Originally published 2/24/2015
Not long after we posted the blog below on rectal/bowel problems following beam radiation treatment for side effects, a protective product called hydrogel was introduced. The injection of this absorbable gel into the area between the prostate gland and the neighboring rectal wall is designed to widen the space between the two structures, and thereby act as a shield to protect the rectal wall from radiation scatter. Once it’s in place, the gel “… can maintain integrity for three months and is eventually degraded, with the residual excreted in the urine.”[i] It washes out completely by 6 months with no ill effect.
- In the six years since then, hydrogel spacers have improved the delivery of radiation and reduced rectal side effects. For instance, one study found that at 3 years, 27% fewer hydrogel spacer patients experienced a decline in bowel quality of life than those without spacers.[ii] This is good news, though it still indicates that bowel dysfunction is a risk of prostate radiation. This includes not just beam radiation, but also late-onset side effects due to brachytherapy (seed implants).[iii]
- One of the hallmarks of our practice at Sperling Prostate Center is Dr. Sperling’s interest in and knowledge of Artificial Intelligence as an increasing clinical resource in radiology. A recent publication by Massi, et al. (2020) discusses a Deep Learning model that uses genomic biomarkers to predict individual patient risks for tissue damage and organ dysfunction following beam radiation for prostate cancer.[iv] (Toxicities included late-onset rectal bleeding as well as increased urinary frequency, blood in urine, more nighttime urinary urgency, and decreased urinary stream).
- We hope you will read (or re-read, if you read it back in 2015) the earlier blog for more information on rectal side effects of beam radiation.
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Beam radiation is an accepted whole-gland treatment for prostate cancer. It is also called radical radiation or radical radiotherapy. Radiation is often prescribed for men who can’t have or don’t want surgery (radical prostatectomy). Many improvements in the technology, and refinements in the dosage, have occurred over the last two decades in a concerted effort to improve cancer control yet decrease the risks of side effects. Today, there are several different types of radical radiation:
- Conventional external beam radiation therapy (EBRT)
- Intensity modulated radiation therapy (IMRT)
- Conformal beam radiation
- Stereotactic radiation
- Proton beam
Side effects of prostate cancer radiation, if they occur, are usually temporary. They can include fatigue, bladder/urinary dysfunction, sexual dysfunction, and rectal or bowel problems. Because of the “scatter effect” of all radiation, including proton beam, longer-term side effects include a small, increased risk of future secondary cancers (bladder or rectal). Prostate cancer radiation also eliminates the option of treating recurrence or other pelvic cancers with any more radiation.
Cancer destruction by thermal ablation (e.g. cryo, HIFU or focal laser), is immediately effective against prostate cancer. However, radiation is not! Over time, it has a cumulative effect on the genetic mechanisms that allow cancer cells to reproduce themselves, so they gradually die off. Beam radiation is delivered daily over a period of weeks so the cancer cells are continually exposed to radiation. Radiation exposure can cause delayed side effects due to its gradual damage to healthy tissues. I recently read two reports concerning rectal problems that can show up weeks, even months, after radiation.
A 1999 study compared conventional EBRT vs. conformal radiation to measure which caused more late onset (>3 months) side effects of rectal inflammation and bleeding.[v] (Note: conformal radiation is intended to “shape” the most intense dosage to strike the prostate with less scatter effect to the bladder and rectum.) Conformal radiation had fewer side effects, but the rates were still rather high:
|Grade 1 problems||Grade 2 problems (worse)|
A much more recent study tracked the incidence of adverse rectal events, especially rectal bleeding, following proton beam therapy.[vi] It was a fairly large study with 1285 consecutive patients. Grade 1 rectal bleeding occurred in 217 patients (16.9%), Grade 2 in 14.5%, and Grade 3 in 11 (0.9%). It should be noted that men on blood thinners were at greater risk for developing rectal bleeding, as were those receiving investigational (higher) doses of radiation that affected the rectal wall.
There will always be a place for radiation as a potentially curative treatment for prostate cancer. What’s important, as with any treatment modality, is the two-pronged question: How effective is the treatment, and what are the side effect risks? The 1999 study reported that with a median follow-up period of 3.6 years, the cancer control rates were 83% for EBRT and 78% for conformal. This suggests that even though the conformal group had fewer rectal side effects, almost 1 in 4 patients (22%) were at risk for recurrence.
Patients should be fully informed by their doctors regarding the cost/benefits ratio of the treatments they are considering. It is to be hoped that improvements in targeting radiation to the cancer while protecting nearby healthy structures will continue to be made.
 Chao Y, MacDougall D, de Nanassy A. Hydrogel Spacers for Patients with Prostate Cancer: A Review of Clinical Effectiveness and Cost-Effectiveness. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2019 Feb 22.
[ii] Hamstra D, et al. “Continued Benefit to Rectal Separation for Prostate RT: Final Results of a Phase III Trial.” Int J Radiat Oncol Biol Phys; Dec. 2016.
[iii] Feasibility and early toxicity of focal or partial brachytherapy in prostate cancer patients
Kim TH, Kim JN, Yu YD, Lee SR et al. J Contemp Brachytherapy. 2020 Oct;12(5):420-426.
[iv] Massi MC, Gasperoni F, Ieva F, Paganoni AM et al. A Deep Learning Approach Validates Genetic Risk Factors for Late Toxicity After Prostate Cancer Radiotherapy in a REQUITE Multi-National Cohort. Front Oncol. 2020; 10: 541281.
[v] Dearnaley D, Khoo V, Norman A et al. Comparison of radiation side-effects of conformal and conventional radiotherapy in prostate cancer: a randomized trial. Lancet 1999 Jan; 353(9149):267-72.
[vi] Colaco RJ, Hoppe BS, Flampouri S et al. Rectal toxicity after proton therapy for prostate cancer: An analysis of outcomes of prospective studies conducted at the University of Florida Proton Therapy Institute. Int J Radiat Oncol Biol Phys. 2014 Nov 5. pii: S0360-3016(14)04060-7.