How does radiotherapy treat advanced prostate cancer?

Radiotherapy can be used in different ways to treat advanced prostate cancer:

• As part of your first treatment for advanced prostate cancer – If you’re offered radiotherapy as part of your first treatment, you’ll have a type called external beam radiotherapy.
• To improve symptoms in areas where the cancer has spread – You may have external beam radiotherapy to the part of the body where the cancer is causing problems.
• To help some men with bone pain live longer – If your cancer is causing bone pain, you may be offered a type of internal radiotherapy called radium-223 (Xofigo^®) to help you live longer and to treat the bone pain.

A clinical oncologist or radiographer will plan your radiotherapy with you. They will explain which type of radiotherapy you will have, how long the treatment could take and the possible side effects. This could depend on where your cancer has spread to, any symptoms you’re having, and your general health and fitness.

A team of treatment radiographers will give you the treatment. They'll also give you support and information during your treatment.

The information on this page is for men with advanced prostate cancer. If your cancer hasn't spread to other parts of the body, read our information on external beam radiotherapy for localised or locally advanced prostate cancer instead.

External beam radiotherapy

This is high-energy X-ray beams targeted at the area being treated from outside the body. Radiotherapy permanently damages and kills cancer cells, but healthy cells can repair themselves and recover more easily.

As part of a first treatment for advanced prostate cancer

If you’ve just been diagnosed, you may be offered external beam radiotherapy to your prostate alongside other treatments. It won’t cure your cancer, but it can help some men live longer. It will only be an option if the cancer has only spread to bones in your pelvis or spine, or to lymph nodes. The treatment doesn’t appear to help men whose cancer has spread to bones away from the pelvis or spine, or to organs like the liver.

You'll have radiotherapy alongside hormone therapy, often with chemotherapy as well.

To treat symptoms

Advanced prostate cancer can cause symptoms in the areas it has spread to. External beam radiotherapy can help control these symptoms by slowing the growth of the cancer in those areas. You may hear this called palliative radiotherapy. For example, radiotherapy is effective at relieving pain caused by prostate cancer that has spread to the bones. Up to eight in every ten men (80 per cent) who have external beam radiotherapy for bone pain get some pain relief from it.

External beam radiotherapy can also treat prostate cancer that’s spread to the lymph nodes and can help with other symptoms of advanced prostate cancer, such as blood in the urine, bowel problems or kidney problems. It can also be used to treat an emergency condition called metastatic spinal cord compression (MSCC).

Other treatments that may help to manage symptoms include pain-relieving drugs and treatments for the cancer itself, such as hormone therapy or chemotherapy.

What are the advantages and disadvantages?

The advantages and disadvantages of radiotherapy depend on your general health, previous treatment and how far your cancer has spread. What may be important to one person might be less important to someone else. Talk to your doctor, radiographer or nurse about your own situation.

Advantages

• External beam radiotherapy to the prostate can help some men live longer if their cancer hasn’t spread far from the prostate.
• It is painless, but you may find the treatment position uncomfortable if you have pain.
• Treatment sessions only last around 10 minutes, including the time it takes to get you into position. You don’t need to stay in hospital overnight.
• Most men who have radiotherapy for pain find it helps control their pain.
• You might be able to reduce the dose of any pain-relieving drugs you’re taking. This could be useful if they are causing side effects.
• Radiotherapy may control other symptoms, such as blood in the urine and bowel problems.
• If your pain comes back, you may be able to have more radiotherapy to the same area. This will depend on the dose you've already had and how long ago you had it.

Disadvantages

• External beam radiotherapy to the prostate may not help men live longer if their prostate cancer has spread to distant bones or organs.
• If you’re having radiotherapy as a first treatment, you'll need to go to a specialist hospital for treatment daily or weekly for a few weeks. This might be difficult if you need to travel far.
• If you’re having external beam radiotherapy to the prostate, your bowel may need to be empty during each treatment session. You may be given medicine to help empty your bowel each day. This can take a while to work, and some men find it inconvenient.
• For a few men, radiotherapy won’t help to control their pain.
• Radiotherapy can cause side effects. The risk of different side effects depends on the part of the body being treated.
• You might have slightly more pain during treatment, and for a few days afterwards. This should soon improve.
• The pain can come back after several months. If this happens, you might need further treatment with radiotherapy or other treatments.

Preparing for treatment

Before starting treatment you will usually have a planning session. This might involve having a CT (computerised tomography) scan. The planning session is to make sure the person treating you knows the exact position, size and shape of the area that needs treating.

At the end of your planning session, your radiographer will make a few very small permanent marks, like tiny tattoos, on your skin in the area to be treated. These help the radiographers put you in the right position for your treatment.

What does treatment involve?

You will have your treatment in the outpatient radiotherapy department at the hospital.

• If you’re having radiotherapy to the prostate, you may have radiotherapy five days a week for four weeks. Or you may have radiotherapy once a week for six weeks. You will probably need to have an empty bowel during your treatment. Some hospitals ask you to have a full bladder and others ask you to empty your bladder. This helps to make sure the radiotherapy beams target the exact same area during each treatment, and reduces the risk of side effects to your bowel or bladder. Your radiographer may give you an enema (liquid medicine) or a suppository (a pellet) to use either at home or at the hospital. These are put inside your back passage and help make sure your bowel is empty.
• If you’re having radiotherapy to treat symptoms, such as pain, you’ll have either a single dose directed at the area causing problems, or a series of smaller doses spread out over a week or more. You might have a dose every day, every few days or once a week. This type of radiotherapy uses a lower dose of radiation overall than radiotherapy for earlier stages of prostate cancer. The course of treatment is also often shorter.

At the beginning of each treatment, the radiographer will help you get into the right position on the treatment couch. They’ll use the marks made on your body as a guide.

The radiographer will then leave the room, but they’ll be able to see you at all times through cameras. The radiotherapy machine moves around your body and it will make a slight noise. It doesn’t touch you and you won’t feel anything – a bit like having an X-ray. You’ll need to lie very still, but the treatment only takes around 10 minutes, including the time it takes to get you into position. You should be able to go home after the treatment has finished.

It’s safe for you to be around other people, including children and pregnant women, while you’re having radiotherapy. The radiation doesn’t stay in your body so you won’t give off any radiation.

If you’re having radiotherapy to treat pain, it may take a week or more for your pain to improve, and it can take several weeks for the treatment to have its full effect. You may need to continue taking painkillers during this time. Pain relief usually lasts for an average of four to six months, but this can vary from person to person.

What are the side effects?

After external beam radiotherapy as a first treatment

Healthy tissue near the prostate may get damaged and this can cause side effects. These may only last a few weeks or months, but some side effects can last for longer or develop months or years after treatment. Possible side effects of radiotherapy to the prostate may include:

• urinary problems, such as needing to urinate often, a burning feeling when you urinate or difficulty urinating
• bowel problems, such as loose or watery bowel movements (diarrhoea), passing more wind than usual, needing to empty your bowel more often, feeling an urge to have a bowel movement but then not being able to go, a feeling that your bowels haven’t emptied properly, or pain in the stomach area (abdomen) or back passage
• blood in your urine or from your back passage (rectum)
• sore skin between your legs and near your back passage – this is rare
• erection or ejaculation problems, such as discomfort when you ejaculate, a reduced amount of semen or a ‘dry orgasm’, where you have the feeling of an orgasm but don’t ejaculate
• not being able to have children naturally – if you’re worried about this, your doctor, nurse or radiographer can talk to you about storing sperm for fertility treatment later
• a build-up of fluid in your legs (lymphoedema) – this affects a small number of men after radiotherapy to the lymph nodes.

After external beam radiotherapy to treat symptoms

There are usually only a few, if any, side effects from external beam radiotherapy when it’s used to treat symptoms of advanced prostate cancer. This is because you’ll only have a few doses of treatment. The risk of side effects is higher if you are having radiotherapy to several different areas or larger areas of your body, or if a higher total amount of radiotherapy is used.

The possible side effects will depend on the part of your body that’s treated and may include:

• red, dark or itchy skin in the treated area, similar to sunburn – if this happens, ask your radiographer for advice on how to look after your skin
• loose and watery bowel movements (diarrhoea) – this can be caused by radiotherapy to the pelvis or abdomen, but there are treatments that can help
• a slight increase in pain during the course of treatment or for a few days afterwards – it’s important to keep taking any pain-relieving drugs you’ve been given, and the pain should soon get better.

Radium-223 (Xofigo®)

This treatment is for men whose prostate cancer has spread to the bones and is causing pain. It will only be an option if your cancer has stopped responding to your first hormone therapy.

Radium-223 is a type of internal radiotherapy called a radioisotope. A very small amount of a radioactive liquid is injected into a vein in your arm. It travels around the body in the blood and is drawn towards bones that have been damaged by prostate cancer. It collects in these parts of the bones and kills cancer cells there.

Radium-223 helps some men to live longer. It can also help to reduce bone pain and can be particularly helpful if you have pain in more than one area. Up to 7 in every 10 men (70 per cent) who have radium-223 get some pain relief from it. It can also delay and reduce the risk of MSCC. But it won’t be suitable if your cancer has spread to organs such as the liver, or if you have large amounts of cancer in your lymph nodes.

In England, Wales and Northern Ireland, you can only have treatment with radium-223 if you have already had a type of chemotherapy called docetaxel or if docetaxel isn't suitable for you. In Scotland, you can have radium-223 before or after chemotherapy. You may also be able to get radium-223 through a clinical trial.

Speak to your doctor, radiographer or nurse about whether radium-223 might be an option for you. You can also speak to our Specialist Nurses.

What are the advantages and disadvantages?

The advantages and disadvantages of radiotherapy depend on your general health, previous treatment and how far your cancer has spread. Talk to your doctor, radiographer or nurse about your own situation.

Advantages

• Most men who have radium-223 for pain find it helps control their pain.
• You might be able to reduce the dose of any pain-relieving drugs you’re taking. This could be useful if they are causing side effects.
• Radium-223 can help relieve bone pain, helps some men with advanced prostate cancer to live longer and can improve your day-to-day life.

Disadvantages

• For a few men, radium-223 won’t help to control their pain.
• Like all cancer treatments, radium-223 can cause side effects.
• You can only have one course of radium-223.

Preparing for treatment

Before having radium-223 there are things you should discuss with your doctor, radiographer or nurse.

• Let them know if you are taking any medicines. You can’t have radium-223 if you’re taking a drug called abiraterone. If you take calcium, phosphate or vitamin D supplements, you may need to stop taking these for a while.
• Tell them if you have a bowel condition, such as Crohn’s disease or ulcerative colitis, or leakage from the bowel. Radium-223 may make bowel inflammation worse. Your doctor will talk to you about whether radium-223 is suitable for you.
• Your doctor or nurse may ask you to have a blood test before treatment to check your blood cell levels are high enough.

What does treatment involve?

Radium-223 is injected into a vein through a small tube put into your arm (cannula). You will normally have an injection every four weeks, for up to six injections. Each injection only takes a couple of minutes and you should be able to go home straight after each one.

After your injection, your urine, bowel movements and blood will be slightly radioactive. It is safe for you to be around other people, including children. But your doctor, radiographer or nurse will let you know what safety guidelines you need to follow for a week after each treatment. For example, you may need to take extra care to wipe up any spills after going to the toilet and flush tissues away.

What are the side effects?

Radium-223 doesn’t damage many healthy cells, so it doesn’t usually cause many side effects.

If you do get side effects they may include feeling or being sick (nausea or vomiting) and diarrhoea.

In a few men, radium-223 may affect the bone marrow, which causes a drop in the number of blood cells. Tell your doctor, radiographer or nurse straight away if you have unusual bruising or bleeding, a very high temperature or lots of infections.

What happens after radiotherapy?

After you finish your radiotherapy, you will have regular appointments to check how well your treatment is working and monitor any side effects. Your doctor or nurse will let you know how often you’ll have appointments.

You will have regular blood tests to measure your level of PSA (prostate specific antigen). Your doctor will also ask you about any side effects from your treatment and any symptoms you might have.

If you’ve had external beam radiotherapy to treat bone pain, you may find the pain gets worse during treatment and for a few days afterwards – this is called a pain flare. Your doctor might prescribe some pain-relieving drugs to help with the pain, or increase the dose that you already take.

You should notice that the pain gradually improves, though it might take a few weeks for the treatment to be most effective. 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. But speak to your hospital team or GP first – you shouldn’t reduce the dose suddenly. If your pain or other symptoms don’t improve, talk to your doctor, radiographer or nurse.

If your pain comes back, they might suggest another course of radiotherapy. If you’ve already had external beam radiotherapy to one area, you may be able to have it again to the same area. This will depend on the dose you’ve already had. If you have bone pain in more than one new area, you might be able to have more external beam radiotherapy or a course of radium-223.

Questions to ask your doctor, nurse or radiographer

• Which type of radiotherapy are you suggesting for me and why?
• Will I have any other treatments while I’m having radiotherapy?
• How long will the pain relief last? What other treatments are available to help with my pain?
• Will I get any side effects? What can help with these?
• Are there any safety guidelines I should follow during and after treatment?
• Who should I contact if I have any questions at any point during my treatment? How do I contact them?
• Will having this treatment mean I can’t have other types of treatment later on (for example, chemotherapy)?

References and reviewers

Updated: March 2019 | Due for Review: May 2021