Brachytherapy for prostate cancer
Brachytherapy is a form of internal radiotherapy. There are two main forms of brachytherapy, permanent seed brachytherapy, when radioactive 'seeds' are implanted permanently into the prostate, and high dose brachytherapy, when the 'seeds' are only left in place for a short period of time. Brachytherapy on its own as a treatment is not recommended for men with high-risk localised prostate cancer (NICE 2014 CG175).
Men, who had seeds permanently implanted, described their treatment. One wished he had been warned about discomfort following brachytherapy, while others recalled that they had been given detailed explanations about the procedure and its side effects, (See 'Side effects - bowel and bladder section').
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Yes, no matter what happens with seeding or Brachytherapy the actual seeds have to come from America because the company that made them, although it was one of the big National Health companies many years back only makes the seeds in America. And there's two types of seeds, there's the palladium and there's the iodine and the iodine is half strength so it lasts longer but it is weaker. So to get the same radiation effect you say it's going to last twice as long. They had to be brought from America and when you've been surveyed and declared suitable for seed implantation one of the things they do is they, using the ultrasound, they actually measure the volume of the prostate and depending on the volume will depend on how many seeds they're going to require to put in it because the seeds have to go in at equal spacing across around and all over. And it's shaped like a walnut, in fact in America there are people who wear badges shaped like a walnut with a ribbon on to indicate that they are prostate people. But having worked it out and in my case it was 62 seeds that were needed they then sent to America who make the seeds and they then, the seeds then come back and you're given an actual booking and they only come over a day or two before.
How long did it take to get the seeds from America?
Well in my case it was, it was taking 2 months, it has taken longer sometimes I know but 2 months is a reasonable one.
What sort of seeds were they, which ones?
Mine were iodine seeds and they're the only ones that have been used in England, only ones I believe that still are used really in England for this permanent seed implantation. Now this is permanent seed implantation where they put the seed in and it stays with you for the rest of your life although it's, to intents and purposes it stops emitting the radiation after about week 53, the actual seeds, so it's a declining radiation from when it's put in.
After 53 weeks?
Down to 53 weeks yes. The other higher density seeds definitely in 97 could not be imported under the laws of atomic materials so you could only have the iodine ones at the time I went forward for them.
Are the other ones also left in?
They're left in as well. There's a third, there's permanent implantation on one of the two isotopes, the iodine or the P and then there's the high density temporary one where they are put in for may be you know a couple of minutes and pulled out and the next day put in and pulled out again, that's a totally different procedure. And I know there has, there is one that has started up doing that in UK but at the time I had mine done there was only one and it was doing standard Brachytherapy and permanent implantation.
I must stress about the hospital where I did have the Brachytherapy done was that they're a total one off within all the NHS ones I've come across because they weren't NHS and the staff had no clue whether you were private or NHS in there, absolutely no clue, you were treated the same and you were treated brilliantly. And everything was explained from the minute you went in the door, absolutely everything was explained which was the first time it had been to me. And I was talking to an NHS patient in there and he was exactly the same, no difference...
(Laughs) well the seeds are implanted every - - - basically in the perineum. They're inserted on long needles.
Through the perineum?
Yes and you are, you're actually in a stirrup position
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Brachytherapy - brachy comes from the Greek word new and therapy for treatment so it's a new treatment, so there's nothing sinister about the wording. And what is entailed is an injection which leaves seeds of radiotherapy or iodine treated seeds in the prostate which will destroy it over a period of time, probably 3 months. The injection is made very precisely, there are a couple of fittings you have on an ultrasound machine and you're then marked in indelible ink with tattoos, very small tattoos which don't come off when you wash, and the injection is made in the perineum, I think it's called, which is in between the anus and the scrotum. And there are a number of holes made and the seeds are then left at equidistance according to exactly where your prostate is and within the prostate. In the meantime there is an ultrasound machine which is entered into the rectum which ensures that the seeds are only left in the prostate so the chance of incontinence or any damage to the sexual nerve is not necessarily completely eradicated but is unlikely.
The percentages are very low whereas with radiotherapy on the arc treatment of radiotherapy the beam will obviously cover some 5% of the external organ which can result in more serious damage because of the sensitivity of the patient. In my case I seem to fairly sensitive because since I had the treatment which was 6 weeks ago I've had problems urinating, however this is improving the whole time and the doctor is fairly confident this is not a long term problem. Whereas I believe that being of a sensitive nature in that area I probably would've had problems if I'd have had radiotherapy which would've been longer term.
The tattoos, the tattoos are small indelible marks which they judge from the ultrasound so that the treatment for radiotherapy or the Brachytherapy can be very precise. And you are put into an ultrasound machine, a tunnel and these, you have a small injection of an indelible ink which in my case was in my left and right side and across the top of my prostate below my belly button for the more precise. These then allow them when you go for any treatment to align you exactly. And I've been for ultrasound since to see exactly where the seeds were and it takes several minutes for them to align you on the platform inside the tunnel so that you're absolutely centre and they can actually do the ultrasound on exactly that position.
And this is what you do, you go in the Sunday, you're prepared for the operation, only in as much as your diet, you can't eat and then on the Monday morning in my case I had the operation and I came home Tuesday lunch time. And I think the only thing is that I think the doctors should warn you of the discomfort. I'm not saying they're wrong in not warning you of it because you'd still have this, you'd still have it done but it is quite uncomfortable in some cases. However in some cases there's no reaction at all, this is probably like other treatments, some people react badly to radiotherapy but one must remember you're having a gland burnt daily and constantly and it must rather be like having sunburn and you then go and lay in the sun again and obviously that aggravates it even further. So the symptoms that you get from it are fairly obviously and you know if you think it through you know you only get, you only get practical advice from the doctors and you can discuss the problems with them and there's always help lines and they do encourage you to use them and I think that's you know it's very good. And I've used the help line a couple of occasions, not when I've been panicking but when I've been extremely uncomfortable.
You have a general anaesthetic because you have, you have an ultrasound, a rectal ultrasound and you have the injections which
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I was given a patient information folder, which included a copy of a learned paper giving a professional review of prostate Brachytherapy. This concluded in part 'Brachytherapy appears to perform at least as well as either surgery or external beam therapy,' for local carcinoma of the prostate. The actual brachytherapy operation involves an overnight stay also, in my case two nights, because I needed an extra night's post operative recovery time.
On the evening before you go through the purgative procedure again because the rectal ultrasound scanner is in use through the seed implant operation. Apart from this the ordinary general anaesthetic procedure is followed and you are only aware of post operative recovery. In my case with the use of oxygen which I did not find pleasant. Afterwards they get you to drink vast amounts of water in order to encourage a return to normal urine flow. The hospital leaflet had described this procedure and the usual immediate after effects. A letter reporting on my operation told my GP that as the radiation from the seeds is building up in the prostate over the next 2 to 3 weeks he's likely to develop urethritis with dysuria, frequency, urgency, hesitancy and nocturia. Dysuria will usually settle in 10 to 14 days but hesitancy, urgency and nocturia may continue for three to four months.
And they have a, gradually they become weaker don't they?
Yes, there is a build up as I mentioned but after a year they start to run down and for that reason they are left in position but are harmless. There's no danger to other people although immediately after the operation it's suggested that you don't pick up young children until about a month has gone by.
You may have mentioned this but I can't remember, when you came round from the operation did you have a catheter for a little while?
Yes they do that as a matter of procedure for a few hours and usually the following day this is removed. In some ways the removal of the catheter is the most painful part of the whole thing although of course that's only just momentary.
One of these men stressed the importance of finding a skilled and experienced surgeon for any new procedure. One man, who went to the USA for his treatment, had this type of brachytherapy (with permanent seeds implanted) combined with Conformal beam radiation. A computed tomography scan (CT scan) of the prostate produces an image, which is fed into a computer. This produces a 3D image of the prostate and the radioactive beams can then be emitted to the exact size and shape of the gland, thus reducing damage to the surrounding normal tissue.
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I should explain that the way that the Radiotherapy Clinics of Georgia work is that they use Brachytherapy supplemented by conformal beam radiation so there's Brachytherapy which is the insertion of permanent radioactive seeds into the prostate followed by a period of 6 or 7 weeks external conformal beam radiation.
And how are the seeds actually put into the prostate?
The way the seeds are put into the prostate is that the urologist, through the back passage inserts needles into the prostate and then the oncologist pushes the seeds along the needles and then the needles are withdrawn and the seeds are left inside the prostate. It's a very difficult job to do well because its very important to space the seeds correctly because if they're bunched together and not evenly distributed then you can get what they call cold spots, in other words areas in the prostate that are not sufficient irradiated. Anyway the placing of the seeds is absolutely key and they have to be put in very precisely. And it's up to about 100 seeds that they put in.
Did you start to have any side effects from the conformal radiation?
I had some tiredness may be about half way through and that happened to something like 20% of the patients but it was very mild and I didn't really have any, I did have some, may be some problems with bowel movements to some extent but that was the only area that I had any problems with and it was nothing serious.
And how long do these seeds go on giving out radiation?
So they have a half life of 60 days, that means that every 60 days they lose half of their strength so I guess you could say after a year that they've pretty much petered out.
So what happened after that?
So after that I was required to go back, I was required to have a PSA test after 3 months and then after another 3 months and thereafter every 6 months. The PSA test that I had immediately before the biopsy was 4.4 and I've had since then 2 PSA tests. The first one I had in November and the PSA had gone down to 1.0 and I've just had another PSA test and it's gone down to 0.26 (laughs).
Another man had brachytherapy with seeds that were removed after treatment. This man also had some external radiotherapy just before the brachytherapy.
Ordinary, that's right yes, yes from three sides, the left, centre and the right.
And you had how many sessions for that?
I had 13 I went every day except weekends for the 13 consecutive visits and the brachytherapy afterwards. I had to wait a week because of problems with the machine, I think, but I went in hospital for 2 nights and had the brachytherapy, but they called it something else I can't remember what they called it, no I can't remember what they called it anyway the general term was brachytherapy.
And can you explain in detail about those 2 days when you were in hospital?
Yes, on arrival I was checked over for blood pressure and that sort of thing and I had my last meal on the, on arrival at the hospital, and then the following day I had to go without breakfast because I would be having a general anaesthetic to insert the cannula into the prostate. I was wheeled down the operating theatre and then wheeled back not knowing anything [laughs] just feeling it was a little painful until I was wheeled down to the, to have the brachytherapy where pellets of radioactive material are inserted in to the prostate area for a few seconds and then after that you go back to the ward.
Were you under anaesthetic for all of that?
Just for when they put the cannula in?
Only when they put the cannula in yes.
I was then taken down to the room where the Brachytherapy was going to be provided and there were, I can only assume there were various tubes connected to the cannula because the radioactive pellets went into the various tubes at various times and the whole thing didn't take very long but it was fitting the various tubes to the cannula and making sure that the connections were there. And then the staff retired and then the machine automatically I think blew the little pellets into the cannula in turn and went back to the machine, and I'm told there was no possibility that one could be left inside because they were all counted before they went in and when they came out.
How does it feel while this is going on, while this is happening?
You don't actually feel anything. One is observed on a television screen to make sure that one is comfortable and that sort of thing you know and of course you can speak if there are any problems so the staff know, can keep an eye on you while it's happening but it doesn't take very long and then you're disconnected from the machine and then you go up, back to the ward and to my great delight I felt like eating [laughs]. But I had to remain in another night because I would have another session of the brachytherapy before being allowed to go home after that.
So you're up in the ward, still with the cannula there?
Is that uncomfortable?
It was very uncomfortable because one was restricted from movement because of the pain but one could bear it because you knew that it was going to be removed the next day so it helps.
So if you lay still it was alright?
That was alright, yes, yes.
So you went back down for one more session the next day?
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