Pain can occur for a variety of reasons, many of which may be unrelated to cancer. Therefore, the cause of the pain needs to be accurately diagnosed to ensure that optimal treatment is selected. Generally, the situation should be analyzed with a five-step process:  

I. Query the Patient Specifically about Pain.

The way we perceive pain is strongly influenced by our psychological stage of mind. In a Bayer survey of 410 men with advanced prostate cancer, two-thirds were reported to be handling their pain by ignoring it! One would normally think that uncomfortable patients visiting a doctor’s office would spontaneously volunteer to their doctors that something is hurting. According to the Bayer survey, this assumption is often wrong. Unless men are specifically asked about whether they have any “aches” or “discomfort,” they may visit their doctor’s office and never mention that that they are in pain. Denial blocks access to a correct diagnosis and ultimately to finding a solution for the pain.  

II. Develop an Accurate Diagnosis. Is the Pain Cancer-Related?

Cancer pain from prostate cancer is characteristically located in the bone and tends to have the characteristics of being continuous and progressive. Pain in the joints, pain that comes and goes and transient stabbing or shooting pains are not usually from cancer. While cancer can spread to the bones, it is does not spread to the joints. Joint pain comes from many things including the arthritis. Arthritis can simply be due to aging. It can also come from hormone therapy. Bone pain that is suspected to be coming from metastatic cancer should be confirmed by checking a bone scan. A diagnosis of cancer pain is confirmed when the pain that the patient describes is in the same location as reported on the scan.  

III. If the Pain is Coming from Cancer, First Start a New Cancer Treatment. 

The best quality of life and the best survival rate comes by controlling the cancer (and its pain) with effective therapy. A reduction in cancer pain generally occurs soon after starting a new therapy and is a reliable sign that the therapy is working. While waiting for the anticancer medicine to kick in, which may take days to a few weeks, pain medicines are used. 

IV. Utilize a Stepwise Escalation of Pain and Other Supportive Medications.

Milder analgesics are usually initiated first. Nonnarcotic medications such as Aleve, Motrin, Advil, Tylenol and Celebrex are effective and often underutilized. Generally, with pain medications, treatment will be much more effective if the pain is kept suppressed with continues usage of the medication. Controlling recurring pain after the medication wears off is more difficult and will require a higher dose of medication than if the pain had been kept under control by staying on a regular schedule. All the pain medications are different and have different durations of action. Talk with your doctor about what side effects might occur.  Also discuss how long the medication you are taking is expected to last in your system so you will know how often you need to do repeat dosing. 

If the milder analgesics are ineffective, escalating doses of a short-acting narcotic are usually the next step. Once adequate pain control is achieved, a long-acting narcotic that only requires once or twice a day dosing can be substituted. When there is an urgent need for pain relief, cortisone medications in combination with the nonnarcotic and narcotic medications are helpful. Anti-anxiety medications or antidepressants can also be beneficial.  

V. Consider Radiation and Nerve Blocks.  

If the pain is in one area, a beam of radiation can be very effective. If there are multiple painful areas, injected radiation, called Xofigo, is another option to consider. Neuroleptic pain, due to a tumor pushing or pinching a nerve, may be controllable with a nerve block. 

With good communication and proper medical management, pain can almost always be effectively controlled. Proper management relies on a diagnostic and therapeutic sequence that accurately determines the source of the pain and utilizes medications in a stepwise and escalating fashion. If these basic measures listed here are unsuccessful, consultation with a pain specialist is the logical next step.


ABOUT THE AUTHOR

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Mark Scholz, MD is the Executive Director of the Prostate Cancer Research Institute. He is also the Medical Director of Prostate Oncology Specialists Inc. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is co-author of Invasion of the Prostate Snatchers.  He has authored over 20 scientific publications related to the treatment of prostate cancer.

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