A practical guide to understanding cancer

Transcription

1 A practical guide to understanding cancer

2 This booklet is one of a series of booklets on prostate cancer. It gives information about locally advanced prostate cancer. This is when prostate cancer has started to spread beyond the prostate gland and may be affecting surrounding structures. Our information booklets on prostate cancer are: Having tests for prostate cancer Understanding the PSA test Understanding early (localised) prostate cancer Understanding locally advanced prostate cancer Understanding advanced (metastatic) prostate cancer It s important to check with your hospital consultant or nurse specialist that this is the right booklet for you, and whether you need any additional information. If you would like more information about these booklets, you can contact our cancer support specialists on They will be able to send you the booklet or booklets that contain the information you need.

3 Contents Contents About this booklet 4 What is cancer? 5 The lymphatic system 7 The prostate gland 8 Prostate cancer 9 Risk factors and causes 10 Staging and grading 14 Treatment 17 Radiotherapy 24 Hormonal therapy 37 Watchful waiting 43 Surgery 45 Research clinical trials 55 After treatment follow-up 57 Beginning to recover 58 Dealing with the side effects of treatment 62 Who can help? 67 Your feelings 70 What you can do 74 If you are a relative or friend 76 Talking to children 77 1

4 Financial help and benefits 79 Work 84 How we can help you 85 Other useful organisations 90 Further resources 97 Questions you might like to ask your doctor or nurse 101 TNM staging 102 2

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6 About this booklet This booklet is for men who have been diagnosed with locally advanced prostate cancer. This is when prostate cancer has started to spread beyond the prostate gland and may be affecting surrounding structures. We hope it answers some of your questions and helps you deal with some of the feelings you may have. We ve also listed other sources of support and information, which we hope you ll find useful. We can t advise you about the best treatment for you. This information can only come from your doctor, who knows your full medical history. If you d like to discuss this information, call the Macmillan Support Line free on , Monday Friday, 9am 8pm. If you re hard of hearing you can use textphone , or Text Relay. For non-english speakers, interpreters are available. Alternatively, visit macmillan.org.uk Turn to pages for some useful addresses and websites, and page 101 to write down questions for your doctor or nurse. If you find this booklet helpful, you could pass it on to your family and friends. They may also want information to help them support you. 4

7 What is cancer? What is cancer? The organs and tissues of the body are made up of tiny building blocks called cells. Cancer is a disease of these cells. Cancer isn t a single disease with a single cause and a single type of treatment. There are more than 200 different kinds of cancer, each with its own name and treatment. Although cells in different parts of the body may look different and work in different ways, most repair and reproduce themselves in the same way. Normally, cells divide in an orderly and controlled way. But if for some reason the process gets out of control, the cells carry on dividing, and develop into a lump called a tumour. Tumours are either benign (non-cancerous) or malignant (cancerous). Doctors can tell if a tumour is benign or malignant by removing a piece of tissue (biopsy) and examining a small sample of cells under a microscope. Normal cells Cells forming a tumour 5

8 In a benign tumour, the cells do not spread to other parts of the body and so are not cancerous. However, they may carry on growing at the original site, and may cause a problem by pressing on surrounding organs. In a malignant tumour, the cancer cells have the ability to spread beyond the original area of the body. If the tumour is left untreated, it may spread into surrounding tissue. Sometimes cells break away from the original (primary) cancer. They may spread to other organs in the body through the bloodstream or lymphatic system (see next page). When the cancer cells reach a new area they may go on dividing and form a new tumour. This is known as a secondary cancer or a metastasis. 6

9 The lymphatic system The lymphatic system The lymphatic system is part of the immune system the body s natural defence against infection and disease. It s made up of organs such as bone marrow, the thymus, the spleen, and lymph nodes. The lymph nodes throughout the body are connected by a network of tiny lymphatic tubes (ducts). The lymphatic system has two main roles: it helps to protect the body from infection and it drains fluid from the tissues. Neck (cervical) lymph nodes Thymus Armpit (axillary) lymph nodes Spleen Groin (inguinal) lymph nodes The lymphatic system 7

10 The prostate gland The prostate is a small gland only found in men. It s about the size of a walnut and gets a little bigger with age. It surrounds the first part of the tube (urethra) that carries urine from the bladder along the penis. Spine Pubic bone Vas deferens Prostate gland Bladder Seminal vesicle Rectum Penis Urethra Scrotum The male sex organs and surrounding structures 8

11 Prostate cancer The prostate produces a thick white fluid called semen that mixes with the sperm produced by the testicles. It also produces a protein called prostate-specific antigen (PSA) that turns the semen into liquid. The prostate gland is surrounded by a sheet of muscle and a fibrous capsule. The growth of prostate cells and the way the prostate gland works are dependent on the male sex hormone testosterone, which is produced in the testicles. The back of the prostate gland is close to the rectum (back passage). Near to the prostate are collections of lymph nodes. These are small glands, each about the size of a baked bean. Prostate cancer Prostate cancer generally affects men over 50 and is rare in younger men. It s the most common type of cancer in men. Around 37,000 men in the UK are diagnosed with prostate cancer each year. It differs from most other cancers in the body, in that small areas of cancer within the prostate are very common and may stay dormant (inactive) for many years. Around half of all men in their fifties have some cancer cells within their prostate, and 8 out of 10 men (80%) over the age of 80 have a small area of prostate cancer. Most of these cancers grow very slowly and so, particularly in elderly men, are unlikely to cause any problems. 9

12 In a small proportion of men, prostate cancer can grow more quickly and in some cases may spread to other parts of the body, particularly the bones. Risk factors and causes In the UK, about 1 in 9 men are diagnosed with prostate cancer in their lifetime. In the USA, the incidence is much higher. This is thought to be due to the fact that in the USA more men have PSA testing to try to detect early prostate cancer. The PSA test is a blood test that measures a type of protein called prostate specific antigen (PSA). A small amount of this is normally found in the blood, but men who have prostate cancer tend to have a high level of PSA in their blood. If you d like to know more about PSA testing we can send you our free booklet Understanding the PSA test. The number of men being diagnosed with prostate cancer in the UK (and many other countries) has increased in recent years. It is thought that the incidence is increasing because more men are having tests that detect very early prostate cancers that would previously not have been found. It may also be because the number of older men in the population is growing. Researchers are trying to find out more about the causes of prostate cancer. Although the causes of prostate cancer are still unknown, there are some risk factors that are known to increase a man s chance of developing the disease. 10

13 Risk factors and causes Age This is the strongest risk factor for prostate cancer. Men under 50 have a very low risk of prostate cancer, but their risk increases as they get older. It s estimated that around 80% of men in their 80s will have some degree of prostate cancer. Ethnicity Some ethnic groups have a greater chance of developing prostate cancer than others. For example, black African and black Caribbean men are more likely to develop prostate cancer than white men. Asian men have a lower risk of developing it. Family history Men who have close relatives (a father, brother, grandfather or uncle) who have had prostate cancer are slightly more likely to develop it themselves. It is thought that a man s risk of developing prostate cancer is higher if: their father or brother developed prostate cancer at or under the age of 60 more than one man on the same side of the family has had prostate cancer. If this is the case in your family, it may indicate that a faulty gene is present. 11

14 A specific gene linked to prostate cancer has not yet been identified. However, research has shown that faulty genes that are linked to a higher risk of breast cancer (called BRCA 1 and BRCA 2) may also increase the risk of getting prostate cancer. So, if there s a strong family history of breast cancer on the same side of the family (especially before the age of 40), it could also indicate that a faulty gene may be present. Only a small number of prostate cancers (5 10%, or less than 1 in 10 cases) are thought to be due to an inherited faulty gene running in the family. If you re concerned about your family history of prostate cancer, we can send you our leaflet Are you worried about prostate cancer? We also have a booklet called Cancer genetics how cancer sometimes runs in families. Call to order these. Diet There s often a lot of information in the press and on TV about diet and cancer. There is no single superfood or special diet that can give you complete protection from getting cancer. However, eating a healthy balanced diet that s high in fibre and low in fat and sugars may reduce your risk of getting certain types of cancers and other illnesses. Men from western countries, such as the UK and USA, have a higher rate of prostate cancer than men from eastern countries such as China and Japan. It s thought that this might be because western diets tend to be higher in animal fat (including dairy products) and lower in fresh fruit and vegetables. Asian men also tend to have a higher intake 12

15 Risk factors and causes of soy in their diet. Soy and soy products contain chemicals called phyto-oestrogens. Researchers believe these might reduce the risk of prostate cancer, but more research is needed to confirm this. A high intake of calcium (such as from dairy foods) may increase the risk of developing prostate cancer. However, it s important not to cut dairy products out altogether, as they provide essential calcium for healthy bones. Research studies have looked into whether tomatoes and tomato products (such as ketchup) may help to protect against prostate cancer. This may be because they contain high levels of a substance called lycopene. Studies so far have shown mixed results and more research is needed. 13

16 Staging and grading Staging The stage of a cancer is a term used to describe its size and whether it has spread. There are a few different staging systems for prostate cancer. Two of the most commonly used systems are a numbered staging system and the TNM staging system. A simplified numbered staging system is described below: Stage 1 The cancer is very small and confined to the prostate. It can t be felt during a rectal examination. Stage 2 The cancer can be felt as a hard lump during a rectal examination, but it s still within the prostate gland. Stage 3 The cancer has started to break through the outer capsule of the prostate gland and may be in the nearby tubes that transport semen (seminal vesicles see page 8). Stage 4 The cancer has spread beyond the prostate gland to nearby structures such as the bladder or back passage (rectum), or to more distant organs such as the bones or liver. This booklet covers locally advanced prostate cancer (stage 3). We have separate booklets about early (localised) prostate cancer (stages 1 and 2) and advanced prostate cancer (stage 4). The TNM staging system is more complicated than the number staging system. We have more detailed information about TNM staging at the back of this booklet if you d like to know more see pages

17 Staging and grading 15

18 Grading The grade of a cancer gives an idea of how quickly it might grow. Prostate cancer is graded according to the appearance of the cancer cells when the biopsy sample is looked at under the microscope. There are several grading systems, but the Gleason system is the most commonly used. This system can help doctors decide which treatment might be best, as it gives them more information about the cancer. The Gleason system looks at the pattern of cancer cells within the prostate. There are five patterns, which are graded from appears very similar to normal prostate tissue whereas 5 appears very different to normal tissue. The biopsy samples are each graded and then the two most commonly occurring patterns are added together to get a Gleason score of between The lower the Gleason score, the lower the grade of the cancer. Low-grade cancers (6 or under) are usually slow-growing and less likely to spread. A score of 7 is a moderate grade. High-grade tumours (8 10) are likely to grow more quickly and are more likely to spread. High-grade tumours are sometimes called aggressive tumours. Prostate biopsies with a Gleason score of 2 are rare. It s more common to get scores from

19 Treatment Treatment The treatment options for locally advanced prostate cancer include: radiotherapy see pages hormonal therapy see pages watchful waiting see pages surgery see pages Sometimes a combination of treatments will be given. Deciding on the best treatment isn t always straightforward and a number of factors have to be taken into account. The most important of these are: your general health the stage of the prostate cancer the grade of the prostate cancer your PSA level the likely side effects of treatment your views about the possible side effects of treatment and whether you are willing to risk getting them for the possible benefits of controlling the cancer whether you ve had treatment before. 17

20 In most hospitals a team of specialists will discuss the possible treatments for your situation. This multidisciplinary team (MDT) will include a surgeon (urologist) and doctors who specialise in radiotherapy, hormonal therapy and chemotherapy treatments (clinical oncologists). The team may also include specialist nurses, social workers and physiotherapists. It s common for patients to have appointments with a surgeon, clinical oncologist and a specialist nurse to help them make decisions about treatment. Second opinion The MDT uses national treatment guidelines to decide the most suitable treatment for you. Even so, you may want another medical opinion. If you feel it will be helpful, you can ask either your specialist or GP to refer you to another specialist for a second opinion. Getting a second opinion may delay the start of your treatment, so you and your doctor need to be confident that it will give you useful information. If you do go for a second opinion, it may be a good idea to take a relative or friend with you, and to have a list of questions ready, so that you can make sure your concerns are covered during the discussion. 18

21 Treatment Treatment decisions Not having treatment straight away You may be advised not to have treatment immediately but to be monitored instead. This is known as watchful waiting (see pages 43 44). Many locally advanced prostate cancers grow very slowly and may cause very few problems in a man s lifetime. The grade of the cancer (Gleason score see page 16) can give doctors more information, but will not be able to predict the exact outcome. It s impossible for doctors to tell from blood tests and biopsies what will happen with your cancer in the future. The treatments for prostate cancer can cause side effects such as erection problems or incontinence, which for some men may be worse than the effects of the cancer. Your doctors may advise waiting to see whether the cancer is likely to cause problems, rather than giving treatment straight away. Choosing between two or more treatments In some situations, men with locally advanced prostate cancer are given the choice between two or more types of treatment. This is because sometimes treatments are thought to be equally effective and there is no clear benefit of having one treatment over another. In this situation, doctors offer men a choice of treatments. This is because some men with prostate cancer may have a preference over which treatment they want in terms of what the treatment involves and the possible side effects. If you re asked to choose a treatment yourself, it s important to make sure you have all the information you need about the different types being offered to you. Your doctor or specialist nurse will answer any questions you have. Don t worry if you 19

22 need to ask the same questions again treatments for cancer can be very complex and it s common to need repeated explanations. You may also want to ask your doctor or specialist nurse for some time to think about your options. You may find our booklet Making treatment decisions helpful. Call to order a copy. Common treatment choices for men with locally advanced prostate cancer Most men with locally advanced prostate cancer will need a combination of several treatments. Many men are offered radiotherapy to the prostate (see pages 24 36). Hormonal therapy (see pages 37 41) is often given with radiotherapy. It can be given before radiotherapy starts and continued after it finishes. Some men are offered hormonal therapy on its own. It s often used to treat men who aren t able to have radiotherapy. It can also be used to treat men who can t have surgery because they re unable to have a general anaesthetic, or men who can t have surgery because of other medical problems. In elderly men who have no symptoms from the cancer, or who have medical problems in addition to cancer, it may be best to give no treatment. Instead, PSA levels will continue to be monitored and treatment can be given to control any symptoms that do occur. This is called watchful waiting (see pages 43 44). Surgery to remove the prostate gland (prostatectomy see pages 46 48) may be possible for a small number of men with locally advanced prostate cancer. Sometimes radiotherapy is given after surgery as well. 20

23 Treatment Advantages and disadvantages of treatments It s important that you re fully aware of the advantages and possible disadvantages and side effects of the treatments before you have them. Your doctor or specialist nurse will explain these to you. You can then decide which treatment is best for you. The advantages and disadvantages of individual treatments for locally advanced prostate cancer are highlighted in green boxes in the relevant treatment sections on pages It s important to remember that everyone reacts differently to cancer treatment. It s impossible for doctors to accurately predict who will and who won t be affected by the side effects of each treatment. Giving your consent Before you have any treatment, your doctor will explain its aims. They will ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent, and before you're asked to sign the form you should be given full information about: the type and extent of the treatment its advantages and disadvantages any significant risks or side effects any other treatments that may be available. 21

24 If you don t understand what you ve been told, let the staff know straight away so they can explain again. Some cancer treatments are complex, so it s not unusual for people to need repeated explanations. It s a good idea to have a relative or friend with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write a list of questions before your appointment (you can use the form on page 101 to do this). People sometimes feel that hospital staff are too busy to answer their questions, but it s important for you to know how the treatment is likely to affect you. The staff should be willing to make time for your questions. You can always ask for more time if you feel that you can t make a decision when your treatment is first explained to you. You are also free to choose not to have the treatment. The staff can explain what may happen if you don t have it. It s essential to tell a doctor, or the nurse in charge, so they can record your decision in your medical notes. You don t have to give a reason for not wanting treatment, but it can help to let the staff know your concerns so they can give you the best advice. 22

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26 Radiotherapy Radiotherapy treats cancer by using high-energy x-rays to destroy the cancer cells, while doing as little harm as possible to normal cells. Radiotherapy for prostate cancer is usually given from an external machine. This is called external beam radiotherapy. There are other, newer types of external beam radiotherapy, but these aren t available at every NHS hospital. These include conformal radiotherapy (CRT) and intensity-modulated radiation therapy (IMRT) see page 26. Some men can have brachytherapy (see pages 31 36). This is when small radioactive seeds are inserted into the tumour. It s only suitable for a small number of men with locally advanced prostate cancer. Whether it s given or not depends on how much the cancer may have spread beyond the prostate gland. Brachytherapy is usually given in combination with external radiotherapy. Depending on your situation, your doctor may suggest you have hormonal therapy (see pages 37 41) before or after your radiotherapy. 24

27 Radiotherapy External radiotherapy External radiotherapy is given in the hospital radiotherapy department, usually as daily sessions from Monday Friday, with a rest at the weekend. For locally advanced prostate cancer, the course of treatment may last up to seven weeks. Planning external radiotherapy External radiotherapy is planned by a cancer specialist (clinical oncologist). Planning is a very important part of radiotherapy and may take one or two visits to hospital. The treatment has to be carefully planned to make sure it s as effective as possible. You ll be asked to have a CT scan, which takes x-rays of the area to be treated. You can read more about what a CT scan involves in our booklet Having tests for prostate cancer. Tiny tattoos or permanent marks may be drawn on your skin. These show where the radiotherapy is to be given, and help the radiographers position you accurately when they give you your treatment. The marks are usually permanent because they must remain visible throughout your treatment, but they are the size of pinpoints and will only be done with your permission. Having the tattoos done can be a little uncomfortable, but they can help to make sure that treatment is directed accurately. You ll be given advice about how to look after your skin during your treatment. Some radiotherapy departments may ask you to follow a special diet before planning treatment. Occasionally, you may be asked to have an enema. This involves having liquid passed into your rectum via a small tube. The liquid will help you to empty your bowel before the scans are taken. Having an empty bowel can help make sure radiographers have as clear a picture as possible when planning your treatment. 25

28 Treatment sessions At the beginning of each session of external radiotherapy, the radiographer will position you carefully on the couch and make sure you re comfortable. During your treatment, you will be left alone in the room but you ll be able to talk to the radiographer, who will watch you from another room. Radiotherapy isn t painful but you do have to lie still for a few minutes during the treatment. Conformal radiotherapy (CRT) and intensity-modulated radiation therapy (IMRT) In CRT, a special attachment to the radiotherapy machine carefully shapes the radiation beams to match the shape of the prostate gland. Shaping the radiotherapy beams reduces the radiation received by the healthy cells in nearby organs such as the bladder and rectum. This reduces the side effects of radiotherapy and may allow higher doses to be given, which could be more effective. IMRT is a more complex type of conformal radiotherapy that allows the specialist radiotherapy doctor (oncologist) to vary the dose of radiation given to different parts of the tumour and surrounding tissue. It s not yet known whether IMRT is a more effective treatment than CRT. There is more information in our fact sheet Intensity-modulated radiation therapy (IMRT). Planning and treatment sessions of CRT and IMRT are carried out in the same way as standard external beam radiotherapy. 26

29 Radiotherapy Short-term side effects Most of the side effects of radiotherapy gradually disappear once the treatment has finished. Your cancer specialist, nurse or radiographer can tell you what to expect. Let them know what side effects you have, as there s usually something that can be done to help. Radiotherapy causes tiredness, especially if you re travelling a long way for treatment each day. It s important to get enough rest, but try to balance this with regular, gentle exercise, which will give you more energy. We can send you a booklet about coping with tiredness. Call to order a free copy. Radiotherapy to the prostate area may irritate the rectum, cause soreness around the anus, and cause diarrhoea. Your doctor can prescribe medicines to reduce these effects and you may be advised to make some changes to your diet. Radiotherapy can also cause inflammation of the bladder (cystitis), which can make you want to pass urine more often or cause a burning feeling when you pass urine. Your doctor can prescribe medicines to reduce this. It s important to make sure you drink plenty of fluids. These effects usually disappear gradually a few weeks after the treatment has finished. A small number of men may have difficulty passing urine. In this situation, it may be necessary to have a urinary catheter put in. This is a tube that is placed inside the bladder to help the urine drain out of the body. Rarely, some men may experience leakage or incontinence of urine. 27

30 Radiotherapy to the pelvis may make some of your pubic hair fall out. When you ve finished the course of treatment, the hair will grow back. However, it may be thinner or finer than before. External radiotherapy doesn t make you radioactive and it s perfectly safe for you to be with other people, including children, throughout your treatment. Our booklet Understanding radiotherapy gives more information about this treatment and its side effects. Possible long-term side effects Some men may have side effects that don t improve, or may develop side effects many months or years after radiotherapy. These are known as long term or late effects. We have a booklet called Pelvic radiotherapy in men possible late effects, which is for men who are experiencing late effects. Impotence Radiotherapy for prostate cancer can cause the inability to have an erection (impotence) in about 3 5 in 10 men (30 50%) who have this treatment. The risk may be higher if you re having hormonal therapy as well. After radiotherapy, men might not experience erection problems straight away, but it can sometimes develop over a period of 2 5 years. There are various treatments that can help; pages discuss ways of coping with erection problems. This side effect of treatment can be difficult to deal with, and can affect your sex life and your relationship with your partner. Whether you develop erection problems or not will depend on your age and whether you're being treated with hormonal therapy as well. 28

31 Radiotherapy You may find it helpful to read our booklet Sexuality and cancer. Many organisations offer counselling for sexual or relationship problems. These are listed on pages Infertility Radiotherapy to the prostate can cause permanent infertility. Some men find this very difficult to cope with. If you want to father children after your treatment, it may be possible to store sperm before treatment starts (see page 66). Bowel or bladder problems Some men may have bowel or bladder changes as a result of radiotherapy. The blood vessels in the bowel and bladder can become more fragile, which can make blood appear in your urine or bowel motions. This can take many months or years to occur and can sometimes be a long-term effect. If you notice any bleeding, it s important to let your doctor know so tests can be carried out and appropriate treatment given. Occasionally, bowel movements may be more urgent after radiotherapy, and very rarely some men experience difficulty controlling their bowels (faecal incontinence). Let someone from your healthcare team know if this happens. Although it may feel embarrassing to talk about, they can give you practical advice. Often, radiotherapy can improve problems with passing urine. But for a small number of men, it can lead to leakage of urine (urinary incontinence) due to damage to the nerves that control the bladder muscles. However, this is unlikely unless you ve had a TURP (see pages 51 52) or prostatectomy (see pages 46 48), as well as radiotherapy. 29

32 If this side effect occurs, it s important to discuss it with your doctor, who can arrange for you to see a specialist continence nurse. You may also find it helpful to contact the Bowel and Bladder Foundation (see page 90 for details). Lymphoedema If radiotherapy has been given to the lymph nodes in the pelvic area as well as to the prostate, it can cause some swelling of the legs and genitals. This is known as lymphoedema. We can send you a booklet about lymphoedema. Advantages External radiotherapy can help control locally advanced prostate cancer for many years and may lead to a cure for some men. Giving hormonal therapy before and during the radiotherapy may improve the results. Disadvantages For a small number of men, external radiotherapy to the prostate can cause long-term bowel problems such as loose or more frequent bowel motions or bleeding from the back passage. Occasionally, a small number of men will develop urinary leakage or incontinence. Some men will develop erection problems, and radiotherapy to the prostate can cause infertility. 30

33 Radiotherapy Brachytherapy This type of radiotherapy is available in some hospitals in the UK. It is also sometimes called internal radiotherapy, implant therapy or seed implantation. It can be carried out under a general anaesthetic or a spinal anaesthetic (epidural). There are two ways of giving brachytherapy: High-dose rate (HDR) brachytherapy This involves placing tiny plastic tubes (catheters) into your prostate gland. Radioactive seeds are inserted into the catheters for a set period of time, and then withdrawn. After the treatment, the catheters are easily removed and no radioactive material is left in the prostate gland. You ll usually have this along with external beam radiotherapy and hormonal therapy. Low-dose rate (LDR) brachytherapy or permanent seed implantation This uses small, radioactive metal seeds that are inserted into the tumour so that radiation is released slowly. The seeds are not removed but the radiation gradually fades away over about six months. There is no risk of it affecting other people. This type of brachytherapy isn t commonly used to treat locally advanced prostate cancer. Brachytherapy is a simpler procedure than external beam radiotherapy, as it usually only involves one planning and one treatment session. It s usually done under general anaesthetic and you may be able to go home the same day. Occasionally, a hospital stay of one or two days is necessary. 31

34 Planning brachytherapy Before the seeds are put into the prostate, a study of the prostate gland will be done. This is called a volume study. It s done to confirm the exact size and position of the prostate gland. Brachytherapy may not be suitable if you have a very large prostate. However, in some situations hormonal therapy can be given to reduce the size of the prostate before brachytherapy is given. An ultrasound probe is passed into your rectum to take pictures of the prostate. These provide a three-dimensional model, which is then used to decide the number of seeds needed for treatment, and exactly where they should be placed. For 24 hours before the volume study you may be asked to follow a special diet to make sure your bowel is empty. You may also be given an enema to empty your bowel so that the ultrasound picture is as clear as possible. The volume study can be done under local anaesthetic, but occasionally some men may need to go to an operating theatre and have a general anaesthetic. Treatment sessions The procedure is carried out under general anaesthetic and usually takes about an hour. An ultrasound probe is inserted into the rectum to show the prostate. The radioactive seeds are inserted through the skin between your prostate and anus, and guided into your prostate gland. If you re having HDR brachytherapy, the radioactive seeds will be inserted into fine plastic tubes (catheters). These tubes are then guided into your prostate. A computer will monitor the 32

35 Radiotherapy length of time the tubes stay in place for, and when the treatment is finished, the tubes are removed with the radioactive seeds inside. If you are having permanent seed implantation (LDR brachytherapy), the seeds are passed into your prostate using a needle. The needle is removed and the seeds are left inside the prostate gland. A catheter is sometimes inserted into the bladder to drain urine during the treatment session. This is because the procedure may cause some swelling of the prostate, which can lead to blockage of the urethra (the tube that drains urine from the bladder). The catheter may be removed after a couple of hours or will be left in place overnight. You ll be given antibiotics after the treatment to prevent infection, as well as medicine (Flomax ) to help improve the flow of urine. Most men go home on the same day as soon as they ve recovered from the anaesthetic and are able to pass urine normally. Occasionally, some men may have to stay overnight. After treatment, it s best to avoid heavy lifting or strenuous physical activity for 2 3 days. All the radioactivity is absorbed within the prostate, so it s completely safe for you to be around other people. However, if you ve had permanent seed implantation, as a precaution, you should avoid long periods of close contact with women who are (or could be) pregnant, and children. You shouldn t let children sit on your lap, but you can hold or cuddle them for a few minutes each day. It s safe for them to be in the same room as you. Your specialist can give you more information about the precautions you should take. 33

36 The seeds stay permanently embedded in your prostate gland, but there is a tiny chance of a single seed being passed in the semen during sex. So it s advisable to use a condom for the first few weeks after the implant. During this time the semen may look black or brown. This is normal and is due to bleeding that may have occurred during the procedure. Double-wrap used condoms and dispose of them in a dustbin. Side effects of brachytherapy Brachytherapy causes similar side effects to external beam radiotherapy (see pages 27 30). It s also common to feel mild soreness, and to have some bruising and discoloration between the legs for a few days after the procedure. Your doctor can prescribe painkillers to relieve this. You may also notice some blood in your urine and semen. This is normal at first but if it becomes severe or there are large clots present, let your doctor know immediately. It s important to drink plenty of water to help prevent blood clots and to flush the bladder. Around 3 4% of men may not be able to pass urine immediately after the procedure and may need to have a catheter inserted for a while. Some men may develop narrowing of the urethra weeks or months after the treatment, which may cause problems with passing urine. As with external radiotherapy, erection problems develop in 3 5 out of 10 men (30 50%), usually over a period of 2 5 years after the treatment. This may be higher if you re having external beam radiotherapy or hormonal therapy as well. Brachytherapy may also cause infertility in some men (see page 66). 34

37 Radiotherapy 35

38 Brachytherapy may be less likely to affect the bowel than external beam radiotherapy, although the risk of urinary problems (such as narrowing of the urethra) is higher. However, as mentioned earlier, men with locally advanced prostate cancer often have these two treatments together. Around 1 in 100 men (1%) experience leakage of urine after brachytherapy. Some men find they have pain or discomfort when they pass urine, need to pass urine more often, or have a weaker urine stream. This is usually due to the radiation from the seeds in the prostate and improves over 3 12 months as the seeds lose some of their radioactivity. Drinking plenty of fluids and avoiding caffeine may help reduce these effects. Most men will be able to return to their normal activities within 1 2 weeks after this treatment. This is likely to take longer if you have external beam radiotherapy as well. Advantages Brachytherapy combined with external beam radiotherapy can help control locally advanced prostate cancer for many years and may lead to a cure for some men. Brachytherapy usually only involves one treatment session and one planning session. Disadvantages Brachytherapy is usually given in combination with external beam radiotherapy, so it may not be possible to avoid frequent visits to hospital for treatment. It may also cause problems with erection difficulties, difficulty passing urine and urine leakage. Brachytherapy can also cause infertility. 36

39 Hormonal therapy Hormonal therapy Hormonal therapy may be given to men with locally advanced prostate cancer before radiotherapy. This is known as neo-adjuvant therapy, which can help make radiotherapy treatment more effective. Hormonal therapy is also sometimes given after radiotherapy (adjuvant therapy), where the aim is to reduce the chance of the cancer coming back. Hormonal therapy can also be given as a treatment on its own, and some studies have shown that it can improve survival. Hormones control the growth and activity of normal cells. In order to grow, prostate cancer depends on the hormone testosterone, which is produced by the testicles. Hormonal therapies reduce the amount of testosterone in the body. They can be given as injections or tablets. Occasionally, an operation called a subcapsular orchidectomy is done to remove the part of the testicles that produces testosterone (see pages 40 41). Injections Some drugs switch off the production of male hormones by the testicles by reducing the levels of a hormone produced by the pituitary gland. These drugs are called pituitary down-regulators or gonadotrophin-releasing hormone antagonists (GnRH antagonists). They include: goserelin (Zoladex ) leuprorelin (Prostap ) triptorelin (Decapeptyl ). 37

40 They are usually given as a pellet injected under the skin of the abdomen (goserelin), or as a liquid injected under the skin or into a muscle (leuprorelin or triptorelin). Injections are given either monthly or every three months. Tablets Other hormonal therapy drugs work by attaching themselves to proteins (receptors) on the surface of the cancer cells. This blocks the testosterone from going into the cancer cells. These drugs are called anti-androgens and are often given as tablets. Commonly used anti-androgens are: bicalutamide (Casodex ) flutamide (Chimax, Drogenil ). Anti-androgen tablets are usually given for two weeks before the first injection of a pituitary down-regulator. This prevents tumour flare, which is when symptoms get worse after the first dose of treatment. Research trials are being carried out to find out whether it s better to start the hormonal therapy before or after radiotherapy (if you are having both), and to find out how long to give the treatment for (it can range from two months to two years). 38

41 Hormonal therapy Side effects Impotence Unfortunately, most hormonal therapies usually cause erection difficulties (impotence) and loss of sexual desire for as long as the treatment is given. If the treatment is stopped, the problem may disappear. Some types of anti-androgens are less likely to cause impotence than others. Bone thinning Hormonal therapy can cause bone thinning (osteoporosis), which can sometimes lead to tiny cracks in the bone (fractures). The risk of bone thinning increases if you are taking hormonal therapy for long periods. You may have to have a special type of x-ray called a DEXA scan (dual-energy x-ray absorptiometry scan). This scan allows doctors to check the bones for any areas of weakness or fractures. You might also be given bone-strengthening drugs called bisphosphonates, which can help if you experience problems. Our booklet Bone health has more information. Hormonal effects Most men who have hormonal therapy experience hot flushes and sweating. Your doctor can prescribe medicines to help relieve this side effect while you re having treatment. The flushes and sweats will stop if treatment is stopped. We can send you more information about this. Other effects Hormonal treatment can also make you put on weight and feel constantly tired, both physically and mentally. Some drugs (most commonly flutamide and bicalutamide) may also cause breast swelling and tenderness. 39

42 Different drugs have different side effects, so it s important to discuss the possible effects with your doctor or specialist nurse before you start treatment. By being aware of the effects that may occur, you may find them easier to cope with. Advantages Hormonal therapy can slow or stop the growth of cancer cells for many years. It doesn t involve surgery or radiation, so there s little risk of bowel or bladder problems. Disadvantages Hormonal therapy won t get rid of all the cancer cells if it s the only treatment given. It can cause a range of side effects that include breast swelling, hot flushes, erection problems (impotence) and a lowered sex drive. We have fact sheets about individual hormonal therapies with more information about how the drugs work and tips on coping with possible side effects. We also have a fact sheet called Prostate cancer and hormonal symptoms, which you may find helpful. Removal of part of the testicles (subcapsular orchidectomy) There are many different hormonal therapy drugs available today, so a subcapsular orchidectomy is not commonly used. But it can be effective in certain situations. It s mostly used in men who can t have the other types of hormonal therapy mentioned on pages It can be effective in controlling prostate cancer and reducing symptoms. A subcapsular orchidectomy is a simple operation. A small cut is made in the scrotum (the sac that holds the testicles), and the 40

43 Hormonal therapy part of the testicles that produces testosterone is removed. After the operation the scrotum will appear smaller than it was before. You can have the operation as a day patient under a local or general anaesthetic. Sometimes, both testicles are completely removed (bilateral orchidectomy). Some men find the idea of this operation distressing. You may find it helpful to talk through the procedure with your cancer specialist, who can give you more information about what this operation involves. After the operation, you re likely to experience some pain, and some swelling and bruising of the scrotum. You will be given painkillers to ease any pain. You ll also start to have side effects similar to those of hormonal therapy drugs, which include hot flushes and impotence (see pages 39 40). Advantages A subcapsular orchidectomy is a simple operation that avoids the use of drugs and some of the associated side effects such as breast swelling and tenderness. Subcapsular orchidectomy and other hormonal treatments are equally effective. Disadvantages Some men find the idea of this operation difficult to cope with. As with any operation, there are risks associated with surgery. Your specialist will give you more information about these risks and the side effects you re likely to have. 41

44 42

45 Watchful waiting Watchful waiting Some locally advanced prostate cancers grow very slowly and may never cause any symptoms. For this reason, some men decide with their specialists to wait and see whether the cancer is getting bigger (progressing) before starting any treatment. This is called watchful waiting and is a way of avoiding treatment for as long as possible. Your doctors (either your GP or hospital doctor) will monitor you to see if the cancer is growing significantly or causing any symptoms. At each visit your doctor will ask you about your symptoms. They may also examine you, which may include a digital rectal examination. If your symptoms change or your doctor suspects that the prostate is growing, further tests will be done. You are likely to have the PSA test repeated. X-rays, MRI scans and bone scans may also be needed. If these tests show that the cancer is starting to grow, or if you develop more symptoms, your doctors will then consider treatment options that will aim to control the cancer and improve its symptoms. If the cancer is not growing or developing, it s safe to continue with watchful waiting. You can read more about the tests used during a period of watchful waiting in our booklet Having tests for prostate cancer. 43

46 Advantages Many men who choose watchful waiting will avoid the side effects of treatments such as hormonal therapy or radiotherapy. Disadvantages Some men find it difficult to wait and see if their cancer progresses before starting any treatment, especially since doctors can t predict when this might happen or whether it will happen at all. Some men will need treatment with radiotherapy or hormonal therapy anyway if their cancer shows signs of developing. 44

47 Surgery Surgery Some men are offered surgery to treat their prostate cancer or to help with the symptoms they have. Your doctor will discuss the operation with you. It s important you understand what it involves, the possible side effects, and whether or not there are other treatments that may be more appropriate for you. Your doctor may also be able to discuss how successful it might be in treating your cancer. There are three types of surgery used in men with locally advanced prostate cancer: Radical prostatectomy (see pages 46 51) The aim of this operation is to treat the prostate cancer by removing the prostate gland. This is only suitable for a small number of men with locally advanced prostate cancer. Transurethral resection of the prostate (TURP see pages 51 52) This operation can relieve symptoms such as difficulty passing urine, but does not treat the cancer. Subcapsular orchidectomy (see pages 40 41) This is an operation to remove part of the testicles. Sometimes both testicles are removed (bilateral orchidectomy). These procedures are done to reduce the levels of the male hormone testosterone in the body, so you can read more about this in our section about hormonal therapies. 45

48 For any type of surgery there are risks such as problems with bleeding or infections. But surgeons have a very high level of expertise and the risks are very small. Surgery for prostate cancer carries the risk of some long-term side effects as well, such as problems with controlling your bladder (urinary incontinence) and the inability to have and maintain an erection (impotence). Your specialist can give you more information about the type of surgery appropriate for you, and its effects. Radical prostatectomy A radical prostatectomy is carried out by a urologist a surgeon who specialises in operating on the prostate, kidneys and bladder. The whole prostate gland is removed, either through a cut made in the tummy area (abdomen) or through a cut made between the scrotum and the back passage. This operation is known as an open prostatectomy. The aim of the operation is to get rid of all of the cancer cells. This operation is only suitable for a small number of men with locally advanced prostate cancer, depending on how far the cancer has spread outside the prostate. You can discuss with your specialist whether a prostatectomy would be suitable for you. The operation often causes the inability to have and maintain an erection (impotence) and the inability to father children (infertility). It can also cause problems with controlling your bladder (urinary incontinence). Sometimes it s possible to do an operation called a nerve-sparing prostatectomy, which can reduce the risk of erection problems. However, this is often not possible for men with locally advanced prostate cancer. 46

49 Surgery As doctors can t predict which men will be affected by these side effects, it s important that you re fully aware of the risks beforehand. Your doctor will discuss the operation, its possible side effects and other treatment options with you. Advantages Removing the whole prostate gland may stop the cancer from spreading and may result in a cure. A radical prostatectomy appears to prolong life for some men with fast-growing cancers, but is only suitable for a small number of men with locally advanced prostate cancer. Disadvantages Although a prostatectomy can get rid of the cancer cells completely for some men, the cancer cells may come back in the surrounding area some time after the operation. If this happens, external radiotherapy may be given to the prostate area. Radiotherapy is given over a larger area, which can cause more side effects. Over half of men who have a prostatectomy for locally advanced prostate cancer will have a recurrence of their cancer and need further treatment with either radiotherapy or hormonal therapy. Laparoscopic radical prostatectomy With a laparoscopic prostatectomy your surgeon doesn t need to make a large cut. Instead they can take out your prostate gland using only four or five small cuts (about 1cm each) in your tummy area (abdomen). The surgeon uses specially designed instruments that can be put through these small cuts. This type of surgery is also known as keyhole surgery. After making the small cuts the surgeon uses carbon dioxide gas to fill the abdomen. A tiny video camera shows a magnified view of the prostate gland on a video screen. 47