Managing Prostate Cancer Pain

Some patients with advanced prostate cancer may experience associated pain, especially if the prostate cancer has metastasized to the bone, or become resistant to treatment. However, most patients with localized prostate cancer, or even biochemically recurrent prostate cancer, do not have pain from their cancer.

Pain is likely to influence mood and introduce fatigue and anxious or depressive symptoms as well. While a treatment plan can help manage your pain, there still remain chances for breakthrough pain — times where your pain may flare up worse than usual, making it difficult for you to go about your day.

Before talking to your doctor about your pain, you may wish to consider the following:

• What does the pain feel like? (e.g. dull, aching or sharp and stabbing)
• Where is it located?
• How long does it last?
• What helps or worsens the pain?
• Does touching your skin hurt?
• Is there any numbness or tingling?

Not all pain is the same, and some types are described as below:

• Nociceptive
  • Deep, dull, aching, constant, and worsening with time
  • May be due to tissue damage or inflammation
• Neuropathic
  • Sharp shooting, burning, stabbing
  • Numbness or tingling may be felt together with pain
  • May be due to nerve damage
  • Less likely to respond to opioids or non-steroidal anti-inflammatory drugs (NSAIDs)
• Movement pain
  • Usually fine at rest, but becomes excruciating when moving
  • May be due to bone damage

Palliative care consists of a dedicated team of specialists in managing the physical and emotional aspects of cancer or other serious illnesses. Importantly, palliative care is not the same as hospice care; palliative care can go hand-in-hand with anti-cancer treatments, whereas hospice care is used to focus 100% on treating symptoms when anti-cancer treatments are no longer more helpful than hurtful.

It is often very helpful to have a palliative care team on board when going through treatment for advanced cancer so that you have a team entirely focused on how your body and mind are doing, alongside your oncologist who remains responsible for the anti-cancer treatments.

Drug-based pain relief treatments include:

• Non-opioids
  • Aspirin, ibuprofen, naproxen, or other NSAIDs
  • Acetaminophen (also known as Tylenol)
  • Duloxetine or gabapentin (best for nerve-related pain)
• Weak opioids
  • Tramadol or codeine
• Opioids
  • Morphine, hydromorphone or others

Comparing your options

Opioids may be short-acting for breakthrough pain or long-acting to provide continuous pain relief. For those requiring frequent use of short-acting opioids, a long-acting opioid may be added to reduce the need for breakthrough pain relief. Notably, opioid treatment includes the following common side effects: constipation, brain fog and nausea. You may be prescribed laxatives to avoid issues with constipation.

NSAIDs are sometimes considered “weaker” than opioids, but they can actually be equally or more effective for bone pain and at minimum should be included alongside opioids. They are often most helpful taking on a standing basis rather than as-needed.

For patients who cannot take NSAIDs due to kidney problems, stomach irritation, or being on blood thinners, low doses of steroids can also be used for anti-inflammatory effect, although ideally for short periods of time given that long-term steroid usage can have its own side effects. Ultimately, a combination approach using different types of medications together may be most effective.

Are opioids bad for cancer pain?

In the US, fears of the opioid crisis may make you feel like you should take on more pain than you can. However, if you’ve considered diminishing your pain to your doctor in order to avoid taking opioids, remember that this only worsens your suffering unnecessarily.

In 2016, the American Society of Clinical Oncology released a statement to protect access to opioid treatment from being limited for cancer patients. Rest assured that your dosage will be carefully measured to only provide enough to mitigate your pain sufficiently, while minimizing other side effects.

Unfortunately, for at least 15% of patients, the treatments above may not be enough. Nonetheless, alternatives remain, including:

• Radiotherapy for pain relief

This can be particularly helpful for advanced prostate cancer. Targeted radiation can help with pain from a specific bone metastasis. Radium 223 is an infusion form of radiation for patients with pain from multiple bone metastases. It is able to specifically target cancer cells in the bone, minimizing detrimental effects to nearby healthy tissue. Such treatments aim to improve your quality of life and reduce bone pain.

• Bone strengtheners

Another treatment that is frequently used for advanced prostate cancer, bone strengtheners can help prevent bone pain and/or broken bones related to cancer. These are often used for castration resistant prostate cancer.

These can include: bisphosphonates and denosumab. While denosumab delays the start of bone pain for a few months longer than bisphosphonates, it remains much more expensive.

• Electrical nerve stimulation

While dealing with pain stemming from nerve damage can be difficult, some relief can be sought from electrical stimulation of the nerves. This treatment aims to jolt your nerves, to remind them they no longer have to send out “danger” signals of pain.

• Nerve blocks

Nerve blocks allow for the specific and direct delivery of anesthetic medication to your nerves, similar to how dentists prepare you for teeth extractions. If they are effective for you, you will be able to see the effects soon after the injection. These can be very helpful for deep pain related to metastases in organs or lymph nodes (e.g. pelvic pain related to tumors in the pelvis).

• Topical drugs

Other solutions include creams, ointments or patches which can be applied to the skin for pain relief. Examples include menthol cream and lidocaine patches.

Generally, prostate cancer pain can be managed, but it will still need careful balancing to optimize pain relief while minimizing the side effects that come with more medication. On the psychological side, a structured mindfulness practice has also shown improvements in mitigating the side effects of fatigue and poorer brain function associated with pain.

However, if the frustration feels overwhelming at times, reaching out to your support network or considering counseling to process your difficulties can help support you over this trying period.