Full Course

External Beam Radiation

Utilizing

IMRT

(Intensity Modulated Radiation Therapy)

for

Cancer of the Prostate

Patients with Prostate Cancer have many treatment options. This particular treatment option may be selected over a radioactive seed implant or surgical prostatectomy for many reasons:

1. The patient is not a surgical candidate for other health reasons

2. The patient chooses not to undergo the radioactive seed implant

3. The prostate cancer has spread outside the prostate gland and involves a larger area

4. The patient has metastatic disease.

Full course external beam irradiation treatment allows the Radiation Oncologist to deliver a dose beyond the prostate gland to the seminal vesicles and/or side-walls surrounding the prostate gland.

Measurement of the Prostate Gland

I. Measurement of the prostate gland by a transrectal ultrasound exam may be helpful to determine the extent of the disease. This exam on the otherhand may not give any valuable information to the physician if the patient has known metastatic disease. Therefore, it is not always performed.

II. If a transrectal ultrasound exam is done, it is performed by the physician. The prostate gland is measured for size and shape. This information is recorded on film. The Radiation Oncologist and Medical Radiation Physicist may use this information to decide the area to be irradiated.

III. If the prostate gland measured is found to be large and depending on your other clinical findings, the Urologist or Radiation Oncologist may give Lupron, Casodex, Flutamide or Eulexin medication to block testosterone production. This will stop the tumor growth and decrease the size of the prostate gland. The medication is given once a month basis.

IV.
A smaller gland will lead to a safer (Fewer complications) treatment course and we now feel, that a course of Anti-Androgen (Anti-Testerone) therapy actually enhances the overall cure rate.Unfortunately, there are some side effects to this medication. This can include hot flashes, tiredness and weakness. They are temporary, and resolve after the medication wears off.

Here are samples of the transrectal ultrasound films:

The prostate gland, in the transverse view, has been outlined for you in the film on the right.

When does the External Beam Radiation begin?

You will need to schedule your appointments with the Radiation Oncology Department.

1. Call as soon after your consultation when you have decided to undergo treatment.

2. Simulation and 3-D reconstruction for planning. You will first be scheduled by the Radiation Technologists for insertion of fiducial markers and a planning CT scan. Just prior to the CT scan, Dr Tokita will insert 3 to five gold seeds (fiducials) as markers to target the prostate with extreme accuracy. This will be followed by a high quality (3mm) interval CT scan for prostate modeling.

This will allow Dr Tokita and his staff to very precisely reconstruct a 3-D image of your prostate, rectum bladder, pelvis, hips and small bowel (if necessary). From this computer 3-D model a very detailed treatment plan can be constructed. The therapist may ask you to drink some barium in order to identify your small bowel on X-Ray. Also an injection of dye may be necessary to better outline the bladder from the prostate.During the next several days, Dr Tokita and his staff will spend well over 14 hours on your plan. Treatments will not start until, Dr Tokita is 100% satisfied with the treatment plan.

3. Three to five working days later you will be scheduled for a beam film and machine simulation. This is the process in which the therapist takes you into the treatment room and localizes the area to be irradiated. The therapist will be making marks on your skin with a felt tip pen to “map” out the area to be treated. Films will be taken. If we are happy with the set-up you will be tattooed to preserve the 3-D laser positioning points on your body.

4. You will be scheduled to return in the next day or two to begin treatment. The first day and every day thereafter, X-ray films called port films will be taken to verify once again that the area “mapped” out is the area that is being targeted for treatment. The gold fiducials will clearly guide us to perfect targeting.

5. Your treatments will be scheduled Monday through Friday for approximately 8 weeks. This means you will make approximately 40 to 48 visits to see us for treatment. Each treatment takes 15-30 minutes. Normally, you will be in and out of the department in 30-=45 minutes.

There is no pain or discomfort with the treatment. It is ok to drive yourself to treatment.

Short Term Side Effects during Radiation

If you think of radiation as the “sun”, but going through you, you will understand the possible side effects. For the first 2 –3 weeks there will be little or no effects.

About the 3^rd week, you may begin to notice:

Skin: your skin above your pubic bone, anal area and hips may turn a little red and occasionally irritated. The technicians will instruct you on skin care. With the new IMRT radiation, we are seeing almost no skin reaction, but it can occur.
Rectum: your anterior rectum will be in the radiation field. The irritation can lead to increased bowel movements and even diarrhea. Your technicians will instruct you on diet and medications, to help control these symptoms.
Bladder: since we are treating your prostate, your lower bladder (bladder base) will be in the field. This can lead to burning with urination, frequent urination and some urgency.
Tiredness: Just as anyone going into the sun, after 3-4 weeks, you may get tired. Don’t hesitate to take a nap and exercise is very good. It will give you strength and help get you through the treatments.
Depression: It is absolutely normal for anyone diagnosed with cancer and undergoing treatment to get depressed. If the depression gets difficult, please tell Dr. Tokita. Up to 70% of the Cancer Center patients are put on anti-depressants at some time before, during or after treatment.

Short Term Reaction After Treatment

You may experience some short-term effects of the radiation for the immediate month to month and a half following your last treatment.

These may include burning upon urination (dysuria), frequency in urination, the need to urinate at night (nocturia), loose bowels, diarrhea, and/or skin irritation. You may also experience some discomfort in the bladder, rectum, and urethra commonly referred to as the “sunburn effect”.

Dr Tokita will be seeing you regularly until these effects subside.

Long Term Effects

Even though long-term side effects are not common, they could appear after a period of three months to a year.

Obstruction: As the prostate tumor cells are killed and the gland shrinks, urinary obstruction may be problematic. Scar tissue along the urethra may account for narrowing of the passage of urine from the bladder. This can be very serious, and require surgical intervention to open the channel. If this becomes necessary, the patient should consult Dr Tokita before surgery. Inappropriate, aggressive surgery can lead to permanent incontinence. This is fortunately rare, but possible, and must be understood. It usually occurs in patients who have had previous surgeries, such as TURP (Roto-Rooter surgery), multiple infections or injuries. Such concerns may keep us from recommending seed implants for some patients.
Impotence, is a definite possible side effect of radiation. Most men able to have intercourse before radiation recover this ability after radiation. This usually occurs 2-3 months after the effects of the hormone treatments disappear. The patient may need help in the form of Viagra, injections etc. As we age, sexual ability normally fades. All of the treatments for Cancer of the prostate can add to this decline, and radiation is no exception, but seems to affect the erection ability the least of the present curative procedures.
Rectal Injury: Other possible side effects include rectal injury, rectal-urethral fistula, rectal-vesicle fistula and in the worst situations, even lead to a colostomy. Again, these problems are unusual, but you should be aware of them. Mild rectal injury can occur in as many as 25%, moderate in up to 10%, and severe in 2-3%. In Dr Tokita’s 27 years, he has seen 5-6 severe and 20 or so moderate injuries in approximately 900 cases covering his experience starting with the earliest Stanford Rotational arc radiation. He has seen only one rectal-urethral fistula or rectal-vesicle fistula in his practice but realizes they can occur anytime.

Cure

Finally, we hope every patient we treat will be cured. Realistically, that is not possible. Patients, who are candidates for radiation, in general are reasonable candidates for cure. But under the best of circumstances, the overall cure rate will vary dramatically with the grade (Gleason’s score) and stage (Extent of tumor). That means many of you will be cured and live to hopefully enjoy a longer healthy life. Unfortunately some will not be cured, and we will explore other salvage techniques when possible and work to keep you comfortable if we are not able to offer you an alternative chance for cure. Since cancer of the prostate is often slow growing, non-cure is not an immediate death sentence for most. A large number live many more comfortable productive years, with a slow growing cancer.

The only promise, warranty, or assurance we can give, is to promise the finest treatment available today. Our experience and record speak for themselves.

Special Note:

Dr. Tokita uses the sequence of events and the individual treatments outlined in the above document in his treatment of the prostate gland using External Beam Radiation Therapy. If you have other resources that differ with this information, please keep in mind that there are multiple methods of available for treating this cancer, but this is what we have found to be the best for our patients.

For more information, please contact:

Dr. Kenneth M. Tokita

Medical Director, Cancer Center of Irvine

16100 Sand Canyon Ave. #130

Irvine, CA 92618

Phone 949-417-1100

1.		The patient is not a surgical candidate for other health reasons
2.		The patient chooses not to undergo the radioactive seed implant
3.		The prostate cancer has spread outside the prostate gland and involves a larger area
4.		The patient has metastatic disease.

I.		Measurement of the prostate gland by a transrectal ultrasound exam may be helpful to determine the extent of the disease. This exam on the otherhand may not give any valuable information to the physician if the patient has known metastatic disease. Therefore, it is not always performed.
II.		If a transrectal ultrasound exam is done, it is performed by the physician. The prostate gland is measured for size and shape. This information is recorded on film. The Radiation Oncologist and Medical Radiation Physicist may use this information to decide the area to be irradiated.
III.		If the prostate gland measured is found to be large and depending on your other clinical findings, the Urologist or Radiation Oncologist may give Lupron, Casodex, Flutamide or Eulexin medication to block testosterone production. This will stop the tumor growth and decrease the size of the prostate gland. The medication is given once a month basis.
IV.		A smaller gland will lead to a safer (Fewer complications) treatment course and we now feel, that a course of Anti-Androgen (Anti-Testerone) therapy actually enhances the overall cure rate.Unfortunately, there are some side effects to this medication. This can include hot flashes, tiredness and weakness. They are temporary, and resolve after the medication wears off.