Download Cryotherapy - Prostate Cancer UK

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Cryotherapy
In this fact sheet:
• How does cryotherapy treat
prostate cancer?
• Who can have cryotherapy?
• Focal cryotherapy
• Where can I get support?
• Questions to ask your doctor or nurse
• What are the advantages and disadvantages?
• More information
• What does cryotherapy involve?
• About us
• What are the side effects?
This fact sheet is for men who are thinking
about having cryotherapy to treat their
prostate cancer. Partners and families of
men with prostate cancer may also find this
information useful. It is one of several fact
sheets that have been written to help you
decide which treatment best suits you.
This fact sheet describes how cryotherapy
treats prostate cancer and what the side
effects can be. Each hospital will do things
slightly differently. Use this fact sheet as a
general guide and ask your doctor or nurse
for more details about the treatment you
will have. You can also call our Specialist
Nurses on our confidential helpline for more
information about cryotherapy and other
treatments for prostate cancer.
How does cryotherapy treat
prostate cancer?
Cryotherapy is a way of treating prostate cancer
that uses freezing and thawing to kill the cancer
cells in the prostate gland. It is also sometimes
known as cryosurgery or cryoablation. It is done
using a number of thin needles (cryoneedles)
which are inserted into the prostate gland under
local or general anaesthetic. This process kills
both cancer cells and healthy cells within
the gland.
There have been improvements in cryotherapy
in recent years, which have reduced the risk of
side effects and improved the success of the
treatment. However, we need more research
to show whether cryotherapy is as good as
other treatments in the long term. For more
information on the side effects of cryotherapy
see page 4.
Who can have cryotherapy?
Cryotherapy can be used to treat prostate
cancer that has not spread outside the prostate
gland (localised prostate cancer). It is also
sometimes used to treat cancer that is breaking
through the capsule of the prostate (locally
advanced prostate cancer). It is not suitable
for cancer that has spread beyond the prostate
gland to other parts of the body (advanced
prostate cancer).
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Cryotherapy is usually used for men whose
prostate cancer has come back after treatment
with radiotherapy or brachytherapy (recurrent
prostate cancer). It is less commonly offered as
a first treatment for prostate cancer. However,
it may be an option for men who are unable
to have other treatments such as surgery or
radiotherapy. For example men with heart
problems (cardiovascular problems) may not
be able to have surgery for prostate cancer.
Men with severe urinary symptoms may not be
suitable for cryotherapy as it can make these
problems worse. If you have difficulty passing
urine or have to pass urine frequently you may
wish to discuss this with your doctor before
choosing a treatment.
Cryotherapy is newer than some of the other
treatments for prostate cancer. We do not know
as much about how effective it is in the long
term, or the risk of side effects compared with
other treatments. Researchers are studying
better ways of carrying out cryotherapy. Because
of this, it is only available in specialist centres
in the UK, or as part of a clinical trial. You can
find more information about clinical trials in our
Tool Kit fact sheet, A guide to prostate cancer
clinical trials.
Your doctor or nurse should discuss all your
treatment options with you. It is important that
they give you information about the advantages,
disadvantages and all the possible side effects of
cryotherapy to help you decide whether it is right
for you. Your options will depend on whether you
have just been diagnosed, or if the cancer has
come back after previous treatment.
Other first treatment options for localised
prostate cancer may include:
• active surveillance
• surgery to remove the prostate
(radical prostatectomy)
• external beam radiotherapy (EBRT), or
• brachytherapy (a type of radiotherapy).
You may also be offered high intensity focused
ultrasound (HIFU). Like cryotherapy, it is not
widely available in the UK and researchers are
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studying better ways of carrying it out. It may
be available in specialist centres or as part
of a clinical trial.
You can find more information about all these
treatments in our individual treatment Tool Kit
fact sheets or you can call our Specialist Nurses
on our confidential helpline.
For more information about treatment options
after your first treatment read our booklet,
Recurrent prostate cancer: A guide to
treatment and support.
Unsure about your diagnosis and
treatment options?
If you have any questions about your
diagnosis you can ask your doctor or nurse.
They will be happy to explain your test results
and talk you through your treatment options.
It is important you feel you have enough
time and all the information you need before
making a decision about treatment. We
have more information about diagnosis and
treatment in our Tool Kit.
What are the advantages and
disadvantages?
The advantages and disadvantages of
cryotherapy may depend on whether you are
having it as a first treatment for prostate cancer
or because the cancer has come back after
another treatment. There is a higher risk of
side effects if you have already had treatment
for prostate cancer. See page 4 for more
information on side effects. You can ask your
doctor or nurse if you are unsure about any of
the advantages or disadvantages of cryotherapy.
Advantages
• Cryotherapy is less invasive than some other
treatments, with little blood loss.
• You will only be in hospital for a short time
and recovery time is quick.
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• Cryotherapy may be a treatment option
if your cancer has come back after
radiotherapy or brachytherapy.
Disadvantages
• Many men who have cryotherapy have long
term erectile problems following treatment.
• There is also a risk of other side effects which
could affect your quality of life such as urinary
problems and a small risk of bowel problems.
• We do not know as much about how effective
the treatment is in the long term (after 10 or
15 years), compared with other treatments.
• Cryotherapy is only available in specialist
centres in the UK or as part of a clinical trial.
What might be an advantage for one person
may not be for someone else. Please talk to
your doctor or nurse about your own situation.
What does cryotherapy involve?
Each hospital will do things slightly differently,
so ask your doctor or nurse for details of how
they carry out the procedure.
Before having treatment
Your doctor or nurse may ask you to take some
medicine, called a laxative, to help empty your
bowels immediately before treatment. This will
give your doctor a good view of the prostate
gland during treatment using an ultrasound
probe (see below).
During treatment
Cryotherapy is usually done under general
anaesthetic so that you are asleep during the
treatment. It is sometimes done under local
anaesthetic so that you are awake but won’t
feel anything.
A tube, known as a warming catheter, is passed
through your penis into your bladder. Warm
liquid is circulated through the catheter during
the treatment. This is to help prevent the tube
which you pass urine through (your urethra) from
freezing and being damaged during treatment.
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An ultrasound probe is inserted into your back
passage. This allows your doctor to see an
image of the prostate gland and make sure the
cryotherapy needles are in the right place. Several
thin needles, known as cryoneedles or cryoprobes,
are then inserted into the prostate gland through
the skin between the testicles and back passage
(perineum). Probes to monitor temperature are also
inserted into and around the prostate gland.
Freezing gasses are passed down the needles,
causing the temperature to drop to about –40oC.
This freezes and destroys the surrounding tissue.
The prostate gland is then allowed to warm up,
either naturally, or by passing a different gas
through the needles to warm the gland more
quickly. This is called a freeze-thaw cycle. The
process of freezing and thawing is repeated.
There are usually two freeze-thaw cycles but there
may be more if you have a large prostate gland.
The needles and probes are then removed and,
after about 20 minutes, the warming catheter is
also removed. Another tube, used to drain urine,
will be passed into your bladder either through the
penis (urethral catheter) or through a small cut in
your abdomen (suprapubic catheter). This will be
left in for one to two weeks after you go home. The
whole process usually takes around two hours.
Going home after treatment
Most people can go home on the same day
or the following day. It is normal to have some
discomfort, and your doctor or nurse will tell you
which pain-relieving drugs you can take. You will
be given antibiotics to reduce the risk of infection
which you will need to take for a few days after
you go home. If your urine starts to smell strongly
or if you have a temperature, contact your doctor
or nurse. These could be signs of an infection and
you may need more antibiotics.
You will go home with a catheter in place to
avoid any problems passing urine. This will be
left in for one to two weeks. Your nurse will show
you how to care for the catheter before you
leave the hospital. Some treatment centres may
also give you medication called alpha-blockers
to relax the muscle in and around the prostate
to help you pass urine.
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When you have your catheter removed at the
hospital it may be uncomfortable, but it should
not be painful. You will need to stay for a few
hours after the catheter has come out to check
that you can pass urine without difficulty. You may
wish to take some spare underwear and spare
pair of trousers with you. In some centres your
doctor or nurse may arrange for you to have your
catheter removed at home.
You may see some blood in your urine, both while
the catheter is in and after it has come out. This
is normal, and you should drink plenty of fluids to
help clear the blood. If you are worried about it at
all, contact your doctor or nurse for advice.
You may also have some bruising and swelling of
the skin around the testicles (scrotum), buttocks
and inner thigh in the few weeks after the
procedure. Your doctor or nurse may advise you
to avoid long periods of standing for the first few
weeks. You should be able to go back to your
day-to-day activities as soon as you feel able
to, although it may take a few weeks or months
before you feel back to normal.
What happens afterwards?
You will have follow-up appointments with your
doctor or nurse at the hospital to check your
recovery and monitor your response to the
treatment. Your prostate specific antigen (PSA)
level will be monitored regularly to help check
how well the treatment has worked. How often
will vary depending on the treatment centre, but
you should have a PSA test about every three
months for at least the first year, and every six
months after that. You can ask your doctor or
nurse how often you will have a test.
If you had cryotherapy as a first treatment and
your cancer starts to grow again, you may be
able to have more cryotherapy. In some cases
you may be offered radiotherapy or, rarely,
surgery. If you had cryotherapy as a second
treatment and your cancer starts to grow again,
you will be offered hormone therapy.
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You can find more information about treatment
options after cancer has come back in our
booklet, Recurrent prostate cancer: A guide
to treatment and support or you can call our
Specialist Nurses on our confidential helpline.
What are the side effects?
Like all treatments, cryotherapy can cause
side effects. Cryotherapy will affect each man
differently, and you may not get all of the side
effects. The most common side effects include
erection problems (see below) and urinary
problems (see page 5).
Many of the side effects of the treatment
are caused when healthy tissues are frozen
and damaged. There is a greater risk of side
effects if you have already had radiotherapy or
brachytherapy to treat prostate cancer. This is
because these treatments may have already
caused some damage to the tissues surrounding
the prostate gland.
Short term side effects
Short term side effects include:
• blood in the urine (haematuria)
• difficulty or discomfort passing urine
• bruising and swelling of the penis, skin
around the testicles (scrotum), inner thigh
and the area between your testicles
and back passage (perineum), or
• pain and bleeding where the needles
were inserted.
Mid or long term side effects
Erectile dysfunction
The most common long term side effect is
difficulty getting or keeping an erection
(erectile dysfunction). This is because the nerves
responsible for erections can be damaged by
the treatment. More than three quarters of
men (over 75 per cent) will be unable to get an
erection following cryotherapy. If sex is important to
you, you should discuss with your doctor or nurse
whether cryotherapy is a suitable treatment for you.
Some men will find that they gradually get
back their erections but for most men this is likely
to be a long term problem. We do not know for
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sure how many men will get their erections back.
There are medical treatments available which may
be helpful and you can discuss these with your
doctor of nurse. Our Tool Kit fact sheet,
Sex and prostate cancer gives more information
on treatments for erectile dysfunction.
If you are planning to father children in the future,
it might be possible to store your sperm before
having cryotherapy. Speak to your doctor or nurse.
Urinary problems
Cryotherapy can cause urinary problems
including leaking urine (urinary incontinence)
and having a weak or slow flow of urine. These
problems usually improve with time. Up to one in
twenty men (five per cent) who have cryotherapy
as a first treatment will find that they leak urine
to some degree. This is more likely if you have
cryotherapy as a second treatment and affects
up to one in six men. For some men this may
improve with time. However for some men the
problem will be long term and you may have to
wear pads in your underwear either temporarily
or permanently. Making some changes to your
lifestyle, such as doing pelvic floor muscle
exercises may help to improve urinary problems
or make them easier to manage. You can
read about these in our Tool Kit fact sheet,
Pelvic floor muscle exercises.
A recent study found that about four in every
hundred men who had cryotherapy as a first
treatment had a weak or slow flow of urine after
treatment. This is more likely if cryotherapy is
a second treatment, affecting up to one in five
men. The problem can be caused by swelling
of the prostate gland and may pass in time.
In a small number of cases a weak or slow flow
of urine can be caused by damage to the tube
that carries urine out through the penis (urethra).
Small pieces of dead tissue are passed through
the urethra (urethral sloughing) and may cause
a blockage, making it difficult or impossible
to pass urine. This can affect up to three out
of every 100 men (three per cent) who have
cryotherapy. Having a catheter for a short while
may ease the problem or if necessary you can
have an operation to help this.
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There is also a small risk that the urethra may
become narrowed (stricture) after treatment.
This will also cause a weak or slow flow of urine.
Some men may need to have a procedure in
hospital to help with this.
Speak to your doctor or nurse if you are having
difficulty passing urine. You can read more about
urinary problems and possible treatments in
our Tool Kit fact sheet, Urinary problems after
prostate cancer treatment.
Bowel problems
A small number of men may get a complication
where a hole forms between the back passage
(rectum) and the tube which carries urine
through the penis (urethra). This is known as a
fistula, and is rare in men having cryotherapy
as a first treatment. It is more likely, though still
uncommon, if you have had an earlier treatment
for prostate cancer which may have damaged
the wall of the back passage. It can affect up to
two out of every 100 men (up to two per cent).
Fistulas can develop up to several weeks after
cryotherapy. Sometimes pain and infections of the
urethra can be early signs of a fistula, although
these can also be caused by something else.
Contact your doctor or nurse if your urine is
strong smelling or you have a temperature, which
could be signs of an infection. Discharge from the
urethra or back passage or diarrhoea may also be
signs of a fistula. If you develop a fistula, you will
need to have an operation to repair the hole.
Pain
It is normal to experience some pain or
discomfort after having cryotherapy. This can
be managed with pain-relieving drugs and your
doctor or nurse should tell you which you can
take. However some men will have pain that
lasts for a few weeks or months. The pain may
be in the area in or around the penis, testicles
and back passage. There is a greater risk of
pain if you have had another treatment before
cryotherapy. Antibiotics may help and the pain
will usually improve. Speak to your doctor of
nurse if you have any pain.
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Focal cryotherapy
Some specialists are looking at a new way of
using cryotherapy called focal cryotherapy. This
means that cryotherapy is used to treat only
the areas of the prostate gland where there is
cancer, rather than treating the whole gland. The
aim is to avoid the side effects of cryotherapy by
leaving healthy tissue unharmed. This is a new
area of research and we need more information
about how successful this treatment option is
before it is made widely available.
Where can I get support?
As well as getting medical help to treat your
cancer, you may find that it helps to talk to family
or friends about how you are feeling. Sharing
concerns can make any decisions about your
treatment easier to deal with. You could also
speak to your doctor or nurse or you can call our
Specialist Nurses on our confidential helpline.
Partners and family also often worry about their
loved one, and may find it helpful to talk to your
doctor or nurse or call our Specialist Nurses on
our confidential helpline.
Some people find that it helps to talk to other
men who have had cryotherapy. There are
prostate cancer support groups throughout the
country. You can ask your doctor or nurse for
details, or you can find a list of support groups
on our website at prostatecanceruk.org
You might find it helpful to speak to someone
who has been affected by prostate cancer. Our
peer support volunteers are men and women
who have personal experiences of prostate
cancer. They are trained to listen and offer
support over the telephone. Call our Specialist
Nurses on our confidential helpline.
Questions to ask your doctor or nurse
You may find it helpful to keep a note of any questions you have
to take to your next appointment.
How successful is cryotherapy at treating prostate cancer?
What is the risk of side effects?
What are my other treatment options?
How much experience does the specialist have in carrying out cryotherapy?
How often will you check my PSA after the treatment?
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If you have access to the internet, you can
sign up to our online community on our
website, where you can share your views
and experiences with others affected by
prostate cancer. Our website address is
prostatecanceruk.org
If you would rather speak to a professional
counsellor, you can ask your GP if there is one
available on the NHS or you can get a list of
private counsellors from The British Association
for Counselling and Psychotherapy (see below).
More information
British Association for
Counselling & Psychotherapy
www.itsgoodtotalk.org.uk
Phone 01455 883300
Information about counselling and details of
therapists in your area.
CancerHelp UK
www.cancerhelp.org.uk
Nurse helpline 0808 800 4040
Cancer Research UK’s patient information
resource. It includes a database of clinical trials
and advice on finding a trial.
Healthtalkonline
www.healthtalkonline.org
Watch, listen to and read personal
experiences of men with prostate cancer
and other medical conditions.
Macmillan Cancer Support
www.macmillan.org.uk
Helpline 0808 808 00 00
Practical, financial and emotional support for
people with cancer, their family and friends.
National Institute for Health and Care
Excellence (NICE)
www.nice.org.uk
Phone 0845 003 7780
Guidelines for care and for the use of
treatments and procedures on the NHS in
England and Wales.
7
UK Prostate Link
www.prostate-link.org.uk
Helps you find and compare reliable information
about prostate cancer.
About us
Prostate Cancer UK fights to help more men
survive prostate cancer and enjoy a better life.
This fact sheet is part of the Tool Kit. You can
order more Tool Kit fact sheets, including an
A-Z of medical words, which explains some
of the words and phrases used in this sheet.
Download and order our free publications from
our website at prostatecanceruk.org or call us
on 0800 074 8383.
At Prostate Cancer UK, we take great care to
provide up-to-date, unbiased and accurate facts
about prostate cancer. We hope these will add
to the medical advice you have had and help you
to make decisions. Our services are not intended
to replace advice from your doctor.
References to sources of information used in the
production of this fact sheet are available at
prostatecanceruk.org
This publication was written and edited by:
Prostate Cancer UK’s Information Team
It was reviewed by:
• Professor Damian Greene, Consultant
Urologist, City Hospital, Sunderland
• Susan Asterling, Urology Research Nurse,
Sunderland Royal Hospital
• Fiona Birrell, Cryotherapy Clinical Nurse
Specialist, Gartnavel General Hospital
• Hashim Ahmed, MRC Clinical Research
Fellow (Uro-Oncology), Division of Surgery
and Interventional Science, University
College London
• Prostate Cancer UK Volunteers
• Prostate Cancer UK Specialist Nurses
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