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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. 1 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] 2 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. 3 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 4 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. 5 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. 6 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 7 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 8 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 9 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. 10 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. 11 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. 12 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 13 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. 14 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. 15 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. 16 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. 17 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 18 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. 19 NOTES 20