Guest post: my experience of brachytherapy

By Trevor Pope

January 2022 marks ten years since my diagnosis and brachytherapy treatment for cancer of the prostate.

As anybody who has been given a dread-disease diagnosis will tell you, this can be life changing, even life-ending. So it is a BIG THING. There is a lot to deal with at various levels. Sometimes it can be helpful to read accounts by others who have made the journey, to be able to deal with the issues at various levels. Two of my neighbours were diagnosed in the last two years, (must be something in the water…) and one of them is Mish, who started this blog. He encouraged me to record my journey. Given my ten-year anniversary, perhaps now is a good time.

Ten years is a long time to be able to recall details, so there may be a few gaps. I kept some records so the chronology is accurate. But there are gaps and some of the personal milestones may be a bit hazy. Nevertheless, here is my short account.

Diagnosis

As part of regular check-ups, my PSA level was monitored. In my 50’s it started creeping up, enough to be a concern to the endocrinologist I saw every six months. At age 53, I was referred to urologist Mr Kevin Fisher at Linksfield Clinic in October 2011. He had a feel (the proper medical term is DRE- Digital Rectal Examination) and was concerned enough to send me for a biopsy.

Next I saw Dr Mickey Cohen, (now retired) who had many years of experience in biopsies and a good reputation. He had a feel too, and pronounced some firmness on the left side of my prostate. He then did the biopsy. It was rather unpleasant despite local anaesthesia, and seemed to go on forever.

The urologist, Mr Kevin Fisher, got the results and broke the news that there were malignant cells on the left side.

Follow up appointments for an MRI and bone scan were scheduled. The MRI confirmed that the cancer was confined to the prostate. The bone scan was done using Technetium-99m, injected into a vein. (If I recall correctly, Technetium-99m is a radioactive isotope with a half-life of 6 hours. It is made in Pelindaba. Being bound to calcium, it is selectively taken up at sites of active bone growth – potential cancer sites. These show up on an image of radioactivity.)

The only hot-spots that showed up were old injury sites in joints. These were almost a catalogue of past aches and pains and surgeries, where one would expect some inflammation. Apparently when prostate cancer metastasizes, the common sites are the lymph nodes and bone. In my case none of these were active. The final assessment was a Gleason score 4+3 = 7, organ confined, with no remote sites detected. Relatively good news.

Brachytherapy treatment

The recommended treatment was brachytherapy, with a high chance of complete remission.

An appointment was scheduled with an oncologist, Dr Frank Michaelis. He designed the radiotherapy treatment, based on the biopsy and MRI images that gave the size of the prostate. He selected the number of radio-active seeds and the required locations.

The brachytherapy procedure was done on a Friday morning at Linksfield Clinic in January 2012 by Mr Kevin Fisher and Dr Frank Michaelis. Three of us were scheduled that day. There were radioactive warning signs outside our ward, as we were about to become mildly radioactive. The procedure is a precise one, where the seeds are accurately implanted into the prostate to cover the full extent of the organ using ultrasound imaging of the prostate and the implantation needle.

Radioactivity only lasts a few months

The seeds contain radio-active Iodine-125, with a half-life of 59 days. So the radiation soon decays to unmeasurable levels once the job of killing the cancer cells is done. The seeds then remain there permanently and are visible on an X-ray image. I don’t recall the exact number of seeds used in my case – perhaps 70? The number varies with the size of the prostate to ensure adequate coverage.

The day after the procedure, I was sent home with a warning that I was mildly radioactive. I had to stay away from children for a week and to pee through a filter in case any seeds should escape. None did. There was some pain around the perineum which was bright purple from the bleeding caused by all the holes made by the large needle required to insert the seeds. It quickly faded. I was able to return to work on the Monday.

Recovery

A follow-up CT scan (illustrating this post) with a contrast medium was scheduled to confirm the locations of seeds and identify any other potential issues. The contrast medium (iodine if I recall correctly) was injected into the bladder using a catheter so the urethra and prostate could be imaged. This didn’t identify any issues and the seeds were still in place, and I presume are still there 10 years later.

The use of condoms for penetrative intercourse was recommended for a few weeks afterwards. This was a precaution against any seeds being expelled. Hematospermia (blood in the ejaculate) was noticed for the first few weeks post the procedure, but this quickly resolved. Discomfort around the prostate quickly subsided. A tamsulosin drug (you may know it as Flomax, Tamsul or Uromax) was prescribed. This was to ease urination difficulties due to the inflammation caused by the procedure, to continue for 6 months thereafter.

PSA undetectable after ten years

For the first 5 years post the Brachytherapy, my PSA was tested every 6 months, and then annually thereafter. There was the predicted “benign hump” that showed up as an elevated PSA for about 18 months. But then it dropped down to low levels, where it has remained to date. The present PSA levels are down at the limits of detectability of the test. I still have annual DRE’s (Digital Rectal Examinations) where my prostate is pronounced to be “small, soft and smooth”.

Usually, men do not like to be told that they are small and soft, but for us prostate cancer survivors, this is good news (for our prostate glands)!

Brachytherapy – ten years on, I couldn’t have asked for better outcomes

I wouldn’t rank the outcome at 100%, but it is not far off. Given all the things that could have gone wrong, I couldn’t have asked for better. If you are considering brachytherapy, my experience is definitely on the positive side. Obviously, everybody is different and different treatments are appropriate in each case. No outcomes are certain, but I would recommend it as an option.

Mr Kevin Fisher and Dr Frank Michaelis had already done several hundred procedures when I had mine done in 2012. Now, ten years later, Kevin says he stopped counting. There is a long history of the procedure and many studies confirming its effectiveness. Kevin said he no longer does conventional surgical treatment (radical prostatectomy) for prostate cancers like mine, only brachytherapy.

Each man’s story is unique

From my limited understanding, there are a number of factors that are considered when designing a treatment plan, so my experiences may not mirror yours. Your outcomes may be better or unfortunately, sometimes worse… I wish you good luck and a positive outcome. A positive attitude is highly correlated with better outcomes, so keep on smiling!

Next: side effects on urogenital systems