Prostate cancer is the most common malignancy diagnosed in men in North America. The two main options of treatment are either radical prostatectomy with surgery or radiation. Radiation, whether it’s external radiation or brachytherapy all works on the same principle that it’s energy. Much like light shines through the cells and then preferentially kills cancer cells, whereas normal cells can repair themselves. Here at Sunnybrook we see and treat over a thousand men a year. It would be probably the biggest radiation prostate facility certainly in Toronto if not Ontario. It’s an area of expertise and excellence at our centre. We have eight radiation oncologists that treat prostate cancer alone. There are three main types of radiation we do here at Sunnybrook, the first being external beam radiation, which is probably the most common.
That’s where men lie down have external radiation, much like an x-ray. The second is called brachytherapy, or internal radiation, where radioactive seeds are inserted permanently inside the prostate. That’s for select men with low-grade disease. And for low-risk disease. And the third is a combination of external-beam radiation therapy as well as temporary brachytherapy, or high-dose radiation, or HDR, where the radioactive seeds are temporarily placed into the prostate at certain areas and that’s used in combination with external beam radiation therapy for very select men with certain features. With external beam radiation therapy, the process entails coming in, having a consultation with the radiation oncologist being marked up or planned and that involves having a special CAT scan done where measurements are made, small tattoos are put on the skin for localization. A scan is done as long as men have filling of their bladder and an adequate and some of the things we are very particular regards to primary radiation. Men have their scans, the tattoos are made permanent they go home and then within the next week or two the oncologist, the radiation therapist will go over the plan and devise a specific plan based on that person’s anatomy mapping out the prostate, bladder and the rectum, which are the two main organs that are at risk when we treat men.
Then men will typically start about two weeks later. Something called a VacLock bag, that’s a little that’s essentially a bag of beans where patients are laid onto and their legs and hips are molded around this device. All the air is sucked out so that allows them to have a very cosy cushion that is to their anatomy and minimizes them from moving around during radiation. Each treatment lasts between about 60 seconds, so we have new technology that allows us to get the radiation done very quickly or traditionally seven or eight minutes. The radiation plan is devised of seven different angles around the person’s body with this scanner moving around and each time that beam stops in a certain angle Before every radiation treatment this scanner will go completely around the patient, provide a small CAT scan so if the prostate is more than two millimeters away from where it was when we planned the radiation that adjustments can be made to make sure we are very precise.
This decreases side effects. Men will typically come in Monday to Friday for eight weeks if they have a prostate we’re treating for cure. Six and a half weeks if we’re treating those men after surgery and we give small doses each day so that a certain percentage of the cancer cells are killed, but in the intervening 24 hours normal cells can recover to minimize side effects. The patient sees the physician to go over the bowel and bladder symptoms and things like that and be followed long term.
When we treat men with a combination of external beam radiation therapy and the HDR brachytherapy, the external beam component is the exact same. But then what men get is an ultrasound of the prostate to map out the prostate. They then come in for the HDR brachytherapy component of treatment, which involves a general anesthetic so men are put to sleep, catheters are placed inside the prostate and then a small radioactive seed is inserted along those catheters at certain intervals to deliver a very high dose of radiation to that prostate in a single setting. Men are taken out, woke up to make sure they can pee and they go home.
In general, the external radiation will start two weeks after that or in some cases before the brachytherapy depending on availability of that resource. It’s not available in every centre. It’s slowly becoming more available because it’s been found to be a very effective way to treat prostate cancer, specifically those men who are young and have more aggressive disease, so that’s what we select fore now. The last option, which is very popular for men with very low-risk disease is called permanent seed brachytherapy, or low-dose rate LDR, that’s where the seeds are permanently placed inside the prostate and it involves men coming, being assessed by ultrasound, having pictures taken essentially and then a plan is devised based on that person’s prostate and they come in a week or two later.
The seeds have since been ordered and received and are then placed inside the prostate at the appropriate areas and a CAT scan is done afterwards to make sure the seeds are where they are supposed to be. And that radiation stays active for several months. Men do have to carry around little cards saying they are radioactive in case they go into airports and things like that, but it’s a common thing and the authorities are aware of that. Men are asked to strain their urine for a while because there is a small chance one of the seeds will fall out, which doesn’t pose a risk to anybody but we take all the precautions necessary. This is for men with low grade disease, relatively low PSAs and men that have prostates that aren’t too big. Because if the prostate is too big, then the side effects of treatment go up. Radiation makes people tired because some of our bone marrow is in our hips and the blood is suppressed a little during radiation, not enough to cause infections, but it’s probably one of the reasons why guys get anemic and a bit tired by the end of radiation.
But also coming here every day for weeks is tiring. It’s a good relatively non-invasive way to be treated. It’s time consuming but in general a short amount each day. It avoids surgery in those men that don’t want to have the side effects of surgery or are not surgical candidates and it provides at least what appears to be the exact same chance of living to whatever ripe old age they were supposed to live in the first place. Less in one out of ten men now will need to have a medication because we’ve able to keep radiation off the rectum and the bladder and that’s despite the fact we’ve increased the dose a lot over the last few years as well. There’s more sessions, but less side effects. So we in fact, quote cure more men, .
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