For anyone thinking about seed brachytherapy as a potential treatment option, whether for yourself, a friend, or family member, you'll no doubt have a number of questions about the various aspects of the treatment.
Here we aim to give you practical treatment information to help answer those queries. Please contact your local clinic to find out more, or to talk to someone in more detail about seed brachytherapy.
Brachytherapy Patient Treatment Pathway
If your family doctor (GP) suspects that you have problems with your prostate gland he/she will arrange for you to see a specialist who will be able to confirm or rule out prostate cancer. A doctor who specialises in prostate cancer may be either a urologist (expert in the urinary system) or an oncologist (cancer expert) and a specialist nurse will typically also be involved. There are a series of steps and tests in confirming the diagnosis of prostate cancer and one involves obtaining a biopsy (sample of prostate tissue) in order to confirm whether cancer is present and, if it is present, to grade how aggressive it is. The typical steps in a brachytherapy procedure are outlined here.
Biopsy, Ultrasound & Magnetic Resonance Imaging
A biopsy is a surgical procedure in which small samples of tissue (usually 6) are removed from different parts of the prostate gland through a needle and examined under the microscope by a pathologist, a medical person specialising in identifying disease through the study of cells, tissue and organs. The procedure takes about 15 minutes and is usually performed under local anaesthetic.
In some centres a transperineal template guided biopsy is performed to gain more information on the prostate. Here needles are inserted using a template in the skin between the scrotum and back passage(the perineum) to target tissue samples. This gives doctors more precise information on the tissue in the prostate.
Ultrasound scans of the prostate will also be performed in order to find out the size and shape of the prostate gland.
You may also undergo an MRI (Magnetic Resonance Imaging) scan which is a scan using magnetic fields and radio waves to produce detailed images of the prostate to help pinpoint the exact locations of the cancer.
The information from all these procedures gives the doctor and you more information on which to base the choice of treatment.
Planning Stage I
If you do have localised prostate cancer (cancer contained within the prostate gland) and you decide with your doctor and nurse that LDR brachytherapy (seed implantation) is the best treatment for you, the next step (B) will be to undertake a volume study during what is called the ‘planning stage’. You will have an enema to empty your bowels the day before you go in to hospital. On the volume study day you will be given a general anaesthetic and an ultrasound probe will be put into the rectum (back passage). This is not painful for you, and it means that the doctor can see a picture of your prostate gland. A three-dimensional model is then constructed by the brachytherapy planning computer and a dose plan is produced. The plan will be specifically tailored to you and will determine the position and number of seeds needed.
After the volume study, you will be scheduled for the actual brachytherapy procedure and the seeds are then specially ordered for you.
Implantation Stage II
Seeds are then implanted into the prostate (implant stage) through fine needles under general anaesthetic. Implantation involves placing between 120 seeds through 15–25 hollow needles which are inserted into the skin between the scrotum and the anus into the prostate gland. The doctor uses an ultrasound image to guide the implantation. Once all the needles are inside the prostate gland in the exact planned position, the seeds are pushed out and the needles removed. Because of the ultrasound probe the doctor can see on the computer and ultrasound screen just where the needles and the seeds are going and know that they are precisely on target.
The volume study and implantation of the seeds may be carried out on separate days a few weeks apart, or they may be carried out at the same time depending on the centre performing the procedure. Finally a computer image is generated to confirm the position of the brachytherapy seeds inside the prostate gland.
The implantation procedure takes approximately one hour. Afterwards you will spend an hour or two in the recovery room recovering from the anesthesia. You will then be discharged from the hospital (either later that day or the following morning) and given an appointment to return for a follow-up outpatient appointment within 2-4 weeks. You will then be asked to return for a follow-up visit in approximately 3-6 months when your PSA level will be checked.
Some treatment centres do planning on one day, then order the seeds, and then do the implantation a few weeks later - so you would have to visit the hospital twice. Some treatment centres order the approximate number of seeds in advance and then do the planning and implantation at the same time - so you would only have to visit the hospital once for the actual procedure.
Newer forms of brachytherapy such as 4D Brachytherapy enable centres to do the procedure in one visit. Please ask you doctor about 4D Brachytherapy.
Recovery time is usually quite fast. LDR brachytherapy is highly targeted and therefore damage to surrounding tissue is limited which keeps the level of side effects low. You should not drive for 24 hours, but you can usually return to most normal activities the next day.
Precautions After Treatment
The seeds are only radioactive for a certain time. Most of the radiation is released into the prostate gland over the first 3 months and they continue to be biologically active for a further 9 months . After that they are effectively inactive and they remain in the prostate as there is no need to remove them. The seeds are not dangerous, but as a precaution doctors advise that you should not make physical contact for long periods of time with small children or pregnant women for the first 2 months after treatment.
Sexual intercourse may start again after a few weeks. Very occasionally a ‘seed’ can be ejaculated in the semen so it is advisable to wear a condom for the first two or three occasions you have sex.
You may experience some immediate effects from the implantation procedure but these wear off after a little time. For example, soreness, bruising and discolouration between the scrotum and anus, tenderness between the legs where the needles entered, and some discomfort when passing urine.
Often, patients experience few problems during the first couple of weeks following the implant. If symptoms occur they may then peak at around 4–6 weeks after the implant as the radiation begins to work, but then improve over the following months. Symptoms may include the following:
Blood in the urine and semen
A very low number (fewer than 5 out of every 100 men [5%]) of patients may have difficulty passing urine and require a catheter
Impotence occurs in 15 out of every 100 men (15% patients) who were sexually active before the procedure
Swelling of the prostate gland may cause a feeling of constipation or an increased urge to go to the toilet
The brachytherapy team at the hospital will give you more advice on what to expect, and help you to overcome any difficulties you may experience.
For further information on side effects, click here.
Completion Of Treatment
The radioactivity in the seeds wears off over time and they do not need to be removed from the body. The low dose of initial radioactivity will have decreased by half within 60 days and then to a very low level after 9–12 months when treatment is considered to be complete.
Follow-up Care & Finding Out If The Treatment Has Worked
Most importantly, you will want to know how successful the treatment has been. You will be given regular blood tests to measure your levels of prostate-specific antigen (PSA) which provides an indication of the level of treatment success. PSA levels will be measured at 3–6 months after treatment and then again at 12–18 months. Remember, even after successful treatment there will always be a low level of PSA present for as long as the prostate gland remains.
The Hospital Team That Will Be Involved In Your Brachytherapy Treatment:
Anaesthetist: a doctor who gives both local and general anaesthetics.
Nursing staff: qualified nurses who look after your general care and treat any side effects, and health care assistants who support the nursing team.
Nurse specialist: a nurse who is trained and experienced in working within a particular area of cancer or other type of disease. They also have specific experience in the different types of treatment.
Oncologist: a doctor who specialises in treating cancer. Some oncologists specialise in particular types of cancer treatment.
Physicist: a healthcare scientist who calculates the number of seeds and their position for your treatment, and is also responsible for making sure that safe radiation practices are followed.
Radiologist: a doctor who specialises in x-rays and reading body scans and images. They will also carry out the ultrasound for planning and guidance of the brachytherapy implant procedure.
Urologist: a doctor who specialises in treating problems of the urinary system.