Maureen Salamon

After James Levy finished his high-dose-rate (HDR) brachytherapy to treat his localized prostate cancer, he celebrated by getting a tattoo that included the StandUp2Cancer logo, the date his treatment ended and the word “radioactive.” It was his way of acknowledging his successful treatment with this relatively new approach.

“I’m a big fan of HDR brachytherapy,” says Levy, of Richmond, Va. “I went in Friday and was back at work on Monday. There was nothing to it.”

HDR brachytherapy, which involves placing strong sources of radioactivity in or near the cancerous tissue for a few minutes and then removing them, joins other, more established forms of radiation as a treatment option.

These techniques include one other type of brachytherapy and many forms of external beam radiation therapy (EBRT), which sends beams of radiation into the prostate from outside the body. In addition, for men whose prostate cancer has metastasized to the bone, a fairly new radiopharmaceutical is available. These approaches give patients a variety of choices if they select radiation treatment as either a first-line or follow-up therapy.

The common variable that internal and external radiation share is their increasing ability to deliver higher doses to the prostate while reducing exposure to nearby healthy tissues. Nonetheless, the treatments can cause side effects, including temporary fatigue or later development of permanent urinary incontinence, bowel problems and erectile dysfunction, among others.

For Levy, 57, who completed treatment about a year ago, side effects have not been an issue. “I’ve had none of the common long-term effects, like incontinence, erectile dysfunction or bowel issues,” says Levy. This is likely because of HDR’s ability to direct radiation specifically at the tumor and avoid nearby tissue and organs — and its short duration.

To treat his localized prostate cancer, James Levy chose high-dose-rate brachytherapy, and has not experienced any long-term side effects. [Photo by Liza Bishop, VCU Massey Cancer Center]

While that outcome is compelling, HDR may not be right for everyone. In fact, sifting through possibilities to arrive at the best radiation option for each patient can be challenging, says James B. Yu, a radiation oncologist at Yale University School of Medicine in New Haven, Conn. The decision, he says, is as individual as the man and his cancer.

“It depends on what you’re looking at — cure rates or complications,” he says. “Patients care about some complications more than others, such as erectile dysfunction, so the choice of treatment is intensely personal.”

Questions about the relative value of newer radiation methods may, in particular, give men pause.

For instance, in administering EBRT, “Physicians are looking at shortening the number of radiation treatments by increasing the dose per treatment,” Yu explains. He says there continues to be concern that giving more intense radiation treatments, even if there aren’t as many, could be more toxic overall. Adding to the confusion is that current research is mixed, highlighting “the complexity of comparing these treatments and saying that one is better than the other.”

Yu urges patients to learn as much as they can about the pros and cons of various treatments before making a decision, and to discuss any questions they might have with their health care providers. Levy agrees, adding that “the Internet makes it possible to become really well-informed.”

For men with localized prostate cancer (meaning it hasn’t spread outside the gland), often the first step after diagnosis is choosing between active surveillance (particularly for lower-grade tumors, as indicated by the level of prostate-specific antigen [PSA] in a man’s blood and the Gleason score doctors use to describe aggressiveness); surgery to remove the prostate gland (called a radical prostatectomy), or radiation therapy. If a man has localized prostate cancer and plans to undergo treatment, he should know that surgery and radiation are considered equally effective when it comes to preventing the advancement of the disease, according to the American Cancer Society (ACS).

One option for men with locally advanced prostate cancer (in which lymph nodes or other nearby tissues are involved) is radiation therapy plus hormonal therapy, which several studies have shown is more effective at fighting the cancer than hormonal therapy alone. In addition, men with this condition and a higher risk of recurrence should be informed that radiation therapy after a radical prostatectomy decreases their risk of cancer recurrence or progression, according to national guidelines issued in May 2013. Issued jointly by the American Society for Radiation Oncology and the American Urological Association, the guidelines also state that doctors should offer “salvage radiotherapy” to patients whose PSA levels rise, or who have a local recurrence after prostatectomy but show no evidence of distant metastases.

In 2015, the National Comprehensive Cancer Network (NCCN) issued new guidelines for patients. These guidelines recommend EBRT as a staple of treatment for men with various stages of the disease: as a first-line treatment for those at low risk for developing metastatic disease and who are expected to live 10 years after diagnosis; as a first-line or adjuvant therapy for many categories of men at intermediate risk, and for many groups of men with high-risk disease.

Most radiation options fall under the umbrella of EBRT, which is typically administered over a seven- to nine-week period, according to the ACS. Among EBRT therapies, intensity modulated radiation therapy (IMRT) is the most common and has been adopted extensively over the past 15 years. This approach uses a machine that moves around the patient, shaping the beams and aiming them from several angles. In this way, the dose of radiation can be adjusted, directing higher doses to the places where there are cancerous cells.

Other high-tech options include three-dimensional conformal radiation therapy (3D-CRT), image-guided radiation therapy and intensity-modulated arc therapy. The shared element among these therapies is a careful mapping of the exact size, shape and location of the prostate gland and tumor using imaging tests, such as computed tomography and magnetic resonance imaging scans or X-rays. This information helps doctors determine precisely where to aim higher and lower doses of radiation for maximum effectiveness and minimum side effects. One recent comparative study showed that IMRT offers a disease-control advantage over 3D-CRT.

Stereotactic body radiation therapy (SBRT), which is often referred to by the names of the machines that administer the radiation, including CyberKnife, Gamma Knife and X-Knife, is a form of EBRT that delivers large doses of radiation to the prostate. Although the benefit of SBRT is that its entire treatment course is days and not several weeks, some studies have shown side effects to be worse with this form of therapy.

Another promising, yet controversial, form of EBRT is proton beam therapy, which aims protons (the heavy, positive parts of atoms) at tumors and releases their energy after traveling a specific distance, thereby causing less damage to tissues they pass through. Although research is inconclusive about whether proton therapy reduces sexual complications, one study did find that men aged 60 or younger treated with this modality experienced little sexual dysfunction; in comparison with the findings of other studies cited in the paper, the amount of dysfunction was comparable to that in populations treated with EBRT in general, but better than that in men treated with prostatectomy.

LDR AND HDR Brachytherapy Round Out Options

But other research has suggested limited advantages of proton therapy. A 2012 study comparing IMRT with proton therapy found that the newer therapy was no more effective in getting cancer in check. In addition, experts warn that proton beam therapy is not only more expensive than other forms of radiation (primarily due to costly machinery), but also might not be the best choice to treat prostate cancer because “critical structures, such as the rectum and urethra, will still get radiation no matter how perfect your particle is,” Yu explains.

Men with early stage, slow-growing tumors who would prefer fewer radiation treatments — or even just a single treatment &mdash; might be candidates for traditional brachytherapy, which places radioactive seeds directly, and permanently, into the prostate gland during a short surgical procedure. Radiation is then delivered slowly, for months, at a low-dose rate (LDR); eventually, the seeds lose their radioactivity.

HDR brachytherapy, a newer approach, is administered through temporary catheters, in which a high-activity source is placed for just minutes to deliver HDR radiation.

[Photo by Liza Bishop, VCU Massey Cancer Center]

Experts have placed some caveats on these treatments. Current guidelines from the NCCN recommend that brachytherapy as a standalone treatment be limited to low-risk or intermediate-risk cases. And for now, HDR is usually reserved for cancers that are progressing.

“Only when you need to deliver a big radiobiological punch — like when the disease is aggressive &mdash; do you go with HDR, typically not for early-stage prostate cancer,” says Dorin Todor, director of the brachytherapy program at Virginia Commonwealth University’s Massey Cancer Center in Richmond. “I think this is where brachytherapy combined with EBRT really shines.

These rules of thumb may be changing, though. According to Todor, “There are ongoing clinical trials trying to prove the equivalence between LDR treatments and one large fraction of HDR for early-stage prostate cancer. Both have the advantage of being a ‘one-stop shop,’ but during HDR, radiation is delivered for only 10 to 15 minutes, as opposed to months or years.”

Radiation can also be delivered directly to bone metastases via radiopharmaceuticals — drugs that contain radioactive elements &mdash; in patients with advanced prostate cancer. These drugs are a particularly useful approach when multiple areas of bone are involved. They can shrink painful lesions and improve quality of life with less exposure to normal tissue.

In May 2013, the U.S. Food and Drug Administration approved Xofigo (radium-223) to treat bone metastases, and a study published in July 2013 in 

 showed that those receiving Xofigo had improved median overall survival (14.9 months) compared with those on placebo (11.3 months).

Although there are many radiation treatment options, with the guidelines continuing to evolve, Levy is pleased that he chose HDR brachytherapy for his localized tumor.

“I didn’t want to take any chances,” he says. “Two days of treatment meant that I would likely not have any problems down the road.”

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New advances in radiation treatment enable higher doses with less damage to nearby tissue.

Scanning the Horizon: Advances in Radiation Treatment for Prostate Cancer

For localized disease, guidelines state that both surgery and radiation are acceptable forms of treatment, and men in this category make up a large number of cases. According to data from the Surveillance, Epidemiology, and End Results (SEER) program, localized disease accounts for about 80 percent of the nearly 221,000 new cases projected for 2015 in the United States.

“It’s mostly early-stage cancers in which radiation therapy is competing with surgery,” says Dorin Todor, director of the brachytherapy program at Virginia Commonwealth University’s Massey Cancer Center in Richmond. “Surgery doesn’t make much sense for anything but early-stage prostate cancer, because if more than the prostate is involved, you’ll need some form of systemic approach.”

To help make a sound decision, patients should consider the following factors.

Younger patients can better tolerate the general anesthesia that’s used in the vast majority of surgical cases, but new minimally invasive techniques (such as robot-assisted surgery) have made surgery a broader option, says James B. Yu, assistant professor of therapeutic radiology at Yale University School of Medicine in New Haven, Conn.

 Insurance coverage varies, but external beam radiation therapy of any type might be more expensive than surgery, according to a 2013 study in the British Journal of Urology International. Researchers found that the costs ranged from about $20,000 for a robot-assisted prostatectomy for low-risk cancer to approximately $50,000 for combined radiation therapy for high-risk cancer. Brachytherapy, however, may be cheaper than surgery. Patients should always discuss the cost of treatment with their health care providers.

 Any side effects from surgery — even the nerve-sparing type &mdash; tend to show up immediately, whereas radiation takes time to produce some of the same changes, experts say. (Which side effects occur and their frequencies vary from patient to patient, regardless of the choice.) For example, about half the men who had normal erections prior to EBRT became impotent within five years, and about one-third of the men who received brachytherapy experienced incontinence.

“We’ve made great strides over the past couple of decades, and prostate cancer remains a very curable disease for the most part,” Yu says. “That’s why we’re focusing so much on side effects and cost. In a way, focusing on these subtle questions is a good problem to have, since so many of these men go on to live such good, long lives.”

Whether to opt for surgery or radiation to treat localized prostate cancer depends mainly on the stage and grade of disease.

Surgery or Radiation for Prostate Cancer: What Determines the Choice?

In 2010, researchers estimated there were more than 1.5 million cancer survivors in the United States parenting children under age 18, so when Christine Egan was diagnosed with stage 2 breast cancer in 2011, she was well aware that hers wasn’t the only family with young children dealing with a cancer diagnosis. But the Bayport, N.Y. mom wanted to make sure her three children—who were 9, 11 and 13 years old when she was diagnosed&mdash;also understood they were far from alone.

Egan enlisted her kids’ help in creating a series of sticky notes with handwritten inspirational messages that she affixed to the dressing room mirror where she underwent 33 radiation treatments. With phrases such as, “Don’t look back—you’re not going that way,” and “Every day may not be great, but there’s something great in every day,” the gesture was designed to boost the spirits of fellow patients. Egan hoped it would also offer her own kids a valuable coping mechanism during a trying time.

“This showed them that this experience was way bigger than just us and made them understand how we can impact someone else,” Egan says.

Honesty, consistency and creativity are vital for children in adjusting to a parent’s cancer survivorship, experts say. Several tried-and-true tactics include:

 Parents should call cancer by its name and tell children what they’re doing to treat the illness, as well as expected side effects. They should make sure kids understand they did not cause their parent’s cancer and that it’s not contagious, says Meredith Cooper, executive director and co-founder of Wonders & Worries, an Austin, Texas-based nonprofit that supports children through parental illness.

 “Children thrive when they know their world is predictable,” Cooper says, adding that they need reassurance they’ll be cared for no matter what. “Keeping routines as normal as possible enhances their sense of security. Likewise, when the routine needs to change—either expectedly or unexpectedly&mdash; having the child know the new plan is very important.”

 Kids can draw pictures, keep journals or even make bracelets with bead colors representing their different emotions about a loved one. “We find expressive art activities one of the best ways to help children express their feelings,” says Sue Heiney, co-director of the Cancer Survivorship Center at the University of South Carolina College of Nursing in Columbia, S.C.

One parent should try to spend at least 15 minutes each day focusing solely on each child in the family, Heiney says. “Talk to them about school, read a book . . . you don’t need huge amounts of time,” she adds. “Just some quality time so the child knows ‘My mother or father hasn’t forgotten me.’”

Consistency, truthfulness and age-appropriate conversations are vital for children in adjusting to a parent's cancer survivorship.

Helping Kids Cope Requires Honesty, Creativity

A few minutes after learning she had breast cancer in 2011, Christine Egan marched up to the makeshift third-floor classroom where she and her husband home-school their children, to share the news. While she didn’t yet know all the details of her stage 2 diagnosis—for which she later underwent a lumpectomy, chemotherapy and radiation&mdash;she did realize that she wanted to be honest about the entire process with her children, who were ages 13, 11 and 9 at the time.

“This was something so tremendous there was no way I could hide it from my kids,” says Egan, a 46-year-old certified health coach from Bayport, N.Y., who’s now cancer-free.

From the start, Christine Egan (second from right) was open about her breast cancer diagnosis with her family: husband Frank (center) and children Emily, Jack and Frank III (from left to right). Photo by Owen Kassimir.

As stunning as a cancer diagnosis may be for an individual, cancer is ultimately a family affair for the 14 percent of survivors who, like Egan, are living with children under 18 years old, according to National Cancer Institute estimates. These youngsters need their own form of healing from the emotional strain of a serious diagnosis, uncertainty about its course, and upended family routines. And just as issues remain for patients moving into survivorship, so too do they remain for their children.

Research indicates that children of all ages may face challenges adjusting to a cancer diagnosis, and an August 2014 study in the journal 

by Birgit Möller and colleagues noted that children of cancer patients are especially vulnerable to developing emotional and behavioral problems because of the disruption to the family that cancer brings. As a result, the study recommended identifying families most in need of psychosocial support and providing not only family-oriented services, but also child-centered services, focusing on family dysfunction to prevent mental health problems in the children.

“I think it’s important children are told as much as they can handle,” says Lynnette Wilhardt, a licensed clinical social worker and director of clinical services for Kids Konnected, a nonprofit organization based in Laguna Hills, Calif., that offers counseling, camps and other support to children whose parents have cancer. “I equate it to the ‘sex talk’—they’ll walk away when they’ve had enough.”

After addressing their immediate worries about how sick mom or dad (or aunt, grandparent or other family member raising them) is, and how the illness will affect their own lives, most children need regular assurances throughout treatment that everything medically possible is being done to deal with the malignancy, says Sue Heiney, a professor of nursing and co-director of the Cancer Survivorship Center at the University of South Carolina College of Nursing in Columbia, S.C. This information needs to be repeated as kids get older, if only because children can absorb more— possibly triggering heightened worries&mdash;as months and years pass.

[Carrie Corey: Parenting with Advanced Cancer]

Cancer in Our Family: Helping Children Cope with a Parent’s Illness

, published in 2013 by the American Cancer Society, the normal spectrum of kids’ possible reactions depends on their ages, but can include resisting naps and bedtimes, clinginess, inattentiveness and arguing more with siblings. More serious reactions that may require professional help, she says, include nightmares, bedwetting, lower grades in school and talking back to parents. A parent’s illness may present unique challenges for older children, including preteens and teenagers, whose worlds are broadening and who consider peers increasingly important. Teens may be resentful, angry and confused about changes in their family life but unable to express their feelings as they test out adult emotions and responsibilities.

With a record 14.5 million cancer survivors in the United States today—almost two-thirds of whom, according to the American Cancer Society, received their diagnosis more than five years ago&mdash;chances are good that most children know someone who has had the disease. But when cancer hits home, even the awareness that it’s increasingly beatable doesn’t inoculate kids from significant psychological effects.

Just as many cancer survivors discover that the end of treatment doesn’t spell the end of cancer’s impact on their lives, so too do their children. Finding a “new normal” can be challenging for all family members, especially for kids old enough to understand that sometimes cancer comes back.

Tailoring information to children’s ages—from simple to more complex, but always honest&mdash;remains the goal as a parent transitions from patient in treatment to survivor, Heiney says.

“Ideally, the cancer experience would be integrated into family life and would be a topic of discussion at various times, including (follow-up) surveillance such as a mammogram or colonoscopy,” she says. “The parent needs to avoid the cancer diagnosis being a family secret, but during survivorship it does not need to be a focus of life.”

Egan uses psychotherapy to manage her own fears of recurrence, an approach akin to parents donning their own oxygen masks on a plane before attending to their children. “If parents are OK, the kids are OK—that’s what we usually say,” explains Heiney, who agrees with other experts that counseling for children&mdash;which can include individual or family therapy&mdash;can be helpful, but isn’t a must unless they’re exhibiting unusual anxiety or other behavioral problems. On the other hand, support groups for children can help normalize the experience and decrease isolation the child may feel, she says. These groups are not intended as therapy, but to help the child cope.

"Tailoring information to children’s ages—from simple to more complex, but always honest&mdash;remains the goal as a parent transitions from patient in treatment to survivor." 

As Heiney recommends, Egan uses her periodic follow-up tests as a springboard for ongoing conversations with her children about her health. But she says they haven’t seemed anxious about what survivorship means or what the future may hold.

“They know cancer can come back, since people are always coming to me for advice when they’re diagnosed,” Egan says. “I think they buy into my message...that cancer sucks, but how can you deal with it? They don’t ask about recurrence... they see that I work on my health every single day.” Heiney contends that most children aren’t as worried about an eventual return of the cancer as they were initially about their parent dying. Still, bringing these fears to the surface instead of bottling them up is a skill like any other that parents can teach and nurture, she says.

Another way to broach survivorship is by participating as a family in an awareness event, such as National Cancer Survivors Day, where the parent’s story can be told, Heiney says.

“I would really impress that this is an opportunity for a family,” says Wilhardt, director of clinical services for Kids Konnected. “Embrace the fact that the whole family is going through this. Our instinct is to protect our kids, but we have to trust that they can handle this and, more importantly, they need to be given the respect to go through this with us.”

During treatment, family roles often realign as members assume new domestic or financial responsibilities to alleviate stress on the ill parent. Teens in particular may end up nursing the parent with cancer, “parenting” younger siblings, or taking on tasks such as house maintenance or meal prep—a shift that can provoke anger at cancer’s impact on their growing-up years. “If teens in the family are given additional responsibilities, we advocate trying to balance that with giving them additional privileges,” says Meredith Cooper, executive director and co-founder of Wonders & Worries, a nonprofit organization based in Austin, Texas, that supports children through serious parental illness. “So if they’re responsible for picking up siblings after school, for instance, maybe their curfew can be extended. This validates to them that they’re meeting those responsibilities well.”

But new burdens, both physical and psychological, can prove crushing in families already in crisis before cancer strikes, whether from divorce, addiction, abuse or financial strain. Numerous studies, including the one by Möller and co-authors that appeared in 

in August, have found that general family dysfunction is the strongest predictor of emotional and behavioral problems in children whose parents have cancer, not the cancer diagnosis itself.

> Children should be told about a parent’s cancer and given regular assurances that everything medically possible is being done to treat it.

> A parent’s cancer can mean a reshuffling of familial roles, which will require some emotional adjustment for both adults and children.

When a parent has cancer, survivorship becomes a family affair.

Maureen Salamon | Contributors

Scanning the Horizon: Advances in Radiation Treatment for Prostate Cancer

Surgery or Radiation for Prostate Cancer: What Determines the Choice?

Helping Kids Cope Requires Honesty, Creativity

Helping Children Heal

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