Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
Our topic today is pain and this question comes up all the time when the word 'cancer'
comes up. One of the frightening things about cancer is the thought of a progressive
disease, unremitting pain leading to early mortality. This is the horrors of prostate
cancer and I'm gonna put that right up front because thankfully with prostate cancer we
don't deal with this problem very much and when I'm giving this talk today I'm drawing
more on my experience when I did general oncology 20 years ago and in rare cases with prostate
cancer patients. But that doesn't mean that the issue or the questions surrounding pain
don't come up all the time in my practice. What happens is that once a person's been
diagnosed with cancer every symptom, every pain seems to take on heightened significance.
So I get questioned every day, "Is this pain I have... Or, is this pain from the prostate
cancer?" And that is a natural question once someone has been diagnosed it's always on
their minds. Thankfully, not only is the pain almost never due to prostate cancer—the
average patient with prostate cancer is in his 70s and has aches and pains from all kinds
of things—but also, we can give a reassuring message and diagnose what the pain is coming
from and help them solve it, which is just part of being a physician.
So let's talk first about the type of pain that is from cancer. New prostate cancer patients
that are walking around with undetectable PSAs, it's essentially impossible for you
to have pain from prostate cancer. The two just don't go together. The pain, if you're
having pain, must be coming from something else. But if your PSA is above 5 or 10, or
maybe it's quite high, maybe it's 50, and you're having a new pain, how do you make
a distinction between something from prostate cancer from, say, arthritis, kidney stone,
or something of that nature? Well, cancer-related pain from prostate cancer is almost always
related to an issue in the bones, and I'm not talking about the joints. The joints,
the elbows, the shoulders, those are probably arthritic pains because prostate cancer doesn't
spread to the joints. Pain that is outside the elbows and below the knees is almost never
from prostate cancer because there's no red marrow in those areas and the cancer doesn't
spread there. So pains in the bone that are enduring, progressive could possibly be from
prostate cancer and the next step is usually to get a scan—a bone scan or an MRI—and
determine if there is actually a spot in the area where the pain is occurring and that's
how it can be confirmed that the pain is indeed from prostate cancer. Once a site of pain
is detected it's actually fairly easy to treat because radiation therapy to that spot will
almost always eliminate the pain completely. A problem, of course, can arise if people
have multiple sites and it could then, therefore, be dangerous to give radiation to multiple
sites as it could have an immunosuppressive effect. There are injectible types of radiation
such as Xofigo which circulates through the blood and concentrates in the areas where
the cancer is occurring and that can also relieve pain.
But let me backtrack a minute and talk about this issue with treating pain for prostate
cancer. The best treatment, of course, is to simply treat the disease with whatever
the best available therapy is, and in our previous videos we've gone through the Royal
category and talked about using Lupron, Xtandi, Taxotere, [and] other agents to try and control
the disease, and if the disease is controlled, the pain will be controlled. In fact, one
of the earliest signs of an effective therapy is the elimination of pain, if pain was occurring
at the time the treatment was started. But what about confusing situations where there
may be a spot on the bones, maybe its sort of close to this area where it's hurting,
but people aren't quite sure? A careful history [and] communication with your doctor is what
will help clarify the situation. Cancer pains, when they come, don't go away without treatment
so they're persistent. They tend to be progressive. So pains that seem to be occurring in the
morning and going away in the afternoon or are relieved by certain activities are probably
not related to cancer. So cancer paints tend to be very consistent and progressive and
that is the character that the doctor is going to be trying to determine when questioning
you.
There are a couple of other tricks that we've learned over the years to help people bridge
through a time when they're going on a new therapy. Oftentimes in Royal, someone may
have a rising PSA and develop some pain in a bone perhaps and during the time that the
doctors are waiting for the new therapy to take hold and eliminate the pain, it's logical
to use different types of analgesics. Non-steroidals such as Motrin, Aleve, Celebrex, these types
of things can be quite effective actually and they're relatively safe. If those less
potent analgesics aren't effective, narcotic medications are also a good choice and they
come in short-acting and long-acting, and these medicines can be used to bridge through
the time until the new treatment starts working and then the analgesics can be stopped.
Another trick that doctors can use during this bridge period is cortisone. Prednisone
in doses of 20-30mg has a rather remarkable analgesic effect. It also improves energy
temporarily and if we could use cortisone on a long-term basis it would solve a lot
of our problems. That's not safe. But taking it for a few weeks is very safe actually and
often times quite effective.
So with prostate cancer, thankfully, we're not dealing with pain issues on a common day-to-day
basis. For those exceptional cases and in the men that have very advanced prostate cancer
the issue can arise and thankfully there's a sequential logical way to pursue a solution.
If you are encountering problems finding a solution with your physician, consider asking
for a referral to a pain specialist. There are doctors out there. Oftentimes they're
trained as anesthesiologists who sub-specialized simply in pain management and they have developed
the art to a very high level and they have other additional methods and tricks that they
can use to try and help when people are experiencing difficulty in this area.