Palliative Brachytherapy: A Focused Approach to Symptom Control

Palliative brachytherapy is an internal radiation therapy that delivers targeted radiation to tumors, aiming to alleviate symptoms and enhance the quality of life for patients with advanced or incurable cancers. This approach is utilized across various cancer types to manage symptoms such as pain, bleeding, obstruction, and dysphagia.

Types of Palliative Brachytherapy

Palliative brachytherapy is used across various clinical settings to alleviate symptoms in patients with advanced cancers. It can be classified by dose rate, treatment site, and delivery method.

High-dose-rate (HDR) brachytherapy delivers large doses of radiation over a short period, often in outpatient settings. It is commonly used in palliative care due to its efficiency and precision. Low-dose-rate (LDR) brachytherapy, which delivers radiation continuously over several hours or days, is less commonly used for palliation today but may still be applied in select cases. Pulsed-dose-rate (PDR) brachytherapy combines the biological effect of LDR with the technical advantages of HDR, making it a hybrid option in some centers.

In terms of anatomical sites, palliative brachytherapy is used in esophageal cancer to relieve dysphagia, where HDR radiation is delivered intraluminally using a catheter. For non-small cell lung cancer, endobronchial brachytherapy helps relieve airway obstruction and hemoptysis through catheters inserted via bronchoscopy. In rectal cancer, brachytherapy may reduce bleeding and obstruction using endorectal applicators. For gynecologic malignancies like advanced cervical or vaginal cancer, intracavitary or interstitial HDR brachytherapy is used to control bleeding and discharge.

Head and neck cancers may benefit from surface or interstitial brachytherapy to manage pain, bleeding, and local symptoms. In prostate cancer, particularly metastatic or hormone-refractory cases, interstitial brachytherapy can control hematuria and urinary obstruction. Breast cancer patients with advanced or recurrent disease may also receive surface or interstitial brachytherapy to manage ulcerated or bleeding tumors.

Delivery techniques vary based on tumor location. Interstitial brachytherapy involves placing radioactive sources directly into tumor tissue, as in prostate or head and neck cancers. Intraluminal brachytherapy delivers radiation inside hollow organs, such as the esophagus, bronchus, or rectum. Intracavitary brachytherapy places sources in body cavities, commonly used in gynecologic cancers. Surface or mold brachytherapy is used for treating superficial lesions, including skin metastases or chest wall recurrences.

How Effective Is Palliative Brachytherapy

Palliative brachytherapy has shown clinical effectiveness in relieving symptoms associated with advanced and metastatic cancers. According to a systematic review of 129 studies, approximately 81% reported symptom improvement after palliative brachytherapy, although the review also highlighted limitations such as publication bias and a general lack of randomized controlled trials. Alborz Jooya Brachytherapy 2022

In esophageal cancer, brachytherapy has been effective in relieving dysphagia. A study found that high-dose-rate brachytherapy was associated with rapid and durable improvement in swallowing function, offering a valuable option for patients unsuitable for stenting or surgery. Lorenzo Fuccio Radiother Oncol 2017

In advanced non-small cell lung cancer, endobronchial brachytherapy (EBT) has been used to palliate symptoms such as cough, hemoptysis, and dyspnea. When compared to external beam radiation therapy (XRT), EBT was similarly effective in symptom control, though XRT tended to offer longer duration of relief. However, EBT may be preferable for localized endobronchial obstruction, especially in patients with poor performance status. R Stout Radiother Oncol 2000

The Procedure and Preparation Steps for Palliative Brachytherapy

Palliative brachytherapy involves careful planning and preparation to ensure safety and effectiveness. Before the procedure, patients undergo a comprehensive medical evaluation that typically includes blood tests, imaging studies such as CT scans or MRIs, and a review of current medications. This helps the care team determine the most appropriate approach to treatment. Patients may be asked to stop taking certain medications, particularly blood thinners like aspirin or NSAIDs, several days prior to the procedure to reduce bleeding risk.

In cases where the procedure involves pelvic organs, patients may need to follow a bowel preparation regimen using laxatives or enemas to empty the intestines. Fasting is usually required for several hours before the procedure, especially if sedation or anesthesia will be used. Patients are also typically instructed to shower with antibacterial soap the night before and the morning of the procedure to reduce the risk of infection.

During the procedure, imaging techniques such as ultrasound, CT, or MRI are used to guide the accurate placement of radioactive sources near or within the tumor site.The radiation is delivered using applicators like catheters or needles, which are inserted depending on the location and size of the tumor. High-dose-rate (HDR) brachytherapy involves short sessions where the radioactive source is temporarily placed inside the applicator, whereas low-dose-rate (LDR) brachytherapy may involve longer durations with the source remaining in place for hours or days.

After the procedure, patients are monitored for immediate side effects and are usually discharged the same day if the treatment is done on an outpatient basis. Side effects are typically mild and may include localized discomfort, fatigue, or irritation in the treated area. Patients are provided with specific post-procedure care instructions to aid recovery and reduce complications. Following all preparation and care instructions closely helps optimize the effectiveness of palliative brachytherapy and improve patient comfort.

Palliative Brachytherapy Side Effects: What Should You Expect?

Palliative brachytherapy is generally well-tolerated, but patients may experience side effects depending on the treatment site, radiation dose, and individual health factors. Common side effects include localized tenderness, swelling, or discomfort at the treatment site. Fatigue is also a common symptom, typically resolving within a few weeks after treatment. These acute reactions are generally mild and manageable.

For patients receiving treatment in the pelvic region (e.g., prostate, cervix, uterus), urinary symptoms such as increased frequency, urgency, or discomfort during urination may occur. Bowel changes, including diarrhea or rectal irritation, can also happen.
In cases of esophageal cancer, brachytherapy can cause inflammation that leads to pain or difficulty swallowing. For endobronchial brachytherapy in lung cancer, side effects may include coughing, shortness of breath, or, in rare cases, severe bleeding.

Patients treated for breast cancer may experience skin changes such as redness, tightness, or bruising around the treatment area.
Long-term side effects are less common but can occur. Some patients may experience persistent urinary incontinence or bowel irregularities, particularly following prostate cancer treatments. In terms of sexual health, erectile dysfunction in men and vaginal dryness or narrowing in women can result from pelvic radiation.

How Long Does It Take to See Results?

In cases of esophageal cancer, studies have shown that patients experience significant improvement in swallowing difficulties (dysphagia) within approximately 16 to 26 weeks after treatment. Notably, patients who received external beam radiotherapy (EBRT) combined with brachytherapy reported quicker symptom relief compared to those who underwent brachytherapy alone. However, the duration of symptom relief was similar across both groups, with a median response duration of about five months . J Cancer 2016 Jan

For patients with bone metastases, particularly those treated with iodine-125 (^125I) seed implantation, pain relief can begin within 12 hours post-treatment. Significant improvements in pain levels and quality of life, as measured by the Karnofsky Performance Status (KPS) scores, were observed at 1, 4, and 8 weeks following the procedure .(PMC) Yuan Yao Diagn Interv Radiol. 2021 

In the context of lung cancer, specifically for patients undergoing endobronchial brachytherapy, symptom improvement was noted in 60% of patients, with a median time to symptom relapse of five months. The most significant improvements were observed in symptoms such as hemoptysis (coughing up blood).

How Much Does Palliative Brachytherapy Cost?

The cost of palliative brachytherapy varies based on factors such as the type of cancer, treatment modality, healthcare setting, and regional differences. In general, palliative brachytherapy is considered a cost-effective option compared to other treatments.
For instance, in the context of esophageal cancer, a study comparing single-dose brachytherapy to metal stent placement found that the initial treatment costs were lower for brachytherapy (€570 vs €1,500). However, when accounting for total medical costs, including follow-up care, the difference was minimal, with brachytherapy costing €10,078 and stent placement €11,195. This suggests that while the upfront costs of brachytherapy may be lower, the overall expenses can be comparable to other palliative treatments.

In the United States, the cost of radiation therapy, including brachytherapy, can range from $4,500 to $50,000 for a full course of treatment, depending on the number of sessions and specific treatment plan . Medicare data indicates that the mean total radiation therapy costs for patients with metastatic cancer range from $2,156 to $9,044, depending on the number of treatment fractions.

It’s important to note that these figures are general estimates and actual costs can vary. Insurance coverage, the specific healthcare facility, and the patient’s individual treatment plan all influence the final cost. Patients are encouraged to consult with their healthcare providers and insurance companies to obtain a more accurate estimate of the costs associated with palliative brachytherapy in their specific situation.

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How Does Palliative Brachytherapy Compare to Other Treatments?

Its effectiveness and suitability compared to other palliative treatments depend on the specific clinical context.

Comparison with External Beam Radiation Therapy (EBRT)

In the treatment of esophageal cancer, short-course EBRT has been found to be at least as effective as brachytherapy in relieving dysphagia, with both treatments offering significant symptom palliation. However, EBRT is associated with higher acute toxicity, including more pronounced urinary and sexual side effects, compared to brachytherapy. Therefore, while both modalities are effective, brachytherapy may be preferred for its lower toxicity profile in certain cases . Paul M Jeene J Thorac Oncol 2020

Comparison with Metal Stent Placement

For patients with inoperable esophageal cancer, single-dose brachytherapy has been shown to provide better long-term relief of dysphagia than metal stent placement. Additionally, brachytherapy is associated with fewer complications, making it a preferable option for palliation in this context. Marjolein Y V Homs Lancet 2004

Comparison with Stereotactic Body Radiation Therapy (SBRT)

SBRT delivers high doses of radiation precisely to small tumors, minimizing exposure to surrounding healthy tissue. While SBRT is effective for certain cancers, it may result in more acute urinary toxicity and potential sexual impairment compared to brachytherapy. However, data on long-term outcomes are still limited, and further studies are needed to fully assess the comparative effectiveness of SBRT and brachytherapy. Manon Kissel Cancers (Basel). 2022

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How Does Palliative Brachytherapy Affect Sexual Health and Fertility?

Palliative brachytherapy can have significant effects on sexual health and fertility, particularly when administered to the pelvic region. The extent of these effects varies based on the specific area treated, the patient’s age, and whether they have undergone other treatments.
In women, pelvic radiation—including brachytherapy—can lead to vaginal changes such as dryness, narrowing (vaginal stenosis), and decreased elasticity. These alterations can cause discomfort or pain during sexual activity. Additionally, radiation may induce premature menopause by damaging the ovaries, leading to hormonal changes that further affect sexual function.

For men, particularly those undergoing prostate cancer treatment, brachytherapy can result in erectile dysfunction. This occurs due to radiation-induced damage to the nerves and blood vessels responsible for erections. While brachytherapy is associated with a lower incidence of erectile dysfunction compared to other treatments, such as external beam radiation therapy, it remains a significant concern for many patients.
Radiation therapy to the pelvic area can impair fertility. In women, it may cause damage to the uterus and ovaries, leading to infertility or complications during pregnancy. In men, radiation can decrease sperm production, affecting fertility. These effects are dose-dependent and can vary based on the specific area treated and the patient’s age.

Patients undergoing palliative brachytherapy should discuss potential sexual and fertility-related side effects with their healthcare providers. Supportive care, including counseling, physical therapy, and medical interventions, can help manage these effects and improve quality of life. Additionally, fertility preservation options, such as sperm banking or ovarian transposition, may be considered prior to treatment for patients wishing to have children in the future.

Recovery After Palliative Brachytherapy

Recovery after palliative brachytherapy varies based on the cancer type, treatment modality, and individual patient factors. Generally, the procedure is well-tolerated, and many patients resume normal activities within a short period.
Most patients can resume walking within a few hours of the procedure and return to normal activities within a few days, thanks to the minimally invasive nature of brachytherapy. However, some may experience fatigue, which can last from a few days to several weeks, depending on the individual and the extent of the treatment.

Maintaining a well-rounded diet and staying hydrated are essential during the recovery phase. Patients are encouraged to choose healthy foods and drink plenty of water or unsweetened juice to support their recovery.
While many patients can resume normal activities relatively quickly, it’s advisable to avoid heavy lifting and strenuous physical activity during the initial recovery period to allow the body to heal properly.

Common side effects include localized swelling, bruising, bleeding, or discomfort at the site where the radiation was delivered. These usually resolve within a few days following completion of treatment. Patients may also experience transient urinary symptoms such as urinary retention, incontinence, or painful urination, as well as gastrointestinal symptoms like diarrhea, constipation, or minor rectal bleeding, depending on the area treated.

While most side effects are temporary, some patients may experience long-term effects, such as erectile dysfunction in men or vaginal changes in women, particularly when the pelvic region is treated. These effects can vary in severity and may require ongoing management.
Regular follow-up appointments are crucial to monitor recovery progress, manage any persistent side effects, and address any new symptoms that may arise. Patients should maintain open communication with their healthcare team to ensure comprehensive care during the recovery process.

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How Can Patients Support Their Health During Palliative Brachytherapy?

Patients undergoing palliative brachytherapy can take several steps to support their health and enhance their well-being during treatment. These measures encompass physical care, emotional support, and adherence to medical guidance.
Maintaining adequate hydration is crucial during palliative brachytherapy. Patients are advised to consume 8 to 12 cups of non-caffeinated fluids daily, such as water or herbal teas, to prevent dehydration and alleviate common side effects like dry mouth . However, the use of medically assisted hydration in palliative care has not shown significant benefits and should be considered on an individual basis.

Nutritional support plays a vital role in managing symptoms and maintaining strength during treatment. Patients should aim for a balanced diet rich in proteins, vitamins, and minerals, tailored to their specific needs and tolerances. Consulting with a registered dietitian can help in developing a personalized nutrition plan. In some cases, artificial nutrition may be considered, but its use should be carefully evaluated based on the patient’s condition and prognosis.

Physical activity, as tolerated, can aid in reducing fatigue and improving overall well-being. Gentle exercises, such as walking or stretching, may be beneficial. Patients should consult with their healthcare team to develop an appropriate exercise plan that aligns with their capabilities and treatment goals.

Emotional support is equally important. Engaging in open communication with healthcare providers, family members, and support groups can help address concerns and alleviate anxiety. Oncology nurses and counselors are valuable resources for providing emotional care and guidance throughout the treatment process .

Adhering to medical instructions is essential for safety and treatment efficacy. Patients should follow all prescribed guidelines, including those related to medication, activity levels, and follow-up appointments. Additionally, it’s important to inform healthcare providers about any other treatments or medications being used to avoid potential interactions.

By actively participating in their care and collaborating with their healthcare team, patients can better manage the challenges of palliative brachytherapy and maintain a higher quality of life during treatment.

Written by Nare Hovhannisyan, MD