High Dose Rate (HDR) Brachytherapy

I have been reading this board for a while and joined so I could post my treatment so far in the hopes it might help someone else. 

Caveat

This is a description of my experience.  I am not a medical professional and have no medical training.  I would never recommend any treatment to anyone.  Being treated for prostate cancer is a very serious decision that is based on so many factors to generalize from my experience to someone else.  I am not proposing the treatment I sought is the best for anyone other than myself.  Everyone has to make up their own mind and go with what they feel is their best shot.  My choices were based on extensive research on the Internet, reading numerous posts on a couple web sites, reading Dr. Walsh’s latest book several times, and talking with a surgeon and two different radiation oncologist.

Decisions/Background

My first decision was whether to be treated or not.  In late 2012 I had a biopsy.  The results of the biopsy were Gleason 7 (3+4).  Of the 12 cores, one had a 5% involvement and the other had a 50% involvement and two other cores had high grade PIN and ASAP.  My PSA was 11.2 the day before my first treatment.  It had been rising rapidly.  I have a loving family consisting of the greatest wife in the world, the greatest daughter in the world, and the two greatest grandchildren in the world.  I decided I had to seek treatment.

My next decision was between surgery and radiation.  I knew either choice would entail further decisions but I first I had to choose between these two options.  I dismissed HIFU and cryotherapy due to lack of a proven track record.  I spoke to a surgeon that I highly respected and he was very honest and advised against surgery.  He felt I would be better served by radiation. 

I did a lot of research on the various forms of radiation.  I decided on internal radiation.  This decision was based on the fact that I thought the internal radiation would cause less collateral damage.  In any form of external radiation every beam of radiation has to go thru normal healthy tissue at a higher intensity than the intensity of the radiation that would be delivered to the prostate.  This is easily proved it you look at the inverse square law that describes how radiation decreases as the distance increases.  Granted multiple beams would produce a higher collective intensity delivered to the prostate than any single beam delivers  to the normal tissue assuming the multiple beams are non-coplanar and non-isocentric (as in CyberKnife).  However the fact remains radiation is going through normal tissue to get to the prostate.  In internal radiation the inverse square law works to your advantage in that the radiation intensity decreases as it leaves the prostate and as it reaches health tissue.  Iridium¹⁹² also has the advantage of a rapidly decreasing strength as distance to source is increased.  The second reason I opted for internal radiation has to do with aiming.  In all forms of external radiation the beam is aimed at the prostate.  Aiming at something always has the risk of missing the target.  Granted the aiming may be accurate to millimeter accuracy but with internal radiation there is no aiming – the radiation source is in the prostate.  In my opinion this is the best conformal radiation can get.

My next decision was between High Dose Rate (HDR) and Low Dose Rate (LDR).  From what I have ready HDR has equal to or better results than LDR.  This is true both from a side effects and cancer killing standpoint.  From what I have read cancer responds better as the dose is escalated.  Also HDR has the ability to treat the seminal vesicles.  I also had a personal reluctance to leaving the hospital and being radioactive.  I didn’t feel comfortable exposing my family (which includes pets) to unnecessary radiation despite the level and an assurance that is was harmless.  In my opinion HDR had the advantage of conformal radiation as well as intensity modulation (the strength can be controlled by the location of the see and the dwell time or duration the seed stays in a particular location. 

In summary I chose HDR because:

·         Less invasive that surgery

·         Shorter recovery time than surgery

·         Equal or better results than LDR

·         Less chance of side effect than surgery or LDR

·         Highly conformal radiation pattern possible

·         The advantage of intensity modulation

·         No requirement to aim the radiation

·         No high levels of radiation going through health tissue

·         Lower doses of radiation reaching healthy tissue

·         Higher does radiation has been shown to have better outcomes

·         No residual radiation left in my body

 

HDR Fraction #1

My show time at the cancer center was 6:15 AM and my wife and I were right on time.  My doctor came in and reviewed what the procedure would entail and the risks.  My preparations in the days preceding the appointment included avoiding any Non-Steroidal Anti-inflammatory Drugs (NSAIDs) or blood thinners for the week prior to the appointment, a day of all liquid diet prior to the appointment, nothing to eat or drink after 6:00 PM the night before the appointment, showering with an antibacterial soap the night before and the morning of the appointment, and the standard surgical bowel prep.  I was also advised to avoid caffeine which I did.  Part of the following description is from what I was told as I was under anesthesia for parts of the procedure.  I was taken from Pre-Op and on the way to the operating room I was given anesthesia via an IV.  In the operating room, under general anesthesia, my doctor inserted 17 catheters into my prostate and then sutured the template to my perineum (this was the part that was relayed to me as I was under general anesthesia during this time).  This clinic also uses a procedure where DuraSeal^® is injected into the tissue between the prostate and rectum to increase the space between the prostate and rectum.  This reduces the radiation dose delivered to the rectum (inverse square law again).  I was brought out of the anesthesia and transported to the CT scan room.  The template and the needles hurt quite a bit at this time and I had a patient controlled analgesic (PCA) with dilaudid in it.  I pressed it as often as I could but it didn’t help much and wound up making me very nauseous.   After the CT scan was completed I was taken to a holding area until they were ready to do the radiation.  I kind of faded in and out during this time – probably because I hit the PCA so often.  During this time the CT scan was used by the doctors and others to create the isodose plan.  After a short time I was taken to the radiation delivery room.  The catheters were attached to the afterloader and then everyone exited the room.  The room was equipped with an intercom system and video cameras so the staff could see me and communicate with me.  The radiation began and took approximately 45 minutes.  The dosage of this fraction was 14 Gray.  After that the staff came back in the room, checked me for radiation and then put me under anesthesia again and removed the catheters.  The removal took less than ten minutes.  From there I was taken to recovery and was allowed to leave as soon I was over being nauseous and could urinate.  That only took a short time and I was discharged.  I was sick a little on the way home but not in pain.  In the following day I had about three days where I was passing a moderate amount of blood rectally.  That subsided without medical intervention.  I had a very faint amount of blood in my urine for a day or so – again no medical intervention necessary.  I seem to need to use the restroom more frequently now and it is a lot more urgent – when I have to go, I have to go now!  I am on tamsulosin (Flomax) 0.8 mg/day and it helps somewhat but not to a great extent.  I still use the restroom hourly.  The doc says that should resolve in about three months after the last treatment.  .  Nothing leaks as of now.  Bowl movements have been more frequent but otherwise normal with the exception of the couple of days of bleeding.  My wife is happy.

 

HDR Fraction #2

It has been three weeks from the day I had fraction #1.  This is the day for the second of two fractions.  This day up to the recovery room was pretty like the last time except I didn’t hit the PCA so often and wasn’t nauseous.  Again the rules for discharge were “as soon as you can urinate you can leave”.   This was problematic this time.  My urine was extremely bloody and I had a heck of a time getting the required 250 ml of urine.  They added up each time I tried and finally when I was at 175 ml they said I could go.  Urinating for the rest of the evening was difficult and at 1:30 AM I woke my wife up and said I needed to call the clinic.  I was in extreme pain and could not relieve myself.  I spoke to the radiation oncologist that was on-call and he instructed me to return to the clinic’s emergency room if I could get there quickly.  His instructions were “if you can’t get to the clinic quickly, go to the nearest emergence room and tell them you have an acute urinary obstruction”.  My wife drove me to the clinic and they were waiting with a room ready for me with a catheter kit on the bed.  The nurse put the catheter in and 1000 ml of urine drained into the bag.  The urine was pretty blood at this time.  They said to check back with the radiation clinic on Monday.  All Saturday and Sunday the urine I passed was still bloody.  I went in to the clinic as instructed and the doctored advised me that this was not uncommon and he wanted to leave the catheter in for a few days.  The nurse was kind enough to give me a larger bag (I had been using a leg bag which filled up in around three hours so I was setting the alarm to get up in the middle of the night to empty it).  At 8:00 PM that evening I was unable to urinate and getting to be in pain.  I called the clinic again and was told to come into the emergency room.  The pain increased drastically and by the time I got there I was in extreme pain.  The nurse was ready for me and quickly flushed the catheter out and I was “relieved”.  They got about 800 ml this time.  She gave me a bottle sterile water and a syringe and showed me how to flush catheter out.   On Wednesday the nurse called and asked how I was.  By this time I was passing clear urine (thanks to drinking a lot of water).  She made an appointment for the next day to have the catheter out.  The catheter was removed without incident and I have not had any blood in my urine since.  The issues of urgency and frequency are still present.  Bowl movements are a little more frequent and I pass a little watery substance with each bowl movement.  The wife is still happy.

A suggestion to anyone having a catheter for any reason:  Insist on having a leg bag and a night bag.  Changing the bag out is not rocket science.  Also insist on having the sterile water and a syringe to flush it out if it becomes necessary.  Trust me – you don’t want to be driving in traffic with a bladder that feels like it is going to burst.  Also know what to do and where to go if you have a blockage.  I was told a urinary blockage can lead to renal failure if untreated.