Radiotherapy to the prostate

Side effects

Side effects from radiotherapy vary. Some people have hardly any side effects. Even people who have had very similar treatments can have different side effects.

As part of your treatment, a team of specialist radiographers/nurses or doctors will contact you to ensure you are coping with any side effects and discuss how these can be managed to make you feel more comfortable. These reviews are often conducted via the telephone.

Please let the radiographers on treatment know of any side effects and they can advise or pass this information onto the specialist team who can re-assess these with you.

Early side effects

Most people notice the side effects during the second half of their course of treatment. They may take 6 to 12 weeks to disappear and in some cases longer.

Bladder symptoms

You may develop some symptoms during treatment including urine frequency, urgency with occasional leakage, irritability to pass urine and poorer stream of urine making it difficult to pass urine.

Occasionally blood is visible in the urine. These are normal radiotherapy side effects, please tell your treating team about any new symptoms.

Tips for managing urine symptoms:

• Reduce/stop caffeine and alcohol intake as these can act as irritants. Instead try decaffeinated tea/coffee and aim to drink clear fluids such as water or juices.
• Some people find cranberry juice can reduce irritation. If you are on blood thinning tablets such as Warfarin, do not drink cranberry juice.
• Try to stop or cut down smoking. Cigarettes can cause further irritation and it may take longer for symptoms to settle after treatment.
• Do not drink large volumes of fluids in the evening before bed.
• Plan journeys with rest stops.
• Consider using over-the-counter paracetamol to relieve irritation. Always check the label to ensure this is suitable for you. It does not interact with radiotherapy treatment.
• Ask your team for a ‘toilet card’ which can be shown when you need urgent access to a toilet, or you can order one from the Macmillan or Prostate Cancer UK websites.
• Medicines for difficulty urinating may be considered and can be discussed with your team.

Bowel symptoms

You may develop some symptoms during treatment including frequent, looser bowel movements although occasionally constipation. Bowel movements can be more urgent, or you may develop a sensation you want to open your bowels but there is no motion to pass. This is called ‘Tenesmus’ and is due to swelling in the back passage.

You may notice an increase in the amount of wind you pass – this can be ‘wet wind’ or with a mucous discharge. You may develop bleeding from the back passage – this is normal and should settle. Continue to mention symptoms to your treating team or doctor.

Tips for managing bowel symptoms:

• Do not strain or force a bowel motion as this can add to irritation. Instead speak to your team who can advise/prescribe medications to ensure the stools are passed.
• Sit on the toilet to pass wind in case this is wet wind.
• Monitor the foods you eat. If you develop diarrhoea after certain foods, it may be best to avoid these for the rest of your treatment.
• Consider reducing fibre content in your diet if you develop diarrhoea. This involves reducing fresh fruit and vegetables that have high fibre content. Do not attempt to reduce too much before developing diarrhoea, as this can lead to constipation.
• You may be prescribed a medicine called Fybogel to regulate and firm the stool content. You can discuss this with your treating team. Please discuss any bowel medications with your team before taking anything not prescribed by your Christie team.
• Consider using haemorrhoid cream if there is irritation in the back passage. Your treating team can also give you a prescription for medicines which cannot be bought over the counter. Avoid inserting ointments into the rectum just before treatment. Instead, wait until after the treatment each day.

Skin reactions

Developing a skin reaction during and after prostate radiotherapy is uncommon (less than 10 in 100 men). Occasionally, the area can become slightly pink/red or darker pigmented if you have darker tone skin.

Your skin may feel tighter or itchy. You will be given advice about moisturising the area if this is recommended for your treatment.

Tiredness

Tiredness is one of the most common side effects of cancer treatment. Some people describe feelings of extreme fatigue, although some continue to work and carry out busy lives as normal. This can vary between individuals.

Try to maintain a normal sleeping routine and don’t feel that you must do everything that you normally do. Ask your family and friends for help.

It is a good rule of thumb to listen to what your body is telling you – if you feel tired, rest. For people in good general health, it may be beneficial to do some gentle exercise such as walking.

Your tiredness should start to gradually improve a couple of weeks after completing your radiotherapy. If you feel that you would like more help and advice about coping with tiredness, please speak to a radiographer treating you.

Late or permanent side effects

It is possible for some types of reaction to occur months or years after the treatment has finished, although this is less common (less than 10 in 100 men) these days because of recent improvements in treatment. Your doctor at The Christie will discuss any possible late effects with you.

Late or permanent side effects are classed as those lasting or developing longer than 12 to 18 weeks. Most of these symptoms are mild.

Expected (1 in 2 or more)

• Radiotherapy will affect your fertility. Please let us know about your plans for having children and we can advise accordingly.

Common (up to 1 in 2)

Long-term urinary symptoms

• Daytime/night-time frequency.
• Passing urine more often than normal.
• Urgency: sudden urge to pass urine.

Long-term bowel symptoms

• Looser stools compared to your usual.
• Urgency: a sudden urge to open your bowels.
• Passing more mucous or wind compared to what is normal for you.

Changes in sexual experience

• Changes in ejaculate such as reduced amount/altered consistency or blood in ejaculate.
• Dry ejaculate or loss of orgasm.
• Change to penile length/appearance.
• Inability to achieve an erection (please note ability may also be reduced with age, other health conditions or hormone medication you may be on as part of your treatment)

Less common (less than 1 in 10)

Long-term urinary symptoms

• Cystitis/pain when you urinate due to bladder inflammation.
• Incomplete emptying of your bladder or reduced bladder capacity.
• Stricture: a narrowing in your water pipe which may require surgery.

Long-term bowel symptoms

• Frequency: opening your bowels more often than normal.
• Rectal pain/discomfort due to irritable bowel syndrome (IBS).
• Symptoms similar to irritable bowel syndrome such as intermittent tummy discomfort, altered bowel habit, passing more wind or mucous.
• Bleeding from your bladder or bowel which is usually mild and resolves, if not further management may be required.

Rare (less than 1 in 100)

• Urinary incontinence including urine leaking (1 in 100).
• Pelvis/hip bone thinning and/or fractures.
• Bowel/bladder damage which may require surgery. An increased risk of a different cancer in the treatment area which may occur many years after treatment.
• Lymphoedema: fluid build-up in your legs and potentially scrotum if we have treated your lymph glands.
• Malabsorption: problems with nutrient absorption which may require medical management.
• Neuropathy: damage to nerves which could lead to issues with pain, numbness, weakness in your legs. This is very rare.

You can get further information from the Macmillan booklet ‘Pelvic radiotherapy in men: possible late effects’ available from the cancer information centre.

What you can do to help

Skin care

Some radiotherapy treatments to the pelvis may cause sore skin, although this is uncommon when patients are having radiotherapy to the prostate area. We will advise you at the start of treatment if this is likely, and what you can do to help yourself.

For further information on skincare advice during treatment please refer to the ‘Skin care during and after your radiotherapy treatment’ leaflet which can be given to you by a member of your clinical team.

Some patients find that their pubic hair falls out during or shortly after treatment. This usually grows back but it may be thinner.

Your diet

Follow the advice under the heading Dietary advice before CT scan and treatment before and during treatment.

Further dietary restrictions are only advised if you develop diarrhoea during your course of treatment.

Further dietary restrictions may include following a low fibre diet. Fibre is the part of grains (flours and cereals), pulses, vegetables and fruit which is not digested and passes down the gut. Please do not cut out all dietary fibre initially as you could become constipated.

Follow the lower fibre diet for as long as your side effects last, then gradually resume your normal diet by adding one new food each day that contains fibre. If the diarrhoea returns, you should be able to work out which food has caused it and eliminate this from the diet for a further few weeks.

If you have diarrhoea, you must drink enough to replace the fluid that is being lost. Aim for a minimum of 10 to 12 glasses of water a day.

If you are following a low fibre diet for several weeks, you could consider taking a complete multivitamin and mineral supplement such as Centrum, Boots A-Z, Sanatogen A-Z Complete, and Nature’s Best A-Z multi. You can purchase these over the counter.

If you have followed a lower fibre diet and are still having problems with diarrhoea, we can prescribe Fybogel (also called Senokot High Fibre or Normacol). This acts by absorbing fluid and helps to form more solid, less frequent motions.

Fybogel is a powder which needs to be mixed with water and then drunk immediately. If your bowel problems persist, then you may need additional medication such as loperamide (Imodium®) or which can be prescribed for you.

The bowel symptoms vary greatly between patients. Most people start to see some improvement 2 to 3 weeks after treatment has finished. Some patients are virtually back to normal within 6 weeks, for others they remain unsettled for several months and for some they never return to what was normal for them.

Diet and the prostate

Although studies are continuing about the effect of diet and the development and control of prostate cancer, there is no conclusive evidence. What we would suggest is that once the side effects have settled following treatment you have a healthy diet including a variety of sources of protein, carbohydrate and 5 portions of fruit and vegetables a day.

Relatives and carers

Please share this information with your family and friends. It is important that they feel well-informed and understand what is happening. Families and carers can have a role in helping you. There are additional information resources on radiotherapy and films on the website.

Aftercare

After your treatment has ended, you should continue to follow any advice/medications previously given to you until you feel your side effects from radiotherapy have subsided. This is usually 6 to 12 weeks after your treatment has finished.

Who should I contact if I have any questions/symptoms?

If you have any problems before you are due for your follow-up appointment, you can contact the specialist nursing team/radiographers at The Christie, your GP, or your keyworker nurse who may be at your local hospital.

How will I know that the cancer is gone?

The PSA (Prostate Specific Antigen) measured from a blood test is used as the most accurate way of showing that the cancer cells in the prostate have been treated effectively. You will not need further scans or biopsies.

The rate at which the PSA falls is variable, but commonly it will take 12 to 18 months after completing radiotherapy for it to reach its lowest point. This means that we do not need to take a blood test from you in the first few weeks after your radiotherapy has finished.

The oncologist will then ask to see you in the outpatient clinic on a yearly basis. As part of your follow up you will have regular PSA tests. A rise in the PSA rate in the future could be an early warning sign that the cancer may have returned.

Appointments and follow up after treatment

After your treatment has finished and you have been discharged home, you will be followed up regularly by the appropriate consultant’s team.

At this point, we need to check that any side effects that you may have developed during or just after the radiotherapy have settled. As you do not need a physical examination at this assessment, we normally carry out this review over the telephone instead of asking you to come to an outpatient appointment.

This is a booked appointment, and you will receive a letter with a time and date for this telephone follow-up. Your Christie team will arrange a further follow up appointment 6 months after completion of your radiotherapy.

At this appointment, an overall check for your health will be made and a blood sample taken for a PSA (Prostate Specific Antigen) test if not obtained prior to the visit. Your urologist will also arrange to see you at varying time points.

If you are in a clinical trial, your follow up may be more frequent and your research nurse will discuss this with you. Continued follow up appointments between both teams is arranged for several years until we can safely discharge you back to your GP.

Contacts

Via your consultant’s secretary:

• Dr Logue
• Dr Wylie
• Dr Serra
• Dr Hudson
• Professor Choudhury
• Dr Tran
• Dr Coyle
• Dr Conroy
• Dr Song

Nurse specialists:

• Jane Booker – 0161 446 8018
• Cath Pettersen – 0 161 918 7328
• Sharon Capper – 0161 446 3856
• Stephen Booth – 0161 918 2369
• Helen Johnson – 0161 918 7000
• Kam Patel - 0161 446 8594

Radiographer specialists:

• Cathy Taylor (for queries after brachytherapy) – 0161 446 3048
• Hannah Nightingale (radiotherapy) – 0161 918 2096

For queries about appointments:

• The Christie at Withington radiotherapy department – 0161 446 3485
• The Christie at Salford – 0161 918 7800
• The Christie at Oldham – 0161 918 7700
• The Christie at Macclesfield – 0161 956 1700

For queries out of hours: If you have urgent problems related to your treatment, please contact The Christie Hotline on 0161 446 3658.