Temporary brachytherapy, also known as high dose-rate (HDR) brachytherapy, involves inserting a source of high dose-rate radiation into the prostate gland for a few minutes at a time to destroy cancer cells. Because the radiation is delivered from inside the prostate, the healthy tissue nearby gets a much smaller dose of radiation and is less likely to be damaged.

You may have temporary brachytherapy on its own or, more often, you will have it together with external beam radiotherapy. If you have external beam radiotherapy with temporary brachytherapy, you get high doses of radiation to the whole gland as well as to the area just outside the prostate.¹ You may also have hormone therapy before and/or after temporary brachytherapy to shrink the prostate and make the treatment more effective.

There is another type of brachytherapy called permanent seed or low dose rate brachytherapy that involves implanting tiny radioactive seeds into the prostate. This is more commonly used than temporary brachytherapy for men whose prostate cancer has not spread outside the prostate gland.

Temporary brachytherapy is most suitable for men whose cancer has not spread outside the prostate gland (localised prostate cancer) and is 'medium risk'.

Your cancer may be described as medium risk if:

• your PSA level is between 10 and 20 ng/ml, or
• your Gleason score is 7, or
• the stage of your cancer is T2b or T2c

Some men whose prostate cancer is beginning to spread to the area just outside the prostate such as the seminal vesicles (locally advanced prostate cancer), or with higher Gleason scores, may also be able to have temporary brachytherapy, which will usually be combined with hormone therapy and external beam radiotherapy.

You will not be able to have temporary brachytherapy if your cancer has spread (metastasised) outside the prostate gland to other parts of the body.

Temporary brachytherapy is newer than some of the other treatments for prostate cancer and it is not as widely used. We do not know as much about how effective it is in the long term, or the risk of side effects compared with other treatments. More research is needed before we can say for sure if it is as effective as other treatments for locally advanced prostate cancer.

Temporary brachytherapy is not available at every treatment centre in the UK. Ask your treatment centre if they offer temporary brachytherapy and what their success rates are.

If you are considering temporary brachytherapy as a treatment option, your doctor or nurse will look at the following factors to find out if you are suitable for the treatment.

Urinary problems
Temporary brachytherapy may not be suitable for men who have severe problems passing urine because the treatment can make the problems worse. These can include symptoms of an enlarged prostate such as a weak urine flow or not emptying your bladder properly. Before you have treatment, your doctor or nurse will ask you about any urinary problems and you may have some tests. If you have any urinary problems, your specialist will work with you to try to reduce these.

Transurethral resection of the prostate (TURP)
Transurethral resection of the prostate (TURP) is surgery to remove prostate tissue. You may have had a TURP in the past to treat symptoms of an enlarged prostate. If you have recently had a TURP, you may have to wait three to six months before you can have temporary brachytherapy. Some centres do not offer temporary brachytherapy to men who have had a TURP.

Anaesthetics
Anaesthetics are used during temporary brachytherapy so that you do not feel any pain or move during the procedure. Temporary brachytherapy will only be an option for you if you are fit and healthy enough to have anaesthetics.

Other treatment options may include:

• active surveillance
• watchful waiting
• surgery (radical prostatectomy)
• external beam radiotherapy
• permanent seed brachytherapy (also known as low dose rate brachytherapy)
• hormone therapy.

You may also be offered HIFU (high intensity focused ultrasound) 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 centres or as part of a clinical trial. You can find out more about all of the treatments mentioned here by reading our treatment choices page or by calling our confidential helpline.

Planning a family?
Brachytherapy can have an effect on your ability to father a child (fertility). If you are planning to have children, ask your GP or doctor or nurse about this. See the section 'What are the side effects?'.

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 with you about 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.

You may be given temporary brachytherapy with another type of radiation called external beam radiotherapy. During external beam radiotherapy, high energy X-ray beams are directed at the prostate gland from outside the body. This may also be combined with hormone therapy to shrink the prostate and make the cancer easier to treat.

Having external beam radiotherapy as well as temporary brachytherapy can help make the treatment more effective but it may also increase the risk of side effects. As you will be having further treatment in addition to temporary brachytherapy you will also have more hospital visits.

Advantages

• Treatment in hospital with temporary brachytherapy takes just one or two days.
• It delivers a high dose of radiation direct to the prostate gland so healthy tissue nearby only gets a small dose of radiation and therefore is less likely to be damaged and cause side effects.
• Recovery is quick, which means you can usually return to your normal activities within a week of treatment.

Disadvantages

• It can cause side effects such as urinary, bowel and erection problems.
• You will need a general or spinal anaesthetic. See the section 'What does treatment involve?'
• If you require more than one radiation treatment you may need to stay in bed for at least six hours between treatments whilst the tubes are in your prostate. Some men find this very uncomfortable. See the section 'What does treatment involve?'
• You may need to stay in hospital overnight.
• It may be some time before you will know whether the treatment has been successful. See the section 'What happens afterwards?'

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.

If you decide to have temporary brachytherapy, you will be referred to a specialist who treats cancer with radiotherapy, known as a clinical oncologist. The treatment itself may be planned and carried out by specialists including therapy radiographers, urologists, physicists, and sometimes a specialist nurse.

If you have a relatively large prostate gland, you may have hormone therapy before brachytherapy starts. You may continue to have hormone therapy after treatment if you have a higher risk cancer. You may also have a short course (three to five weeks) of external beam radiotherapy before or after your treatment.

Before treatment
Your doctor or nurse will discuss the treatment with you to make sure that you understand what is involved and that it is the right treatment for you. If you are happy to go ahead, you will go into hospital on the day of, or the day before, your treatment.

You will have some medication, an enema, to help you empty your bowels. An enema is a fluid which is inserted directly into your back passage (rectum). The nurse may then give you a tablet to stop you needing to open your bowels when the radiation is being delivered.

It is likely that you will have a general anaesthetic so that you are asleep during the procedure. Another option is to have a spinal or epidural anaesthetic, so that you are awake but cannot feel anything. The specialist team will discuss the different options with you.

The specialist will gently insert an ultrasound probe into your back passage (rectum). They will then pass thin plastic or metal tubes through the perineum, which is the area between your testicles and the operning of the back passage (anus), into the prostate gland and the surrounding tissues. There are normally 10 to 20 tubes, and once they are in the right position, they are secured in place.

The specialist will pass a thin tube (catheter) through the penis into the bladder so that urine can pass out easily and you will not have to get out of bed to use the toilet while the tubes are in place. The whole process takes about 45 minutes to an hour.

You will then have a computerised tomography (CT), magnetic resonance (MRI) or ultrasound scan, which shows the outline of the prostate and the surrounding tissues. This takes about 20 minutes. Each centre does things slightly differently and you may need more than one scan. Your doctor will use the scan to plan the doses of radiation needed for your treatment. This can take about an hour. You will then have your treatment.

Treatment
You may have your treatment while you are still under general anaesthetic in the operating theatre, or you may have it in the brachytherapy treatment room once you have woken up.

During treatment, flexible tubes from the brachytherapy machine are attached to each of the tubes that are in your prostate. A highly radioactive pellet travels down each of the tubes in turn. The pellet stays in each tube for a set period of time, giving a higher dose of radiation to the tumour than to the healthy surrounding tissues. The machine automatically removes the pellet at the end of the treatment.

The number of treatments you have will depend on the hospital where you are being treated. Check with your doctor or nurse how many treatments you will have and whether you will be asleep or awake during treatment.

• You may have just one treatment. In some centres, you will have the treatment while you are asleep in the operating theatre and the tubes will be removed before you wake up. You will be in theatre for three to four hours in total. In other centres, you will have the treatment in the brachytherapy room while you are awake. Treatment takes about 10 to 20 minutes and is completely painless. The specialist will then remove the tubes.
• You may have two or three treatments in total, with a gap of at least six hours between each one. You will have each treatment in the brachytherapy room while you are awake. Each treatment takes about 10 to 20 minutes and is completely painless. You will need to stay in bed on the hospital ward until you have had the last treatment. The specialist will then remove the tubes.

Some men find that having the tubes in place is uncomfortable. You normally have to lie on your back and keep still to make sure the tubes do not move. Most men find that this discomfort goes away once the specialist takes the tubes out. Speak to your doctor or nurse before the procedure to find out what they will do to make you as comfortable as possible.

After treatment
After treatment is finished, the nurse will take out your catheter. This should be painless.

Many people feel fine after anaesthetic but some people may have side effects such as feeling sick or dizzy. Some men find it difficult to pass urine after anaesthetic. You can go home when you have recovered from the anaesthetic and are passing urine normally. This may be on the same day as treatment but most men need to stay in hospital overnight. Your doctor or nurse will give you any medicines that you need at home. These may include drugs to help prevent urinary problems (such as tamsulosin) and antibiotics to prevent infection.

No radioactive material is left in the prostate so it is safe for you to be around other people, including children and pregnant women.

You may pass small amounts of blood in your urine for a few days after your treatment. You may also have some discomfort and bruising in the area where the tubes were placed, particularly if you sit on a hard chair, and your bowel movements may feel a little uncomfortable. This should settle down after a few days.

Going back to normal activities and work
You should be able to return to your normal activities within a week of treatment. You can go back to work as soon as you feel able, and this will depend on how much physical effort your work involves.

Travel
If you have had a general anaesthetic, you should not drive a vehicle for 24 hours after treatment.

Your follow-up appointment

If you are having external beam radiotherapy after the temporary brachytherapy, you will start this around two weeks after your treatment.

If not, a few weeks after your treatment, you will be invited back to the hospital for an appointment with your doctor or nurse. They will monitor how well you are recovering from the treatment, check your PSA level and ask about any side effects.

You will have your PSA level checked regularly after your treatment to monitor how well the temporary brachytherapy has worked. Your PSA level will be checked at least every six months for two years and at least once a year after that. Your specialist will also ask you about any side effects that you may have.

Follow-up will vary between centres. Your doctor or nurse will tell you how often your PSA level will be measured.

If your treatment has been successful, your PSA level should drop. However, how quickly this happens, and how low the PSA level falls, varies between men. If you have been on hormone therapy alongside temporary brachytherapy, then your PSA may rise a little when you stop the hormone therapy. This is because some normal prostate cells may have recovered from the treatment and may release small amounts of PSA.

However, a significant rise in your PSA level or a continuous rise over repeat PSA tests 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 or nurse about what treatment might be suitable for you. You may be offered hormone therapy, or very rarely, surgery. Cryotherapy or high intensity focused ultrasound can also be options though these treatments are not widely available in the UK.

You can read more about treatment options after temporary brachytherapy in our booklet, Recurrent prostate cancer.

Like all treatments, temporary brachytherapy can cause side effects. These will affect each man differently, and you may not get all of the side effects.

Some of the possible side effects are listed here. Ask your doctor or nurse for more information on the risk of side effects.

Some men who have temporary brachytherapy and external beam radiotherapy together find that they have worse side effects.

You might also get more side effects if you had problems before the procedure. For example, if you already had urinary, erection or bowel problems, you may find these problems are worse after treatment.

Tiredness
You may feel tired for the first few days after treatment as you recover from the anaesthetic.

Problems passing urine
Temporary brachytherapy causes the prostate gland to swell. This can make the tube you pass urine through (urethra) narrow and may irritate your bladder. This may lead to problems such as²:

• needing to pass urine often.
• feeling like you need to pass urine urgently.
• hesitating before starting to pass urine.
• a weak flow of urine.
• discomfort or burning sensation when you pass urine.

These problems tend to be worse in the first few weeks after treatment but usually start to improve after a few months.^{3 4}

Temporary brachytherapy can cause acute urinary retention. This means that you have a sudden and painful inability to pass urine. If this happens, you will need treatment straight away, usually at a hospital. You should contact your doctor or nurse or visit your hospital's accident and emergency (A&E) department as soon as possible.

Medicines called alpha blockers and non-steroidal anti-inflammatory drugs (NSAIDs) may help ease problems with passing urine. You can help yourself by drinking plenty of liquid (two litres or three to four pints a day) and cutting down on drinks that may irritate the bladder such as fizzy drinks, caffeine based drinks (tea, coffee and cola), and alcohol.

Men may find that they leak urine (urinary incontinence) after temporary brachytherapy but some studies have suggested that the risk of this is low.^{6 7} If you have previously had a transurethral resection of the prostate (TURP) then you may be more likely to have problems with leaking urine.

Read our page on Urinary problems and prostate cancer treatment for more information about how to manage urinary problems.

Erection problems
Temporary brachytherapy can damage the blood vessels and nerves that control erections, which may make it difficult for you to get and keep an erection (erectile dysfunction). This may gradually get worse over several years.⁵

It is difficult to say how many men will have erection problems after treatment as different studies measure it in different ways and the risk can vary from man to man. However, in one study 3 out of 10 men (30 per cent) at 30 months and 45 out of 100 men (45 per cent) at three years had problems with erections after temporary brachytherapy.⁵

Your risk will increase if you had any problems getting and keeping an erection before treatment or if you are having hormone therapy or external beam radiotherapy alongside brachytherapy.

Some men may notice a reduced sensation along the penis immediately after brachytherapy which should slowly improve.

There are ways to manage erection problems. Ask your doctor or nurse for more information about these and read our page on Sex and prostate cancer.

Fertility
Temporary brachytherapy may have less of an effect on fertility than other treatments for prostate cancer⁸ but we still need more research into this. You may have a 'dry orgasm' where you do not produce any semen. Or you may notice that you produce less fluid, but it is possible that you are still fertile.

Changes to your sperm during brachytherapy could affect any children you may conceive during this time⁹ but the risk of this happening is very low.^{10 11} You may wish to avoid fathering a child during treatment and for a while after having treatment, for example, by using a condom or other form of contraception.

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 for fertility treatment. If this is important to you, ask your doctor or nurse whether sperm storage is available locally.

Bowel problems
The risk of bowel problems, such as passing more wind, loose and watery stools (diarrhoea), and inflammation and bleeding in the back passage (proctitis), is low in men treated with temporary brachytherapy.¹² However, you are more likely to have problems if you are also having external beam radiotherapy.

Bleeding from the back passage is a rare side effect of brachytherapy, but it can be a sign of other bowel conditions such as bowel cancer so it is important to tell your nurse or GP about any symptoms. They will also be able to tell you about treatments that can help with this side effects.

As well as getting medical help to treat your cancer, you may find that it helps to talk to family or friends about how you are feeling. Sharing concerns can make any decisions about your treatment easier to deal with. You could also speak to your doctor or nurse or call our Specialist Nurses on our confidential helpline.

Partners and family also often worry about their loved one, and may find it helpful to talk to your doctor or nurse.

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

We can also arrange for someone who has experience of prostate cancer to speak to you about making a treatment choice through our one-to-one support service. Please call our Specialist Nurses on our confidential helpline for more information.

You can also sign up to our message boards, where you can share your views and experiences with others affected by prostate cancer.

• Will I have external beam radiotherapy before or after temporary brachytherapy?
• Do I need hormone treatment before and/or after temporary brachytherapy?
• What are the chances of side effects such as urinary problems, erection problems and bowel problems with this treatment?
• How many treatments will I have? Will I be asleep or awake during treatment?
• How long will I need to stay in hospital for the treatment?
• How will we know if the treatment has worked?
• What should my PSA level be after treatment and how often will you measure it?
• If my PSA continues to rise, what other treatments are available?

Your doctor or nurse will give you a telephone number to call if you have any questions or worries. Contact them or visit your hospital's accident and emergency (A&E) department if any of the following things happen.

• If your urine is very bloody, has clots in it or you are suddenly not able to pass urine this could mean that you have bleeding in your prostate or acute urinary retention. This will need treatment as soon as possible.
• If you have a high temperature (more than 38˚C or 101˚F) with or without chills this may be a sign of infection.

Bladder and Bowel Foundation
www.bladderandbowelfoundation.org
Continence nurse helpline 0845 345 0165
Provides information and support for all types of bladder and bowel related problems.

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

Health Talk Online
www.healthtalkonline.org
Watch, listen to, or read personal experiences of cancer diagnosis and treatment.

Macmillan Cancer Support
www.macmillan.org.uk
Macmillan Helpline: 0808 808 00 00 (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.

Prostate Brachytherapy Advisory Group
www.prostatebrachytherapyinfo.net
This website is written by health professionals and provides information about brachytherapy treatment.

Sexual Advice Association
www.sda.uk.net
Helpline 020 7486 7262
Information on treatments for erectile problems.

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

Reviewed by:

• Ben Challacombe, Consultant Urological Surgeon & Honorary Senior Lecturer, Guy's Hospital & King's College London
• Peter Hoskin, Consultant Clinical Oncologist, Mount Vernon Cancer Centre, Northwood, Middlesex
• Linda Welsh, Prostate Specialist & Research Radiographer, Torbay Hospital
• Prostate Cancer UK’s information Volunteers
• Prostate Cancer UK’s Specialist Nurses

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

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