Cancer is a rising problem, and it is significantly associated with pain.
According to the American Cancer Society’s most recent statistics, 16.9 million Americans were alive fighting cancer or had a history of cancer by January 2019. This number is increasing because, in January 2012, the same agency gave a statistic of 13.7 million people. The numbers have a clear rising trend, and many of these patients experience significant pain (1).
Cancer pain is common, and we should address the problem from the start.
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A research group in the Netherlands studied the prevalence of this symptom. Their findings include almost 1,500 survey respondents diagnosed with cancer. 55% of them reported experiencing moderate or severe pain. Nearly all of them reported discomfort and mild pain. 42% of them had pain syndromes that did not respond to therapy. In other words, their medications were not enough to control their symptoms (2).
Cancer-related pain has a very high prevalence in these patients, and it affects their quality of life. Cancer itself causes pain, and cancer therapy may also cause pain. Thus, cancer survivors often deal with this crippling symptom after their primary disease is gone. Even after finding relief from cancer, some of them still experience pain.
These patients need specialized analgesic therapy, even after cancer is gone.
Despite the current advances in medical sciences, there is still much to do in the field of analgesic therapy. We do have a neurobiological understanding of cancer pain. But this is not always easy to translate into a clinical application. That’s why so many patients in the Netherlands’ study reported pain despite ongoing therapy.
In more than 20 years, the prevalence of pain resulting from solid cancer has remained unchanged. It is definitely a problem that doctors need to assess, but not only them. Pain management often requires emotional and psychological support, too.
That is why this article has pain as the main topic, evaluating this symptom and possible solutions for prostate cancer patients.
Questions this article will answer
After reading this piece, you will understand:
- Why does cancer trigger pain?
- Why does cancer therapy trigger pain?
- What should you expect from pain management therapy?
- What else can you do to cope with cancer pain?
Pain as a symptom of cancer
If you look for signs and symptoms of any type of cancer, one of the first on the list will be pain. Cancer pain can be located in the site of the tumor, nearby, or other organs. It can be triggered by cancer growth or as a side effect of cancer treatment. Thus, one of the first things that doctors need to evaluate in cancer patients is their pain symptoms. It is usually a specialist who leads the analgesic therapy, and it often includes opioid analgesics.
Relieving pain is not only a way to make patients feel better. It also leads to a clinical improvement of the outcome. According to scientific evidence, adequate pain management may increase the survival rate. When the patient has their symptoms under control, they have better psychosocial functioning. They have a better quality of life and an increased chance of staying alive after 5 and 10 years (3).
A multidisciplinary approach to cancer does not only focus on taking out the tumor and starting chemotherapy. Pain should be evaluated and improved from day one. It should also provide multidisciplinary support, including emotional and psychological assessment, cognitive-behavioral therapy, and coping skill training. All of this contributes to the patient’s survival and quality of life.
What doctors do before starting pain management therapy
Doctors can evaluate pain in different ways. One of the most accurate tools for this is the McGill Pain Questionnaire. Other pain scales are also available, especially for neuropathic pain. One of the best is known as Douleur Neuropathique or DN4.
Another essential evaluation at the moment of the diagnosis has to do with the patient’s psychological character. They often need opioid therapy to manage their symptoms. Thus, it is vital to know the risk of opioid misuse and abuse. Additional tools and questionnaires can be helpful to evaluate this risk (4,5,6).
After completing this assessment, many patients find significant relief from pharmacologic treatment. Others require more invasive pain treatment. However, this is only considered when the maximum doses of opioids are reached without improvements. This type of treatment often includes neurolytic blocks, intrathecal therapy, and other interventions.
Cancer pain statistics
According to systematic reviews and comprehensive studies, here’s what we know about cancer pain (7,8):
- 59% of patients with anticancer treatment report pain symptoms
- Over 75% of patients with advanced-stage cancer experience significant physical pain
- 33% of patients still experience pain after cancer remission
- 25% of newly diagnosed patients have pain as one of the main symptoms
Acute and chronic pain
Depending on the time extension of pain, it can be acute or chronic. Acute pain is only limited to a period of time. Chronic pain is long-standing, usually lasting for weeks, months, or years. Cancer patients experience both acute and chronic pain in different circumstances (9):
Acute pain in cancer patients
Acute pain is not always common in a cancer patient because the disease develops over time. The pain symptoms usually do not appear all of a sudden. There are exceptions, of course. For example, a tumor could start causing a hemorrhage or create pressure upon new structures and trigger alarming signs in a few days or hours.
However, in most cases, acute pain in cancer patients links with therapy. For example, after using the chemotherapy agent paclitaxel, patients have acute pain syndrome. This syndrome includes joint pain, muscle pain, tingling, numbness, and other sensory abnormalities. Chemotherapy-related pain is reversible after decreasing the dose or stopping therapy.
Radiation exposure also produces side effects and acute pain, especially when it affects local nerves. Patients often report weakness, tingling, and other symptoms, but they limit to a few weeks. In some cases, pain comes back in flare-ups, often described as shock-like pain.
Postsurgical pain is also acute and expected as the tissue heals, usually treated with pharmacotherapy.
Chronic pain in cancer patients
Chronic pain is more common in cancer, and it becomes worse as the tumor keeps growing. It is the most common manifestation, often close to the area where the primary tumor is.
Cancer therapy may also trigger chronic pain, especially after surgery. There is an entity, chronic post-surgical pain, and it is not the most common but still a possibility. It happens after amputation, thoracotomy, mastectomy, and other surgical interventions. The pain lasts for months after surgery in up to 10% of patients.
In chemotherapy, pain is common as an acute side effect. In most cases, the symptom improves after stopping the chemotherapy. When pain persists, it is “coasting,” and it is not common.
Radiotherapy produces acute pain, as noted above, and pain syndromes are usually reversible. But sometimes, symptoms persist for 90 days or more. This is chronic pain. In most cases, it is located in the abdominal area due to mucosal changes, obstruction, strictures, and other consequences of radiotherapy. The incidence of chronic pain depends on the radiation dose, schedules, and volume of irradiated tissue.
Corticosteroid therapy may also cause chronic joint and muscle pain. In some cases, it leads to vertebral compression and fractures.
Types of pain
As noted above, cancer-related pain can be another symptom or become triggered by cancer therapy. In each case, there are different types and causes of pain, with various mechanisms, too (10):
Nerve structure abnormalities trigger this type of pain, usually due to compression. It is often felt close to the primary tumor or its metastases. In some cases, the tumor invades the nerve tissue causing severe pain known as plexopathy. For neoplastic plexopathy, the tumor involves the lumbosacral, brachial, or cervical plexus. In these cases, patients experience sensory and motor abnormalities (pain, muscle weakness, and other symptoms).
Inflammation is a common immune function. But cancer uses inflammation to increase the blood flow and nutrients to the tumor. In the process, a lot of inflammatory substances release. They trigger pain by contacting nerve terminals near the tumor microenvironment. One of the most common inflammatory cytokines that trigger pain is prostaglandin E2. Luckily, this type of pain often improves with anti-inflammatory medications.
There are many chemotherapeutics classes, and they affect cancer cells because they divide rapidly. They have in common their toxicity to healthy cells if they tend to divide rapidly. For example, cells in the gastrointestinal tract and the bone marrow are constantly dividing. Thus, chemotherapy agents attack them believing it is cancer. Therefore, gastrointestinal pain and bone pain are common if you’re receiving chemo. For example, oral mucositis causes ulcers and discomfort in 40% of patients under cytotoxic agents. In some cases, patients may also have neurologic pain after chemotherapy because some chemotherapeutic agents create nerve disruption and hypersensitivity.
Radiation toxicity has different side effects. One of them is neural injury, which causes pain. Radiation-induced neuropathies are caused by fibrosis, inflammation, and vascular changes to the tissues. Fibrosis gets in the way, inflammation fires nerve terminals, and vascular changes create biochemical and permeability alterations that contribute to pain.
Surgery to take out the tumor is sometimes extensive and requires taking out a significant portion of healthy tissue. Along with healthy tissue, many nerves are affected, and there’s something called postsurgical neuronal plasticity. Nerve damage after surgery causes the spontaneous firing of the affected nerves. They send out pain signals to the brain, even if there’s no reason to feel pain. This neuroplasticity reaches the central nervous system and causes central sensitization. Another problem after surgery is neuroinflammation, which creates a positive feedback loop that feeds and increases pain sensation.
Prostate cancer and pain
Cancer in the prostate gland is the most common type of cancer in males. It won’t always give pain symptoms, and not all cases are diagnosed. However, there is a severe burden of disease. According to 2012 statistics, 27% of new cancer diagnoses in that year were prostate cancer. Prostate cancer is also responsible for up to 10% of total cancer deaths. As you can see, they are disparate statistics, and what they mean is that many patients live with prostate cancer, often enduring pain symptoms (11).
Pain is common in the early and late stages of prostate cancer. 30-50% of these patients experience chronic pain. The proportion reaches 90% in cases of terminal-phase disease. In these cases, pain is caused by tumor infiltration in the nerve tissue, soft tissue, bones, and other organs. More than 75% of these patients feeling pain experience the symptom as a result of cancer. Only 19% start experiencing pain as a result of cancer treatment. In both cases, it is usually located in the perineum or rectum (11).
Bone metastasis is one of the most common distant spreads after lymph nodes and local tissue. Up to 75% of patients with aggressive prostate cancer have bone metastases. This spread sometimes reaches the sacroiliac spaces and the lumbar spine, affecting the bone and sometimes the nerve roots.
One of the most commonly involved bony structures is the spine, especially the vertebral pedicle. This causes compression of the spinal cord, pressing on the nerves and causing neuropathic pain. Prostate cancer symptoms keep escalating and turn into crippling pain for weeks or months. Straight leg raises, abdominal pressure, and spine flexion worsens the pain, and sometimes surgical decompression is required.
One of the most commonly involved nerves is the pudendal nerve. This nerve provides sensation to the skin of the perineum, anus, and external genitalia. It is often injured by tumor spread and causes significant pain in these areas. Radiation therapy may also affect the pudendal nerve, causing nerve entrapment neuropathies (12).
Another common consequence after radiation treatment is radiation cystitis, proctitis, or enteritis. It is also possible to experience pelvic fractures after radiation, depending on the dose and volume. In the bladder, radiation causes irritation and often translates into obstructive symptoms. These symptoms are acute in up to 80% of patients and only become chronic when bladder fibrosis develops (13).
Managing prostate cancer-related pain
Treating prostate cancer pain is similar to treating other forms of cancer pain. There is a pain management protocol, and doctors start with mild and conservative treatment. If they fail, they will move ahead to prescription treatment and then surgical treatment.
Here’s an overview of the available options to manage prostate cancer-related pain (9):
This is the first step of the pain relief ladder. It would be ideal if you manage your pain by over-the-counter therapy, but it only works for mild or moderate pain. In cancer patients, pain symptoms often have additional components. Thus, they often require a combination of oral therapy instead of only one drug.
Weak opioid treatment
They are more common for use in cancer-related pain. Weak opioids include codeine and tramadol. They can be used along with over-the-counter anti-inflammatories to maximize their performance. This type of therapy is appropriate for moderate to severe pain, and it is relatively safe for all patients. However, it is a prescription drug, and you need to follow instructions and ask your doctor before changing your dose.
Morphine and other strong opioids
This is the third step of the pain management ladder and uses strong opioids combined with other treatments listed above. This approach is commonly administered in a hospital setting or under careful medical surveillance. Most patients with a terminal disease require morphine to control their pain symptoms. It is also likely that you need morphine to endure pain as a result of radiotherapy or chemotherapy. If you’re allowed to follow your treatment at home, be sure to follow the instructions very closely. You don’t want to wait for the pain to go back before taking your next dose. You don’t want to increase your dose before talking to your doctor. If you do, pain symptoms may get out of control, or you can start experiencing severe side effects.
Neuropathic pain medications
As noted above, many patients with cancer-related pain have a type of nerve involvement. Neuropathic pain is common in prostate cancer, and it is not relieved by the usual medications. You don’t actually need morphine to ease this type of pain.
Most patients experience significant improvements with drugs that inhibit the nervous system. For example, amitriptyline, pregabalin, or gabapentin. They are administered for epilepsy and depression, but this time, they slow down nerve impulses and control their pain signals.
In some cases, you may also benefit from creams, patches, and other topical painkillers. They are prescribed if you have regional pain due to radiotherapy or unexpected side effects in soft tissues.
Prostate cancer and treatment for cancer often cause swelling. Then, swollen tissues press on the adjacent nerves and cause pain. Steroid treatment works for pain management because it reduces pain by reducing swelling. Steroids also have an anti-inflammatory potential that contributes to relieving inflammatory pain.
Radiotherapy for pain management
In patients with advanced prostate cancer, bone metastasis is one of the most common pain causes. Radiotherapy can contribute to managing this type of pain by shrinking metastasis areas. It also slows down the growth of tumors, allowing our healthy tissue to repair the area.
Bone density therapy and surgical bone repair
In metastatic prostate cancer to the bones, many patients have bone density problems and pathological fractures. Thus, using zoledronic acid and other bisphosphonates contributes to improving bone density and reducing pain sensation. In some cases, surgical bone repair is also necessary in case of fractures.
When doctors know precisely which nerve is firing pain signals, they can block the nerve with injections. This is a very advanced cancer pain management treatment, and it is not available in every medical center. However, it provides significant pain relief for patients who are not responding to any of the conservative measures above.
Getting support with cancer pain
Getting support for cancer pain is fundamental. As mentioned in the introduction, pain management therapy is only the start. One of the first steps is to keep close communication with your doctor and nurse. Be sure to notify changes in the nature and severity of pain and if new pain symptoms start to develop. After pain-relieving therapy, it is also essential to describe the outcomes as accurately as possible. Do not try to mask or endure pain and keep a pain diary to ensure that you’re not missing anything when you talk to your doctor or nurse.
Besides the medical group, support also comes from your family and yourself. Following a healthy diet, sleeping your night hours, and using relaxation techniques can relieve pain. There are also effective home remedies such as hot and cold packs and many complementary therapies at home, such as massage therapy and aromatherapy.
Psychological evaluations are very important for cancer patients, too. From the day of the diagnosis, cancer is a shocking problem, even if doctors say that prostate cancer has one of the best survival rates. Since pain has an emotional component to it, therapy is also important to cope with the disease.
An enlarged prostate can be due to benign prostatic hyperplasia, a benign condition. However, if you have risk factors for a prostate condition, healthcare providers recommend prostate cancer screening using a PSA test and digital rectal examination. This allows doctors to detect the disease early and provide treatment before pain symptoms start to arise.
Pain due to prostate cancer is more common in advanced cases such as castration-resistant prostate cancer and metastatic disease. Metastasis to the bone is a very common source of pain. They are often treated with a combination of chemotherapy, radiotherapy, and hormonal therapy. And throughout this process, pain management is achieved through a variety of opioids, non-opioids, medications for neuropathic pain, and more.
Treatment for prostate cancer can also cause cancer-related pain, as in radical prostatectomy. However, most cases of cancer-related pain are from tumors. The remaining 19% of cases start experiencing pain as a side effect of cancer therapy.