Prostate cancer is the most common cancer in American men. According to the American Cancer Society, one in every six men will develop prostate cancer in his lifetime. This year, approximately 191,930 men will be diagnosed.

Treating Prostate Cancer
If you find out you have cancer, you should discuss your treatment options with a radiation oncologist – a cancer doctor who specializes in treating disease with radiation therapy, a urologist – a surgeon who specializes in the genital and urinary systems and a medical oncologist – a cancer doctor who specializes in treating cancer with chemotherapy.

Prostate cancer treatment options include:

• External Beam Radiation Therapy – a radiation oncologist directs high-energy radiation to kill the cancer cells.
• Brachytherapy – a radiation oncologist surgically implants high-energy radiation seeds or delivers a high-energy radiation source through catheters within the prostate.
• Surgery – a urologist surgically removes the entire prostate.
• Active Surveillance – a physician monitors men with low-risk prostate cancer with repeat PSAs and biopsies.
• Hormone Therapy – radiation oncologists, urologists or medical oncologists prescribe medicine to stop the production of hormones that help prostate cancer grow.
• Chemotherapy – a medical oncologist prescribes medication as a pill or medicine delivered through the veins to kill cancer cells.

Sometimes a combination of treatments is best for your cancer, such as hormonal therapy along with external beam radiation therapy. Ask your doctor about the risks and benefits of all treatment options including active surveillance.

EXTERNAL BEAM RADIATION THERAPY

External beam radiation therapy (also called radiotherapy) involves a series of daily treatments to accurately deliver radiation to the prostate. Research has shown that higher doses of radiation can improve cure rates. Modern radiation therapy is as effective as surgery to cure prostate cancer.

Before treatment begins, your radiation oncologist will develop a treatment plan using information from your biopsy, imaging and physical exam. A CT scan is done in the position you will be treated, often with a supportive device to keep you comfortably in the same position for treatment. This is often called a simulation. Sometimes, your treatment plan will include not only the prostate but also the seminal vesicles (glands on the back of the prostate) and lymph nodes. Ask your doctor to explain what treatment area is appropriate for you.

With CT scans, 3-D targets of the prostate and normal tissues are created. These treatment plans focus radiation beams on the prostate while limiting radiation to healthy tissues around it such as the bladder and rectum. Intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) are treatment approaches that allow the radiation beams to treat the cancer and lessen the risks of side effects.

External beam radiation therapy can be delivered using a variety of techniques. In most cases, external radiation is in the form of high-energy photons, or X-rays. In a few clinics around the country, proton beam therapy is used to treat prostate cancer. Proton therapy is a form of external beam radiation therapy that uses protons rather than photons to treat cancer cells.

With all external beam therapy, treatment is delivered in a series of daily sessions, Monday through Friday, for several weeks. Each treatment is painless and similar to a long X-ray. You will hear noise but will feel nothing.

The length of your treatment will depend on your health and the type of radiation used. The use of even shorter schedules of external beam radiation therapy is being studied for patients with early-stage prostate cancer.

Hypofractionated radiation is a form of daily treatment giving higher doses over four to six weeks compared to a more standard treatment time of seven to nine weeks. Stereotactic body radiation therapy (SBRT) is a technique for treating cancers in five or fewer treatments at substantially higher doses. Hypofractionated and stereotactic radiation are currently being evaluated for long-term data and may be considered for certain patients.

PROSTATE BRACHYTHERAPY

Brachytherapy involves treating the cancer by inserting radioactive sources directly into the prostate.

Permanent seed, or low dose rate (LDR) brachytherapy, consists of inserting small metal “seeds” directly into the prostate gland. This treatment is done as an outpatient surgical procedure and requires anesthesia. The seeds are temporarily radioactive and deliver the radiation to the prostate over several months. After losing their radioactivity, the seeds remain in the prostate. The seeds are then harmless and should not bother you.

For the short time that the seeds are giving off larger amounts of radiation, men should avoid being in close proximity to children or pregnant women. Ask your radiation oncologist or oncology nurse for instructions about radiation safety and exposure for family members or pets.

Temporary, or high dose rate (HDR) brachytherapy, delivers radiation to the prostate with a few treatments using a single small radioactive source traveling through each of the narrow tubes called catheters. These narrow tubes are inserted into the prostate by your radiation oncologist. You will be under anesthesia and will not feel any pain. The tubes remain in place for one to two days only.

Once the treatment is complete, the tubes are taken out. HDR brachytherapy is temporary and there is no radioactivity left in your body. You will not need to take special precautions around others after treatment. Often multiple treatments are planned to give an effective dose to treat the cancer.

Brachytherapy may be used to treat prostate cancer alone or may be combined with external beam radiation therapy and hormonal therapy. Ask your doctor whether LDR or HDR is a reasonable treatment option for you.

CARING FOR YOURSELF DURING TREATMENT

It is important to care for yourself as well as possible during radiation therapy.

• A balanced diet, a mild amount of physical activity, and taking time to rest are all important parts of your cancer treatment.
• Nutrition is important. Eat a balanced diet. Let your doctor know if you have trouble swallowing, food tastes funny or you have trouble eating.
• Follow your doctor’s orders, and if you are unsure of anything, ask your nurse or doctor any question you may have about your treatment.
• Be sure to tell your radiation oncologist about any vitamins or dietary supplements that you are currently taking to make sure they are safe to take during radiation therapy.
• Treat the skin exposed to radiation with special care. Stay out of the sun, avoid hot or cold packs, and only use lotions and ointments after checking with your doctor or nurse.
• You should also be sure to clean the skin over the areas receiving radiation therapy with warm water and mild soap.

Completing treatment and recovery can be challenging. Seek out help from support groups and friends ahead of time. If you have a support network in place before and during treatment, it will be easier to get through side effects, since people you can count on will be around to help you. If you need additional support, let your doctor and nurse know.

POSSIBLE SIDE EFFECTS

External beam radiation therapy is not invasive, so it is rare for side effects to show up immediately. With brachytherapy, there may be some swelling, soreness and frequent urination just after the procedure. However, these side effects are from the brachytherapy procedure rather than the radiation itself. Over a period of weeks, other side effects may develop:

• Urinary frequency, urgency or a weaker stream are reasonably common side effects. Sometimes there is mild discomfort. The symptoms tend to be more noticeable with brachytherapy. Your doctor can prescribe medication to help relieve these symptoms.
• Changes in bowel habits are also common. There is usually some urgency or loose bowel movements. In some cases, you may have some diarrhea, increased gas or some mucus. Less commonly, some men have a flare of hemorrhoids. These side effects are temporary, with long-term symptoms less likely.
• Mild tiredness may develop, starting in the middle of treatment. However, tiredness from radiation should improve within a few weeks after radiation treatment ends.
• Mild skin irritation may occur with external beam radiation. Clean the area regularly with mild soap and warm water.
• Impotence is a common side effect of any treatment for prostate cancer. The risk depends partly upon the ability to have an erection before treatment. Many men treated with radiation can maintain erectile function. Don’t be shy about talking to your doctor about your sex life. He may be able to suggest remedies or prescribe medication.
• Infertility can often occur after radiation. If you are considering having children after radiation treatment, ask your doctor about sperm banking before treatment.

Some side effects can be controlled with medications and changes to your diet. Ask your doctor or nurse whether you should make any changes in your diet. Tell them if you experience any discomfort so they can help you feel better.

© American Society for Radiation Oncology, 2019.