Prostate Cancer Radiation Therapy

Fifteen years after diagnosis, 97 in 100 men were alive of their prostate cancer whether they chose radiotherapy, surgery or monitoring. The decision turns on what each path costs you.

That finding comes from the ProtecT trial, which randomized 1,643 men in the United Kingdom and followed them for a median of 15 years. Radiotherapy for prostate cancer has changed more in the last decade than in the thirty years before it. A course that took seven and a half weeks now takes four, and for some men five sessions, and the trials behind each of those choices are set out below. Send us your PSA history, biopsy report and MRI, and a radiation oncologist will tell you which course fits your cancer and how long you would need in Istanbul.

What does hormone therapy add, and what does it take?

Prostate cancer grows on testosterone. Remove the fuel and the fire dims. Injections that switch off the testicles' production of it, given every one to six months, shrink the gland before radiotherapy and starve the cancer cells that the beam damages. Four to six months suffice for intermediate-risk men. For high-risk men the courses run 18 months to three years, and it is the hormones, more than the radiotherapy, that dominate the experience of treatment. Hot flushes, tiredness, loss of libido and erections, weight gain, loss of muscle, tender breasts and a low mood are the common effects, and over years the drugs thin bone and raise the risk of diabetes and heart disease. Some high-risk men also receive newer hormone tablets. Newer trials are testing whether the courses can be shorter still, and the answer differs by risk group. A man who is told he needs hormones should ask three things, namely for how long, on which trial evidence, and whether his risk group could be treated without them, because a year of injections given to a man who did not need them is the most avoidable harm in the whole of prostate cancer care.

Ask. The answer should come with a trial name.

What are the side effects, and how has technique changed them?

Late bowel side effects of grade 2 or worse occurred in 6.4 percent of men with intensity-modulated radiotherapy and 21.7 percent with older three-dimensional planning. Late bladder effects occurred in 3.7 against 12.3 percent. Cure rates were identical.

Randomized trial of 215 men, Cancer 2016

Because of that trial, a patient should ask which technique a unit uses. Modulated radiotherapy, delivered today as VMAT arcs with a cone-beam CT before every session, wraps the dose around the prostate and holds it away from the rectum and bladder in a way that older planning could not. The rest follows, organ by organ.

Bowel

Loose stools, urgency and passing mucus begin in the second or third week and settle within a month of finishing. Diet helps a little. A spacer helps more. One man in ten in the modern trials has lasting changes, rectal bleeding from fragile vessels above all that is more alarming than dangerous and is treated through a flexible scope if it persists. Anyone with a colonoscopy due should have it before radiotherapy rather than after, because a biopsy or polyp removal from an irradiated rectum heals poorly and endoscopists avoid it for years afterward.

Bladder

Frequency, urgency, burning and getting up at night build over the course and peak in the last week. Tamsulosin and drinking well through the day help. Lasting urinary effects of grade 2 or worse affected one man in ten after 20 sessions and one in four after five sessions in the trials above. Men who begin with a weak stream do worse. Units therefore score urinary symptoms before choosing the course.

Erections and fertility

Erections weaken slowly.

Over two to five years after radiotherapy the blood vessels that supply them scar. Half of the men who function well beforehand keep function at five years without help, tablets help most of the rest, and hormone therapy suspends both desire and function for as long as it is given and for some months after. Ejaculate becomes scant or dry. Assume fertility lost, and bank sperm beforehand if it matters.

Late risks measured in years

A second cancer of the bladder or rectum caused by the radiation is a small risk that grows with time and matters most to men under 60. Narrowing of the urethra occurs in a few percent, more after a previous prostate operation. Both come up at consent, with the numbers for your plan.

Weeks in Istanbul

Plan on the course plus two weeks.

A 20-session course means five to six weeks in the city, a five-session course means three, and a course with markers or a spacer adds a week at the start because the tissues have to settle before planning. Hormone injections can begin at home two months earlier and continue at home afterward. Radiotherapy alone sets the stay. You can fly the day after the last session.

What decides the cost?

Session count decides less than patients expect. Planning and physics take the same effort for five sessions as for twenty, and a stereotactic plan takes more. The technique named in writing, daily cone-beam imaging, markers and their placement, a hydrogel spacer, the PSMA PET-CT and the prostate MRI, brachytherapy where it is used, and hormone injections are each separate items, and a quote should say which of them it contains. Hotel nights for two people over five or six weeks form a large share of what a family spends on a 20-session course and a small share on a five-session course. Your own health moves the figure, since blood thinners, a pacemaker, diabetes and a previous prostate operation add checks and consultations, and a man on long-term hormone therapy needs a bone density scan and a cardiology review that a man without it does not.

Packages published by hospitals in Istanbul for prostate radiotherapy are sold by session count, most often 30 to 35 sessions, with consultation, interpreter and transfers included and hotel nights sometimes added. Ask why the package is longer than the 20 sessions that CHHiP made standard, and whether a 20-session or five-session course is offered at a lower figure.

Your own figure follows the free review of your file.

What about language, companions and follow-up at home?

One coordinator from the international patients team is assigned from your first message and stays with you to the last session. The team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and arranges interpreting in other languages on request, and an interpreter attends the consultation and consent. An invitation letter naming the hospital and the treating doctor is sent about ten days before travel. The international patients office arranges the airport transfer, a hotel or apartment for you and a companion, and the daily ride to the hospital, and for a course of five or six weeks an apartment near the hospital suits most couples better than a hotel. Nobody is admitted for this treatment. Should you be admitted for any other reason, the room has a companion bed. Halal, vegetarian and diabetic meals are available, and a prayer room is on site. Urology, radiation oncology and medical oncology share one hospital, so a change of plan at the tumor board does not mean a change of address.

Back home, the coordinator stays reachable on the same WhatsApp number, and your PSA results can be sent to the treating oncologist. The first PSA is checked three months after the end and then every six months. It falls slowly after radiotherapy, over one to two years. A small rise and fall in the second year, called a bounce, is common. It does not mean relapse. The treatment summary you leave with lists every dose to the prostate, the rectum, the bladder and the femoral heads, and any doctor who treats you later, for this cancer or for another, will plan around the numbers in it, so keep it with your passport.

Prostate cancer radiation therapy FAQ