Prostate Cancer

Prostate Cancer and Back Pain: Is it a Symptom?

Back pain is something that most of us will experience during various parts of our lives.

However, if you are experiencing severe and long-lasting back pain, this may be a symptom of metastatic prostate cancer.

If an aggressive form of prostate cancer occurs, which is more prevalent in younger prostate cancer patients, cancer can spread to the bones.

This article will be discussing the relationship between advanced prostate cancer and back pain.

Symptoms of Prostate Cancer

Although you cannot feel the presence of prostate cancer, there are signs to be aware of.

However, it is worth noting that these can also be signs of benign prostatic hyperplasia (BPH). Some common symptoms include:

  • Painful urination

  • Painful ejaculation

  • Difficulty urinating, or weak flow

  • Nighttime urination (nocturia)

  • Loss of bladder control

  • Blood in your urine (hematuria)

  • Persistent pain in the bones

  • Frequent or easy breaks and fractures

  • Swelling in your legs and pelvic area

  • Pelvic pain

  • Numbness in the feet, legs, and hips

How is metastatic prostate cancer diagnosed?

A prostate biopsy will usually be performed to confirm the presence of cancer and determine the aggressiveness of the cancer cells.

If your doctor suspects your cancer has spread, they will perform additional tests, such as:

• Bone scan

• Computerized (CT scan) or positron emission (PET) tomography scans.

• Ultrasound.

Prostate Cancer Staging

The Gleason score is a measurement used to indicate the aggressiveness of prostate cancer tumors.

A high Gleason score indicates a greater risk of your prostate cancer spreading to other organs, bones, or lymph nodes.

If prostate cancer spreads to nearby lymph nodes, it can become more dangerous and life-threatening.

The different patterns of prostate cancer cell growth are ranked from 1 to 5.

When your pathologist checks your samples from a prostate biopsy, they examine your prostate cells under a microscope. These patterns show how quickly and aggressively they are growing.

The lab will choose the two most commonly appearing patterns and give you a score. The score might look something like this 3+4 = 7.

The first number indicates the most common pattern in all the samples. The second is the second most common pattern.

Metastatic Spinal Cord Compression

Prostate cancer is metastatic if it has spread to:

  • Lymph nodes

  • Bones

  • Other organs

For example, if prostate cancer has spread to the pelvic bones, you may feel lower back or pelvic pain.

When cancer cells spread to the spine, they can apply pressure on the spinal cord (Prostate Cancer UK). This is called metastatic spinal cord compression (MSCC) and can lead to nerve damage in the spinal cord.

These nerves are responsible for sending signals to the brain (1), allowing for movement and sensations.

One of the consequences of cancer cells pressing on the spinal cord can be the sensation of severe and prolonged back pain (2). Severe back pain is experienced in 95% of patients with MSCC (3).

Treatment

Radical prostatectomy and radiation therapy are generally used to treat localized prostate cancer. However, for patients that eventually develop locally advanced or metastatic cancer, hormone or radiation therapy may be required.

Hormone therapy is used to inhibit the growth of prostate cancer cells.

More than 85% of men who receive hormone therapy develop metastatic castration-resistant prostate cancer (CRPC) within 3 years of hormone treatment. This is caused by prostate cancer cells adapting to low androgen levels.

Radiotherapy

Radiotherapy is widely used for treating bone metastases at all sites, including the spine, and will be effective for up to 12 months. Sometimes radiotherapy is used to prevent MCSS (4).

However, there is a lack of evidence to show that radiotherapy is effective at preventing MCSS. Some of the side effects are tiredness, diarrhea, and sometimes pain may worsen for the next couple of days.

Surgery

Surgery is only suitable for a limited number of patients with MCSS. The goal of surgery is to remove as much of the tumor as possible without weakening the spine. This takes the pressure of the spinal cord (4).

If you have advanced prostate cancer or are taking hormone therapy, your provider may suggest calcium or Vitamin D for your bones.

Radiotherapy may be given alongside surgery if the tumor cannot be removed entirely.

One study found that MCSS patients were more likely able to walk after undergoing surgery combined with radiotherapy, compared to patients that only underwent only radiotherapy (5). Drugs are regularly used to manage pain in cancer.

The severity of pain will determine the type of drugs that are used. For mild pain, non-opioid drugs are recommended because they are fewer side effects (6).

Paracetamol and non-steroidal anti-inflammatory drugs are commonly recommended.

However, they should not be used for longer than 5 weeks (6). These drugs become loss effective long-term, and several side effects can occur with long-term use.

This includes:

  • stomach

  • ulcers

  • headaches

  • liver issues

  • blood-thinning

For moderate pain, mild opioids such as codeine and tramadol. There is no conclusive evidence to suggest that weak opioids are very effective at reducing moderate pain (6).

For severe pain, it is recommended that strong opioids are prescribed. This includes morphine and methadone.

Frequent and or high dosages of strong opioids long-term are toxic to the body. This toxicity can cause changes in cardiac rhythm and respiratory distress (6).

Corticosteroids are regularly administered to patients with MSCC because it is thought that they decrease the bulk of the tumor or swelling of the spinal cord (7).

However, there is a lack of randomized control trials that display the efficacy of corticosteroids. In the United States, the most commonly administered corticosteroids are prednisone

  • prednisolone

  • methylprednisolone

  • dexamethasone

  • hydrocortisone

If a patient is receiving a high-dose of corticosteroids for an extended period are at a high risk of serious side effects or even death.

Some of the common side effects of corticosteroids include:

  • weight gain

  • edema

  • cataracts

  • osteoporosis

  • proximal myopathy

  • thinning of the skin
  • infection

  • impaired wound healing (8)

Physical Therapy

Physical therapy can be used to alleviate the severity of pain associated with back pain (9).

Patients with advanced prostate cancer are typically discouraged from undertaking physical activity. This leads to substantial muscle loss and an increased risk of falls and bone fracture. This can lead to a significant drop in quality of life.

A randomized control trial looked at the effects and the safety of undertaking a resistance exercise program in prostate cancer patients diagnosed with bone metastases (10). The program lasted for 12 weeks. The patients that underwent the program had a significant increase in strength, aerobic fitness, and lean muscle, compared to the group that did not undertake the exercise program.

This initial evidence suggests that a well-designed and supervised resistance exercise may be safe and well-tolerated by prostate cancer patients with metastatic bone disease. Furthermore, resistance exercise can lead to improvements in physical function, physical activity levels, and lean mass

Conclusion

Although there is no cure for prostate cancer, advances in science mean cancer growth can be slowed. Treatment can also help to reduce cancer-related symptoms, so you feel better. New treatment options are improving survival and quality of life, especially for men with no cancer-related pain.

Sources

  1. https://prostatecanceruk.org/media/2492022/metastatic-spinal-cord-compression-mscc-ifm.pdf
  2. Rajer M, Kovač V. Malignant spinal cord compression. Radiology and Oncology. 2008 Mar 1;42(1):23-31.
  3. Robson P. Metastatic spinal cord compression: a rare but important complication of cancer. Clinical Medicine. 2014 Oct 1;14(5):542-5.
  4. Al-Qurainy R, Collis E. Metastatic spinal cord compression: diagnosis and management. BMJ: British Medical Journal (Online). 2016 May 19;353.
  5. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. The Lancet. 2005 Aug 20;366(9486):643-8.
  6. Marras F, Leali PT. The role of drugs in bone pain. Clinical Cases in Mineral and Bone Metabolism. 2016 May;13(2):93.
  7. National Collaborating Centre for Cancer (UK. Metastatic spinal cord compression: diagnosis and management of patients at risk of or with metastatic spinal cord compression.
  8. http://www.cancernetwork.com/nausea-and-vomiting/corticosteroids-advanced-cancer/page/0/2
  9. Abraham JL. Management of pain and spinal cord compression in patients with advanced cancer. Annals of internal medicine. 1999 Jul 6;131(1):37-46.
  10. Cormie P, Newton RU, Spry N, Joseph D, Taaffe DR, Galvao DA. Safety and efficacy of resistance exercise in prostate cancer patients with bone metastases. Prostate cancer and prostatic diseases. 2013 Dec;16(4):328.

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