extends beyond the prostate. Long-term results with SBRT or cyberknife are needed in order to recommend this treatment, especially for younger patients or those with intermediate or high-risk cancer. Side effects (and management): With recent advances in Image Guided Radiation therapy, side effects during or after treatment are generally rare , mild, and transient. When side-effects occur, they typically begin in the third week of treatment, increase slightly during treatment, then resolve within 4 weeks of completing treatment. There should be NO nausea, vomiting, or skin changes and you will be able to continue all normal activities. In fact, for most patients, the most difficult part of therapy is making time in their schedules for daily treatments. Of course, we will do our best to accommodate your scheduling needs to minimize inconvenience. You will see your radiation oncologist weekly during treatment to answer any questions and to treat any side effects. After treatment is complete, be sure to see your urologist and your radiation oncologist within 4 weeks after your procedure for routine symptom evaluation and cancer surveillance, then every 3 to 6 months, thereafter. Slight increase in the frequency of urination, particularly at night time or weak urinary stream or hesitation with urination (take alpha-blocker medication (Flomax/tamsulosin, Uroxatrol/alfuzosin, Cardura/doxazosin, Hytrin/terazosin) or other medications as prescribed by your doctor. o Mild burning with urination (take Tylenol (acetominophen) as needed. o Slight increase in the frequency of urination, particularly at night time or weak urinary stream or hesitation with urination (take alpha-blocker medication o (Flomax/tamsulosin, Uroxatrol/alfuzosin, Cardura/doxazosin, Hytrin/terazosin) or other medications as prescribed by your doctor. o Mild constipation or loosening of stools, frequent small stools, or increased flatulence (avoid coffee and decaffeinated coffee, and take bulk laxative such as Metamucil or Citrucel. o Difficulty achieving an erection (ask your doctor if you may take a medication such as Viagra, Levitra, or Cialis, any of which are equally effective in restoring erections in approximaterly 85% of patients potent prior to implant. o o o o o o o o o Other EBRT Recommendations See your urologist and your radiation oncologist within 4 weeks after completing your treatment for routine symptom evaluation and for cancer surveillance, then every 3 to 6 months, thereafter Resume normal diet, and physical and work activities including exercise immediately as tolerated. Continue urinary medications as recommended by your doctor. Continue fiber powder (Metamucil or Citrucel) twice daily forever. Loss of pubic hair may occur in the area treated, but is usually temporary. You will not lose hair anywhere else. Intimacy: it is important that you and your partner understand that your cancer is not contagious and that intimate relations do not pose any threat to either of you or to the outcomes of your treatment. Because of medications prescribed and/or because of radiation treatments, you may notice less fluid coming out when you ejaculate; this is normal, and expected, and not dangerous. It is vital that you and your partner understand that radiation therapy and brachytherapy are NOT birth control and that conception and full-term pregnancy can occur. If you notice a decrease in the strength of your erections, you should ask your physician if you may take an erectile enhancement medication such as Viagra, Levitra, Cialis, etc., that have been reported to restore erections in nearly all patients who were potent prior to their radiation treatment(s); 10-year potency preservation with these medications is expected in 85% of men who were potent prior to radiation treatment. Always call your radiation oncologist immediately for recommendations if blood is seen in the stool. Always ask your gastroenterologist to speak with your radiation oncologist prior to doing a colonscopy.