This is sometimes called LDR brachytherapy or low-dose rate brachytherapy or sometimes seed implants.
At the present time prostate brachytherapy is undertaken in 2 centres in Scotland – Edinburgh and Glasgow. Brachytherapy is available to all men with prostate cancer (who are suitable for and select this treatment option) across Scotland. Eligible patients will be referred to the brachytherapy consultant in Edinburgh or Glasgow by their local hospital urology or oncology team and must be prepared to travel to Edinburgh or Glasgow.
Brachytherapy is a method of delivering a kind of radiotherapy where tiny metal seeds that emit radiation are placed or implanted into the prostate, working to kill cancer cells from inside the body. The ‘seeds’ are placed throughout the prostate to match the shape and size of the prostate. This is to try to make sure that the radiation reaches all the cancer cells.
About 60-120 seeds will be placed into the prostate with each seed being smaller than an uncooked grain of rice. The exact number of seeds used will vary according to the size of the prostate itself and where the cancer cells are. The amount of radiation, and the effect it has on the cancer cells, is decided by the number of seeds implanted (put) into the prostate and by getting them into exactly the right place; the number of seeds and where they are placed will vary from patient to patient.
The seeds stay in the prostate, slowly giving out radiation for around 9 months, until they are no longer active. Because the seeds send out low level radiation, very little escapes from the prostate, so don’t worry you won’t be radioactive. The seeds will remain in the prostate when they are no longer active. There is a booklet on Brachytherapy which can be downloaded here
Why might Brachytherapy be suggested?
- When the cancer is contained within the prostate and is thought to be low or intermediate-risk; see Early prostate cancer booklet (page 29)
- When your Gleason Score is 7 and below or Prognostic Grade Group 1, 2 or 3; (see EPC page 25)
- When the prostate is measured and is not too bulky (less than 50 cc). Sometimes, hormone treatment is used to shrink prostate glands that are between 50 and 70 cc, so brachytherapy can be used;
- For men who are expected to live for at least 10 years;
- When the PSA level is below 20 ng/ml;
- For men who don’t have severe problems when passing urine; in other words have a strong flow of urine
- For men who have not had external beam radiotherapy (EBRT) to the pelvis;
- If the man has previously had a Transurethral Resection of the Prostate (TURP) then brachytherapy may be a less suitable treatment option. The oncologist or CNS responsible for care will give more advice on this.
Preparing for a brachytherapy
Why might hormone therapy be needed before brachytherapy?
Some men may need hormone treatment. If the prostate is measured and is too large for the seed implant, the oncologist may decide to start hormone treatment for around 3 – 6 months. As the male hormone testosterone fuels the growth of prostate cancer, the aim of hormone therapy is to remove as much of this testosterone as possible. Reducing the amount of testosterone allows the prostate to shrink making brachytherapy possible.
What is hormone therapy?
Hormone treatment can be given in two ways, by an injection or taking tablets. At the beginning, you will often have both.
By taking a tablet, testosterone can be blocked from getting into the cancer cells. This may be given for a week or two before starting injections and may be continued for a week or so after your injections have started.
Testosterone production is ‘switched off’ by having an injection. The site (where on your body) and how often you are likely to have the injection will vary according to individual circumstances. Injections might be given once every 4 weeks or every 12 weeks or every 24 weeks. You will most likely be given the injection by your GP or nurse at your local clinic.
What happens with brachytherapy
Brachytherapy is usually done in two stages. In both Edinburgh and Glasgow, you will be admitted to the ward on the day that you are having your seed plants done.
The planning stage. This measures the size and shape of the prostate. This information helps the specialist team work out and plan how many radiation seeds to use and where to put them. Each man will have an individual plan.
What happens during the operation
An ultrasound probe will be put into the back passage to help the oncologist see exactly where each needle is going.
The seeds are loaded into about 20 – 35 very fine, hollow needles. To make sure the needles reach the correct area of the prostate, a metal grid or template which has a very regular pattern of holes is placed in front of the perineum. (The perineum is the skin behind your scrotum and in front of the back passage) The needles containing the seeds are inserted through the grid and perineum into the target areas in the prostate. When the doctor confirms that all the needles are in the correct position to accurately target the tumour(s), the seeds are pushed out of the needles and the needles are withdrawn.
Usually between 60-120 seeds are passed through the needles, either as individual seeds or as strands with several seeds joined together. The seeds stay in the prostate slowly giving out radiation until they are no longer radioactive and will remain in the prostate forever.
After the operation it’s likely that some medication will be given to help the man pass urine. It may be that he is asked to use a urine bottle rather than the toilet in case a seed(s) is passed in urine although this is not very common and it’s nothing to worry about.
Will I have an anaesthetic?
Yes. You will usually have a general anaesthetic (where you will be asleep) and the operation generally takes about 1-2 hours. Very occasionally, a spinal anaesthetic may be used instead of a general anaesthetic.
Will I have to stay in hospital?
An overnight hospital stay may be required on the other hand you may be discharged on the day that the implant was done. It’s a good idea to wear some loose fitting trousers for going home so that you feel comfortable.
Potential side-effects of brachytherapy
This is usually for a short time and it is caused by the needles going through the perineum into the prostate. Pain-killers will help with this. A warm bath may also help ease the discomfort.
Problems passing urine
You may find passing urine causes some pain, have a slow stream when passing urine and you may need to pass small amounts of urine but much more often. These symptoms should settle after about 10-12 weeks. If you’re concerned, contact your CNS. It’s also quite common to see traces of blood in your urine for several days after your operation.
Difficulties with erections
You may find that you have difficulty in getting and keeping erections. If this is the case then speak with your consultant or CNS as there are treatments that can help. It’s quite common for it to be slightly painful when you ejaculate and the ejaculate may be stained dark brown or red. For further information about erectile dysfunction see our Prostate conditions and erectile dysfunction.
For the first 2-3 months (or for 6 ejaculations) you should use a condom during intercourse in case you pass a seed.
You may not have any side-effects for the first few days. However, if you feel any discomfort you can take simple painkillers, such as paracetamol or ibuprofen, to help with this. Remember to finish your full course of antibiotic tablets to prevent an infection after the implant.
You may be given a tablet (tamsulosin) to help make it easier for you to pass urine. This might continue for between 3-6 months. A small supply may be given from the ward then prescribed by your GP.
How you might feel:
In the first 2 or 3 days after the implant you may find:
- Tenderness over your bottom when you sit down;
- A small amount of blood in your urine which will possibly last a few days;
- Bruising underneath your scrotum and possibly going down your thighs, but this should disappear within a week or two.
Although this doesn’t happen very often, if you have any of the following signs then you should get in touch with your GP or NHS 24 as these could be the signs of an infection:
- Your temperature goes up, you feel chills and are shivering;
- You can’t pass urine;
- Your urine is very bloody or there are blood clots in your urine;
- You have difficulty in passing urine.
Follow up appointments
After 4-6 weeks you will most likely go back to the hospital to have a CT scan to check that the dose and position of the seeds were correct.
How do I know if the treatment has worked?
To make sure that the treatment has worked, you will have a PSA blood test in about 3 months and then 3-6 monthly afterwards. The PSA level often gradually decreases over many years.
Occasionally, at around 2 years, some men may experience ‘bounce’ or ‘spike’ in the PSA level. This doesn’t necessarily mean that your treatment isn’t working and your oncologist or CNS will most likely want to chat over why this might happen.
Your Brachytherapy Information Card (BIC card)
After your implant you will be given or sent an information card to carry and you should carry this card with you at all times. The card gives other doctors and nurses who may be treating you essential information that they need to know to keep them safe. You, the CNS or oncologist should fill in any blanks on the card with the information about your treatment. If you’re not given a card, it may be a good idea to ask for one.
It’s particularly important to carry this with you, if travelling away from home or going abroad. Some security monitors, such as at airports, are very sensitive and can detect low levels of radiation. To get over this difficulty, you can show your brachytherapy information card which gives details about your seed implants so you can confirm your treatment with security people.