Men with advanced prostate cancer may have palliative radiotherapy to slow down the growth of the cancer and control symptoms. Advanced prostate cancer is cancer that has spread from the prostate to other parts of the body, such as the bones. It is also called metastatic prostate cancer. Treatment for advanced prostate cancer can keep it under control for many months or years.

Prostate cancer can spread to any part of the body, but most commonly to the bones or lymph nodes. The cancer that has spread to the bones is called 'bone secondaries' or 'bone metastases'. It is not the same as bone cancer, which starts in the bones. It can cause pain and problems moving around. You can read more about this in our Tool Kit fact sheet, Pain and advanced prostate cancer.

In some cases, men with advanced prostate cancer may also experience other symptoms, such as blood in their urine¹ or discomfort from swollen lymph nodes. These symptoms can often be helped with palliative radiotherapy.

Other treatments to help control the symptoms of advanced prostate cancer include:

• Pain-relieving drugs, which can be used alone or in combination with other treatments
• Treatments for the cancer itself, such as hormone therapy or chemotherapy
• Drugs called bisphosphonates which help to relieve bone pain
• Steroids to reduce swelling around the cancer and relieve pain

Talk to your specialist team about what treatment may be right for you. This may depend on where your cancer has spread to and what treatment you have already had.

Palliative radiotherapy can also be used to treat a condition called metastatic spinal cord compression (MSCC). This can happen if the cancer cells spread to the bones of the spine (vertebrae) and press on the spinal cord. This is rare, but it is a serious condition. If it does happen, it needs to be treated quickly.

MSCC may cause any of the following symptoms:

• Pain in your lower, middle or upper back or neck that is severe or different from usual pain. The pain may get worse when you cough, sneeze, lift, strain, or go to the toilet, and it may wake you at night or stop you from sleeping.
• A narrow 'band' of pain around your stomach area or chest.
• Pain that moves down your arms or legs.
• Weakness in your arms or legs, difficulty standing or walking, or falling.
• Numbness or tingling in your arms, legs, buttocks, stomach area or chest, which does not go away.
• Problems emptying your bladder and/or bowel. You may be unable to empty your bladder and/or bowel, or you may have no control over emptying them.

These symptoms may also be caused by other conditions, but it is still important to get medical advice in case you do have MSCC. You can read more about MSCC in our fact sheet, Metastatic spinal cord compression (MSCC).

The aim of all types of radiotherapy is to destroy cancer cells. Radiotherapy damages cells and stops them from dividing and growing. Cancer cells are not able to recover from this damage and die but normal healthy cells can repair themselves more easily.

The aims of palliative radiotherapy are:
• To shrink the cancer cells, wherever they are in the body. This may stop them pressing on the nerves and causing pain.
• To slow the growth of the cancer, giving your bones time to repair and strengthen.

There are two types of palliative radiotherapy:
• External beam radiotherapy (EBRT)
• A type of internal radiotherapy called radioisotopes

Your specialist team will help you to decide which type of palliative radiotherapy is best for you.

Treatment with palliative radiotherapy involves lower doses of radiation than radiotherapy for localised or locally advanced prostate cancer, and the course of treatment is shorter.

The advantages and disadvantages of radiotherapy depend on your general health, previous treatment and how far your cancer has spread.

Advantages:

• Palliative radiotherapy may help relieve your symptoms for several months and improve your quality of life.
• It may slow down the growth of the cancer in the area that is treated.
• Treatment works quite quickly. Within a few weeks you should have some pain relief.
• You may be able to reduce the dose of any pain-relieving drugs you might be taking.

Disadvantages:

• Like most treatments, palliative radiotherapy may cause side effects.
• You may experience an increase in pain during, and for a few days after, treatment but this should soon improve.
• The pain may come back after several months. If this happens you may need further treatment.

The specialist who treats cancer with radiotherapy is called a clinical oncologist. They should discuss with you whether you will benefit from palliative radiotherapy, which type of radiotherapy you may have, how long the treatment may take and possible side effects.

External beam radiotherapy (EBRT) is a short course of radiotherapy that is an effective and common way of relieving pain from bone metastases.² During EBRT, high energy X-ray beams are directed at the area of pain from outside of the body.

It may be a week or more after treatment before your pain starts to improve.³ It usually takes a few weeks for treatment to have its full effect. Pain relief usually lasts for an average of four to six months, but this can vary from person to person. Around seven out of ten men (70 per cent) will get some pain relief from this treatment.⁴

If you have pain in several areas of your body, you may benefit from having a treatment called hemi-body radiotherapy. This is radiotherapy to the upper half or the lower half of your body, depending on where you have pain. Your specialist team will assess your general health and fitness for this treatment, as it can be quite tiring. Hemi-body radiotherapy is carried out in the same way as EBRT.

What does treatment involve?
Preparing for external beam radiotherapy
Before starting EBRT you will go to a planning session. You may have a CT (computerised tomography) scan so that your specialist team can find the correct position for your treatment. You may then be given small permanent marks (a type of tattoo) on the area to be treated. You will barely be able to see them but they help the staff to put you in the right position on the radiotherapy table each time you are treated. You may also have a practice run (simulation) of the procedure. This uses low energy x-rays. The practice run helps to make sure that the correct area is treated. Planning is very important, and you may have several sessions to plan your treatment properly.

Treatment with EBRT
You will have your treatment in the outpatient radiotherapy department at the hospital. This means that you will not need to stay overnight. You may have either one single dose or a series of smaller doses spread out over a week or more. If you are having more than one dose, you may have a dose every day, every few days or once a week until you complete your course.

At the beginning of each treatment a member of staff will help move you into the right position on the table, using the marks on your body as a guide. The staff will then leave the room but they will be able to see you at all times through cameras. The radiotherapy machine moves around your body and will make a slight noise. It does not touch you and you will not feel anything. You will need to lie still but the treatment only lasts a few minutes. You should be able to go home after the treatment has finished.

Radiotherapy for MSCC
If you are having radiotherapy to treat metastatic spinal cord compression (MSCC) you will need treatment quite quickly. The quicker you have treatment, the more effective it will be. This means that you will only have a short time to discuss your treatment with your specialist team and the planning session will take place just before you have your treatment. You may also have steroids before radiotherapy to reduce swelling caused by the cancer. Ask your specialist team if you have any questions before your treatment starts.

You can read more about MSCC in our fact sheet, Metastatic spinal cord compression (MSCC).

Like all treatments, external beam radiotherapy may cause side effects in some men. The most common side effects are described here but there is no way of knowing which, if any, of these you will get, or how bad they will be. Ask your specialist team for more information on the risk of side effects.

Because you only have a few doses of treatment, there are usually few side effects from EBRT. If you have hemi-body radiotherapy you may have more side effects because a larger area of the body is treated.³ If you do have any side effects, they will depend on which part of your body is treated.

They may include:

• Feeling tired for a week or two after treatment finishes.
• Darkening of the skin and itching in the area treated, similar to sunburn.
• Feeling or being sick if you have had radiotherapy to your ribs or back bone. You may be given anti-sickness medication for this.
• Loose and watery stools (diarrhoea) if you had radiotherapy to your lower body. You may be given medication to help with this.
• A slight increase in pain during the course of treatment or for a few days after it has finished.^{5, 6} This should soon get better.⁷

Hemi-body radiotherapy may also affect how well your bone marrow works.^{8, 9} Bone marrow makes red and white blood cells and blood clotting cells (platelets). If your bone marrow is not working so well, it may not be able to make enough of these cells. A lack of red blood cells can cause anaemia. Symptoms of anaemia include tiredness, lack of energy (lethargy), breathlessness and looking pale. A lack of white blood cells may affect your ability to fight infection and a lack of platelets can make you more likely to bruise or bleed. You may have a blood test before treatment to check that your bone marrow is working properly.

Another way of treating advanced prostate cancer is with an injection of a very small amount of a radioactive substance called a radioisotope. Strontium-89 (Metastron) is a radioisotope which may be used to relieve pain in men with advanced prostate cancer.

Strontium-89 collects in bones damaged by cancer and targets the cancer cells in the bones.^{3, 10} Treatment with strontium-89 can be an effective way of relieving bone pain and preventing new pain from occurring.^{2, 11} It can be particularly helpful if you have pain in more than one area.³ It can take up to two weeks to start working and lasts for around four to 15 months. Around three quarters of men (75 per cent) will find that their pain improves significantly.¹²

What does the treatment involve?
Preparing for treatment with radioisotopes
Before having strontium-89 you should let your specialist team know if:

• You are taking prescription or over-the-counter medicines. For example, you may need to stop taking anti-inflammatory medication such as ibuprofen or blood thinning drugs such aspirin. This is because strontium-89 can affect the way your blood clots.
• You have a history of blood disorders, bone marrow problems or kidney disease. You may not be able to have treatment with strontium-89 if your cancer or previous treatment has damaged your bone marrow.
• You are planning to father a child within four months after your treatment. This is because you may have some strontium-89 in your ejaculate or sperm after treatment.¹³

Treatment with radioisotopes
Strontium-89 is given as an injection into a vein in your arm.

After you have had the injection, your urine and blood will be slightly radioactive. It will be safe for you to be around other people, including children, but your specialist team should let you know what precautions you should take.

These may include:

• Using a toilet that can flush rather than a urinal, and flushing the toilet twice after use. Wiping away any urine or blood spills with a tissue and then flushing it down the toilet.
• Washing your clothes or bed covers separately from other laundry if you get urine or blood on them.
• If you leak urine (incontinence) you may need to have a catheter for two weeks after having the injection of strontium-89. A catheter is a small tube inserted through the penis to drain urine from the bladder. This will help to prevent any leaking of urine.^{10, 14}

Strontium-89 will stay in the bones for several months and continue to deliver radiotherapy to the cancer cells. Any strontium-89 that is not taken up by the bones will be gone from your urine and blood within a few days.¹⁰

Most side effects of strontium-89 only last a short time and are not severe. They may include:

• An increase in pain a few days after treatment, but this should only last for a few days.¹²
• Changes to the way your blood clots and an increased risk of infection and anaemia. You may get a fever, chills, bruising, bleeding or tiredness. It is rare for infection or anaemia to be severe,¹² but you may have regular blood tests after treatment.
• Feeling or being sick (nausea or vomiting) or diarrhoea.¹⁵ This is not common.

If you have treatment with strontium-89, you may not be able to have treatment with chemotherapy in the future if your pain returns. This is because strontium-89 affects your bone marrow.² There will usually be another treatment that you can have.

Your specialist team will monitor you and your symptoms. Pain can sometimes get worse during treatment and for a few days afterwards. This is called a pain flare. This should soon get better, but you may need to take some pain-relieving drugs during this time or your doctor may increase the dose that you are already taking.

You should notice that the pain gradually improves. It may take a few weeks for the treatment to be most effective.^{12, 16} The pain relief usually lasts for several months and you may be able to reduce the dose of any pain-relieving drugs you are taking. Speak to your specialist team or GP about this, as it should not be done suddenly.

If your pain or symptoms do not improve then talk to your specialist team. If your pain has come back, your specialist team may suggest another course of radiotherapy. If you have already had EBRT to one area, you may be able to have another course of EBRT to the same area.¹⁷ This will depend on the dose you have already had. If you have a lot of bone pain in many new areas, you may be able to have hemi-body radiotherapy or treatment with strontium-89. However, you will not be able to have hemi-body radiotherapy twice to the same half of your body because of possible side effects. If you have had treatment with strontium-89 you may be able to have another course of strontium-89.

If more radiotherapy is not possible there will usually be other treatments that can help reduce or control any symptoms you have. Speak to your specialist team about your options. There is more information in our Tool Kit fact sheet, Pain and advanced prostate cancer. You can also speak to one of our specialist nurses by calling our confidential Helpline.

As well as getting medical help to treat your pain, most men find it helps to get some emotional support. Feeling more in control of your emotions can help you feel better.

If you are feeling low or anxious, it may be useful to talk to a counsellor. Counselling can help you cope if you are experiencing pain. You may be able get a referral to a counsellor through your specialist team or GP.

You may find it helpful to speak to someone with personal experience of prostate cancer. There are prostate cancer support groups throughout the country where you and your family can meet other people affected by prostate cancer.

Our online community is for men with prostate cancer and their families to share experiences, information and support.

You may also find that it helps to talk to your specialist team or a specialist cancer nurse such as a Macmillan or Marie Curie nurse. Many specialist nurses have counselling training and can help you work through some of your worries. They also know a lot about cancer pain and how to manage it. Specialist nurses can also offer emotional support for you and your family. They work very closely with the district nurses and your GP. You can ask your GP or specialist team to refer you to these nursing services.

Close friends and relatives often say that it can be difficult to watch a loved one in pain. They can feel helpless and have trouble coping so they may also need emotional and practical support.

• Questions to ask your specialist team
• How will palliative radiotherapy help me?
• What other treatments are available to help me with my pain?
• Which type of radiotherapy would be most suitable for me?
• How long will the treatment last?
• Will there be any side effects from the treatment? What can help with these?
• Are there any precautions that I need to take during treatment?
• Who should I contact if I have any questions at any point during my treatment? How do I contact them?
• Will I still need to see my specialist team after my treatment has finished?
• Will having this treatment mean I am unable to have other types of treatment (for example, chemotherapy) later on?

CancerHelp UK
Freephone: 0808 800 4040 9am-5pm, Mon-Fri
CancerHelp is the patient information website of Cancer Research UK and provides information about living with cancer.

Healthtalkonline
Watch, listen to or read personal experiences of men with prostate cancer and other medical conditions.

Macmillan Cancer Support
Freephone: 0808 800 1234 9am-8pm, Mon-Fri
Practical, emotional and financial support for people with cancer, their family
and friends.

Maggie's Cancer Caring Centres
Telephone: 0300 123 1801
Cancer information and support centres located around the UK where people affected by cancer can drop in to access information and support services.

Marie Curie Cancer Care
Freephone: 0800 716 146 9am- 5.30pm, Mon-Fri
Marie Curie run hospice centres throughout the UK and provide a nursing service for patients in their own home day and night, free of charge.

NHS Choices
Provides medical information and advice, including information about prostate cancer and radiotherapy.

Pain Concern
Helpline: 0844 499 4676 10am-4pm, Mon-Fri
1Offers information and support for people with pain and those who care for them.

UK Prostate Link
The UK Prostate Link website helps you find and compare reliable online information about all aspects of prostate cancer.

1 Din OS, Thanvi N, Ferguson CJ, Kirkbride P. Palliative radiotherapy for symptomatic advanced prostate cancer. Radiotherapy and Oncology. 2009;93:192-196.

2 National Institute for Health and Clinical Excellence, Prostate Cancer: diagnosis and treatment (Full guidance). February 2008

3 The British Pain Society. Cancer Pain Management. A perspective from the British Pain Society, supported by the Association for Palliative Medicine and the Royal College of General Practitioners. January 2010.

4 James ND, Bloomfield D, Luscombe C. The changing pattern of management for hormone-refractory, metastatic prostate cancer: Review. Prostate Cancer and Prostatic Diseases 2006; 9: 221-229.

5 Loblaw DA, Wu JS, Jackson S, Kirkbride P. Pain flare in patients with bone metastases after palliative radiotherapy--a nested randomized control trial. Supportive Care in Cancer. 2007;15(4):451-5.

6 Chow E, Ling A, Davis L et al. Pain flare following external beam radiotherapy and meaningful change in pain scores in the treatment of bone metastases. Journal of the European Society for Therapeutic Radiology and Oncology 2005; 75/1: 64-9.

7 Hird A, Chow E, Zhang L, et al. Determining the incidence of pain flare following palliative radiotherapy for symptomatic bone metastases: results from three canadian cancer centers. Int J Radiat Oncol Biol Phys. 2009;75(1):193-7.

8 Bashir FA, Parry JM & Windsor PM. Use of a modified hemi-body irradiation technique for metastatic carcinoma of the prostate: Report of a 10-year experience. Clinical Oncology. 2008;20:591-598.

9 Clarke N. Management of the spectrum of hormone refractory prostate cancer. European Urology. 2006;50:428-439.

10 Jager PL. Treatment with radioactive strontium for patients with bone metastases from prostate cancer. BJU International 2000; 86: 929-934.

11 Finlay IG, Mason M D & Shelley M. Radioisotopes for the palliation of metastatic bone cancer: a systematic review. Lancet Oncology 2005;6:392-400.

12 British Uro-oncology Group (BUG), British Association of Urological Surgeons (BAUS), British Prostate Group (BPG). MDT (Multi-disciplinary Team) Guidance for managing prostate cancer. 2nd Edition. 2009.

13 Notes for Guidance on the Clinical Administration of Radiopharmaceuticals and Use of Sealed Radioactive Sources. Administration of Radioactive Substances Advisory Committee 2006.

14 GE Healthcare. Metastron (Strontium-89 chloride injection). 2006.

15 Oosterhof GON, Roberts JT, de Reijke Th.M, et al. Strontium89 Chloride versus Palliative Local Field Radiotherapy in Patientswith Hormonal Escaped Prostate Cancer: A Phase II Studyof the European Organisation for Research andTreatment of Cancer Genitourinary Group. European Urology. 44 (2003) 519-526

16 Li KK, Hadi S, Kirou-Mauro A et al. When should we define the response rates in the treatment of bone metastases by palliative radiotherapy? Clinical Oncology (Royal College of Radiologists). 2008;20(1):83-9.

17 Lutz S, Berk L, Chang E, et al. Palliative radiotherapy for bone metastases: An ASTRO evidence-based guideline. Int. J. Radiation Oncology Biol. Phys. 2011;79(4):965-976.

Reviewed by:

• Dr Peter Kirkbride, Consultant Clinical Oncologist, Weston Park Hospital, Sheffield
• Philip Reynolds, Advanced Practice Radiographer (Urology), Guys and St Thomas' Hospital, London
• Linda Welsh, Prostate Specialist & Clinical Research Radiographer, Torbay Hospital, South Devon NHS Healthcare Trust, Torbay
• Dr Cathryn Woodward, Consultant Clinical Oncologist, Addenbrooke's Hospital, Cambridge
• The Prostate Cancer Charity Support and Information Specialist Nurses
• The Prostate Cancer Voices

Written and edited by:
The Prostate Cancer Charity Information Team