Radiotherapy is one of the treatments that can be used to treat cancer that is still contained within the prostate gland (localised prostate cancer). Radiotherapy may also be suitable for some men whose cancer has spread to the area just outside the prostate (locally advanced prostate cancer).¹ Radiotherapy is a suitable treatment for men of any age and is as effective at treating localised prostate cancer as surgery to remove the prostate (radical prostatectomy).^{2, 3, 4}

If there is a risk that your cancer may spread beyond the prostate, you may be given external beam radiotherapy alongside another type of radiation treatment called brachytherapy.⁵ Having brachytherapy as well increases the dose of radiation to the prostate, which can can help make the treatment more effective but may also increase the risk of side effects.^{6, 7, 8}

Radiotherapy can also be used after surgery if there is a risk that not all of the cancer was removed (adjuvant radiotherapy) or if your PSA level starts to rise (salvage radiotherapy).

Your doctor or nurse should discuss the advantages and disadvantages of all the different treatment options with you. Other treatment options for localised prostate cancer may include:
• active surveillance
• radical prostatectomy
• brachytherapy
• watchful waiting

You may also be offered high intensity focused ultrasound (HIFU) or cryotherapy. They are not widely available in the UK and researchers are studying better ways of carrying out these treatments. They may be available in specialist centers or as part of a clinical trial.

For more information on all of the treatments listed above, please read our treatment choices pages or call our Specialist Nurses on our confidential helpline.

Unsure about your diagnosis and treatment options?

If you have any questions about your diagnosis ask your doctor or nurse. They will be happy to explain your test results and talk you through your treatment options. It is important you feel you have enough time and all the information you need before making a decision about treatment. We have more information on our pages on diagnosis and treatment. You can also speak to our Specialist Nurses on our confidential helpline.

The aim of radiotherapy is to destroy prostate cancer cells while limiting any damage to healthy cells. High energy X-ray beams are directed at the prostate gland from outside the body. These beams damage the cells and stop them from dividing and growing. Cancer cells are not able to recover from this damage and die, but healthy cells can repair themselves more easily.

Radiotherapy treats the whole prostate, and, in some cases, the area surrounding the prostate. This is to try to treat all cancer cells, including any that may have spread to the area just outside the prostate. The treatment is painless but you may have some side effects.

If your cancer has spread to the nearby lymph nodes or there is a risk that it might, you may have radiotherapy to a wider area which includes the nearby lymph nodes. The lymph nodes are part of the immune system. There are lymph nodes in the groin and pelvic area near the prostate, and they can be a common place for prostate cancer to spread to. Because a larger area is treated, there may be a greater risk of side effects than treatment to the prostate alone. There is research looking at how effective treatment to the lymph nodes is and the risk of side effects.

There are clinical trials looking at the best ways of using radiotherapy to treat prostate cancer. A clinical trial is a type of medical research study that aims to find out new and improved ways of preventing, diagnosing and treating illnesses. If you are interested in taking part in a clinical trial, speak to your doctor or nurse.

Types of external beam radiotherapy include:
• 3-dimensional conformal radiotherapy (3D-CRT)
• intensity modulated radiotherapy (IMRT)
• stereotactic radiotherapy (one brand is Cyberknife®).

The most common type of external beam radiotherapy for prostate cancer is called 3D-CRT. With 3D-CRT, the radiotherapy machine delivers beams of radiation that match, as much as possible, the size and shape of your prostate. This helps to avoid damaging the healthy tissue surrounding the prostate and so reduces the risk of side effects.^{3 10}

Another type of 3D-CRT called intensity modulated radiotherapy (IMRT) is available in some treatment centres. With IMRT, the radiation beams are delivered in different doses to different parts of the area being treated. This can help to reduce the dose to surrounding healthy tissues and the risk of side effects. It may also mean that a higher dose of radiation can be given to the prostate gland without increasing the risk of damage to the surrounding healthy tissues.^{2 11}

There are a number of different ways in which IMRT can be given. One type that you may hear about is tomotherapy.

Whether you are offered 3D-CRT or IMRT will depend on the centre you are treated at and your individual situation. For example, you may have IMRT if you are having your prostate and pelvic lymph nodes treated, or if you have had a hip replacement as this allows the beams to be angled to avoid the false hip.

Stereotactic radiotherapy is a newer type of radiotherapy, which uses many radiation beams with a low dose instead of using just a few beams with a higher dose. Again, this may mean that more radiotherapy can be given to the prostate whilst reducing the amount given to the surrounding healthy tissues. This treatment is not widely available on the NHS as it should only be used as part of a clinical trial. Your doctor should be able to tell you if you can have it.

For all types of radiotherapy, your radiographer will use images on the treatment machine, which allows them to see the position of your prostate. This means they can check that the treatment is delivered accurately and precisely. This is called image guided radiotherapy (IGRT).

The advantages and disadvantages of radiotherapy will depend on your age, health and the stage of your cancer. Radiotherapy will affect each man differently, and your doctor, nurse or radiographer will discuss your individual situation and options with you.

Advantages
• Radiotherapy has none of the risks of surgery and having a general anaesthetic.
• It can be given when you are considered unsuitable or unfit for surgery.
• Some men may find the treatment position a bit uncomfortable but the radiotherapy itself is painless.
• It is relatively quick. Daily treatment sessions last about 10 to 20 minutes, and you do not need to stay in hospital overnight.
• You can carry on with many of your usual activities while you are having treatment.

Disadvantages
• You will need to go to a specialist hospital for treatment five days a week for several weeks - and each visit could take at least an hour. This might be difficult if you need to travel a long distance.
• There is a risk of side effects including bowel problems, urinary problems and erectile dysfunction.
• It may be some time before you will know whether the treatment has been successful.

What might be an advantage for one person may not be for someone else. You can talk to your doctor or nurse about your own situation.

Radiotherapy may be an option if you have had surgery for prostate cancer (called a radical prostatectomy) and your PSA level has started to rise. This is called salvage or second line radiotherapy.

You may also be offered radiotherapy soon after surgery, if there is a risk that your cancer might have spread.¹² This is called adjuvant radiotherapy.

The treatment is carried out in the same way but radiation is given to the area where the prostate was removed (the prostate bed). You may be given a lower dose of radiotherapy, and you may also be given hormone therapy at the same time.⁷

If you have side effects from surgery, having radiotherapy may make these side effects worse or last longer, as well as causing other side effects.^{3 13} For example, surgery may cause you to leak urine, and radiotherapy may make this worse. It could also cause bowel problems. However, the newer types of radiotherapy, such as IMRT, help to reduce the risk of side effects.¹⁴

Before treatment

Radiotherapy is carried out at specialist hospitals and you will need to go to the hospital every day, except at the weekend, for treatment. You will see a specialist who treats cancer with radiotherapy, known as a clinical oncologist. The treatment itself will be planned and delivered by a team of radiographers.

You may be given hormone therapy for three to six months before you begin radiotherapy. This shrinks the prostate and makes the cancer easier to treat. You may also have further hormone therapy throughout your course of radiotherapy. Men who are at a higher risk of their cancer spreading may continue to have hormone therapy for at least two years after radiotherapy.^{12 15}

Before starting radiotherapy you will attend one or more planning sessions. You will have a computerised tomography (CT) scan and sometimes also a magnetic resonance imaging (MRI) scan to find the exact location, size and shape of your prostate. This is to make sure the treatment is accurate and that the surrounding areas do not receive more radiation than is necessary.

Usually three very small permanent marks will be made on your skin in the area to be treated, to help the radiographers put you in the right position on the treatment couch. You should barely be able to see them.

Some treatment centres may implant a small number of gold seeds, called fiducial markers, into the prostate. These are about the size of a grain of rice. They show up on scans and help the radiographer to locate the exact position of the prostate each day, before the treatment is delivered.

Most hospitals will give you information about how full or empty your bladder and bowel should be during treatment. Some hospitals will give you advice about your diet, and you may be given some medicine called a laxative to help you empty your bowels. This helps the radiographers to make sure they are treating the right area each time, which also helps to reduce side effects.¹⁶

Tell your doctor, nurse or radiographer about any medication, including any complementary therapies or food supplements you are taking before you start treatment.

Treatment

You will have one treatment (known as a fraction) at the hospital every day from Monday to Friday, with a rest over the weekend to help your healthy cells to recover. You can go home after each treatment session and will not have to stay overnight. Treatment normally lasts between seven and eight weeks. Some hospitals may offer a shorter course of about four weeks, with higher doses per session but a slightly lower total dose. But this is usually only available as part of a clinical trial.

At the beginning of each treatment, the radiographer will move you into the right position on the treatment couch using the three permanent marks on your body as a guide. It can take a little while but it is important to get it right. The radiographers then leave the room, but they will be able to see and hear you at all times through monitors.

The treatment then starts and the machine moves around your body. It does not touch you and you will not feel anything. You will need to keep very still but the treatment itself only lasts a few minutes. The whole session lasts about 10 to 20 minutes, including the time taken to position you on the treatment couch.

If you are having treatment with stereotactic radiotherapy, each treatment session will take longer than with 3D-CRT or IMRT. But, because a higher overall dose is given each time, you will need fewer treatments.

You will have regular scans or X-ray images taken during the course of your treatment to check that the radiotherapy is given to the correct area.

It is perfectly safe for you to be around other people, including children and pregnant women, during your course of external beam radiotherapy. The radiation does not stay within your body and you will not give off any of the radiation.

Treatment affects men differently but many are able to continue with normal activities. Many men continue to work while having radiotherapy but some men find that they need time to rest during treatment. If you have any questions about your treatment, speak to your doctor, radiographer or nurse. They can give you advice on coping with any side effects. You can also speak to one of our Specialist Nurses on our confidential helpline.

Your PSA level will be checked, usually six to twelve weeks after your treatment has finished. It will then be checked regularly, often at least every six months for two years, and after that at least once a year.² This is to monitor how well the radiotherapy has worked. You will also be asked about any side effects that you may have. Your follow-up care will vary between different centres and your doctor or nurse will tell you how often you will have follow-up appointments.

If your treatment has been successful your PSA level should drop. However, how quickly this happens, and how low the PSA level falls, will depend on whether you had hormone therapy alongside radiotherapy. If you had radiotherapy on its own, it may take up to two years for your PSA level to fall to its lowest level. If you had hormone therapy as well, your PSA level may fall more rapidly.

Your PSA level may still be detectable after radiotherapy because your prostate will still produce some PSA. If you have a course of hormone therapy with your radiotherapy, there may be a small rise in PSA after the hormone therapy finishes. This is normal and does not mean that your cancer has come back.

However, a significant rise in your PSA level may be a sign that your cancer has returned and you may need further treatment. If your PSA level does start to rise, talk to your doctor about what treatment might be suitable for you. You may be offered hormone therapy or very rarely, surgery. Cryotherapy or HIFU can also be options though these treatments are not widely available in the UK.

You can find more information about treatment options after radiotherapy in our booklet, Recurrent prostate cancer, or call our Specialist Nurses on our confidential helpline.

Like all treatments, external beam radiotherapy can cause side effects. These will affect each man differently, and you may not get all of the possible side effects.

Side effects can happen when the healthy cells next to the prostate are given radiation. Many of these healthy cells are able to recover and so side effects may only last a few weeks or months. However, some side effects can take longer to develop and can become long term problems.

Some of your side effects may be caused by hormone therapy, if you have this before or during your radiotherapy treatment. For more information read our page on hormone therapy.

Ask your doctor, radiographer or nurse for more information on the risk of side effects. Your hospital will arrange for you to have regular appointments, where you can discuss any symptoms that are worrying you. You will also see at least two radiographers every time you go for treatment who will be able to give you information and support. Side effects can often be treated,¹⁷ so if you experience anything unusual after having radiotherapy, ask your radiographer about it. You can also call our Specialist Nurses on our confidential helpline.

These can develop during or shortly after your treatment.

Bowel problems
The bowel and back passage are exposed to radiation because they are close to the area being treated. This may not cause any problems, but in most men it causes the lining of the bowel to become inflamed (proctitis) which then leads to symptoms. Before you start radiotherapy, tell your specialist team if you have ever had any problems with your bowels because this may increase your risk of further bowel problems after treatment.

Symptoms vary from man to man. Many men will notice that their stools become loose and watery (diarrhoea). They may pass more wind, need to go to the toilet more often, or have to rush to the toilet (rectal urgency). Some men feel the need to have a bowel movement, but then find that they are unable to go. You may leak stools (faecal incontinence) or get pain around the abdomen or back passage. You may feel that you have not emptied your bowels properly. Some men get bleeding from the rectum, but this is less common.¹⁸ You should let your doctor or nurse know if this happens so they can check what is causing this.
These symptoms usually start during the first few weeks of treatment. and then begin to settle down a few weeks after you have finished your treatment. However, some men may find that some symptoms last longer.¹¹

You should tell your doctor, radiographer or nurse about any changes in your bowel habits before taking any medication for your symptoms. They may give you medication to help, which could be medicines taken by mouth or medicines put directly into your back passage (an enema).

Your doctor, radiographer or nurse can give you advice on your diet but usually you should follow a normal diet and drink plenty of fluids. Some men may find that too much fibre makes diarrhoea worse. Eating a low fibre diet for a short time may help with these symptoms, but you should not change your diet unless you develop symptoms and until you have spoken to your doctor, radiographer or nurse first. Low fibre foods include rice, potatoes (without skins), pasta and meat.

Foods such as beans and pulses, cruciferous vegetables (for example, cabbage and cauliflower), fizzy drinks and beer can all cause wind and bloating so you may choose to avoid these. You can also reduce these effects by chewing your food slowly.

Urinary problems
Radiotherapy can irritate the lining of the bladder or the urethra (the tube that you pass urine and semen through). This can cause a burning feeling when you pass urine, difficulty passing urine, a need to pass urine more often and more at night, and sometimes blood in the urine. This is known as radiation cystitis. Symptoms may appear within a week or two of starting treatment but these usually start to improve once your treatment is finished.¹⁹

Tell your doctor, radiographer or nurse if you develop any urinary symptoms. They will check whether they are being caused by radiotherapy or by an infection. Drink plenty of fluids but try to reduce coffee, tea and alcohol because they can irritate the bladder. Sometimes, you may be given medication to improve the flow of your urine.

Tiredness
Towards the end of your treatment, you may feel more tired than usual. Regular gentle exercise, such as walking, can help to prevent and improve tiredness.²⁰ Many men continue to work throughout their treatment but if tiredness becomes a problem you may need to take some time off work. Most men recover completely from their tiredness within a couple of months of finishing treatment.

Fatigue can affect your everyday life and be hard to cope with. There are some changes you can make to your lifestyle that can help, such as eating healthily, being physically active, organising your day and addressing any problems you may have with sleep. For more information read our booklet, Living with and after prostate cancer.

Skin irritation and hair loss

Because of improvements in radiotherapy techniques in recent years, skin irritation and hair loss are now rare.

Towards the end of treatment, the skin between your legs and around your back passage may become a bit darker in colour and sore, like sunburn. Tell your doctor, radiographer or nurse if you have any of these symptoms. Avoid using any creams, lotions or perfumed soaps unless you are advised to do so by your doctor, radiographer or nurse. Wear loose, cotton clothes and try to keep the area cool. Avoid hot baths.

You may also notice that you lose some hair in the area that has been treated (pubic hair). This usually grows back but hair loss can be permanent in some men. You will not lose any hair on other parts of your body or your head.

Ejaculation
The tube that you pass urine and semen through (urethra) can become inflamed. This may make ejaculation painful but this should improve after you finish treatment. Some men may have a dry orgasm where they do not produce any semen. If you are worried about these side effects, speak to your doctor, radiographer or nurse.

Most short term side effects will settle down after your radiotherapy treatment has finished but you can have later side effects that develop several months, or even years, after you finish your treatment. These side effects can be long term.

Older age, diabetes, previous bowel or prostate surgery, and previous bladder and bowel problems can all increase your risk of getting long term side effects.²¹ Speak to your doctor or nurse about your own risk.

Bowel problems
Although bowel problems often improve once treatment has finished, some men will find that their bowel habits change permanently. This may be a minor change, such as having to open your bowels twice a day instead of once a day, or it can be a bigger change that affects your everyday life.

Symptoms may develop months or years after treatment and may be similar to the short term bowel problems.¹⁸ If you had bowel problems during treatment, such as diarrhoea or feeling the need to go but being unable to, you may be up to seven times more likely to develop problems later than if you had no problems during treatment.²²

Try not to be embarrassed to tell your specialist or your GP about any new or existing bowel problems. There are often simple treatments available that can help. Bowel problems are common in older men, so it is possible that they are due to something other than the radiotherapy. Your specialist or your GP can arrange simple tests to find out the cause of your symptoms or they may recommend that you are referred to a bowel specialist.

If you have long term bowel problems, you may be offered a test called a flexible sigmoidoscopy. A small tube is inserted into the back passage and the doctor looks at the lining of the bowel. This checks for any damage to the bowel to see whether it is caused by the radiotherapy or by something else.

Urinary problems

Urinary problems may develop several months or years after treatment. If you had problems during treatment, you may be more likely to develop urinary side effects later than if you had no urinary problems during treatment.

You may get side effects similar to the short term urinary problems. A few men may get a narrowing (stricture) of the urethra which makes it difficult to pass urine.¹⁹ This can be treated with a simple procedure.

In a small number of cases radiotherapy can cause you to leak urine.^{3 22} This is more likely if you have previously had prostate surgery such as a transurethral resection of the prostate (TURP) to treat an enlarged prostate or a radical prostatectomy.¹⁹

For more information you can read our page on urinary problems and prostate cancer, or call our Specialist Nurses on our confidential helpline.

Sexual problems
Radiotherapy can damage the blood vessels and nerves that control erections and so can affect your ability to get and keep an erection (erectile dysfunction). It can take up to two years for these symptoms to fully appear.

Erectile dysfunction can affect approximately two in five men (40 per cent) treated with radiotherapy.¹⁹ Other things such as tiredness and the stress of living with prostate cancer can also affect your sex life. There are several treatments available for erectile dysfunction.

Some men may notice that they produce less semen when they ejaculate and some will have a 'dry' orgasm where they do not ejaculate any semen.

For more information about sexual problems after radiotherapy, speak to your specialist. You can also read our page on sex and prostate cancer, or call our Specialist Nurses on our confidential helpline.

Infertility
Radiotherapy can damage the cells that make semen and cause fertility problems. If you are planning on having children you may be able to store your sperm before you start treatment so that you can use it later in fertility treatment. If this is important to you, ask your doctor or nurse whether sperm storage is available locally.

There is a very small risk that radiotherapy could affect any children you may conceive during treatment, so you may wish to use contraception during and after treatment if there is a chance of your partner becoming pregnant.²³ Ask your doctor or nurse for advice.

Other cancers
There is a small chance of developing another cancer after having radiotherapy but this is very rare.^{3, 24, 25, 26} The cells in the tissues surrounding the prostate gland, which have been exposed to the radiation beams, can be damaged, causing a cancer to grow. The types of cancer that may develop include bladder, colon and rectal cancers.²⁷ It would take at least 5-10 years after treatment with radiotherapy for a second cancer to appear.

It can be difficult coping with having treatment for prostate cancer. But there is support available to help you and your family. You may find it helps to talk to a partner, friend or relative about how you are feeling. However, you may find it difficult to talk to people close to you because you do not want to upset them, or you may find it hard to show your emotions.

You and those close to you can speak to one of our Specialist Nurses on our confidential helpline. They can answer any questions you have about your treatment and help you deal with the emotional effects of prostate cancer. You could also speak to your GP or doctor or nurse at the hospital about how you are feeling. If you would like more support, they can put you in touch with a counsellor.

Some people find that it helps to talk to other men who have had radiotherapy. There are prostate cancer support groups throughout the country. You can ask your doctor or nurse for details.

We can also arrange for someone who has experience of radiotherapy to speak to you through our one to one support service. You can also sign up to our online community.

You may find it helpful to keep a note of any questions you have to take to your next appointment.

• How many radiotherapy sessions will I have?
• Will I have hormone treatment? Will this continue after the radiotherapy?
• What side effects might I get? Will these be temporary or permanent?
• Will I be able to continue as normal during the treatment (for example, go to work)?
• How will we know how successful the treatment has been?
• If the radiotherapy is not successful, which other treatments can I have?
• Who should I contact if I have any questions at any point during my treatment?

Bladder and Bowel Foundation
www.bladderandbowelfoundation.org
Helpline: 0845 345 0165. You can leave a message 24 hours a day.
Provides information and support for all types of bladder and bowel related problems, for patients, their families, carers and healthcare professionals.

CancerHelp UK
cancerhelp.cancerresearchuk.org
Freephone: 0808 800 4040 (Mon-Fri 9am-5pm)
CancerHelp UK is the patient information website of Cancer Research UK. It contains information on radiotherapy and living with cancer.

Macmillan Cancer Support
www.macmillan.org.uk
Freephone: 0808 808 0000 (Mon-Fri 9am-8pm)
Information on coping with cancer and treatment as well as financial support for people with cancer, family and friends.

Maggie's Cancer Caring Centres
www.maggiescentres.org
Telephone: 0300 123 1801
Provide information and support to anyone affected by cancer. Their website holds a list of centres across the UK and has an online support group.

Royal College of Radiologists
www.goingfora.com
Interactive information on cancer treatment and scans, which includes descriptions from both staff and patients.

Sexual Advice Association
http://www.sda.uk.net/
Helpline: 020 7486 7262
Information on treatments for erectile dysfunction.

UK Prostate Link
http://www.prostate-link.org.uk
UK Prostate Link helps you find and compare reliable information about all aspects of prostate cancer.

Reviewed by:
• Catherine Holborn, Senior Lecturer in Radiotherapy & Oncology, Sheffield Hallam University
• Peter Kirkbride, Consultant Clinical Oncologist, Weston Park Hospital, Sheffield
• Sean Ralph, Therapy Radiographer, The Clatterbridge Cancer Centre NHS Foundation Trust, Merseyside
• Linda Welsh, Prostate Specialist Radiographer & Clinical Research Radiographer, Torbay Hospital
• Prostate Cancer Voices
• Prostate Cancer UK Specialist Nurses

Written and edited by: Prostate Cancer UK's Information Team

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