Download Patients Guide to Brachytherapy

Patient’s Guide to
Prostate Brachytherapy
Gauteng Oncology
Brachytherapy Unit
www.gautengoncology.co.za
Introduction to Brachytherapy
Brachytherapy entails the insertion of radioactive seeds into
the prostate gland. The specific manner of placement
creates a radiation “cloud” or dose around and within the
prostate gland in order to irradiate cancerous cells. This
has now become the treatment of choice for prostate
cancer throughout the world as the cure rates remain
extremely high for every stage of prostate cancer.
The procedure is done by a multi-disciplinary team, namely
an Urologist, Radiation Oncologist, Anesthetist and Medical
Physicist. The particular procedure done at our
Brachytherapy units is known as intra-operative, real-time
interactive, brachytherapy. This involves the creation and
execution of an individualized radiation plan in real time, in
the theatre. Doses are adjusted as the implant takes place
to ensure maximal efficacy while controlling the dose to
sensitive structures, being the urethra and rectum. As a
result of this new technology, the side effects of the
treatment can be kept to a minimum.
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There are certain examinations and procedures that need to
be considered prior to the procedure and it is vital that you
are seen by both your Urologist and Dr van Niekerk. These
may sometimes include the following:
1.
CAT scan
2.
Bone scan
3.
Blood test
A transrectal ultrasound-based volumetric study (TRUS) will
be done by the Urologist prior to being seen by Dr van
Niekerk.
All motivations and authorizations to medical aids, bed
bookings and theatre times will be arranged by our practice.
Please ensure that you get the authorization for the
urologist’s codes. These can be obtained from his rooms.
Telephonic contact will be maintained with you until the day
of the procedure. If you are concerned about anything,
please contact one of our brachytherapy co-coordinators:
Emma Batten: 0824693943 email: [email protected]
Mary-Ann at Bedford Gardens Clinic:
Tel: (011) 6222247
email: [email protected]
Carna at Linmed Hospital:
Tel: (011) 7486344
email: [email protected]
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Pre-implantation
Report to your doctor any significant changes in your health
or medication status prior to the procedure. It is very helpful
to furnish your doctor with an updated medication and drug
allergy list. Allergies to antibiotics or to anti-inflammatory
drugs are very important to report because you will receive
these types of medication as part of your treatment. If you
are taking anticoagulation (blood-thinning) medication, this
will need to be stopped or altered during the week prior to
the operation.
These include the following:
Plavix, Disprin, Wafarin.
Please inform our brachytherapy coordinators or Dr van
Niekerk.
You are required to have a bowel preparation the day prior
to the procedure.
a) On the day prior to the procedure change to a fluid diet.
b) At midday on the day before the operation a laxative
must be taken; the course will be discussed with you.
c) From midnight do not take any further liquids but please
remember to take any of your prescribed morning
medications with a little water. This excludes blood
thinning agents.
d) Please report to the admitting ward at 06h00, or the time
arranged by our brachytherapy coordinator.
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The day of implantation
Be certain of the time and date that you will be admitted to
hospital. Report to the hospital reception.
The anesthetist will see you prior to the procedure. A preoperative sedative will be administered. When you go to
theatre you may not remember the details. This is because
of the sedative.
The seed implantation takes about one hour.
When you return from the theatre there will be a catheter in
your bladder. This will be removed after the CAT scan has
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been done. This is acts as a post-operative confirmation of
the position of the seeds.
You will be seen by your Urologist or Dr van Niekerk prior to
being discharged.
You will be given a packet of medication on discharge. It is
essential that you take this medication even though you feel
well. The medication will include:
1.
An ointment to rub into the operative site twice
a day.
2.
Some cortisone for inflammation. You will
take this once a day for two days to prevent
further swelling of the prostate.
3.
A drug to relieve difficulty with urination,
namely one of the following: Uromax, Flomax,
Tamsul, Xatral or Hytrin, for three months.
4.
An excellent natural medication, Oncopaladin
Flowrite, can also be used if you experience
any irritative symptoms. It is available through
our practice.
5.
An antibiotic, for 1 week, to prevent urinary
infections.
6.
A mild analgesic for pain. This tablet is
optional as most patients do not experience
pain.
Please arrange for someone else to drive you home after
the procedure.
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Post Operative Side Effects
After the procedure it is possible to experience any one of a
number of symptoms. This is a guide to these symptoms
and what action you should take.
Red urine: Also called haematuria. A pinkish colour or
blood in your urine is common for a few days after the
procedure. Increase your intake of fluids to flush any blood
from your urine. Juices and water are the best fluids to
drink.
Red or brown semen: Also called haemospermia. This is
very common during the first few times of sexual
intercourse. It will gradually resolve without treatment.
Blood in the semen may be seen for up to 3 months after
the treatment.
Frequency: Passing urine often and burning commonly
occur days after your procedure. Frequent urination can
occur for several weeks to a few months.
Urinary symptoms: Due to swelling from the insertion of
needles into your prostate, and the effect of the radiation on
your prostate, you should expect some urinary symptoms.
Urinary symptoms may include: burning, frequency,
urgency, mild pain, a decreased urinary stream, a feeling of
being unable to pass urine freely. These symptoms vary in
severity among patients, and may last several days to a
week or two. In a small percentage of patients, urinary
symptoms may last a month or more.
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Blockage (urine retention): Rarely, a patient will be unable
to pass urine due to swelling of the prostate gland,
obstructing the urethra. If you cannot urinate, go to the
nearest casualty to have a small soft, catheter inserted to
drain the urine. Please inform the urologist of this problem
as soon as possible.
Bruising: Some bruising, discolouration and swelling of the
penis or scrotum may occur. It is also common to have
bruising in the perineal area where the needles were
inserted. This can cause a feeling of fullness when you sit,
like sitting on a golf ball. It can last for about four weeks
and gradually resolves without treatment. Applying an ice
pack to the perineum can help reduce the discomfort.
Pain: Mild to moderate pain where the needles were
inserted can occur. Mypradol given to you on discharge will
ease this pain. An ice bag can be used for the first two
days, twenty minutes on and twenty minutes off, for perineal
discomfort. A warm bath may also help relieve perineal
discomfort.
Infection: At the time of your discharge you will be give an
antibiotic to prevent a urinary infection. Please take all
these pills as prescribed. If you start to feel feverish, and/or
develop unusually irritable voiding symptoms, then please
contact your urologist.
Activity: You may resume normal activity in two to three
days after the procedure. Please avoid heavy lifting
(anything more than 5-6 kg) for the first 2 weeks, or
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exercise such as cycling that will cause further trauma to
the perineum, for six weeks.
Numbness and pain: Penile numbness and pain can occur
and can last for two months. This results from bruising the
sensory nerves of the penis. It will resolve spontaneously
and requires no therapy.
Bowel movements: Due to your bowel prep, you may not
have a normal bowel movement for several days. Avoid
constipation and straining to move your bowels. You may
take a mild oral laxative if needed. If you experience severe
or prolonged rectal symptoms, call your Urologist or Dr van
Niekerk.
You can also experience some diarrhea or mucoid stools.
Medication such as Imodium, available over the counter
from your pharmacist, can treat this problem. A low
roughage diet is also found to be helpful.
Proctitis: This is extremely uncommon. It usually occurs
between four to six months after the procedure. Symptoms
include bowel frequency, painless rectal bleeding and rectal
irritation. Cortisone suppositories are used to treat this
condition. Early symptoms may occur at four to six weeks.
A Guide to Radiation Safety
Radiation safety is a concern of many patients. Radioactive
iodine (I-125) is a low energy radioactive material that will
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lose its radiation quickly. The low energy of the seeds
means that the radioactivity cannot travel far and is thus
mostly contained within the prostate gland. A small amount
of radiation will be given off to the rectum and bladder. A
very small amount of radiation will escape from your body.
Therefore you should observe precautions to ensure that
surrounding people are protected from radiation. Objects
that you touch will not become radioactive.
Very
occasionally a seed can migrate from the prostate into the
bladder. You will pass this seed out when you urinate. The
lost seed will not affect anybody or the result of the
treatment. Please do not try to recover the seed voided into
the toilet bowl. Flush it away.
General Precautions:
1.
2.
3.
Any pregnant or possibly pregnant women should
avoid prolonged personal contact with you for at
least three months after the operation. She
should not hug or sit next to you. She can greet
you briefly and then move to a distance of 1.5 m
away. There is no limit to the length of time she
can then spend in your company.
Children should not sit on your lap for at least
three months after the operation. They can sit
next to you however again with no time limit. You
can still, however, hug and kiss your children or
grandchildren!
Sexual intercourse can be resumed two weeks
after the procedure. Blood will probably be
evident in the semen and there might be slight
pain during orgasm for the first few sessions. A
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4.
5.
6.
7.
condom must be used for the first two weeks of
activity to prevent ejaculating migrating seeds into
your partner. Sexual intercourse is not harmful to
your partner but the blood stained semen may be
unacceptable to that person. If your sexual urges
are high then in that situation it is advisable to
masturbate.
Although brachytherapy may cause sterility, this
is NOT a certainty, and family planning should be
continued until cleared by your urologist
There is no risk for the general public at any time.
To prevent any possible movement of seeds,
insert nothing into the rectum for six months post
implant.
No rectal examinations should be
performed. Oral laxatives should be used for
constipation during this time - no suppositories
unless prescribed by your urologist or Dr. van
Niekerk.
NO colonoscopy is to be performed for six
months post implant. NO rectal biopsy is to be
done unless it is cleared by Dr. van Niekerk.
Follow-Up Studies
One week after the procedure you will return to see your
Urologist for a short visit to confirm that you are fully happy
with your procedure and to note any possible side-effects.
If there are any problems they will be attended to at this
stage.
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At three months you will return for your second visit to your
Urologist and/or Dr. van Niekerk. You will have your first
PSA test and your bladder and sexual function will be
assessed. A similar visit will be scheduled for six months
and then one year and after that every six months.
As was originally explained, your PSA will only fall gradually
and it is possible that you even experience a transient rise
in the PSA during the second year after your treatment.
You are encouraged at these visits to ask as many
questions as you like concerning your current health.
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A Guide to the Transrectal Volume
Ultrasound Study (TRUS)
TRUS is an excellent method of imaging the prostate gland
and the surrounding tissues. Because each mans prostate
is unique, the TRUS is required to assess the size and
shape of the prostate gland. This information is critical in
determining how many seeds will be needed to be
implanted into the prostate gland.
An electronic probe that sends out sound waves is inserted
in the rectum. The sound waves create a picture of the
prostate gland.
The image of the prostate is recorded on paper as well as
digitally. This information is then downloaded to Dr van
Niekerk. Using this information the radiation oncologist
calculates your dose requirements using a technologically
advanced computer program. The radioactive seeds are
then ordered to arrive on the day of your procedure.
If you have been put onto hormonal therapy for three
months prior to your procedure, a second TRUS will be
scheduled because the prostate gland actually shrinks
when a patient goes onto hormonal therapy. A smaller
gland means less seeds need to be ordered. This is
important for your medical aid as the seeds are the most
costly component of the brachytherapy procedure.
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A Guide to Hormonal Therapy
Some patients require hormonal therapy for three months
prior to their brachytherapy procedure. This is known as
neo-adjuvant therapy. Firstly in patients with very large
prostate glands, the hormonal therapy will shrink the gland
to a more manageable size. The larger the gland the longer
and more expensive is the brachytherapy procedure.
Secondly patients are stratified into low, intermediate and
high risk groups for disease reoccurrence after treatment.
Patients in the high risk group and some patients in the
intermediate risk group will be prescribed hormonal therapy.
The treatment comes as an injectable depot preparation
called Zoladex, Suprefact or Lucrin. The effect lasts for
three months. The treatment should be looked upon as the
first stage of your cancer treatment.
The usual side-effects include hot and cold flushes, loss of
sexual libido, and some mild fatigue. These effects will
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cease when the medication wears off. If you experience
any other symptoms it is very important to advise the
urologist immediately.
The medical aids often require motivation for this therapy.
Please be patient whilst they go through their standard
process of assessment.
A Glossary of Terms
Certain technical terms can be mentioned to you during
your treatment. This is a helpful list to peruse if an
unfamiliar term or word has been used.
Digital rectal examination: An examination whereby the
physician palpates the prostate gland for lumps though the
anus.
Dysuria: An uncomfortable or painful feeling when passing
urine.
Frequency: The frequent voiding of urine. This can be
caused by a high fluid intake or an irritated bladder.
Glans: The head of the penis
Haematuria: This is the presence of blood in the urine.
Haemospermia: The presence of blood in the seminal fluid.
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Nocturia: Getting up at night to pass urine.
Perineum: The area of skin behind the scrotum and in front
of the anus.
Post micturitional dribble: The leakage of a small amount
of urine after you have finished voiding.
Real time brachytherapy: The technique of actually
visualizing seeds as they are placed in the prostate gland.
It is the safest form of brachytherapy and ensures an even
dose of radio-activity to the entire prostate gland.
Seeds: Small bullets containing the radioactive iodine. In
appearance, each seed looks like a grass seed.
Seminal Vesicles: A pair of glands attached to the prostate
gland. Spermatic fluid is stored in these glands. These
glands can be involved with the prostate tumor.
Sphincter: This is a valve in the urethra that keeps you
continent.
TRUS or Transrectal Ultrasound: A procedure to measure
the size of the prostate gland.
Urethra: The tube that drains the bladder through the penis.
Urgency: A symptom that describes the urgent need to pass
urine.
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Frequently Asked Questions
Is brachytherpy more effective than surgery or external
beam radiation?
None of the three options have proved to be the more
effective in controlling the disease.
However,
brachytherapy carries a dramatically low side-effect profile
compared to the other options, provided it is done by
competent professionals.
How long will the seeds be radioactive?
The half-life of radioactive iodine (125-I) is about two
months. After 10 – 11 months the seeds have virtually no
activity left.
What long-term effect will these seeds have if left in my
body?
None. It is absolutely safe.
If I experience impotency, is there anything that can be
done?
There is a penile rehabilitation plan that will be of some use
to certain patients. It includes the use of certain drugs to
enhance erection. Please speak to Dr van Niekerk or your
Urologist.
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How long will I be in hospital?
Brachytherapy is a day procedure. You will be discharged
the same day after emptying your bladder without a
catheter.
How long does the implant take in theatre?
Approximately 1 hour.
What equipment is required for the procedure?
Highly sophisticated equipment is required for visualisation
and determination of needle placement. A laptop with the
necessary software is connected to this and the plan is
worked out in real-time by Dr van Niekerk. The seeds are
placed accordingly once the plan is completed. Presently,
Gauteng Oncology has the most advanced equipment in
Africa for brachytherapy.
How many seeds will be placed?
This depends on the size of the prostate. Seed number can
range between 50 and 120 and 18 to 24 needles will be
used to insert the seeds.
What are the seeds, what strength are they and what is
the size of the seeds?
The seeds are radioactive iodine in a solid state (metal).
The strength will vary according to various factors. They
are approximately 4mm in length and 0.8mm in thickness.
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What do the seeds look like?
Here, pictured below, the seeds are shown on the tip of the
index finger.
Is there a web site I can check on brachytherapy?
www.americanbrachytherapy.org
www.gautengoncology.co.za
Who
will
need
radiotherapy?
supplemental
external
beam
The treatment that requires both brachytherapy and
external beam radiotherapy is called combination therapy.
This is done in cases where the risk factors are indicative of
a higher chance of local or regional failure. The addition of
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external beam radiotherapy will increase the chance of cure
in the higher risk group. This will be decided on by Dr. van
Niekerk at the time of your initial consultation.
What if I decide not to have the external beam once the
brachytherapy has been performed?
If the external beam was planned prior to the brachytherapy
(i.e. as combination therapy) then you have NOT been
implanted with the full curative dose. This means that if you
do not have the external beam radiotherapy you have a
GREATER chance of failure! Please do not omit this once it
has been planned. The side-effects are not that bad!
What supplementation can I use to assist in
maintaining the health of my prostate and immune
system?
The only range of natural medication and nutritional
supplementation that is advocated is Oncopaladin®. Please
ask our brachytherapy coordinators or Dr. van Niekerk
about Oncopaladin Prostate Health and Flowrite.
Are other cancers treated with radioactive seeds?
The treatment of Breast Cancer is evolving into the use of
seeds after a lumpectomy.
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NOTES
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