Low Dose Rate (LDR) Brachytherapy to the Prostate

Transcription

1 The Clatterbridge Cancer Centre NHS Foundation Trust Low Dose Rate (LDR) Brachytherapy to the Prostate Radiotherapy A guide for patients and carers

2 Contents LDR Brachytherapy... 1 Who is suitable for LDR brachytherapy?... 2 Advantages... 3 Disadvantages... 3 How effective is the treatment?... 3 Planning your treatment... 4 Your preparation for the implantation of the seeds... 5 What to expect after treatment... 7 Effects related to emptying your bladder... 8 Alert about other treatment in the future Alert Cards What to do if you find a seed Radiation and you Brachytherapy and sex Fertility Possible long term side effects Useful contacts Notes... 16

3 1 This information sheet is about the treatment of localised prostate cancer using permanent seed implant brachytherapy. You may wish to read it all before the procedure or in sections as they become relevant. This leaflet will explain: General information about brachytherapy Treatment planning Implantation of the seeds What to expect when you go home Side effects. LDR Brachytherapy LDR Brachytherapy is a form of radiation treatment and is an alternative to both radical surgery and external beam radiotherapy (EBRT- radiation delivered to your prostate from outside the body). It involves implanting radioactive seeds directly into the prostate gland allowing us to deliver a higher dose of radiation than is possible with EBRT. The radiation is concentrated in your prostate and so reduces the amount of normal tissue treated. Approximately 100 seeds are used and they stay permanently in your prostate. They give most of the radiation dose over the next few months and will have released about 95% of their radiation

4 2 after a year. The treatment is carried out at The Clatterbridge Cancer Centre on the Wirral and requires two procedures, both with a general anaesthetic. (If we think you are suitable for this treatment but not a general anaesthetic, it is sometimes possible to do it using a spinal anaesthetic instead). The treatment is designed carefully so that your entire prostate is treated. Who is suitable for LDR brachytherapy? There are many choices in the treatment of early stage prostate cancer. These include radical prostatectomy, EBRT, active surveillance, and brachytherapy. LDR brachytherapy may be appropriate if you have: No previous surgery to the prostate (TURP) No or minimal urinary symptoms A small prostate A cancer that is small and fully contained within the prostate gland A Gleason score less than 8 A PSA less than 15

5 3 Advantages Relatively simple procedure Usually only requires one overnight stay in hospital Quick return to normal life Reduced risk of long term effects to normal tissues e.g. bowel Your ability to have an erection may be better preserved than with other treatment options Disadvantages Urinary side effects tend to be more noticeable and last longer compared with external beam radiotherapy Two general anaesthetics are required You need to be aware that having radioactive seeds implanted requires some temporary changes to every day life style (see later) It is important that in the unlikely event of your death within 2 years of having the implant you are not cremated (see later) How effective is the treatment? Evidence shows that LDR brachytherapy is as successful as surgery in curing small, slow growing prostate cancers. PSA tests are used to monitor the effectiveness of any treatment. An American study showed that 85% of men had no rise in their PSA in the ten years after treatment, which is similar to the results of surgery.

6 4 Planning your treatment You need a pre-operative assessment. This appointment will be in the radiotherapy department. This will be carried out by a nurse practitioner and will about 45 minutes. You will have the opportunity to ask any questions you may have regarding your treatment. Please let us know if you take Aspirin, Clopidogrel, Warfarin or any other medication to thin your blood. Do not make any changes to your usual medications without first consulting your doctor. Before you can have this treatment, your prostate will have to be assessed to determine its size and shape. This will help us to decide whether this is the right treatment for you. We call this a volume study and it is also used to calculate the number of seeds needed. We admit you to the ward and then give you a micro-enema. You can do this yourself or can have assistance to do this. This is usually effective within 15 minutes. It empties only the lower end of the bowel to ensure it is clear during the procedure. The volume study is quick, but you need a general anaesthetic as we get the measurements by using an ultrasound probe in your rectum and it is important that you are relaxed. You should be able to go home later the same day although we advise you not to drive for 24 hours afterwards. Before you go we will give you the results of the assessment. If

7 5 this procedure is suitable for you, we will make an appointment for you to have the implant in two weeks time. You will receive a letter confirming this (and other information) a few days before hand. If your prostate is too big, we will give you an appointment to talk about other treatment options. One is to have hormone therapy for three months and then repeat the volume study. Hormone treatment usually makes the prostate smaller and will be having an effect against the cancer. If your prostate remains too big, in spite of the hormone therapy, other options will be discussed with you. Your preparation for the implantation of the seeds The need for bowel preparation will have been discussed at the pre assessment clinic. The choices are: A low fibre diet for 3 days beforehand and an enema just before the implant To use a strong laxative (issued at the clinic) the day before the implant This is important because your lower bowel must be empty when we do the implant to get a clear image of the gland and the seeds once placed into your prostate. You will come into hospital for 1-2 nights for the treatment. The length of your stay depends on how quickly you recover from the procedure.

8 6 In theatre you will have a catheter put into your bladder. You will also have the perineum (the area of skin between your scrotum and anus) shaved if necessary. Diagram of procedure image courtesy of The Prostate Brachytherapy Centre, Guildford, Surrey

9 7 A number of needles containing the radioactive seeds are passed through your perineum and into the prostate. The needles are then removed leaving the seeds in place. The procedure takes about 1 ½ hours. Before you go to the recovery room the catheter is usually taken out and we will put a cold compress next to the perineum to help reduce swelling. Later you go back to the ward and can have visitors if you wish. We will check on you regularly and give you painkillers if required. What to expect after treatment On returning from theatre your visitors may be concerned at your appearance. It is normal to look washed out and pale after an anaesthetic, but after short sleep we expect you to look much better. All being well you can go home the next day but only after we are sure that you can pass urine. We will check your urine with a radiation detector to see if you have passed any seeds. This is routine practice; there is no need to be concerned. We will ask you to arrange to be collected. Take plenty of rest for the first few days. You should be able to return to normal activities within a few days. The seeds are continuously giving off radiation to the prostate. These effects build up over time and start to be noticeable after a few weeks. If you do return to work you may find you need to take time off a few weeks after the implant when the side effects start to become troublesome (See side effects on next page).

10 8 We will give you an appointment to return to the hospital a month later to see the oncology doctor and have a CT scan. We use this scan to repeat the dose calculation to update our records. Effects related to emptying your bladder The effect of the implant causes the prostate to swell a little. This causes pressure upon the urethra (tube from bladder to body surface) as it passes through the prostate. As a result you may notice that you: Have a weak flow when you empty your bladder Get an urgent need to empty your bladder Have difficulties starting to pass water Get a stinging sensation when you pass urine We will give you some tablets (400 mcg once a day of Tamsulosin - Flomaxtra) to reduce these symptoms. We will give you a 14-day supply. A repeat prescription should be obtained from your GP. You may need to take it for 6-12 months. You need to get help quickly if you have great difficulty, or stop passing urine, often there is discomfort, pain or swelling of your lower abdomen too. You may need to have a catheter into your bladder. If so it will only be removed when the flow of urine is satisfactory without it. Sometimes this may take several months. If this problem continues for longer, you may need an operation to allow you to pass urine without the catheter. The surgery occasionally causes urinary incontinence.

11 9 You may also: have discomfort when you sit down Have blood stained urine-this should quickly settle Have discomfort at the site of the needle punctures. You can use simple over the counter painkillers (unless you are allergic to them) to relieve this discomfort, but avoid Aspirin. Aspirin thins the blood, which might make any bruising or bleeding worse. Contact your G.P. if you need stronger painkillers Get bruising beneath your scrotum that can spread to your upper thighs; this will gradually disappear In 3-4 weeks feel that you are constipated. The radiation causes inflammation within the prostate which in turn presses on the bowel. A high fibre diet can help but you may need to take something to soften your bowel motions e.g. Movicol 1-2 sachets per day or Lactulose. These can be prescribed by your G.P. Pass small amounts of blood especially when opening your bowels. It is normal and should settle without needing treatment. You can help yourself by: Eating high fibre foods to help keep your stools soft. You may find it helps to eat a piece of fruit with each meal Drinking approximately litres each day. In the first few months limit the amount of coffee, tea and cola type

12 10 drinks as these contain caffeine that can irritate your bladder. Decaffeinated drinks are acceptable. Moderate amounts of alcohol can be taken, but stop if you notice any irritation. Some find cranberry juice helpful, but do not drink it if you take Warfarin. Please note that more than a couple of glasses a day can cause your bowels to be loose. Drink less after 7pm so that you do not have to get up during the night to pass water. Talking to your G.P. if you have difficulty emptying your bladder. The dose of Tamsulosin (Flowmaxtra) can be increased. Some men find that sitting in a bath of warm water can help to start the flow. Alert about other treatment in the future For two years after LDR brachytherapy any form of treatment in your pelvic, abdominal or rectal area should be avoided if possible. If you do need any pelvic surgery your surgeon must contact us for advice beforehand. However it is safe to have an MRI scan. Alert Cards You will be give a yellow laminated card and asked to carry it on your person for 2 years after the implant, and to show it to any medical staff if you require any unrelated treatment (especially abdominal surgery). A second, green card will be given to you to give to your next of kin for reference.

13 11 Please ensure you carry this card if you go abroad as it can help to avoid problems with radiation detectors at airport security checks. What to do if you find a seed It is rare to pass a seed when you empty your bladder. For 2 weeks after the implant use a toilet rather than a urinal and flush it twice. After this time only flush twice if you know or suspect you have passed a seed. If you find one in your clothing do not handle with bare hands. Instead use a spoon and/or tweezers and flush the seed down the toilet as soon as possible. Radiation and you Although you have radioactive seeds inside your prostate, it is safe for you to go home, have visitors, greet, and sit next to most adults - see later. The type of radiation used gives a high dose within the prostate. The level of dose reduces dramatically outside that area and is almost zero at the skin surface but is highest on the back of the pelvis. For this reason we recommend against prolonged pelvic skin to skin contact with anyone for the next two weeks. It is safe for young children to be in the same room as you for as long as they wish. A peace of mind approach would be not to nurse children on your lap or sit very close to each other (less than 0.5m) for more than a few minutes or on multiple occasions per day.

14 12 It is safe to embrace or hold children for a few minutes each day. We recommended that if you wish to they are embraced or held at chest level while standing for the first two months after implantation. Brachytherapy and sex In the first few weeks after the implant, the risk of the seeds becoming dislodged is at its greatest. Ejaculation is most likely to cause this. It is important for the first 2 weeks not to have any sexual activity that causes ejaculation. This includes oral sex and masturbation. If your partner is a woman of child bearing age we strongly advise against having penetrative sex during this time. If one or more radiation seed(s) are passed on to her, there is a risk to the health of any future children should the seeds give a radiation dose to her reproductive organs (especially the ovary). A condom must be used for the first five ejaculations whatever the time delay after implantation and whether this is during sexual intercourse or not. You may prefer to have your first ejaculation without a partner in case of the rare event of a seed being passed into the ejaculate. While the radioactive seeds are inside you they are giving you the benefit of treating the cancer. However if they were to be placed inside another person (caused by your ejaculation) they could cause them harm.

15 13 If your partner is already pregnant you must use a condom for the whole pregnancy. If your partner becomes pregnant after you have had an implant, you MUST contact us so that accurate measurements of radiation dose can be made, and guidance given, if required to ensure the safety of your unborn child. Double-wrap used condoms and dispose of them in a dustbin outside. You may find that is it more difficult to get or maintain an erection and your semen is expelled with reduced force and volume. At first it may be discoloured brown or black. This is caused by bleeding during the implant. Fertility Prostate cancer treatment (i.e. hormones, radiotherapy, surgery), can impair sperm production and cause infertility. Depending on the stage of the disease and treatment choice, some men retain their ability to reproduce while others remain infertile for the rest of their lives, (i.e. after prostatectomy or removal of both testes). A noticeable reduction in the volume and consistency of the semen produced on ejaculation is common, becoming clearer and more liquid than before. This is likely to reduce your fertility but you can not assume that you are not able to make someone pregnant. You should therefore take contraceptive precautions if this is relevant.

16 14 If you want keep the option of having children in the future, discuss this before having LDR brachytherapy. One of the options is sperm banking. If you should die within 2 years of the implant In the unlikely event that you should die within 2 years of having the implant, it is very important that we are notified as soon as possible and before cremation or burial. Our staff can ensure that the regulations for cremation of people who have had this procedure are followed. In order to comply with strict rules it is very important that no person is cremated before this time limit with the seeds still in place. This will be discussed with you before and after your implant. Your next of kin need to know about this and what to do in the unlikely event that this happens Possible long term side effects Serious long term side effects are uncommon but may include persistent rectal bleeding and difficulty passing urine. Both these conditions may respond to simple treatment but occasionally require surgery. Some reminders Even though your prostate carries radioactive seeds, you can (apart from the few things mentioned in this leaflet) continue your usual daily life. Take plenty of rest in the first few days. You should feel

17 15 well and be able to start to return to your usual activities within a few days. How much time off work you take depends on the amount of physical effort and sitting your work requires. Your GP will provide a sick note if necessary. Call Triage on (bleep 5555) if: Your urine is very bloody, smelly, has clots or you are having difficulty in passing urine You develop a fever and/or chills with a raised temperature Questions If you have any queries, please do not hesitate to contact the department during office hours on ext Useful contacts: The Wirral and North Cheshire Prostate Support Group Tel: , or Prostate Support Group (Liverpool) Liverpool Cancer Support Centre, 21 Aigburth Road, Liverpool L17 4JR Tel: The Prostate Cancer Charity Tel: Web: Macmillan Cancer Support Tel: or Web:

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20 How we produce our information All of our leaflets are produced by staff at The Clatterbridge Cancer Centre and this information is not sponsored or influenced in any way. Every effort is made to ensure that the information included in this leaflet is accurate and complete and we hope that it will add to any professional advice you have had. All our leaflets are evidence based where appropriate and they are regularly reviewed and updated. If you are concerned about your health in any way, you should consult your healthcare team. We rely on a number of sources to gather evidence for our information. All of our information is in line with accepted national or international guidelines where possible. Where no guidelines exist, we rely on other reliable sources such as systematic reviews, published clinical trials data or a consensus review of experts. We also use medical textbooks, journals and government publications. References for this leaflet can be obtained by telephoning If you need this leaflet in large print, Braille, audio or different language, please call If you have a comment, concern, compliment or complaint, please call The Clatterbridge Cancer Centre NHS Foundation Trust Clatterbridge Road, Bebington, Wirral, CH63 4JY. Tel: Web: Issue date: 01/06/13 Version no: 1.1 Reference: LRAABRPRO Review date: 01/06/15