Side Effects of Radiotherapy for Prostate Cancer: Risks and What to Know

Side Effects of Radiotherapy for Prostate Cancer radiotherapy is a significant and often highly effective treatment for prostate cancer, utilizing high-energy beams to destroy cancerous cells. It plays a crucial role as a primary treatment, especially for localized cancers, and is also used in conjunction with other therapies like hormone therapy for more advanced cases. While successful in managing the disease, radiotherapy can lead to a range of side effects. These potential effects are generally categorized as short-term, which appear during or shortly after treatment, and long-term, which can develop months or even years later. Understanding both the effectiveness of radiotherapy and the possible side effects is important for patients considering this treatment option.

What is Radiotherapy for Prostate Cancer?

Radiotherapy for prostate cancer is a treatment that uses high-energy beams, such as X-rays or protons, to destroy cancer cells. This works by damaging the genetic material within the cancer cells, preventing them from growing and multiplying. There are two primary ways to deliver this radiation: External Beam Radiotherapy (EBRT) and Brachytherapy.

External Beam Radiotherapy involves using a machine outside the body to focus radiation beams directly onto the prostate gland. This approach can be used to treat prostate cancer at various stages and can also help manage symptoms if the cancer has spread.

Brachytherapy, on the other hand, is a form of internal radiation therapy. It involves placing small radioactive pellets, often called seeds, directly into the prostate gland. This method is frequently used for men with early-stage prostate cancer.

The key distinction between these two types of radiotherapy is the source of the radiation. EBRT delivers radiation from an external machine, while brachytherapy delivers radiation from within the prostate itself through the implanted radioactive sources.

source: www.mhsystem.org

Why Does Radiotherapy Cause Side Effects?

Radiotherapy for prostate cancer leads to side effects because the high-energy beams used to destroy cancer cells can also impact the healthy cells in the area surrounding the prostate, particularly in the pelvic region. The prostate is situated close to the bladder, rectum, and the nerves and blood vessels responsible for sexual function, making these tissues vulnerable to the effects of radiation. When these healthy cells are exposed to radiation, it can cause damage and inflammation. For example, irritation to the bladder lining can lead to increased urinary frequency and burning sensations, while damage to the rectum can result in diarrhea and discomfort.

Furthermore, the nerves controlling erections can be affected, potentially leading to erectile dysfunction. Therefore, the side effects of radiotherapy are a consequence of the radiation’s effect on both the targeted cancer and the nearby healthy tissues.

How Long After Radiotherapy Will I Feel Better?

The timeline for feeling better after prostate radiotherapy varies for each individual, influenced by factors such as the specific type of radiation therapy received, the patient’s general health, and the severity of the side effects experienced. Generally, most of the side effects that occur during or shortly after treatment start to improve in the weeks and months following the completion of radiotherapy. Short-term side effects, such as urinary and bowel issues, fatigue, and skin reactions, typically begin to appear within a week or two after the commencement of treatment.

These side effects might gradually worsen as the treatment progresses and can continue to do so for a couple of weeks after the final treatment session. However, most people start to notice an improvement in these short-term side effects around two weeks after the treatment has ended, and they often fade away within a few months.

On the other hand, long-term side effects can have a more protracted course. Some of these effects might persist for an extended period, continuing for months or even years after treatment. In some instances, long-term side effects might not even become noticeable until months or years after the radiotherapy has concluded. The duration and severity of these long-term effects can also vary significantly among individuals. It’s important to remember that the recovery process is unique to each person, and the time it takes to feel completely better can differ.

What Are the Common Side Effects of Radiotherapy for Prostate Cancer?

Radiotherapy for prostate cancer can cause several common side effects affecting different parts of the body. Urinary issues are frequent, including needing to urinate more often and urgently, sometimes with burning, and about half of men may experience some urine leakage after several years. Bowel problems like increased frequency and looser stools are also common, and early bowel issues can indicate a higher risk of long-term problems.

Regarding sexual function, erectile dysfunction is a potential side effect that can develop over time, although many men retain function in the initial years after treatment. Fatigue is also a common experience during and after radiotherapy. Additionally, some men may notice skin reactions in the treated area. It’s important to remember that the specific side effects and their severity can vary from person to person.

Budäus et al. published a review in European Urology in 2012 focusing on functional outcomes and rectal side effects after radiotherapy for prostate cancer. The review found that recent technical advancements allow for higher doses with equal or less toxicity. Gastrointestinal complications and rectal bleeding are frequently considered outcomes. Risk factors for toxicities include advanced age, larger rectal volume, prior abdominal surgery, androgen deprivation, diabetes, hemorrhoids, and IBD. Mild acute urinary symptoms are common, while severe urinary issues are rare.

Erectile dysfunction is not immediate, and pretreatment erections are a good predictor of preserved function. The authors concluded that future improvements might shift dose-limiting morbidity from the rectum to the urethra and bladder neck.

Urinary Side Effects of Radiotherapy

Urinary side effects like urgency, frequency, burning during urination, and incontinence are common after prostate radiotherapy. To manage these issues, bladder training exercises can help improve bladder control. Staying hydrated by drinking enough water is generally recommended, though the amount might need to be adjusted based on symptoms. Medications are also available to help alleviate urgency, frequency, burning, and incontinence, and specialists can offer tailored treatment plans. It’s important for patients to communicate any urinary symptoms they experience to their healthcare team for proper guidance and management.

Bowel Issues After Radiotherapy

Radiotherapy for prostate cancer can irritate the bowel because of its closeness to the rectum. This irritation can lead to diarrhea, which means having more frequent and looser bowel movements. Doctors often recommend a low-fiber diet and avoiding foods that can worsen diarrhea, such as spicy or fatty items. Inflammation of the rectum can also occur, causing rectal bleeding and a frequent urge to use the bowels. Medications are available to help manage diarrhea, and soothing creams can be used to ease any soreness around the rectum. It is important to tell your doctor or nurse about any bowel problems you experience so they can provide the best advice and treatment.

Sexual Dysfunction and Erectile Issues

Radiotherapy for prostate cancer can affect sexual health, leading to issues like erectile dysfunction due to potential nerve and blood vessel damage over time. Some men may also experience reduced libido and changes in ejaculation, such as decreased semen volume. Treatment options for erectile dysfunction include medications like sildenafil. Hormone therapy, while primarily for treating the cancer, can also have an impact on sexual function. Pelvic floor exercises, often recommended for urinary control, might also offer some benefit. It is important for men to discuss any sexual health concerns they have with their doctor for personalized advice and treatment.

Fatigue: The Most Common Side Effect

Fatigue is a very common side effect of radiation therapy for prostate cancer because the treatment affects healthy cells as well as cancer cells. This tiredness typically begins a few weeks into treatment and can last for weeks or months after it ends. Managing fatigue involves finding a balance between rest and activity, making sure to rest when needed. Gentle exercise has been shown to sometimes help increase energy levels. Eating a nutritious diet is also important for supporting energy and recovery. It’s recommended to discuss any fatigue experienced with your cancer care team.

Skin Irritation and Pelvic Discomfort

Skin in the treatment area can often become red, dry, and irritated during radiotherapy for prostate cancer. To care for your skin, wear loose, soft clothing and gently wash the area with mild soap and lukewarm water, patting it dry. Avoid rubbing or scratching, and don’t use perfumed lotions or heat/cold packs unless advised by your care team. Protecting the treated skin from the sun with clothing and sunscreen is also important. Make sure to tell your doctor or nurse about any skin changes or soreness you notice so they can provide guidance and treatment if needed.

Read OncoDaily’s Special Article About Prostate Cancer Radiotherapy

What Are the Rare but Severe Side Effects of Radiotherapy?

While most side effects are manageable, rare but serious issues from prostate radiotherapy include the development of secondary cancers like bladder or rectal cancer, severe narrowing of the urine tube or bone problems in the pelvis, and in very rare cases, lasting bowel dysfunction or the formation of abnormal connections between organs.

Chronic Radiation Cystitis and Bladder Damage

Long-term bladder irritation, known as chronic radiation cystitis, can sometimes occur after prostate radiotherapy. This can lead to symptoms like blood in the urine (hematuria), scarring within the bladder, and a reduced capacity to hold urine. While not specifically mentioned in the texts, hyperbaric oxygen therapy is sometimes used to help with radiation-related tissue damage. Bladder instillations, where medication is placed directly into the bladder, may also be used to manage inflammation and other symptoms. It’s important to consult a doctor for diagnosis and appropriate treatment if these issues arise.

Pelvic Fibrosis and Chronic Pain

Radiotherapy for prostate cancer can sometimes cause scarring, also known as fibrosis, in the tissues within the pelvic region surrounding the prostate. This scarring can make the tissues less elastic and more rigid than they were before treatment. As a result, individuals might experience chronic pain in the pelvic area, along with a feeling of stiffness. This lack of flexibility can also lead to reduced mobility, making it more difficult to perform everyday activities comfortably.

Managing this pain often involves a combination of approaches. Doctors may recommend various pain relief strategies, starting with over-the-counter medications and potentially prescribing stronger pain relievers if necessary. Physical therapy is also a very important part of managing pelvic fibrosis and the associated pain and stiffness. A physical therapist can develop a personalized exercise program that includes specific stretches and strengthening exercises designed to improve flexibility, increase the range of motion in the pelvic area, and ultimately help reduce pain and improve mobility. It is crucial for anyone experiencing persistent pelvic pain, stiffness, or difficulty moving after prostate radiotherapy to consult with their doctor.

What Are the Worst Side Effects of Prostate Radiation?

While most individuals undergoing prostate radiation experience manageable side effects, there are some severe but less common complications that can arise. One of these is chronic radiation cystitis, a condition characterized by long-term irritation and inflammation of the bladder. This can lead to persistent issues such as blood in the urine, scarring within the bladder tissue, and a reduction in the bladder’s ability to hold urine, significantly impacting a person’s quality of life.

Another serious potential side effect is fibrosis, which refers to the scarring of tissues in the pelvic region. This scarring can cause significant pain, stiffness, and a noticeable reduction in mobility, making everyday activities challenging. The affected tissues may lose their elasticity, leading to chronic discomfort and functional limitations.

Finally, although rare, radiation-induced secondary cancers represent a severe long-term risk. Years after receiving radiotherapy for prostate cancer, some individuals may unfortunately develop new cancers in the treated area, such as cancer of the bladder or the rectum. These secondary cancers can present significant health challenges and require further treatment. It is important to note that while these are considered the worst potential side effects, they are not common, and the majority of men who undergo prostate radiation will not experience them.

When Do Side Effects Typically Occur?

Side effects from prostate radiotherapy can occur at different times. Immediate or early side effects typically happen during or shortly after treatment and are usually short-term, lasting weeks to a few months. Examples include fatigue, skin changes, and early urinary and bowel problems. Delayed side effects can appear in the months following treatment as healthy tissues recover, or some early effects might continue. Long-term or late side effects can take months or even years to develop and depend on the treatment area and radiation dose; these can include issues like erectile dysfunction and, rarely, secondary cancers.

Reinikainen et al. published a study in Anticancer Research in 2022 comparing acute toxicities of three radiation fractionation schedules (78/2 Gy, 60/3 Gy, and 36.25/7.25 Gy) in elderly patients with early prostate cancer.  At 3 months post-RT, there were no significant QoL differences between groups, but the 78/2 Gy group showed increased bowel movements (p=0.036) and significantly more erectile dysfunction than the 60/3 Gy group (p=0.025). 2 At the end of RT, the 78/2 Gy group had more symptoms than the 36.25/7.25 Gy group.  Rectafix did not reduce acute toxicities.

The study concluded that the 78/2 Gy schedule is not recommended due to higher toxicity, while the shortest schedule (36.25/7.25 Gy in five fractions) appears convenient with tolerable acute toxicit

Immediate Side Effects: What to Watch For

Early side effects of prostate radiotherapy can include a burning feeling when you urinate, fatigue (feeling very tired), and mild bowel irritation with more frequent or softer stools. To manage urinary burning, drink plenty of water and tell your doctor if you have pain. For fatigue, try to balance rest with gentle activity. If you experience bowel irritation, stay hydrated and let your healthcare team know about any changes in your bowel habits. It’s always best to keep your care team informed about any side effects you’re experiencing.

Delayed Side Effects: Weeks or Months After Treatment

Some side effects of prostate radiotherapy, like erectile dysfunction and bowel urgency, might not appear until weeks or months after treatment ends. Erectile dysfunction can develop gradually due to radiation’s effect on nerves and blood vessels. Bowel urgency can also be a delayed issue from bowel irritation. Difficulty urinating is another possible delayed side effect. It’s important to contact your doctor if you experience any new or worsening symptoms in the weeks or months after radiotherapy, such as these issues, as they may need medical attention.

Managing Long-Term Prostate Problems After Radiotherapy

Managing long-term problems after prostate radiotherapy involves several approaches. Physical therapy can help with issues like urinary incontinence through exercises, manage swelling (lymphoedema), and potentially ease pelvic pain. Lifestyle adjustments, such as dietary changes for bowel problems and staying hydrated for urinary health, can also be beneficial. For more advanced issues, medical treatments are available, including surgery for a narrowed urethra, medications for erectile dysfunction and urinary incontinence, specialized care for persistent bowel problems, and treatments for bone issues. It’s important to work closely with your healthcare team to find the best ways to manage any long-term side effects.

Schumacher et al. published a systematic review and meta-analysis in the International Journal of Radiation Oncology Biology Physics in 2021, investigating the impact of exercise on men with prostate cancer undergoing radiation therapy. The review of seven publications found that exercise consistently and significantly improved cardiovascular fitness (SMD, 0.83; P < .01) and muscle function (SMD, 1.30; P < .01).

Furthermore, exercise significantly reduced urinary toxicity (SMD, –0.71; P < .01). However, no significant effects were observed for intestinal or hormonal toxicity, depression, or sleep symptoms. The authors concluded that exercise improves physical function and mitigates urinary toxicity in this patient population, while the effects on other side effects require further investigation.

Pelvic Floor Rehabilitation for Urinary and Bowel Control

Pelvic floor exercises can help regain bladder and bowel control after prostate radiotherapy by strengthening the muscles that support these functions. Radiotherapy can sometimes weaken these muscles. Performing exercises, which generally involve squeezing and relaxing the muscles you’d use to stop urination, can improve control and reduce leakage or urgency. Specialists like physical therapists can provide personalized exercise programs and use techniques such as biofeedback to help. Consistency is important, and it’s best to talk to your doctor or a therapist before starting these exercises.

Dietary Strategies to Reduce Long-Term Side Effects

Diet plays a significant role in managing some of the long-term side effects that can occur after radiotherapy for prostate cancer, particularly those affecting bowel health and urinary symptoms. For bowel health, individuals experiencing ongoing issues like diarrhea might find that dietary adjustments can be helpful. Often, a diet that is lower in fiber is recommended in the long term for those who continue to have loose stools. This might involve limiting or avoiding high-fiber vegetables, beans, pulses such as lentils, and other foods that are naturally high in fiber.

Regarding urinary symptoms, staying well-hydrated by drinking plenty of water is generally advisable for maintaining good urinary health. While some people believe that cranberry juice can help with bladder problems, the texts indicate that this is not typically the case for bladder issues that arise as a result of radiation therapy.

The provided texts do not specifically list a wide range of “prostate-friendly” foods or supplements in the context of managing long-term radiotherapy side effects. However, maintaining a balanced and nutritious diet overall is important for supporting the body’s recovery and managing any long-term effects of the treatment. One specific point mentioned in the texts is that radiotherapy to the pelvis can sometimes lead to low levels of vitamin B12, as it can affect the body’s ability to absorb this vitamin from food. If a vitamin B12 deficiency is diagnosed, supplementation under the guidance of a doctor may be necessary.

Do Side Effects Indicate That Radiotherapy is Working?

Experiencing side effects during or after radiotherapy for prostate cancer doesn’t directly tell you how effectively the treatment is targeting the cancer cells. Radiotherapy works by damaging the DNA of cells in the treated area, which includes both the cancerous prostate tissue and some of the surrounding healthy tissues. Side effects occur because the radiation inevitably affects these nearby healthy cells, such as those in the bladder, rectum, and skin. Therefore, the presence of side effects often indicates that the area, including the prostate, has been exposed to radiation, but it doesn’t necessarily mean the cancer cells are being destroyed more effectively if the side effects are more pronounced.

The severity and type of side effects a person experiences can vary greatly depending on factors like the dose of radiation, the area being treated, the individual’s overall health, and the specific radiotherapy technique used. These side effects primarily reflect the impact of radiation on normal tissues. The effectiveness of the radiotherapy in targeting and killing the prostate cancer cells is typically monitored through other means, such as regular Prostate-Specific Antigen (PSA) level tests, imaging scans if needed, and follow-up appointments with your oncologist. These methods provide a more direct assessment of how well the treatment is working to control or eliminate the cancer.

While some level of side effects is often expected with radiotherapy, it’s not accurate to assume that more severe side effects equate to a more successful cancer treatment. Radiation oncologists carefully plan the treatment to deliver a sufficient dose of radiation to the prostate to eradicate the cancer cells while trying to minimize damage to the surrounding healthy tissues. The goal is to achieve the best possible outcome in terms of cancer control with the fewest side effects. Therefore, while experiencing some side effects is common, they are not the primary indicator of whether the radiotherapy is effectively working against the prostate cancer. The effectiveness is assessed through specific monitoring techniques recommended by your medical team.

Radiotherapy vs. Chemotherapy Side Effects in Prostate Cancer

Radiotherapy and chemotherapy have different side effects when treating prostate cancer. Radiotherapy mainly causes side effects local to the pelvic area, such as urinary and bowel problems, sexual dysfunction, fatigue, and skin irritation. These can be short-term, delayed, or long-term. Management focuses on treating the specific symptoms in the affected area. Chemotherapy, being a systemic treatment, affects the whole body and can cause side effects like fatigue, nausea, hair loss, and changes in blood cell counts, which are usually more pronounced during and shortly after treatment. These systemic side effects are typically managed with medications targeting those issues. The main difference is that radiotherapy’s effects are primarily local, while chemotherapy’s are systemic.

When Should Prostate Cancer Patients Contact a Doctor?

It’s important for prostate cancer patients undergoing radiotherapy to be aware of certain symptoms that require prompt medical attention. You should contact your doctor if you experience an inability to pass urine, which is a serious issue that needs to be addressed quickly. Significant or persistent rectal bleeding is another red-flag symptom that warrants medical evaluation. If you develop pain that is severe and not controlled by your usual pain relief methods, it’s important to reach out to your doctor. Signs of infection should also prompt a call to your healthcare team. These signs can include a fever, chills, increased redness or swelling in the treatment area, or any discharge that looks like pus.

Additionally, if you experience severe diarrhea or a sudden and significant worsening of any problems you are having with passing urine, you should seek medical advice. While some skin changes are expected, if you notice significant reddening or increased soreness in the treatment area, it’s also important to inform your nurse or radiographer. Finally, if you see blood or particles in your urine, it’s advisable to contact your doctor for further assessment. These symptoms could indicate a complication or a need for intervention.

Written by Aren Karapetyan, MD