What to Expect During Treatment
Fighting cancer is challenging. To help you prepare for the fight, here is a brief outline of what you can expect during treatment with radiotherapy or radiosurgery. The details of some of the steps may differ, depending on your particular case.
Step 1: The Consultation First, you'll meet with your doctor, a radiation oncologist, to discuss your treatment. Based on your specific case, your radiation oncologist will tell you what type of radiation therapy he or she recommends, whether it will be given alone or in conjunction with other treatment methods, what the specific goals of treatment are, and what side effects you may experience. You can talk to your radiation oncologist about your treatment options and make a decision together. The consultation is an excellent opportunity for you to ask your radiation oncologist whatever questions you may have. Click here for a list of common questions.
Step 2: Imaging In order for the radiation oncologist to design your treatment, the exact size and location of the tumor must first be determined. This is usually done by creating a detailed 3-D image of the tumor with a CT scan. Depending on the general location of the tumor, disease type and other factors, additional scans may be taken, which could include an MRI, a PET scan or an ultrasound scan. Your oncologist can rotate the image on his computer screen to view the tumor from every angle.
It is very important that the position in which you are scanned is reproduced at the time of treatment. Sometimes temporary skin marks and even tiny tattoos (about the size of a freckle) are made on your body to help the radiation therapist (RT) position you correctly each day for treatment. Depending on the location of the tumor, a body mold, head mask or other device may be constructed to make it easier for you to remain in the same position during treatment.
Step 3: Treatment Planning Once your scans have been completed, your doctor, the medical physicist and the dosimetrist will meet to design your treatment plan. They take many factors into account when they design the treatment plan. These can include the type of cancer, its location and size, your medical history, and your lab test results. Based on these factors, the treatment plan specifies the amount of radiation to be delivered, the appropriate angles from which to deliver it, and the number of sessions needed to deliver the prescribed treatment.
Step 4: Getting Positioned for Treatment Before each day's treatment, you may be asked to change into a gown. The radiation therapist (RT) will help you get positioned on the treatment "couch" — a platform designed to work with the radiation machine. If a facemask, mold or other device was created for you during the imaging process, it will be placed on you or under you at this time. The couch will be adjusted so a laser light shines on the mark that was put on your skin, helping to position you correctly. Depending on the type of machine you’re treated on, your treatment team may take a scan immediately prior to treatment, while you are on the couch. The purpose of this new scan is to show if the tumor has changed in size or position since the first one was created during imaging. If it reveals any changes, the RT will make the necessary adjustments to the position of the couch to ensure that you are properly aligned for treatment.
Step 5: Treatment Begins The radiation is delivered by a machine called a linear accelerator, or linac. Most linacs have a gantry, which is the head of the machine. The gantry houses a device called a multi-leaf collimator that "shapes" the radiation beam so it conforms to the shape of the tumor from any given angle. During your treatment, the gantry will move around you to deliver the radiation. The radiation beam is not visible to the eye, so you will not see it when it leaves the gantry.
Your first two treatments may take 15 minutes or more, as your radiation therapist helps you get into position and takes images to verify that your setup on the machine is the same as the treatment plan. Subsequent treatments, however, are often shorter. In fact, some treatments — from entering the waiting room to leaving the clinic — can take as little as 12 to 30 minutes.
Step 6: Post-Treatment and Follow-Ups You may experience some side effects from radiotherapy. If you do, they might not begin until after several sessions because the effects of radiation treatment are cumulative. Talk to your oncologist before and during treatment if you have any questions or experience discomfort. Click here to learn more about possible side effects.
After your treatment has ended, your radiation oncologist will recommend a schedule for periodic checkups to monitor the results. Typically, the first checkup is given in one to three months, and subsequent checkups are scheduled at six-month intervals, but yours may be more or less frequent, depending upon your situation. If symptoms or clinical circumstances suggest a recurrence, diagnostic tests such as blood tests, ultrasound scans, CT scans, MRIs, chest x-rays (CXR), or bone scans may be needed.
Can I Expect Much Down Time from Treatment?
Treatments are given Monday through Friday, 5 days a week, for several weeks depending on your disease and condition. The treatment takes 90 seconds and you feel no sensation when treated, though your time in the center is typically 10-20 minutes.
I heard hormone suppression therapy has a lot of side effects, do I really need it?
This is one of the most common questions, and your potential benefit from hormone therapy depends on the stage and grade of your prostate cancer. It can make a big difference in some cases, and a marginal difference in others. Dr. Kornguth will give you the information we have for your prostate cancer and make a recommendation. The final decision is always yours -- our job is to help guide you through this.
Isn’t Prostate Cancer Slow Growing?
This is a common perception. While many prostate cancers are slow growing, it is important to understand that, if given enough time, prostate cancers transition to a more fast-growing process. Genetic changes at the DNA level (splicing mistakes and mutations) accumulate and result in cells with more DNA disorder. This can translate to a more aggressive cancer.
In my practice, I am seeing more men who are diagnosed with more extensive cancers. Whether this is due to decreased PSA screening is uncertain. I believe that men should speak with their primary physicians, particularly if they have a family history or are in a high risk group (i.e. African American heritage).
Is PSA Screening Helpful?
I believe there is a clear benefit to screening men with PSA. I also believe that politics and policy colors the recommendations of groups that discourage screening for cancer. I screen PSA for myself and I strongly recommend it to men in my family. I have also seen an increase in men with advanced disease who had a prolonged period with no PSA screening. I wonder if regular screening would have changed their outcome.
PSA screening was analyzed in two large trials. The European Randomized Study for Screening of Prostate Cancer (ERSPC) was published in 2008. This study was twice as large as a similar, but flawed, US trial. The European trial had longer follow-up, and was a much cleaner trial (no PSA screening prior to entry on the trial, better compliance in the screened group, much less PSA screening in supposed non-screened group). It showed a clear and convincing 20% reduction of cancer deaths by the use of PSA screening. The study’s conclusions showed that by screening men aged 55-69 with PSA and offering regular follow-ups resulted in decreased deaths from metastatic disease.
The US-run Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial was published around the same time. In this trial (New England Journal of Medicine 2009; 360:1310-1319), 76,693 men at 10 US screening centers were randomized to annual PSA and DRE screening versus no screening. The results showed that there was no reduction in mortality in the screened group at 7 and 10 years. However, only 85% of the screened group actually received PSA screening, and over 50% of the control group indeed were screened outside of the trial, blurring any possible results. Likewise, almost 50% of the subjects in both groups were screened prior to the trial, which most likely selected out cases of more significant cancer even before the trial began.
Why Not Just Remove the Prostate?
Patients should understand that surgery, known as radical prostatectomy, does not always successfully remove all cancer cells. This is particularly true for High Risk and advanced stage prostate cancer. The reason that surgery can’t always cure people is that cancer cells are not visible nor can the surgeon remove cells that have spread beyond the prostate capsule without causing serious side effects. Even years after surgery, patients can have a rising PSA which can mean that the cancer has started growing again. When that happens, patients have several treatment options including radiation, surgery, and hormone therapy. Surgery is a good option for patients, but it is associated with more side effects than radiation (as it is invasive).Patients should know what the risks are and that surgery does not always remove the cancer completely. Discussing these options with your treatment team is critical so you understand the tradeoffs.
What Happens to the Prostate after Radiation Treatment?
The cancer is replaced by scar tissue and most (or all) of the prostate is also replaced by scar tissue. Dead cells are cleaned up by your immune system during and after treatment. Cancer cells are more sensitive to the radiation because of the daily dose schedule. Cancer cells have less time to repair radiation damage and are typically less able to repair damage because they have impaired repair machinery.
Can Acupuncture Help Treat Cancer?
Acupuncture is an ancient Chinese technique used to treat a variety of medical conditions. I do not believe that Acupuncture can cure cancer, though I believe it might help manage some treatment-related side effects like fatigue, discomfort, and mental well-being. Cancer cells are derived from our normal cells but grow in an uncontrolled way. Acupuncture cannot kill these cells nor does any data suggest it can.
Is this the Same Kind of Radiation that Spread in Japan, Chernobyl, and Three Mile Island?
No. The main health issue with industrial radiation accidents is that airborne radioactive particles can be swallowed or inhaled, which can be absorbed into your body for long periods of time and lead to multiple health problems.
Treatment of prostate cancer is a targeted treatment using a temporary emission of radiation with electricity that produces photons. There are no photons when the electricity is turned off. Therefore, you are never “radioactive.” Instead, your prostate is targeted with high energy X-rays for about 90 seconds when you are being treated, and there are no radioactive particles after those 90 seconds are completed.
Why Don’t I Feel Sick Even Though I Have Prostate Cancer?
This is among the most common questions from my patients. In order to “feel” cancer, it has to have spread extensively to the nerves which surround the prostate or spread into the bone in other parts of the body. When either of these events occurs, it is too late to completely cure you of your prostate cancer. Your best chance of being completely cured of prostate cancer is to treat it when it is small and before it causes symptoms. This seems strange to many people since they are treated when they feel perfectly healthy. This is part of the reason you should have a discussion with your primary physician during routine appointments.
Can a Prostate Biopsy Make My Cancer Spread?
The short answer is no. This has been examined in several different ways and there is certainly no evidence that a trans-rectal biopsy can make prostate cancer spread.
Can Supplements Be Used to Treat Prostate Cancer?
Food supplements like vitamins or food products that have certain properties are sometimes marketed as treatments for prostate cancer. While I am skeptical that the supplements can eliminate prostate cancer completely, I do believe that supplements might improve your immune system’s ability to fight cancer. Examples of foods that have been suggested as prostate health items include: Vitamin D-3 (1,000-2,000 IU per day), Curcumin or Turmeric, and Omega-3 Fish Oil (1,000 mg). Some supplements like Selenium have shown potential harm in recent studies. Chinese herbal remedies have been tried by many patients and might have benefits, but I recommend sharing the supplements you use with your physician team to ensure that all medications are safe.
Does PSA Screening Work?
Yes, but it has limitations. PSA is a protein found in both normal prostate tissue and in prostate cancer. Men with a prostate gland usually have a detectable PSA whether or not they have prostate cancer. There are age based guidelines to help make recommendations of whether a certain PSA is worrisome and deserves further investigation. Physicians should use the PSA together with a comprehensive history and physical exam in order to make helpful recommendations. A high PSA that has remained stable for years can simply be the result of an enlarged non-cancerous prostate while a rapidly rising PSA can be more concerning. Talk with your PCP or a prostate cancer specialist to learn more.
What Happens If I Don’t Treat My Prostate Cancer?
If prostate cancer is not successfully treated when confined to the prostate, it can spread to lymph nodes or into to the bones of your body. We call this type of progression metastatic disease. If that happens, pain and disability can occur which influence the quality of life. It can also cause problems that can alter the length of life. There was a study published in the New England Journal of Medicine in 2011 that compared men with treated prostate cancer versus men with cancer who were placed on an active surveillance protocol. There was a benefit in life expectancy in the treated group. However, everyone’s situation is different, and having a honest discussion with a prostate cancer specialist can help you decide the best course of action in your particular case.
What Is Proton Therapy?
Using proton therapy for prostate cancer is controversial in the field of radiation oncology because the prostate is relatively deep inside the patient, which diminishes or eliminates any potential benefit. Proton therapy for prostate cancer usually results in a plan which is slightly less conformal that IMRT and it usually costs 3 times the price of IMRT. Protons have some disadvantages over IMRT, including a poor penumbra (the sharpness of the lateral field edges) and significant uncertainty of the path length of the proton (which requires a significant overshoot of the target to ensure adequate dose). The benefit of protons is not controversial for pediatric cancers because many pediatric tumors are ideally located to exploit the benefits of protons (they are more superficial). I was on faculty at the MD Anderson Proton Therapy Center in Houston, Texas, and can discuss all potential benefits and disadvantages with interested patients. A good discussion about protons for prostate cancer can be found at http://jco.ascopubs.org/content/25/24/3565.full
If my cancer has spread, how long do I have?
A single answer for everyone is not possible. But here's the good news -- as long as the prostate cancer has spread to a limited area, most patients have a long period of control and survival. Even in cases of more significant spread, there are an increasingly large number of options. Every year, new strategies for treatment of advanced prostate cancer are approved by the FDA. We offer immunotherapy (Provenge) for some patients with advanced disease. Dr. Kornguth can discuss all of these options with you.
Does Radiation Hurt; Do I Feel Anything During Treatment?
There is no sensation during treatment. Radiation is given in small daily doses, and if you get side effects, they typically set in slowly and then gradually decrease after the course of treatment is finished.
What Is the Purpose of the Prostate – Do I Need It to Have Sex?
The prostate is attached to the bottom of the bladder and it makes fluid that comes out during sex known as the ejaculate. If the prostate no longer is present or does not function anymore, men can still have erections and orgasms, but they no longer ejaculate.
Won’t Radiation Oncologists Recommend Radiation and Won’t Most Surgeons Recommend Surgery?
In many centers, this is true. At GGCC, we empower patients with information to make their own decisions. Most of our patients have choices and only proceed with treatment when they are comfortable with the choices. With prostate cancer, patients usually have several good treatment options.
Should I Get Surgery or Radiation, or Simply Watch My Prostate Cancer?
That is the biggest question that patients face and there is no simple answer. Multidisciplinary care means that you speak with a surgeon (urologist), and a radiation oncologist who specializes in prostate cancer treatment. Both treatment options are highly effective for most men, but you should speak with a specialist to learn more about the best options for your prostate disease. The good news is that most prostate cancers are highly curable and some can be safely monitored. Most patients weigh the risks of side effects with the likely benefits of treatment.
What Is the Gleason Score?
The grade of cancer describes how strange or aggressive the cancer cells appear under a microscope. For prostate cancer, the Gleason Score is the grade of the cancer. Gleason was actually a physician who described prostate cancer grades by giving all cancer specimens two scores (since many prostate cancers have a combination of two patterns). Therefore, the Gleason scores can be as low as 3 (2+1) all the way up to 10 (5+5). Pathologists only will consider prostate cancer when the score is at least 5 (3+2). The Gleason score or grade helps to describe how aggressive the prostate cancer is.
What Is Genomic Analysis? Should I get that done?
Genomic analysis for prostate cancer involves analyzing your biopsy (or specimen) for genetic signatures of more aggressive cancers. Maybe your Gleason score looks reassuring, but sometimes your cancer contains some more dangerous mutations. DECIPHER is one such lab analysis which is increasingly used to better characterize cancer aggressiveness. Dr. Kornguth can review options for you and determine if it might make sense in your case.
What Is the Difference Between Stage and Grade?
When physicians talk about the stage of cancer, they are describing whether or not the cancer has spread beyond the initial area, such as the prostate. In general, cancers that are Stage IV are those where the disease has spread to other sites in the body. It is usually very difficult or impossible to cure people who have stage IV (or metastatic) disease. The grade of the cancer describes how the cells look under a microscope. For prostate cancer, this is known as the Gleason Score.
Contact us to take advantage of our prostate cancer resources. We treat patients in the San Francisco Bay area.