Royal Prince Alfred Hospital Royal Prince Alfred Hospital
Radiation Oncology

Radiotherapy for Prostate Cancer

Radiotherapy plays a vital role in the treatment and management of prostate cancer. This treatment can be delivered externally [external beam radiation therapy] or internally [brachytherapy]. The method of treatment delivery is dependant on the stage of the tumour and the health status of the patient.

Radiotherapy can be used as the sole treatment for prostate cancer but is commonly used in conjunction with hormone therapy. Sometimes Radiotherapy can be delivered after the prostate is surgically removed [prostatectomy]. 
 
Your Radiation Oncologist will advise you what regime is most suitable for you, how effective the therapy will be and how the treatment will affect you.
 
For more information on what type of treatment is used for each stage of prostate cancer, please see Appendix.
 
 
Pre-planning Patient Requirements
 
 
Prior to commencing your planning session, three gold seeds are surgically placed in your prostate to localise the gland during the course of the external beam radiotherapy treatment. Your Radiation Oncologist will organise this with you and explain how and when this will happen.
 
Your Radiation Oncologist will request pre-scanning requirements, including a comfortably full bladder and empty rectum. Please empty your bladder 30 minutes before your appointment time and drink approximately 500ml of water.
 
 
What should you bring to your Radiotherapy Planning appointment?
 
  • A referral letter from your doctor (if not already submitted)
  • Medicare card
  • All private scans relating to your current diagnosis 
  • A list of your current medications (including any medication allergies)
 
What happens during Radiotherapy Planning?
 
 
When you come into the Radiation Oncology Department, please report to the reception area. You will be guided to the waiting room where you will be met by your Radiation Therapists. The Radiation Therapists will introduce themselves and ask you to confirm your identity by asking you to state:
  • your full name,
  • date of birth, and
  • the body site you will be having treatment to
You will find that this identification process is repeated multiple times during your treatment. This is because correct identification of patients is crucial to ensure that the correct treatment is given to the correct patient.
 
After correct identification, your Radiation Therapist will briefly explain the planning procedure and give you the opportunity to ask questions. You will then be shown to the change rooms to change into a gown. You will then be escorted to the Radiotherapy Simulation and Planning area where your Radiation Therapists will position you on the CT scanner bed.
 

Patient having a planning CT scan 

 
You will be lying on your back with support under your head,  knees and ankles. It is important that you are stable and comfortable in this position for the duration of your Radiotherapy Planning (up to 30 mins) and later for each of your Radiotherapy sessions. 
 
The Radiation Therapists will also ensure that you are lying as straight as possible on the CT scanner bed. They will do this using the lasers situated in the CT scanner room. This process will also be repeated at each of Radiotherapy sessions. 
 
Once your Radiation Therapists have positioned you, they will draw some marks on your skin. 
 
You will then undergo a CT scan in the treatment position. It is very important that you breathe normally and lie very still during the CT scan as any movement can affect the quality of the scans and you may then need to have the scans repeated.
 
Once the scan is complete, your Radiation Therapists will make three of the marks on your skin permanent  with tattoos. This is done so they can use these marks as a reference to position you in exactly the same way for each day of your Radiotherapy. The tattoos are permanent and will be approximately the size of a small freckle. They will be made with a shallow skin prick using a sterile needle and a dab of black ink. In the long term they will appear as black or blue dot. 
 
Your Radiation Therapists will then take photos of the area to be treated and your face for identification purposes. These will be attached to your treatment plan and medical records.
 
Your Radiation Oncologist will be present during the planning session which takes approximately 30-45 minutes.
 
At the end of the Radiotherapy Planning session you will be given an appointment card which will contain details of your first treatment (date and time).
 
Your Radiation Therapist will then escort you back to the change rooms. When you have collected all of your belongings, your Radiation Therapist will show you the location of the treatment waiting room. This is where you will wait for your treatment every day once Radiotherapy starts.
 
You will also be shown how to scan your card at the front desk barcode scanner which you will use every day when you arrive for treatment. This is how you will notify the treatment staff of your arrival in the Department.
 
 
What happens during Treatment?
 
 
When you come in for your first treatment, you will need to scan your card at the front desk and take a seat in the waiting room.
 
One of your Radiation Therapists will call your name when they are ready to treat you.
 
Your Radiation Therapist will introduce themselves and ask you to confirm your identity by asking you to state:
  • your full name,
  • date of birth, and
  • the body site you will be having treatment to.
As with planning, you will be required to have a comfortably full bladder and empty rectum for treatment every day. Please empty your bladder 30 minutes before your appointment time and drink approximately 500ml of water. It is very important to make sure you do this every day.
 
Your Radiation Therapist will then sit down with you to discuss the
treatment process, and expected side effects relating to your treatment. You will have already discussed side effects with your Radiation Oncologist but if you have any questions please feel free to ask your Radiation Therapist who will answer your questions to the best of their knowledge. If necessary they will refer you to the appropriate member of your treatment team who can provide you with further information. 
  
 
 
 
Your Radiation Therapist will take you to your treatment room and you will be asked to lie on the treatment bed in the same position as you were in your planning session. 
 
Your Radiation Therapists will then dim the lights so that the laser beams in the room can be seen clearly. These will be used to guide the Radiation Therapists in setting you up in the exact same position every day.
 

Patient having radiation therapy treatment

The Radiation Therapists may feel for your bones and move you slightly when they are setting you up. It is important that you do not try to help unless asked as usually only millimetre adjustments will be made.
 
The bed and machine will then be moved into the treatment position. The machine may come close to you, but will not touch you at any point during the treatment process.
 
When your Radiation Therapists are ready to turn the machine on, they will let you know and then leave the room. You will hear a doorbell sound as they leave.
 
Just stay nice and still and breathe normally.
 
There are cameras and a microphone inside the room and your Radiation Therapists will use these to monitor you throughout the treatment. If you need your Radiation Therapists for any reason, wave your hand or call out and your Radiation Therapists will come straight in.
 
When the treatment is over, your Radiation Therapist will come back into the room and assist you off the bed.
 
Although the actual treatment only takes a few minutes, the whole treatment session (from positioning to finishing treatment) may take about 10-20 minutes each day.
 
During the course of Radiotherapy, you will see your Radiation Oncologist or another doctor on your treatment team once a week on a set review day. This is important as it allows them to monitor your progress and address any concerns you may have about your treatment. Please allow for more time on this review day as your visit to the hospital will be slightly longer.
 
 
 
 
Due to individual treatment regimes and medical circumstances, side effects will vary from person to person and are specific to your customised plan.
 
Your Radiation Oncology medical team will see you once a week during your treatment to monitor your progress and to help manage any side effects.
 
If you have any problems between these visits please speak to your Radiation Therapist who will contact your doctor for you as needed.
 
Some of the possible side effects are listed in the table below. These side effects usually occur one week into treatment or may appear during the course of your treatment.
 
Many of these side effects can be managed and will gradually disappear after your treatment has finished.
 
Please let your treating team know if you develop any of these symptoms so they can be managed promptly and effectively and you are more comfortable.
 

     Side effects
     What can help? 
 
     Fatigue (tiredness)
 
     Most patients experience reduced energy levels, tiredness and      lack of motivation soon after starting treatment. Just listen to      your body and rest if needed. 
 
     Some people find exercise is beneficial.
 
     Dry, red, itchy skin (in      the treatment area)
 
     Skin reactions tend to appear after about two weeks of      treatment and may develop even further to become itchy and      tender as the treatment continues.
 
     The skin reaction is similar to that of sunburn; it may become      pink, and may feel warm to touch with mild discomfort.
  • Use a mild or moisturising soap
  • Bathe using lukewarm water, and avoid scrubbing in the treatment area.
  • Moisturise the area daily with sorbolene cream.
  • Avoid body powders (eg. Talc)
     Hair loss (in the      treatment area)
 
     Hair loss normally occurs after about two weeks of treatment.      Usually temporary but may be permanent.
 
     Soreness and      discomfort in the groin      region
 
     Wear loose fitting clothes in a breathable material [eg. Cotton].      Avoid items which can rub or irritate skin.
 
     Inflammation of bowel      and bladder
     This can cause diarrhoea, increased gas and cramping,      frequent urination.
 
     If experiencing diarrhoea, the oncologist can prescribe anti-     diarrhoea medication. Also increase your fluid intake and      reduce fibre intake.
 
     Urinary retention
     Occasionally occurs when the prostate is quite large.
 
     These signs can be treated with urinary bladder medication.
 
     Discomfort on      ejaculation
     You can engage in sexual intercourse, but may experience      some discomfort on ejaculation.
 

 
There are some uncommon side effects that may occur months or years after treatment. These are called late effects and may include the following:
  • Erectile dysfunction
  • Possible permanent change in bowel habits - including continued urgency and increased frequency of bowel movement.
  • Urinary side effects are uncommon, but can include very occasional strictures or uncontrolled excretion of small droplets of urine.
  • Loss of sexual function
  • Inflammation of the rectum (Proctitis)
 
Prostate Cancer Links
 
 
 
 
 
 
 
 
 
 
 
Which treatment is appropriate for each stage of prostate cancer?
 
 
In order to guide patients in choosing an appropriate treatment, doctors depend in part on an understanding of prognostic factors that suggest how extensive or aggressive the cancer may actually be. Such factors include digital rectal examination (DRE). Given the impact on prognosis that each of these factors may have, a combination of these factors is often more useful in understanding the potential for treatment success or failure than the use of any one factor alone, PSA test, Gleason score and biopsy.
 
Within the realm of clinically localized cancer, a combination of these factors may be used to categorize patients as "low," "intermediate" or "high" risk in terms of treatment failure. It is important to note that while prognostic factors are helpful in guiding treatment choices, there is no "cookbook" for selection of treatment, and other factors including age, overall health, urinary and bowel function and each patient's own concerns about treatment need to be taken into account. Therefore, a thorough discussion with an individual's urologist and radiation oncologist is an important part of the decision-making process.
 
Prostate cancer that has not spread outside the immediate area around the prostate is often referred to as clinically localized cancer. An important distinction within the realm of clinically localized cancer is between prostate cancers confined to the prostate, referred to as organ-confined disease, and prostate cancer that has spread directly outside the prostate or into the seminal vesicles. The term "clinical" is applied to the setting where the determination that cancer has not spread to other sites, including lymph nodes, distant tissues and organs, is based on the findings of physical exam and diagnostic imaging tests that may include CT scan or MRI and/or whole body bone scan. Proof of cancer stage is only definitively obtained by invasive procedures such as surgical removal of the prostate or biopsy.      
     
 
 
The "low-risk" category generally includes patients with T1 or T2a cancer (normal examination or small abnormality limited to one side of the prostate), PSA less than 10 ng./ml. and/or Gleason grade less than or equal to six. These men are the most likely to have cancer confined to the prostate. Treatment options may include radical prostatectomy, external beam radiation therapy or in certain circumstances observation. Given that almost all men with early detection of prostate cancer are without symptoms, the impact that treatment may have on quality of life is a very important consideration.  prostate brachytherapy
 
 
 
The "intermediate-risk" category generally includes patients with bulky T2a disease, PSA greater than 10 ng./ml. but less than or equal to 20 ng./ml. and/or Gleason grade seven. In addition, recent studies have suggested that the extent of tumor on biopsy, often referred to as "percent positive biopsies" may help define which men in this category have outcomes more similar to the low or high-risk group. Men with just a little cancer found on biopsy might have outcomes more in line with low-risk patients while men with extensive cancer may be at greater risk for treatment failure. Overall, many men in this category may still have cancer confined to the prostate or along the edge of the prostate. The risk of spread outside the prostate is greater, however, than that for men with all low-risk features.
 
Given the many nuances in the presentation of intermediate-risk disease a number of treatment options may be appropriate. These options may include radical prostatectomy, EBRT, LDR brachytherapy (in suitable patients ie those in the very early intermediate group only), HDR prostate brachytherapy or a combination of EBRT and HDR brachytherapy.
 
Androgen suppression therapy (commonly referred to as hormonal therapy), may also have a role in treatment of intermediate-risk prostate cancer when combined with radiation. While in men with high-risk prostate cancer the role of hormonal therapy with radiation is now established, the role in treatment of intermediate-risk prostate cancer remains to be fully defined. The results of two large clinical studies now completed are awaited in the next several years and hopefully will provide some answers. In the meantime, a large study of previously treated patients at the Dana-Farber Cancer Institute suggested a benefit to the addition of six months of hormonal therapy to EBRT in this patient group and therefore at least warrants consideration when radiation therapy is used.
 
 
 
The "high-risk" category includes men with any of the following features: T2c, T3 or T4 disease (abnormal examination on both sides of the prostate or cancer that has spread outside of the prostate as determined by digital rectal examination), PSA greater than 20 ng./ml. and/or Gleason grade between eight and 10.
 
Men in this category have a substantial risk of spread of cancer outside of the prostate. Nevertheless, some men in this category do have cancer confined to the prostate and therefore local treatment including prostatectomy may be appropriate in a small minority of patients.
 
In men deemed to be at greater risk for disease spread, the most standardized radio-therapeutic approach to treatment is the combination of EBRT and hormonal therapy. Other treatments, including combination of EBRT and brachytherapy with or without hormonal therapy, may be considered but the long-term results of newer approaches remain to be fully defined. Sometimes, depending on both tumour and patients factors, pelvic lymph nodes may be encompassed within the radiation field for certain high risk patients, using a technique called IMRT (intensity modulated radiation therapy).
 
Two national studies started in the 1980s in the United States and a third large study in Europe all showed benefit to the use of hormonal therapy when combined with EBRT in men with various high-risk features. The European study was the first to show an overall survival benefit to the addition of hormonal therapy to radiation. Early results of another study indicate a benefit to longer duration hormonal therapy in men with high-risk prostate cancer.
 
The use of chemotherapy in this group of men remains to be defined and is now the focus of a few national studies.
 
Given the variety of presentations within the high-risk group, the correct treatment for any given individual needs to be carefully considered in consultation with a urologist and/or oncologist.
 
 
 
External beam radiation therapy may be used following prostatectomy when there is concern that cancer may remain in the region of the prostate. The use of radiation in this setting to destroy residual cancer has been sporadic for many years but in the past five to 10 years this approach has started to gain widespread acceptance. The possibility of success with radiation following prostatectomy depends on the likelihood that any remaining cancer is confined to the region of the prostate where radiation is aimed. Therefore, the success rate varies widely depending on the presentation at the time treatment is contemplated.
 
Diagnostic studies may be helpful but unfortunately no test can exclude the possibility of microscopic spread of the cancer. The physician must therefore assess a number of factors including the pretreatment prognostic factors, pathological findings at the time of prostatectomy and the post-surgical PSA history in determining which patients are most likely to have localized cancer versus cancer that has spread (metastasised). 
 
 
Radiation therapy treatment for metastatic cancer
 
Radiation is often an effective treatment for preventing or managing symptoms of prostate cancer that has spread. External beam radiation therapy is typically very helpful in decreasing (in 30-40 % of patients treated) or relieving completely (about 30% of patients) pain related to prostate cancer that has spread to the bones. A short course of therapy usually no longer than one to two weeks is sufficient in most cases. In other cases, radiation may be used to prevent debilitating symptoms related to the uncontrolled spread of cancer near critical organs or tissues.