For prostate cancer, there are two brachytherapy techniques: a permanent seed implant known as low dose rate brachytherapy (LDRB) and a temporary seed implant called high dose rate brachytherapy (HDRB). With LDRB, a number of radioactive seeds are placed within the prostate. The seeds emit a low dose of cancer-killing radiation over a period of months, and the seeds are not removed at the end of the radiation treatment. In contrast, HDRB is a procedure where one small radioactive source is moved in and out of the prostate via small tubes (catheters) delivering a high dose of radiation in a matter of minutes. Whether you choose LDRB or HDRB, the goal is to kill the cancer within the prostate in order to cure the patient.

There are two ways that High Dose Rate Brachytherapy can be used. HDRB Monotherapy (HDRB alone) or HDRB with External Beam Radiation (combination therapy). Our website offers detailed information on both forms of HDRB. Click here for further information on HDRB Monotherapy.

Learn more about the expert Radiation Oncology Team at the Prostate Cancer Center at Saint Joseph's. We believe in educating our patients about all treatment options for prostate cancer and assisting with the decision with unbiased and individualized care. Contact our Patient Navigator for more infromation about Brachytherapy treatment options at Saint Joseph's.

What You Can Expect from HDRB Combination Therapy

HDRB for the treatment of prostate cancer is a process which involves several steps to accomplish its purpose. The steps in the process include steps for both HDRB and those for external beam radiation.

The Implant

An outpatient procedure performed in the operating room under anesthesia to implant, or place, small catheters in the prostate.

Radiation Treatment Planning

The behind-the-scene efforts of the radiation oncologist and radiation physicist to ensure the radiation treatment is individually customized to each patient’s needs.

The HDRB Treatment

In combined therapy, HDRB is delivered as two separate procedures but only one treatment per day is given instead of the two per day as with monotherapy. Each treatment consists of a 30-minute HDRB treatment in the radiation therapy department. Following each treatment, the catheters are removed prior to going home, and the entire process beginning with the implant is repeated one week later.

The Implant: A Closer Look

Each treatment to place the implants is approximately an hour-long outpatient procedure performed in the operating room by your urologist and radiation oncologist. On the day of the HDRB procedure, you will meet with the anesthesiologist to discuss how to deliver anesthesia. The goal of anesthesia during the implant is to ensure you do not have any discomfort from the procedure and that you hold perfectly still for the doctors to precisely place the brachytherapy catheters into the prostate. Spinal anesthesia allows you to be awake while ensuring you do not move your hips and legs during the procedure. Some patients prefer to go completely to sleep with general anesthesia. The anesthesiologist will discuss the pros and cons of each approach with you in detail.

Once in the operating room, anesthesia is started, and you are placed on your back with your feet in stirrups in the “birthing” position. A catheter is placed in your bladder, and a rectal ultrasound probe is placed in the rectum in order to visualize the prostate. A 4 x 4 inch guidance template is placed at your perineum (the skin between the scrotum and anus) and sutured in place for stability. Under direct visualization from the rectal ultrasound, 15 to 20 very thin catheters are placed through the template and perineum and into the prostate. The number of catheters used depends on the size and shape of the prostate. It is through the catheters that the radiation will be delivered.

After the procedure, you are then taken to the recovery room for a brief period prior to being transported by stretcher to the Department of Radiation Oncology for the radiation treatment. The catheter remains in your bladder. The template and the very small catheters in the prostate also remain in place. The template ensures the prostate catheters do not move. You should not experience significant pain, but if you have any discomfort during the postoperative period or treatment process, you will be given medication.

Treatment Planning; The Behind-the-Scenes Work

In the Department of Radiation Oncology, a CT scan of the pelvis is performed for radiation treatment planning purposes. With the help of a specialized treatment planning computer, the radiation oncologist uses the CT scan to three dimensionally visualize the prostate, bladder, urethra, rectum and all the catheters in the prostate. Based on the location of each prostate catheter relative to the normal structures (e.g., the bladder, urethra and rectum) the radiation oncologist determines the precise dose of radiation needed for the treatment of your cancer while minimizing the radiation to normal structures.

The HDRB Treatment

A pellet-size radioactive iridium source is stored in the brachytherapy device located within the treatment room. Once you are in the room, the prostate catheters are joined with the catheter on the HDRB device. In an effort to avoid radiation exposure to personnel, the brachytherapy device is controlled remotely just outside the treatment room. The radioactive iridium source is remotely directed into the prostate catheters and remains in each catheter, delivering the radiation, according to the time determined in your specific treatment plan. The treatment takes about 30 minutes. The radiation physicist observes you the entire time by a camera outside the treatment room.

You will not experience any pain or discomfort while the radiation is delivered to the prostate. HDRB as a combined therapy is delivered as two 30 minute treatments done on two separate days. At the completion of each treatment, the bladder catheter, prostate catheters and template are removed, thus concluding the procedure for the day. Some patients experience mild discomfort as the prostate catheters are withdrawn from the prostate. Once the catheters are removed, you are then free to go home.

Prior to leaving, you will be instructed when to return one week later to repeat the entire HDRB process.

Combination Treatment: Adding External Beam Radiation (IMRT)

HDRB is used both as monotherapy and combination therapy. If your doctors determine there is a risk the prostate cancer has spread beyond the confines of the prostate, they may recommend “combined therapy,” utilizing a short course of intensity modulated radiation therapy (IMRT) in addition to HDRB. If you need combined therapy, the IMRT portion is given daily, Monday through Friday, for five weeks. Each IMRT treatment lasts about 15 minutes per day and is completely painless.

Side Effects of HDRB Combined Treatment

All treatments for prostate cancer have side effects. Like other treatments, HDRB side effects are divided into acute effects, which are commonly seen immediately after treatment, and long-term side effects, which can be seen months to years after treatment. It is important to remember that each patient is different, and side effects can vary from one patient to the next. However, most patients experience some degree of acute side effects in the first few weeks.

Common acute side effects after HDRB:

• urinary frequency and/or urgency
• burning sensation with urination
• slow urinary flow
• bruised and tender perineum
• blood in the urine
• mild rectal irritation
• temporary impotency

Common acute side effects of Extermal Beam Radiation (IMRT):

• urinary frequency and/or urgency
• burning sensation with urination
• mild rectal irritation

Most patients recover from the acute side effects in several weeks. Significant long-term problems are less common. For example, the risk of urinary incontinence is very low. Mild rectal irritation can occur but the risk of significant rectal bleeding is uncommon. Erectile dysfunction (ED) is often difficult to quantify; however, men who do not have ED prior to HDRB most often maintain sexual function after HDRB. Men with ED prior to HDRB will likely continue to have ED after the treatment as HDRB is not a treatment for ED.

 

Follow-up after HDRB Comined Therapy

Follow-up is extremely important so your doctors can evaluate both the status of your cancer as well as any symptoms you may have as a result of your treatment. At the completion of all IMRT treatments, the urologist and radiation oncologist participate in the follow-up process at alternating intervals defined by your doctors based on your specific needs.

Why Choose HDRB Combined Therapy?

• HDRB is not major surgery.
• Patients with a large prostate may not need hormone therapy to shrink the prostate prior to HDRB.
• Patients enjoy little “down-time” from work and other activities.
• The risk of quality of life altering side effects (incontinence and Erectile Dysfunction) is low.

Prostate cancer patients must be actively involved in choosing between several equally effective treatment methods. Patients should be encouraged to research the various options and make their decision taking into account their quality of life concerns along with their work and home life schedules. Although a diagnosis of cancer can be an intimidating experience, the more you are informed about the options available to you, the more equipped you will be to make the decision that is best for you.

We encourage you to contact our Patient Navigator at (678) 843-5665 or renee.sevy@emoryhealthcare.org with any questions regarding HDRB Combination Therapy at Saint Joseph's. We're here to help.

 

Information on this page is provided collaboratively by the team at the Prostate Cancer Center at Saint Joseph's and has been medically reviewed by Nancy Wiggers, MD, Radiation Oncologist, 2010. Claims regarding treatment are based on years of clinical experience and industry reported data. The PCC follows American Urological Association and  National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for the treatment of prostate cancer.

Last Updated: April 22, 2012 (RSH)