About Your Image-Guided, Intensity-Modulated Radiation Therapy (IG-IMRT) to Your Prostate

This information will help you get ready for image-guided, intensity-modulated radiation therapy (IG-IMRT) to your prostate. It will help you know what to expect and how to care for yourself before, during, and after your radiation therapy.

Read through this resource at least once before you start radiation therapy. After that, use it as a reference in the days leading up to your treatments to help you get ready. Bring this resource to all your appointments with your radiation therapy team. You and your radiation therapy team will refer to it throughout your care.

About IG-IMRT

Radiation therapy uses high-energy radiation to treat cancer. It works by damaging the cancer cells and making it hard for them to multiply. Your body can then naturally get rid of the damaged cancer cells. Radiation therapy also affects normal cells, but they can repair themselves in a way that cancer cells can’t.

IG-IMRT is a type of targeted external beam radiation therapy. During external beam radiation, a treatment machine will aim beams of radiation directly to the tumor. The beam passes through your body and destroys cancer cells in its path. You will not see or feel the radiation.

IG-IMRT uses images that are taken in real time to mold the radiation beams to your tumor. Because the normal movements of your body can cause your prostate to move slightly during or between treatments, your healthcare team will insert markers into your prostate. These allow your doctors to have a better view of your prostate during your treatments. The radiation machine moves around your body so the beams can be aimed from many angles. In addition, the shape of the beam changes while the treatment is being given. This changes the intensity of the beam, which allows your doctor to target your tumor and avoid your healthy tissue.

You may receive radiation therapy either alone or in combination with hormone therapy. Depending on the stage of the cancer, your doctor may recommend hormonal therapy. The goal of hormonal therapy is to shrink the prostate gland and stop the cancer from growing to help make the treatment more effective. To learn more, read Hormonal Therapy During Radiation Therapy to Your Prostate .

Your role on your radiation therapy team

Your radiation therapy care team will work together to care for you. You’re a part of that team, and your role includes:

• Getting to your appointments on time.
• Asking questions and talking about your concerns.
• Telling someone on your care team when you have side effects.
• Telling someone on your care team if you’re in pain.
• Caring for yourself at home by:
  • Quitting smoking if you smoke. MSK has specialists who can help you quit smoking. For more information about our Tobacco Treatment Program, call 212-610-0507. You can also ask your nurse about the program.
  • Drinking liquids based on your care team’s instructions.
  • Eating the foods your care team suggests.
  • Staying around the same weight.

Marker placement

Before you start IG-IMRT, you’ll have 3 fiducial (fih-DOO-shul) markers placed in your prostate. Fiducial markers are tiny objects made of gold. They help a computed tomography (CT) scanner identify your prostate gland and the tumor.

Your care team in the Urology Service will place your fiducial markers in your prostate. You’ll have them placed at least 5 days before you start your simulation. A nurse will call you to review the procedure with you. You’ll also get a resource called About Your Prostate Fiducial Marker Placement that has more information about the procedure.

Simulation

Before you begin your treatment, you’ll have a treatment planning procedure called a simulation. This is done to make sure that:

• Your treatment site is mapped out.
• You get the right dose of radiation.
• The amount of radiation that gets to your nearby tissues is as small as possible.

During your simulation, you’ll have imaging performed (see below) and your skin will be marked with little tattoo dots. These marks help your therapists to line you up correctly for your treatment.

Take devices off your skin

You may wear certain devices on your skin. Before your simulation or treatment, device makers recommend you take off your:

• Continuous glucose monitor (CGM)
• Insulin pump

If you use one of these, ask your radiation oncologist if you need to take it off. If you do, make sure to bring an extra device to put on after your simulation or treatment.

You may not be sure how to manage your glucose while your device is off. If so, before your appointment, talk with the healthcare provider who manages your diabetes care.

Bowel preparation

You’ll need to clear extra stool (poop) from your body for your simulation and radiation treatments. This is called bowel preparation. Bowel preparation helps lower your risk of side effects by limiting the amount of radiation that gets to nearby healthy tissues.

Supplies

You’ll need these supplies:

• Methylcellulose dissolvable fiber supplement, such as Citrucel® powder.
• Simethicone 125 milligram (mg) tablets, such as Gas-x® Extra Strength.
• A saline enema, such as a Fleet® saline enema.

You can buy these at your local pharmacy without a prescription.

3 days before your simulation

• Mix 1 rounded tablespoon of methylcellulose powder in 8 ounces of water and drink. You must do this every day until the day of your simulation.

The day of your simulation

• Use a saline enema 3 hours before your simulation. Follow the instructions on the box.
• Take your usual medications.
• During the simulation, you’ll stay in one position for a long time. If you think this will be hard for you, take acetaminophen (Tylenol®) or your usual pain medication 1 hour before your appointment.

Diet guidelines to minimize bloating

During your radiation therapy, gas or fluid can build up in your bowels (intestines) and cause bloating. When your bowels are bloated, they can expand into the treatment area and be exposed to radiation. This can cause side effects or make your side effects worse.

Follow the guidelines below to lower your risk of bloating during radiation therapy. It’s best to start 2 to 3 days before your simulation and continue until you have finished your radiation therapy.

• Chew your food well.
• Limit or avoid foods that release gas when they’re digested, such as:
  • Asparagus
  • Beer
  • Broccoli
  • Brussels sprouts
  • Cabbage
  • Cauliflower
  • Corn
  • Dried beans, peas, and other legumes
  • Garlic
  • Leeks
  • Milk and other dairy products with lactose (if you’re lactose-intolerant)
  • Onions
  • Prunes
• Avoid carbonated (fizzy) drinks, such as sodas and sparkling waters.
• Limit or avoid sugar alcohols, such as xylitol, sorbitol, and mannitol. Sugar-free foods often have sugar alcohols. If you’re not sure, check the ingredients list on the food’s Nutrition Facts label.
• Choose cooked vegetables instead of raw vegetables.
• Depending on your symptoms, your healthcare provider may tell you to eat more or less fiber. Follow their instructions.

If you’re bloated, keeping a food journal can help you see which foods may be causing it. Write down your foods and drinks, the time you have them, and the time you start feeling bloated. Bring your food journal to your appointments. Your healthcare provider will use it to help you manage the bloating.

A clinical dietitian-nutritionist can talk with you about your diet and help you design an eating plan that meets your needs. If you’d like to meet with a clinical dietitian-nutritionist, ask your radiation oncologist or nurse for a referral.

What to expect

A member of your radiation therapy team will check you in. You’ll be asked to state and spell your full name and date of birth many times. This is for your safety and part of our standard identification process. People with the same or similar name may be having care on the same day as you.

When you arrive for your appointment, your radiation therapist will greet you and take a photograph of your face. This picture will be used to identify you throughout your treatment.

Your therapist will review and explain the simulation to you. If you haven’t already signed a consent form, your radiation oncologist will review everything with you, and ask for your signature.

During your simulation

Your radiation therapists may also ask you to drink 8 to 12 ounces of water before the simulation starts. This is to fill your bladder. Having a comfortably full bladder and empty bowel during your treatments will help limit the amount of radiation that gets to your healthy tissue. This helps lower your risk of side effects.

When it’s time for your simulation, you’ll change into a hospital gown. Keep your shoes on.

Your therapists will help you lie down on your back on the table and make every effort to ensure your comfort and privacy.

Although the table will have a sheet on it, it’s hard and has no cushion. If you haven’t taken pain medication and think you may need it, tell your therapists before your simulation begins. Also, the room is usually cool. If you feel uncomfortable at any time, let your therapists know.

Throughout your simulation, you’ll feel the table move into different positions. The lights in the room will be turned on and off and you’ll see red or green laser lights on each wall. Your radiation therapists use these laser lights as a guide when they position you on the table. Don’t look directly into the laser. If you do, it may damage your eyes.

Don’t move once your simulation starts. It’s important that you stay in the same position. If you’re uncomfortable or need help, tell your radiation therapists.

Your simulation will take about 2 hours but can be shorter or longer depending on your specific treatment. Your radiation therapists will walk in and out of the room during your simulation, but there will always be someone who can see and hear you. You’ll hear your radiation therapists talking to each other as they work. They’ll also talk to you about what they’re doing. Your therapists can play music for you to help pass the time.

Positioning (mold)

While you are lying on the table, a mold will be made of your lower body. Your therapists will place a warm sheet of plastic over your abdomen, hips, and thigh areas (pelvic area). They’ll press on it to shape it to fit around your body. As the mold cools, it hardens. This procedure takes about 15 minutes.

During your simulation, and every day of your treatment, this mold will be placed over you. It will be attached to the table on which you are lying. It helps ensure that you are in the correct position each time you receive your treatment.

X-rays and CT scan

While you are lying in your position, you’ll get x-rays of the area to be treated (see Figure 1). If you had markers placed, they’ll be seen on these images. These may be done on an x-ray machine called a simulator or on a CT scan machine. These scans are used only to map your treatment. They are not used for diagnosis or to find tumors. If you need other imaging, your nurse will explain this to you.

It will take about 45 minutes to get your scan. During the scan, you’ll hear the machine turn on and off. Even if the noise seems loud, your therapists will be able to hear you if you speak with them.

Magnetic resonance imaging (MRI)

Your doctor may order an MRI to be done on the day of simulation. You’ll lie on a flat table with the mold made during simulation in place over your pelvis.

Skin markings (tattoos)

Your therapists will draw on your skin in the area being treated with a felt marker and make about 4 to 6 permanent skin markings called tattoos. Your therapists will use a sterile needle and a drop of ink to make the tattoo. The sensation of getting one feels like a pinprick. The tattoo marks are no bigger than the head of a pin. The felt markings can be washed off after your simulation. The tattoos are permanent and will not wash off. If you are concerned about receiving tattoos as part of your radiation treatment, talk with your doctor.

After the tattoos are made, your therapists will take several photographs of you in your simulation position. The photographs and tattoo marks will be used to position you correctly on the table each day of your treatment.

After your simulation

At the end of your simulation, we’ll give you your treatment appointments.

Scheduling your treatment

Radiation treatments may be given Monday through Friday. Your treatment will be given for about 5 weeks. You’ll be in the department about 60 to 90 minutes each day.

You must come in every day that you are scheduled for your treatment. Treatment may not be as effective if you skip or miss appointments. If you for some reason you can’t come in for treatment, you must call your radiation oncologist’s office to let your team know. If you need to change your schedule for any reason, speak with your radiation therapist.

Treatment planning

During the time between your simulation and your first treatment, your radiation oncologist will work with a team to plan your treatment. They’ll use the images taken during your simulation to plan the angles and shapes of the radiation beams. They’ll also determine the dose of radiation that you’ll receive. These details are carefully planned and checked. This may take up to 2 weeks.

Your treatment plan is based on your body shape and size at the time of your simulation. Try to keep your weight within 5 to 10 pounds of your usual weight to ensure that the plan remains accurate.

Vitamins and dietary supplements

Many people ask about taking vitamins during treatment. You may take a daily multivitamin, if you wish. Don’t take more than the recommended daily allowance of any vitamin. Don’t take any other vitamins or any supplements without talking to your doctor. This includes both nutritional and herbal supplements.

Set-up procedure

Your first treatment will include a set up procedure. It may take slightly longer than your other treatments. When you come for your first treatment, we will ask you to empty your bladder and then drink 8 to 12 ounces (1 to 1.5 cups) of water. Then you will be shown to the dressing room and asked to change into a gown. Your therapists will bring you to the room where you’ll receive your treatment each day. They’ll position you on the treatment table. You’ll lie exactly as you did on the day of your simulation.

Special images (x-rays or CT scans) called beam films will be taken to make sure that your position and the area being treated are correct. If you had markers placed, these can be seen on the x-rays and will help us position you correctly. The beam films will be repeated throughout your treatment. They are not used to see how your tumor is responding to the treatment.

During your treatment

Your radiation therapy team will tell you if you need to keep drinking the methylcellulose and water mixture during your treatment. They will also tell if you if you need to keep taking 2 (125 mg) tablets of simethicone the night before and morning of each treatment.

After you check in at the reception desk, have a seat in the waiting room. When they are ready for you, your radiation therapists will ask you to undress from the waist down and change into a gown. You should keep your shoes on during the treatment.

Some people will need to have a full bladder for their treatment. If your doctor tells you this is needed, your therapist will tell you how much water to drink and when to begin drinking it.

Your radiation therapists will bring you into the treatment room and help you lie on the table (see Figure 2). You’ll be positioned exactly how you were during your set-up procedure.

Once you are positioned correctly, your therapists will leave the room, close the door, and start your treatment. They will take x-rays to make sure you’re in the right position. Your radiation oncologist may use these to make adjustments to your treatment.

The beams of radiation are shaped by many small leaves of tungsten (a type of metal) sitting at the opening of the treatment machine. The computer will move the leaves into different positions to block the radiation. The radiation that passes through the opening between the leaves creates the beam that is directed toward your body. The leaves move while the beam is passing through. This varies the intensity of the beam and ensures that you receive the exact doses prescribed by your radiation oncologist.

You will not see or feel the radiation, although you may hear the machine as it moves around you and is turned on and off. You’ll be in the treatment room for 15 to 45 minutes, depending on your treatment plan. Most of this time will be spent putting you in the correct position. The actual treatment only takes a few minutes.

Although you are alone during your treatment, your therapists can see you on a monitor and hear you through an intercom at all times. Your radiation therapist will make sure that you are comfortable during the treatment. Breathe normally during your treatment, but don’t move. However, if you are uncomfortable and need help, speak to your radiation therapists. They can turn off the machine and come in to see you at any time, if necessary.

Neither you, nor your clothes will become radioactive during or after treatment. It’s safe for you to be around other people.

Weekly visits during treatment (status checks)

Your radiation oncologist and radiation nurse will see you each week to evaluate your response to treatment, ask about any side effects you may be having, and answer your questions. This visit will be before or after your treatments each _____________. You should plan on being in the department about 1 extra hour on those days.

If you need to speak with your radiation oncologist or radiation nurse any time between these weekly visits, call your radiation oncologist’s office or ask the support staff or your therapists to contact them when you come in for treatment.

Side effects

Some people develop side effects from radiation therapy. The type and severity of side effects varies from person to person. Below are the most common side effects of radiation therapy to the prostate. You may have all, some, or none of these.

Urinary changes

Your prostate gland may swell and the lining of your bladder may become irritated during treatment. About 2 weeks after starting treatment you may have:

• Difficulty starting to urinate.
• Increased frequency of urination.
• Frequent need to urinate at night.
• Sudden urge to urinate.
• Burning with urination.

Below are guidelines to help you manage these symptoms.

• Drink when you’re thirsty.
• Start drinking less 2 hours before bedtime.
• Avoid foods and beverages that may irritate the bladder. Examples are:
  • Caffeine (such as tea, coffee, soda)
  • Alcohol
  • Acidic foods, such as citrus fruits and juices and carbonated (fizzy) drinks.
  • Spicy foods, especially if you have burning with urination.
• Tell your doctor or nurse know if you have any urinary changes. They can recommend a change in your diet or prescribe medication that can help.

Bowel changes

The wall of the rectum may become irritated. About 2 weeks after starting treatment you may have:

• More frequent and softer bowel movements.
• Worsening of hemorrhoidal symptoms.
• Rectal discomfort.
• Mucous discharge.
• A small amount of rectal bleeding.
• Increased gas.
• An increased urge to have a bowel movement.

These symptoms are usually mild. When you begin treatment, there are no restrictions on your diet. If you develop any of these symptoms, talk with your nurse about how you can change your diet to reduce them. If you are still uncomfortable, let your doctor or nurse know. They can prescribe medication to help.

Sexual health

You might have concerns about how cancer and your treatment can affect your sexuality. You aren’t radioactive. You can’t pass radiation to anyone else, so it’s safe to be in close contact with other people.

You can be sexually active during radiation treatment, unless your radiation oncologist gives you other instructions. However, if you or your partner are able to have children, you must use birth control (contraception) to prevent pregnancy during your treatment.

See the resource Sex and Your Cancer Treatment for additional information. The American Cancer Society also has resources about sexual health issues during cancer treatment. The one for men is called Sex and the Man with Cancer. You can search for it at www.cancer.org or call 800-227-2345 for a copy.

Some men have a burning sensation during ejaculation. In most men, it goes away 1 to 2 months after treatment is done.

Some men develop sexual changes after treatment is done. You may have:

• Erectile dysfunction (difficulty or inability to have or maintain an erection).
• A change in the sensation of orgasm.
• A change in the amount or consistency of your ejaculation.

These sexual changes may occur many months or even years after treatment. There are treatments for erectile dysfunction. We can give you a referral to a doctor who treats these problems.

Memorial Sloan Kettering (MSK) has a Male Sexual and Reproductive Medicine Program to help people address the impact of their disease and treatment on sexual health. You can meet with a specialist before, during, or after your treatment. We can give you a referral, or you can call 646-888-6024 for an appointment.

Reproductive health

Exposure of your testes to radiation may affect sperm production and your ability to have children in the future. If you want to preserve your ability to have biological children, we recommend banking your sperm before treatment begins. This involves collecting, freezing, and storing your sperm. Sperm can be stored for as long as you want, even for many years. See the resources Sperm Banking and Building Your Family After Cancer Treatment: For People Born With Testicles for more information.

If you are sexually active with a woman of reproductive age, it’s important to use birth control during treatment and for 1 year after treatment is completed. This is to make sure you don’t conceive with sperm that may have been damaged by exposure to radiation, which could possibly result in birth defects.

Fatigue

Fatigue is a feeling of being tired or weak, not wanting to do things, not being able to concentrate, or feeling slowed down. You may develop fatigue after 2 to 3 weeks of treatment, and it can range from mild to severe. Fatigue may last 6 weeks to 12 months after your treatment ends.

There are a lot of reasons why you may develop fatigue during treatment, including:

• The effects of radiation on your body.
• Traveling to and from treatment.
• Not having enough restful sleep at night.
• Not eating enough protein and calories.
• Having pain or other symptoms.
• Feeling anxious or depressed.
• Certain medications.

You may find that your fatigue is worse at certain times of the day. Below are suggestions to help you manage your fatigue.

Ways to manage fatigue

• If you are working and are feeling well, continue to do so. However, working less may help increase your energy.
• Plan your daily activities. Pick those things that are necessary and most important to you and do them when you have the most energy. For example, you may go to work but not do housework, or watch your children’s sports event but not go out to dinner.
• Plan time to rest or take short naps (10 to 15 minutes) during the day, especially when you feel more tired. If you do nap, try to sleep for less than 1 hour at a time.
• Try to sleep at least 8 hours every night. This may be more sleep than you needed before you started radiation therapy. You may also find it helpful to go to sleep earlier at night and get up later in the morning. One way to sleep better at night is to be active during the day. For example, if you are able to exercise, you could go for a walk or do yoga. Another way to sleep better at night is to relax before going to bed. You might read a book, work on a jigsaw puzzle, listen to music, or do calming hobbies.
• Ask family and friends to help you with things like shopping, cooking, and cleaning. Check with your insurance company to see if they cover home care services.
• Some people have more energy when they exercise. Ask your doctor if you can do light exercise, such as walking, stretching, or yoga. Avoid riding a bicycle during treatment as this may put pressure on your prostate area, but you may use an inclined bike.
• Eat foods that are high in protein and calories. Ask your nurse for the resource Eating Well During Your Cancer Treatment .
• Other symptoms, such as pain, nausea, diarrhea, difficulty sleeping, or feeling depressed or anxious, can increase your fatigue. Ask your doctor or nurse for help with any other symptoms you may have.

Emotional health

Anxious or nervous Afraid Alone Angry

Depressed Helpless Frustrated

Numb Uncertain Worried

You might also worry about telling your employer you have cancer or about paying your medical bills. You may worry about how your family relationships may change, or that the cancer will come back. You may worry about how cancer treatment will affect your body, or if you will still be sexually attractive.

It’s normal and OK to worry about all these things. All these kinds of feelings are normal when you or someone you love has a serious illness. We’re here to support you.

Ways to cope with your feelings

Talk with others. When people try to protect each other by hiding their feelings, they can feel very alone. Talking can help the people around you know what you’re thinking. It might help to talk about your feelings with someone you trust. For example, you can talk with your spouse or partner, close friend, or family member. You can also talk with a chaplain (spiritual advisor), nurse, social worker, or psychologist.

Join a support group. Meeting other people with cancer will give you a chance to talk about your feelings and learn from others. You can learn how other people cope with their cancer and treatment and be reminded you are not alone.

We know that all cancer diagnoses and people with cancer are not the same. We offer support groups for people who share similar diagnoses or identities. For example, you can join a support group for people with breast cancer or for LGBTQ+ people with cancer. To learn about MSK’s support groups, visit www.msk.org/vp. You can also talk with your radiation oncologist, nurse, or social worker.

Try relaxation and meditation. These kinds of activities can help you feel relaxed and calm. You might try thinking of yourself in a favorite place. While you do, breathe slowly. Pay attention to each breath or listen to soothing music or sounds. For some people, praying is another way of meditation. Visit www.msk.org/meditations to find guided meditations lead by our Integrative Medicine providers.

Exercise. Many people find that light movement, such as walking, biking, yoga, or water aerobics, helps them feel better. Talk with your healthcare provider about types of exercise you can do.

We all have our own way of dealing with difficult situations. Often, we use whatever has worked for us in the past. But sometimes this is not enough. We encourage you to talk with your doctor, nurse, or social worker about your concerns.

After your treatment

At the end of treatment, you’ll be told how often to see your doctors for follow-up appointments. Please be sure to keep your follow-up appointments with your radiation oncologist. He or she will evaluate your response to treatment. You may have blood tests, x-rays, scans, and biopsy during these visits. Before coming, write down your questions and concerns. Bring this and a list of all your medications with you. You can also call your doctor or nurse at any time after your treatment is completed, or in between follow-up appointments, if you have any questions or concerns.

Late side effects

Keeping your follow-up appointments will help us identify any late effects of treatment.

Radiation can cause permanent side effects in the bladder and bowel. Many people are not aware of these changes and don’t have any symptoms. However, some people will develop symptoms 4 months or more after treatment. These may be similar to the ones you had during treatment. However, there’s a very small chance that you may develop others. These are very rare but may include:

• Narrowing of the opening of the bladder
• Loss of urinary control
• Blood in the urine
• Rectal bleeding

These symptoms may come and go over time. They can also be persistent and chronic. Even if you don’t develop any late side effects, remember that the tissues in your bladder and rectum have been affected by the treatment. Call your radiation oncologist if you:

• Have any new urinary, bladder, or bowel symptoms.
• Need to have a colonoscopy. Avoid having a colonoscopy for the first year after treatment.
• Need any type of rectal procedure.

If you took vitamins before your treatment, you can re-start taking them 1 month after your treatment is done. If you would like to speak with a dietitian about your diet or supplements, please ask your nurse to arrange this.

Resources

MSK support services

Counseling Center
www.msk.org/counseling
646-888-0200
Many people find that counseling helps them. Our counseling center offers counseling for individuals, couples, families, and groups. We can also prescribe medications to help if you feel anxious or depressed. To make an appointment, ask your healthcare provider for a referral or call the number above.

Integrative Medicine Service
www.msk.org/integrativemedicine
Our Integrative Medicine Service offers many services to complement (go along with) traditional medical care, including music therapy, mind/body therapies, dance and movement therapy, yoga, and touch therapy. To schedule an appointment for these services, call 646-449-1010.

You can also schedule a consultation with a healthcare provider in the Integrative Medicine Service. They will work with you to come up with a plan for creating a healthy lifestyle and managing side effects. To make an appointment, call 646-608-8550.

Male Sexual and Reproductive Medicine Program
646-888-6024
Cancer and cancer treatments can affect your sexual health, fertility, or both. Our Male Sexual and Reproductive Medicine Program can help with sexual health problems, such as erectile dysfunction (ED). We can help before, during, or after your treatment. Call for more information or to make an appointment.

Nutrition Services
www.msk.org/nutrition
212-639-7312
Our Nutrition Service offers nutritional counseling with one of our clinical dietitian-nutritionists. Your clinical dietitian-nutritionist will talk with you about your eating habits. They can also give advice on what to eat during and after treatment. To make an appointment, ask a member of your care team for a referral or call the number above.

Contact information

If you have questions or concerns, talk with a member of your radiation therapy team. You can reach them Monday through Friday from 9 a.m. to 5 p.m.

After 5 p.m., during the weekend, and on holidays, call 212-639-2000. Ask for the radiation oncologist on call.

Questions to ask your radiation oncologist

Before your appointment, it’s helpful to write down questions you want to ask. Examples are listed below. Write down the answers during your appointment so you can review them later.

What kind of radiation therapy will I get?

How many radiation treatments will I get?

What side effects should I expect during my radiation therapy?

Will these side effects go away after I finish my radiation therapy?

What kind of late side effects should I expect after my radiation therapy?