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PROSTATE CANCER

Brachytherapy is a powerful modern treatment for prostate cancer that can help preserve a patient's quality of life. The brachytherapy procedure involves the surgical implantation of radioactive seeds into the prostate gland. Between 60 and 120 seeds are delivered into the prostate through hollow needles under ultrasound visualization, an extremely accurate way of guiding placement. The radioactivity kills the tumor cells.

Brachytherapy is associated with a lower incidence of impotence and incontinence compared to prostate surgery. Even though prostate cancer is the second leading cause of cancer-related death in men after lung cancer, if the cancer is detected early enough, the 5-year survival rate for men is almost 100%.
 
This site is not intended as a substitute for professional medical care. Only your physician can diagnose and appropriately treat your symptoms.
 
 

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FREQUENTLY ASKED QUESTIONS

How long ago did doctors start performing prostate seed implants as treatment for prostate cancer?

Prostate brachytherapy has been performed since the 1960s. Modern techniques were introduced in the early 1980s when Dr. Holm (in Denmark) developed the first transrectal ultrasound-guided transperineal prostate seed implants (TPPI). Physicians from the USA then learned this technique and began performing TPPI in the USA in the late 1980s. The procedure has undergone major technical innovations in the last five years.

How does the implant treat the cancer?

If you think about the way that ripples extend concentrically from a pebble tossed in a pond, you can imagine how the gamma radiation extends out from each seed. Seeds are strategically placed such that the radiation of each seed interact with that of other seeds in a manner that gives the optimal dose of radiation to the prostate while minimizing the radiation dose to the other body tissues.

How does the radiation kill the cancer cells?

The radiation does not actually kill the cancer cells outright, but causes damage to the genetic material (DNA) within the cells. If the treated cancer cells were biopsied and viewed through a microscope, they would appear alive and active. The destruction occurs when these injured cells attempt to reproduce by the process of mitosis (cell division). They self-destruct, die, and are eliminated by the normal body mechanism that eliminates dead cells. The idea is to give a high enough radiation dose to destroy the reproduction capabilities of every last cancer cell.

Are normal tissue and organ cells also killed?

Yes, normal cells of the tissues and organs that receive the radiation dose from the prostate seed implant are also injured. Some of the normal cells can repair the damage while others will die in a manner similar to that described above. Fortunately, however, cancer cells are much more sensitive to radiation than healthy normal cells and one has many more normal cells than cancer cells in the area being treated, and it is by this mechanism that every last cancer cell can be destroyed while sparing enough normal cells for the normal body tissues and organs to recover. It is the damage to the normal body tissues and organs that causes the side effects of the treatment.

Why do prostate seed implants cause less damage to the normal body tissues such as the rectum and bladder than external beam radiation therapy?

Radioactive implant seeds give off a very low energy gamma radiation that travels for a very short distance. When the seeds are strategically placed, it is possible to minimize the damage to the normal body tissues in the rectum, bladder, urethra, and erectile mechanism

When will the commonly observed side effects of prostate seed implant therapy occur?

Some of the side effects from radiation therapy (either external beam radiotherapy or prostate seed implant therapy) occur within days or weeks of the treatment and are called the acute side effects. Other side effects, known as late side effects, may not appear for six or more months after the treatment.

What is the risk of the seed implant therapy affecting your ability to have erections adequate for satisfactory sexual intercourse?

If you already have erectile dysfunction and either are not able to have erections or have only partial erections that are not sufficient for intercourse, more likely than not you will have erectile dysfunction after the prostate seed implant. If your erections are barely rigid enough for intercourse, or if they do not sustain adequately, you will have a very high risk of erectile dysfunction after the prostate seed implant therapy. There are possible treatment options for erectile dysfunction that you may wish to pursue. If you have reasonable good erectile function prior to the prostate seed implant, you will have about a 60% to 80% likelihood of having adequate erections after the prostate seed implant. Nearly all the treatment options will work well for those whose erections were good prior to prostate seed implant but impaired afterwards.

Is it safe to be around other individuals or sleep with your partner after the prostate seed implant?

Since the radiation from radioactive seeds used for prostate implantation is so weak, very little radiation leaves your body and you are not a radiation risk to those around you. From a radiation safety perspective, you may sleep in the same bed with your partner. Sexual intercourse may be resumed within the first few weeks after the seed implant. Since there is a remote risk of ejaculating a seed, you should wear a condom for the first few times you have intercourse. If you notice a seed and can retrieve it, please do so using tweezers, placing the seed in aluminum foil, about 6x6 inch, wrap it tightly and return it to your center to be disposed of safely.

However, It is strongly recommended that you avoid close contact with children and pregnant women for a couple of months following a prostate seed implant. In the future if you seek medical help in any institution or doctor’s office, related to your implant or not, please inform the provider of the date of your seed implant and the name of your Radiation Oncologist.

Please remember to call your Radiation Oncologist if you are in pain or discomfort after the implant or have any questions about your post implant care.

What are prostate implant seeds?

The medical devices commonly referred to as seeds are really small individual radioactive sources. They are 4.5 mm (3/16 in.) in length and 0.8 mm (1/32 in.) in diameter. Each consists of an outer titanium shell (seed) into which the radioactive isotope (Iodine–125 or Palladium–103) is then inserted, along with radiopaque markers (so that the individual seeds can be seen on x-ray films and with fluoroscopy), and microscopically laser-welded shut to keep the radioactive material within the device.

How are Iodine-125 and Palladium-103 produced?

While Iodine-125 is a naturally occurring radioactive element, the I-125 used in the implant seeds is made in a nuclear reactor. Palladium-103 used in radioactive seeds can be produced either in a nuclear reactor or in a high-energy particle accelerator (cyclotron).

What kind of radiation do the implant seeds emit?

Radioactive seeds emit low-energy gamma rays (which are like x-rays) and low energy beta particles (which are like electrons). However, the titanium shell of the seed filters out nearly all the emitted radiation except that which is desirable for the treatment of cancer. What the seed ultimately emits is predominantly a low-energy gamma ray that is a very weak type of x-ray.

Is there any advantage of one isotope over the other?

To date, there is no clear answer as to whether one type of radioactive seed is better than another. The two most commonly used radioactive seeds are Iodine-125 and Palladium-103 seeds. While many physicians have an opinion as to which type of seed is best, it is important to recognize that this is, in reality, an unanswered medical question. Excellent results have been demonstrated with both isotopes.

What is the potential benefit of using radioactive seeds?

Since I-125 and Pd-103 seeds emit a very weak gamma ray, it is possible to strategically place them in and around the prostate in a manner that minimizes the radiation dose to normal tissues and organs such as the urinary bladder, urethra, nerves and blood vessels that allow for erectile function, and rectum while optimizing the dose to the prostate cancer. As a result, the side effects of the treatment are minimized while the cure rate of the cancer maximized. If you are planning to travel via airline, the radioactive seeds may activate the airport security system. Please request a letter to carry with you when you fly.

What is the difference between preplanned prostate implants and real-time prostate implants?

The majority of physicians performing prostate seed implants in the United States do so using a preplanned procedure. Patients having a preplanned prostate seed implant procedure have a special ultrasound scan performed days to weeks before the actual seed implant is performed. Your Radiation Oncologist and Urologist then determine the areas of the prostate and surrounding structures that need to be treated, as well as those that need to be protected. The Radiation Physicist or Dosimetrist then enters this information into a treatment-planning computer. A plan is formulated that optimizes the seed placement for your prostate.

An order is then placed for the number of seeds needed for your prostate implant, at a precise radioactive strength per seed. The Urologist and Radiation Oncologist then follow the preplan in the operating room and perform the procedure as it was designed. Of course, the situation is often slightly different during the operation than at the time of the preplanning ultrasound study, and your physicians will make the necessary intraoperative modifications.

The other commonly used prostate implant technique is called a real-time prostate implant. Based on the volume of your prostate, a given number of seeds of a given radioactive strength are ordered based on a nomogram (a reference table of sorts). Then the Urologist and Radiation Oncologist determine where the seeds will be placed when the implant is performed in the operating room using data from the ultrasound machine and a powerful, portable computerized treatment planning system. This makes adjustments for gland changes due to positioning or other factors far easier.

Will there be a lot of pain after seed implant therapy?

No, most people are comfortable after the procedure and usually an over-the-counter preparation such as acetaminophen or ibuprofen is all that is necessary to alleviate any discomfort that may occur. Avoid heavy lifting or strenuous activity for the first five days following seed implant.

What sort of urinary side effects can occur after seed implant therapy?

Most of the urinary side effects occur after a prostate seed implant and are a minor problem for the first few months after the seed implant. Other potential problems don’t usually occur until six months or longer after the prostate seed implant. Some of the acute side effects of seed implant therapy are due to the swelling and bleeding within the prostate as a result of the trauma of the needle and seed placement that occurs during the operation. Other acute side effects are due to the radiation injury to the normal body tissues. This swelling narrows the urinary tract and often results in the urinary stream being weak, urinary dribbling, stopping and starting of the urinary stream, having to push or strain to begin urination. The acute side effects of the radiation are manifested primarily as increased urinary urgency and a burning or stinging sensation during urination, similar to that of a bladder or prostate infection. Your physician will likely prescribe a variety of medications to help minimize the discomfort from these symptoms. Sometimes the bladder becomes severely obstructed by the swelling and a Foley catheter must be placed back in the bladder for a few days or, on occasion, a few weeks. If it appears that this will be a problem for a few months, the patient will either be taught to catheterize himself or an indwelling catheter will be placed. The main possible long-term side effects are chronic bladder outlet obstruction, urethral ulceration, and urethral necrosis with resultant pelvic pain; very rarely, urinary incontinence; and, extremely rarely, formation of a track between the rectum and urethra (called a fistula) with leakage of urine from the rectum.

What sort of rectal side effects can occur after seed implant therapy?

In general, very few rectal side effects occur after prostate seed implants. However, sometimes side effects do occur. Some may occur shortly after the implant while others may not occur until many months later. The most common side effects during the first few months after the implant are an increased urgency of bowel movements; slight burning sensation of the rectum during bowel movements (kind of like hemorrhoid type of discomfort); and, rarely, some leakage of brown mucous type material with the passage of rectal gas. The main long-term problem is formation of a painful rectal ulcer if an implant seed is placed too close to the rectal wall or even into the muscle of the rectal wall. Some patients will have rectal bleeding similar to that which occurs after external beam radiotherapy. Extremely rarely, there can be a formation of a track between the rectum and urethra (called a fistula) with leakage of urine from the rectum.

What is the post-implant dosimetric evaluation?

Regardless of which technique your physician uses to perform your implant, you will very likely have an evaluation of your prostate seed implant performed the same day as your implant or within the month following your prostate seed implant. This often involves having certain radiological studies performed.

A CT scan through the prostate region is obtained. This allows your Radiation Oncologist to see the implant seeds, the prostate, and other surrounding organs and structures, as well as the actual location of the seeds within and around the prostate. This information is entered into the 3-D treatment-planning computer and your implant can be carefully evaluated to assure that the desired result was actually achieved.

 
 

Questions to Ask Your Doctor

  • What stage is my cancer?
  • Explain the exams and tests for detecting prostate cancer.
  • What is my PSA level? What does this mean?
  • Explain the Gleason Grade.
  • What are my treatment options?
  • What are the risks and side effects for the different treatments?
  • Do you recommend a combination therapy?
  • What are the chances that I will have problems with incontinence or impotence?
  • When can I resume my normal activities?
  • What are the chances my cancer will return?
  • What are my options in case my cancer does return?

UNDERSTANDING THE DISEASE

What is Prostate Cancer?
How is Prostate Cancer Diagnosed?
How is Cancer Staged?
How is Prostate Cancer Treated?
How is Brachytherapy Done?

What is Prostate Cancer?

More Common Than You Think. 
According to the American Cancer Society, prostate cancer is the most common form of cancer in adult males. Not surprisingly, it is the second leading cause of cancer-related deaths in men, trailing only lung cancer in its deadliness. If you are an adult male, you have a one-in-six chance of developing prostate cancer during your lifetime. 

The prostate is a walnut-sized gland that sits below the bladder and surrounds the upper part of the male urethra. The prostate produces nutrients for sperm and typically enlarges as men age.

Prostate cancer usually affects men over 65 and is rarely seen in men under 40. The disease occurs in African-American males at a higher rate than others. Public awareness of prostate cancer is more important than ever considering that the number of men aged 50 or over in the U.S. will have increased by some 30% from 1995 to 2005. 

In its early stages, prostate cancer shows no symptoms. Once they appear, symptoms include weak or interrupted urine flow, difficulty controlling urination, frequent urination, especially at night, painful urination, blood in the urine, and persistent lower back or pelvic pain. 

Because symptoms are silent early on, around 20% of prostate cancers are detected after the disease has spread beyond the prostate gland into other tissues or organs, which dramatically impacts a patient's long-term survival. If the cancer is caught while still in the prostate gland, it can be effectively treated, especially with brachytherapy. 

How is Prostate Cancer Diagnosed?

Several techniques detect and confirm the presence of prostate cancer. Two basic tests—a DRE and a PSA—determine the presence of abnormalities in your prostate. If the tests uncover abnormalities, a biopsy and an imaging test are usually performed to confirm the presence of cancer and to accurately locate it within the prostate. Once the cancer is identified and localized, a process called cancer staging helps physicians characterize the cancer and how far it has advanced into the body. 

DREs and PSAs 
      There are two ways to initially detect prostate cancer. The first is a digital rectal exam (DRE), which can be performed during your annual physical check-up. The doctor inserts a gloved finger into the rectum to feel the surface of the prostate for abnormalities. The second method, a Prostate Specific Antigen (PSA) test, is a simple blood test that checks your blood for elevated PSA levels, which would suggest an enlarged prostate and the possibility of prostate cancer. The PSA is measured in ng/mL. 


PSA Scoring 
      0-4 Low cancer risk 

      4-10 Slightly elevated risk 

      10+ Abnormally Elevated risk 


      Your doctor may be using a different scoring scale depending upon your age, ethnicity or family history. 


Biopsies 
      If either the DRE or the PSA tests show abnormalities, physicians will generally conduct a biopsy of the prostate, during which the physician will remove a small piece of tissue from the prostate and have it checked for cancer. Biopsies are scored on a scale of 2 to 10. The score is a measure of how quickly the tumor is growing. The higher the score the more aggressive the tumor. 


Gleason Scoring for prostate biopsies 
      2-4 Low Aggressiveness 

      5-6 Moderate Aggressiveness 

      7-10 High Aggressiveness 


      Once the biopsy is completed and scored, imaging tests like an MRI, CT scan or ultrasound are used to determine the exact location of the tumor. 

How is Cancer Staged?

After the prostate cancer is confirmed and located, the cancer is staged. Cancer staging defines how far the cancer has spread and whether it has moved beyond the prostate. There are four stages. 

      Stage 1: Cancer in its earliest stage; confined inside the prostate gland. 

      Stage 2: Cancer is still localized in the prostate, in the form of a hard nodule. 

      Stage 3: Tumor has spread outside the prostate to surrounding tissues. 

      Stage 4: Cancer has spread outside to other tissues and possibly other organs. 

Most physicians stage prostate cancer with a system called the TNM staging system. The TNM is internationally recognized and essentially describes the stages of prostate cancer and corresponding treatment methods. Another equally effective system is the ABCD/Whitmore-Jewitt system. In either case, your physician will use the system to tell you the stage of your disease and explain the treatment options.

How is Prostate Cancer Treated?

The ideal treatment for prostate cancer stops the disease in its tracks and eradicates it without disturbing the patient's quality of life. The information provided on this site is not intended as a substitute for professional medical care. It is up to you and your physician to choose the best combination of treatments to best address your situation. The most common treatments are profiled here. 

Watchful Waiting 
Involves regular observation of the cancer to evaluate any changes that may have occurred. Typically used for slow-growing tumors or for very elderly patients. The advantage of watching and waiting is that the patient is not subjected to any treatment. The disadvantage is uncertainty about the progression of the disease. 

Surgery 
Prostate surgery is called radical prostatectomy, and removes the entire prostate gland and often some surrounding tissue. Surgery is a one-time procedure that may remove all of the cancer if it is detected early enough, but the procedure typically requires hospitalization of 5 to 7 days, results in a lengthy recovery period, and may not be well-tolerated by older men. Prostatectomy can also produce side effects that have a significant impact on the patient's quality of life, the most common being impotence (inability to maintain an erection) and incontinence (loss of bladder and/or bowel control). 

External Beam Radiation 
Utilizes radiation to stop the growth of cancer cells. A beam of radiation is delivered from outside the body through normal tissue to the site of the cancer. Since it is not a surgical procedure, external radiation tends to be well tolerated. It has shown a fairly high cure rate when the cancer is detected early, and the incidence of impotence and incontinence is lower than with radical prostatectomy. The disadvantages of external radiation include almost daily visits to the hospital for about two months, the risk of radiation damage to healthy tissue, plus fatigue, nausea and rectal irritation or bleeding. When the cancer is not particularly well defined, external beam radiation is sometimes used in combination with other forms of treatment. 

Hormone Therapy 
A form of therapy, but not a cure for the disease. The goal of hormone therapy is to lower the level of the male hormones (androgens), which promotes the shrinking of the prostate gland and a slowdown in growth of the tumor. Hormone therapy is often used before or combined with other forms of treatment and is usually the preferred option for a patient with advanced prostate cancer. Advantages include relief from symptoms of disease, a slow-down in growth of the tumor, and a prostate gland that becomes more receptive to other treatment. Disadvantages include impotence, infertility, cardiovascular problems, nausea and a decrease in libido. 

Cryotheraphy 
The controlled freezing of the gland in order to destroy the cancerous and the native prostatic cells. Studies show that cryosurgery results in a long-term survival rate equal to that of radical prostatectomy. Precise monitoring during the freezing process has greatly improved with the advent of advanced transrectal ultrasound, advanced cryo technology and improved interventional radiology skills. Advantages to Cryosurgery include no blood loss, no surgical incisions and outpatient surgery. Disadvantages include the fact that no long-term randomized multi-center studies have been conducted. Also, some insurance companies do not cover cryosurgery, usually because they list the therapy as investigational. The American Urologic Association has approved the procedure, however, meaning it no longer has investigational status with them. If you point this out to your insurance company, you may get coverage. Lastly, the procedure is highly operator dependent. 

Brachytherapy 
The permanent implantation through hollow needles of radioactive seeds into the prostate gland, guided by ultrasound imaging. Brachytherapy is often used as a sole treatment approach but may also be used in combination with other therapies, such as external beam radiation or hormone therapy. Advantages of brachytherapy include: the precise targeting of the radiation, which spares healthy tissue, a procedure that lasts about an hour-and-a-half and is performed on an outpatient basis, a lower risk of impotence and incontinence than either surgery or external beam treatment, and little to no impact on the patient's quality of life. Disadvantages include some incidence of impotence and incontinence, frequent urination and, occasionally, blood in the urine.

How is Brachytherapy Done?

The brachy in brachytherapy means short in Greek, and refers to the precision of this remarkably targeted, minimally invasive therapy; radiation seeds are placed in extremely close proximity to/or even within the targeted tumor. Used since 1965, brachytherapy has improved dramatically over the years. The introduction of transrectal ultrasound has vastly improved a physicians ability to guide the insertion of hollow needles into the prostate. New imaging technologies, computerized treatment planning and the advent of palladium in the early 1990s as a source for radiation have further refined the technique. 

Brachytherapy, unlike most treatments, relies on a team of specialists to complete the procedure. The team includes urologists, radiation oncologists and medical physicists. Together they determine in advance the radiation dosage and number of seeds required, as well as the exact location in the prostate where the seeds need to be placed. 

This page walks you through the stages of brachysurgery and familiarizes you with the equipment your physician will use. 

Brachytheraphy Equipment 
The comprehensive nature of brachytherapy treatment means that it requires a range of materials and technologies to implement. 

Seed implants
      (either iodine or palladium)—usually between 60 and 120 seeds for a typical case


Imaging equipment
      —an ultrasound rectal probe and a monitor allow the team to view and ensure the exact placement of each seed. 


Hollow needles
      through which the seeds are inserted into the prostate.

       

      A
mapping template
      serves as a guide for needle placement and seed delivery to the exact site where each seed must be positioned. 


Before The Procedure 
Before brachysurgery, physicians like to do a series of routine tests including a blood test and chest X-ray. Also, you will have an ultrasound test to determine the exact size, shape and location of your prostate. This test basically creates a map of the prostate and helps physicians determine how many seeds will be needed. 

The Procedure Itself 
Brachytherapy is typically treated as an outpatient procedure. The procedure itself generally takes about an hour and a half. You will probably be given general or spinal anesthesia to ensure your comfort during the procedure. During the procedure the ultrasound probe is placed inside the rectum to make the prostate visible on a monitor. This allows the team to view the placement of each seed. The hollow needles that deliver the seeds are inserted through the skin between the scrotum and rectum, and the seeds are placed into the prostate. Once the seeds are planted, your physician will check the X-ray monitor to make sure that all the seeds have been properly placed. 

After The Procedure 
After the procedure is finished, you will be taken to the recovery room until the anesthesia has worn off. Before you leave the hospital, you’ll be given specific instructions, pain medications, as needed and usually advice about avoiding strenuous activity. Sometimes your physician will prescribe an antibiotic. But you should be able to resume your normal daily routine in just a few days. As for the seeds in the prostate, the radiation in the seeds expires after about six months. 

Patient Education

Please click on the following to download and view information about Prostate Cancer.

Brachytherapy Procedure Instructions
Prostate Cancer - Information and Answers
Prostate Cancer - Information and Answers (Spanish)

GLOSSARY

The following terms will help you understand what your doctor tells you about your urinary incontinence, and your possible treatment.

View glossary terms

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