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Pain and advanced prostate cancer

The information on this page comes from our Tool Kit fact sheet on pain and advanced prostate cancer. To order your own tailored copy of the Tool Kit, visit our publications page. You can also download and print a PDF version of this fact sheet.

This page is for men with advanced prostate cancer who are having problems with pain. It describes the types and causes of pain that you might have, as well as possible ways of treating and controlling your pain. Each hospital and specialist team will do things slightly differently so use this information as a general guide and ask your specialist team for more details about the care you will receive. This page also lists other sources of support that may help you cope with pain. You can also call our free and confidential Helpline on 0800 074 8383.

What does having advanced prostate cancer mean?

Having advanced prostate cancer means that the cancer has spread from outside the prostate, to other parts of the body. Your cancer is not curable but treatment can keep it under control for months or years. Prostate cancer can spread to any part of the body, but commonly to the bones and lymph nodes. A bone scan can help show whether your cancer has spread to the bones. Your specialist team may also use other tests such as x-rays, CT (Computerised Tomography) scans or MRI (Magnetic Resonance Imaging) scans to find out if your prostate cancer has spread. You can find out more about all of these tests by reading our fact sheet How is prostate cancer diagnosed.

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Do all men with advanced prostate cancer have pain?

No. Some men will have no pain at all and others will have varying amounts. With the right treatment, pain can be relieved most of the time. You should not have to accept pain as a normal part of having cancer. Let your specialist team know about any pain you have as soon as possible. The earlier you ask for help, the easier it will be to get your pain under control.

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What causes pain in men with advanced prostate cancer?

There may be more than one cause of pain. Possible causes include:

  • The cancer may have spread to the bones or more rarely to the spine.
  • The cancer can sometimes spread to the lymph nodes, making them swollen and uncomfortable.
  • Problems related to the cancer, such as constipation or muscle tension.
  • Side effects from your treatments – for example, chemotherapy or radiotherapy.

It is also worth considering that your cancer might not be causing the pain. Your specialist team should investigate the cause of your pain and then offer you the most appropriate treatments. On this page we have mainly focused on pain caused by the cancer spreading to the bones. For information on other causes of pain speak to your specialist team or call our specialist Helpline nurses on 0800 074 8388.

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What happens if prostate cancer spreads to the bones?

Prostate cancer can spread to the bones. This does not mean that you have bone cancer, but that some of the prostate cancer cells have spread to some areas of bone. This is called secondary prostate cancer. The areas of spread are called ‘bone secondaries’ or ‘bone metastases’. In the following information we use the term ‘metastases’ to describe prostate cancer that has spread to the bone. Up to eight out of ten men (80 per cent of men) with advanced prostate cancer will have bone metastases. 1 The growth of the cancer within the bone damages the bone structure and tissue and can cause pain. Finding bone metastases early helps your specialist team work out the best way to treat them and prevent new metastases forming. The first areas of bone to be affected are likely to be those closest to your prostate including your pelvic bone, hips, lower spine and upper thighs. Pain in these areas can affect how you walk and move around. The pain may only be in one area but over time it can spread to several parts of your body. Men who have bone pain often describe it as a dull aching or stabbing that can get worse with movement. The cancer cells affect the normal strength and performance of your bones, leading to pain and weakening of the bone. There are several effective ways of treating pain caused by bone metastases. These are explained in the section ‘How is pain treated?’

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Spinal cord compression

Prostate cancer can also spread to the spine, this is called ‘spinal metastases.’ This can lead to a complication called ‘spinal cord compression.’ This means that the cancer is pressing on nerves in the spine. Spinal cord compression is rare. At the moment, we do not know how many men with advanced prostate cancer develop spinal cord compression. We do know that spinal cord compression occurs in around one in ten people (five to ten per cent of people) with some form of advanced cancer.2 Early identification and treatment of spinal cord compression is important. Early signs and symptoms include:

  • Pain in the lower, middle or top of your back or neck.
  • A ‘narrow band’ of pain in your arms, legs or body.
  • Pain in your back that gets worse when you cough, sneeze or go to the toilet. It may also be stopping you from sleeping.
  • Weakness or numbness in your arms and legs.
  • Difficulty using your arms or legs.
  • Not being able to empty your bladder or bowel.
  • Problems controlling your bladder or bowels.

Spinal cord compression is a serious condition. If you have any of the symptoms listed above, contact your specialist team straight away. Do not wait to see if it gets better and do not worry if it is an inconvenient time, such as the weekend. You should have been given information about who to contact if you have any symptoms. If you do not have any particular contact details, go to accident and emergency at your local hospital and tell them that you have symptoms of spinal cord compression. They may investigate further, for example with a scan of your spine.

The recommended treatments for spinal cord compression include 2:

  • Radiotherapy.
  • Surgery – in some cases this may help to stabilise the spine.
  • Bisphosphonates - medicines that can be used if normal pain-relieving drugs are not enough to control the pain.
  • Corticosteroids – medicine to reduce swelling and relieve pressure on the spine.
  • Lying flat on your back – your specialist team may ask you to do this to reduce the movement of your spine. They will monitor your condition and check that it is safe for you to gradually sit up.

How much pain might I have?

It is normal to worry about how often you might be in pain and how bad it may become. Predicting this is difficult as pain is a very individual experience. If you are in pain, it is important to let your specialist team know. They can then plan your treatment and care to suit your individual needs. How much pain you have can depend on several factors, including:

  • Where the pain is and what is causing it.
  • How soon you tell your specialist team about the pain.
  • Finding the right pain relief for you.
  • Taking the right amount of pain-relieving drugs at the right times.
  • Other factors such as tiredness, how well you are feeling, if you are anxious and whether or not you feel well supported with your pain.

With the right treatment and management, it is likely that your specialist team will be able to control your pain effectively.

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How will having pain make me feel?

We all react to pain differently. This means that only you can describe how your pain feels. Another person with the same illness may not feel pain in the same way as you do. The fear of having pain can be common for people with cancer and those close to them. Until your pain is under control it may be very difficult to think clearly or believe that the pain will go away. Coping with any type of pain, whether it is constant or short-lived can be tiring. Some people say that they feel very angry about having pain because it is a constant reminder of their cancer. You may feel depressed if you are living with unmanaged pain. Feeling low may also make you feel more aware of your pain. It may be useful to get some extra help if you are feeling down, for example by talking to a counsellor. See ‘Where can I get support?’ for further information.

How is pain assessed?

How you describe your pain to your specialist team is very important in helping find the best treatment for you. Your specialist team will try to gather as much information as possible about you and your pain. Before you see your specialist team, you could think about:

  • Where your pain is.
  • How bad it is.
  • The type of pain it is, for example ‘stabbing’ or a dull ache.
  • How often it happens.
  • Does anything help? For example changing position or having a relaxing bath.

A good way of letting someone know how much pain you are in is to rate it on a scale of zero to ten – zero being no pain and ten meaning the worst pain you can imagine.

Pain scale

A personal experience
"I kept a pain diary, this helped me keep track of when I had pain, how long it lasted and what made it better or worse. I took the diary to my appointment with me, this made it easier to talk about and describe my pain to the doctor."

Your specialist team will need to examine you to see if there are any obvious physical reasons for your pain. This will help them to decide whether you need any tests or investigations, such as blood tests or an X-ray.

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How is pain treated?

The best way to manage your pain can depend on a number of things, including what is causing the pain, your general health, how you are feeling emotionally and what sort of things you do in your daily life. Because pain involves all of these aspects, treating it often means using a few different approaches.

Treatments can include a combination of:

By using this combined approach, cancer pain can be managed well in most cases. Once treatment for pain has started it must be kept under constant review. This is so any changes can be managed as soon as they appear. If one type of treatment does not work for you, then your specialist team may be able to try something else. Tell your specialist team about any new pain. This may or may not be related to your cancer.

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Pain-relieving drugs

Most men who have pain caused by advanced prostate cancer will need to take pain-relieving drugs at some stage during their illness. There are different kinds of pain-relieving drugs. Your specialist team may use a guide called a ‘pain relief ladder’3 to decide which pain-relieving drugs will help you. The ladder recommends which type of drugs to give for which kind of pain.

Step 1 Mild pain Mild pain-relieving drugs such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.
Step 2 Moderate pain Weak opioids such as codeine.
Step 3 Severe pain Strong opioids such as morphine.

By using this approach, your specialist team can ‘step-up’ your drugs to the next stage if your pain is not controlled by one type of pain-relieving drug. You may be offered more than one type of drug, as they work in different ways. You may be taking pain-relieving drugs alongside other treatments such as palliative radiotherapy. If your pain improves after these treatments, your specialist team may be able to ‘stepdown’ your drugs. This should not be done suddenly and you should be able to discuss the plan with your specialist team.

Non-opioid drugs

These are mild pain-relieving drugs, such as paracetamol. You can use them together with stronger pain-relieving drugs. All medicines can cause side effects. You may not get any or all of these. Different types of non-opioid drugs have different side effects, these are usually rare. Check with your specialist team if you are worried.

Anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDS) include ibuprofen (Nurofen) and diclofenac (Voltarol). These can help to reduce any inflammation that may be causing your pain. Some NSAIDS can cause side effects, these include stomach irritation and sickness. You may need to take these drugs with milk, after food, or with antacids to reduce stomach irritation.

Opioid drugs

You may need a stronger type of drug, called opioids. These include morphine and weaker opioids such as codeine. You can take opioids in tablet and liquid form. Some opioids are also available as a skin patch. You may also be able to take ‘slow release’ opioids, so that you do not have to take as many doses throughout the day. In some cases, your specialist team can give you a continuous dose of opioids, commonly diamorphine, through a small tube or needle into the skin. This means that the drug is less likely to wear off. You may use this method if it becomes difficult to take other pain-relieving drugs. For example if you can no longer take drugs by mouth, because of swallowing problems.

Possible side effects of the pain-relieving drugs described above include:

  • Difficulty emptying your bowel (constipation) – this can be very uncomfortable so your specialist team may give you laxatives that should make it easier to go to the toilet. Drinking plenty of water, eating a high fibre diet and exercising if possible, may also help to prevent constipation.
  • Sickness – you may feel sick for the first few days of taking opioid drugs. You may be prescribed anti-sickness tablets.
  • Drowsiness – when you first start taking opioid drugs you may feel drowsy. This usually settles down after a few days when your body has become used to the drug. Check with your specialist team whether it is safe for you to drive when you are taking opioids.

You should take your drugs regularly as prescribed by your specialist team. This will give you more constant pain control. It can take some time for pain-relieving drugs to be absorbed by the body and start working. If you wait until the pain comes back before you take the next dose, you may have a gap where your pain is not properly controlled.

Some men are worried about becoming addicted to stronger pain-relieving drugs like morphine. If you are taking morphine for the right reasons (pain) then addiction is unlikely.4 Remember, you might not have to start with the strongest type of pain-relieving drugs. Some men find that milder drugs such as paracetamol and ibuprofen are enough to control their pain.

Hormone therapy

Men with advanced prostate cancer may be offered hormone therapy. It cannot cure the cancer but it can keep it under control for many months or years. Hormone therapy works by starving the cancer cells of the male sex hormone testosterone. Prostate cancer cells need testosterone to grow. Lowering the testosterone levels in your body can shrink or slow down the growth and spread of your cancer. This may prevent and relieve your pain and can be useful as a first approach to the prevention and management of pain. Read our fact sheet Hormone Therapy for more information.

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Steroids

If your prostate cancer has spread to the bone or the spine, it may cause swelling and press on the nerves causing pain. Steroids do not treat the cancer itself, but can help to reduce swelling around the cancer. You may be able to take steroids in combination with pain-relieving drugs and other types of treatment. Like most medicines, steroids can cause side effects. You may put on weight and have a slightly higher risk of getting infections. Some people find that they feel irritable, as steroids can make your mind more active. Steroids can also cause indigestion and may irritate the lining of the stomach, sometimes causing bleeding. So it is important to take them after a meal or snack. Your specialist team may prescribe additional tablets to help to protect your stomach. Your specialist team should discuss and monitor possible side effects with you. It is important not to stop taking steroids suddenly as this can make you very ill. Instead you could discuss reducing your dose gradually.

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Chemotherapy

Chemotherapy involves using anti-cancer (cytotoxic) drugs to kill cancer cells. The aim of this treatment is to shrink the cancer cells. This can stop the cancer pressing on your nerves and causing you pain. It does not cure the cancer but it can give you a better quality of life. Chemotherapy can cause side effects and other medicines can help manage these. If your specialist team offer you chemotherapy it might be helpful to discuss the advantages and disadvantages of treatment with them. Read our fact sheet Chemotherapy for further information, particularly about side effects.

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Palliative radiotherapy

If treating your bone metastases with hormone therapy is not completely controlling your pain or is no longer working, then your specialist team may suggest radiotherapy, often referred to as palliative radiotherapy. This is different from having radiotherapy to treat cancer that has not spread outside the prostate gland (localised cancer), as it does not cure the cancer. The aim of palliative radiotherapy is to shrink the cancer cells in the bones which will stop them pressing on nerves and causing pain. It may also kill off some cancer cells that are growing, which gives your bones time to repair and strengthen. There are two ways of giving palliative radiotherapy to help treat bone pain: external beam radiotherapy and internal radiotherapy.

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External Beam Radiotherapy (EBRT)

This is a short course of radiotherapy that is an effective way of improving pain from bone metastases.5 It works by aiming the radiation beams directly at the painful areas which are called ‘hot spots’. For many men this can work very well. The treatment can take a few weeks to work but it can give you a better quality of life for longer and help reduce pain. The pain-relieving effect may start within a few days of treatment and lasts for an average of four to six months, but can vary from person to person. You can have external radiotherapy more than once if it is targeting different bone areas.

As EBRT is usually a short course of radiotherapy it is unlikely you will experience many side effects. If you are having treatment to your hips (pelvis), or your bowel is in the treatment area, you may have some diarrhoea. Your specialist can give you medicines to help control this.

If your cancer has spread to several areas of your body, it can be harder to treat with external radiotherapy. Some men may benefit from having treatment called ‘hemi-body’ radiotherapy. This means that you have radiotherapy to the entire upper half of your body and then a couple of weeks later you have radiotherapy to the other half. Your doctor will assess your health and general fitness for this treatment, as it can be quite tiring.

Internal radiotherapy (radioisotopes)

Another way of treating cancer that has spread to many areas of bone is with internal radiotherapy. This is an injection of a very small amount of a radioactive substance called strontium-89 (Metastron). This may need to be repeated every three to six months. This drug makes its way directly to your bones. The cancer cells take up the radioactive strontium-89 and these areas receive a high does of radiotherapy. This targets the bone metastases without having too much effect on the healthy tissues. You can have this treatment as an outpatient so you will not have to stay in hospital. It can take between one and two weeks to start working and may last for an average of four to six months. Around seven out of ten men (70 per cent of men) find that this treatment partially or completely relieves their pain.6 You can have repeat treatments, although not straightaway.

Strontium-89 can affect the immune system, which means you may be more likely to get an infection, anaemia, bruising and bleeding. Your specialist team will check your immune system before and after you receive this treatment. You will have some radioactivity in your body for a while, but the total amount is extremely small and gets lower each day. Your radiotherapist or nurse will let you know if there are any safety guidelines you need to follow after your treatment. This will depend on the dose of Strontium-89 you have received.

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Bisphosphonates

Bisphosphonates are a group of drugs that treat pain caused by cancer that has spread to the bones. They do not treat the cancer, but they can help reduce pain. Bisphosphonates bind to areas of bone where there is a lot of damage. They may also help slow the breakdown of the bone and prevent complications such as fractures, although researchers are still looking into this. There are several bisphosphonates available. The only one licensed in the UK for treating and preventing bone problems in men with prostate cancer is zoledronic acid (Zometa). You would usually have an infusion of zoledronic acid into a vein every three to four weeks. An infusion involves running a fluid containing the drug through a fine tube into a vein in your arm. This allows the drug to enter the blood stream and travel throughout the body. Treatment takes about 15 minutes. You will need to go to the hospital for each treatment. The tube can sometimes feel uncomfortable when it first goes in, but it should not cause any pain once it is in place. Bisphosphonates, like other drugs, can sometimes cause side effects. Read our fact sheet Bisphosphonates for further information or speak to your specialist team.

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Surgery

This is rare, but if your specialist team are sure that there is only one area of bone affected by your cancer, they may offer you surgery to remove this part of bone. A metal pin or a false part (prosthesis) can strengthen and stabilise the area of affected bone.

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Transcutaeneous Electrical Nerve Stimulation (TENS)

Some NHS pain clinics and specialist teams may use TENS to help manage pain. This involves using a small machine that stimulates the nerves, which can help the body release its own natural painkillers (called endorphins). TENS may relieve cancer pain for some individuals, but there is no conclusive research to show it works.7

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Nerve blocks

When other pain control methods have not been successful, nerve blocks are sometimes used. This involves blocking the nerve pathways, to stop ‘pain messages’ travelling to the brain. There are different ways of doing this, for example by injecting pain-relieving drugs around the nerves.

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Complementary therapy

Complementary therapies such as acupuncture, aromatherapy, massage, reflexology and hypnotherapy may help you cope with cancer pain. We need more research to prove that these therapies help relieve pain,8 but some people have found them helpful. Please speak to your specialist team before trying any complementary therapies.

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What other things can I do to help control my pain?

In addition to the treatments already mentioned, you may find it helps to try some of the following ideas:

  • Generally looking after yourself, for example maintaining a good diet may help you feel better. You could read our fact sheet Diet and prostate cancer for more information on healthy eating, or see a dietician for further advice.
  • Use music, reading or television to try and take your mind off your pain.
  • Have a chat with someone close to you to take your mind of things for a while.
  • Change your position frequently to prevent stiffness
  • Practice relaxation techniques such as deep breathing
  • Hot or cold packs may help to relieve some types of pain (be sure to wrap them in a towel to stop them damaging your skin)
  • Have a relaxing bath

These suggestions are not magic cures but they may help some men feel more in control of their pain.

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Where can I get support?

As well as getting medical help to treat your pain, most men find it helps to get some emotional support. Feeling more in control of your emotions can help make you feel better. It is very important not to feel alone with your pain. Close friends and relatives often say that it can be difficult to watch a loved one in pain. They can feel helpless and have trouble coping so they may also need emotional and practical support. If you are feeling low or anxious, it may be useful to talk to a counsellor. Counselling may help you cope if you are experiencing pain.9 You may be able get referral to a counsellor through your specialist team or GP. If you would like to speak to someone with personal experience of pain caused by prostate cancer, call our free and confidential Helpline on 0800 074 8383 and ask to be put in touch with a Support Volunteer.

You may also find it helps to talk to your specialist team or a specialist cancer nurse such as the Macmillan or Marie Curie nurses. These nurses can offer emotional support, information and provide care, so that relatives or carers can have a break. Macmillan nurses can also provide expert advice about different types of pain relief. You can ask your GP or specialist team to refer you to these nursing services.

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Questions to ask your specialist team

  • What is causing my pain?
  • Who will assess my pain?
  • What treatments are available to help manage my pain?
  • Who else can I talk to about my pain?
  • Will I need to take pain-relieving drugs?
  • What are the side effects of pain-relieving drugs?
  • What else can I do to help with my pain?

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Links

The following organisations provide further information relevant to this page:

Macmillan Cancer Support


www.macmillan.org.uk
89 Albert Embankment, London SE1 7UQ
Macmillan Cancer Support has merged with Cancerbackup.
Free and confidential helpline 0808 808 00 00 (9am-8pm, Mon-Fri)
For support and information and any questions about cancer.

Marie Curie Cancer Care

www.mariecurie.org.uk
Marie Curie run hospice centres throughout the UK and provide a nursing service for patients in their own home day and night, free of charge.

Pain Concern

www.painconcern.org.uk
Information about managing pain plus telephone contact with others who have experience of pain.

Reviewed by:

  • Maureen Carruthers, Clinical Nurse Specialist, Palliative Care, Royal Marsden NHS Foundation Trust, Sutton
  • Jenny Draper, Day Hospice Team Leader, Meadow House Hospice, Ealing Primary Care Trust
  • Joe Kearney, Uro-Oncology Clinical Nurse Specialist, Buckinghamshire Hospitals NHS Trust
  • Patricia McClurey, Specialist Nurse, Prostate Cancer, James Cook University Hospital, Middlesborough
  • Melanie Solieri, Nurse Manager, Chronic Pain Management Service, Southend Hospital
  • Bruce Turner, Uro-Oncology Nurse Practioner, Homerton and Whipps Cross Hospitals, London
  • Dr John Zeppetella, Medical Director, St Clare Hospice, Essex
  • The Prostate Cancer Charity Support and Information Specialist Nurses
  • The Prostate Charity Information Volunteers

Sources used in the compilation of this page

1: Yuen KY, Shelley M, Sze WM, Wilt T, Mason M. Bisphosphonates for advanced prostate cancer. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.:CD006250.

2: National Institute for Health and Clinical Excellence. 2008. Metastatic spinal cord. compression: diagnosis and management of adults at risk of and with metastatic spinal cord compression. Available at http://www.nice.org.uk/Guidance/CG75

3: World Health Organisation. Cancer pain relief: with a Guide to Opioid Availability, 2nd ed. Geneva: WHO 1996.

4: Royal College of Physicians. Principles of pain control in palliative care for adults. [Consensus statement on the Internet]. London: Royal College of Physicians. 2000

5: National Institute for Health and Clinical Excellence. 2008. Prostate cancer: diagnosis and treatment. Available at http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11924

6: Jager PL, Kooistra A, Piers D.A. Treatment with radioactive 89strontium for patients with bone metastases from prostate cancer. BJU Int. 2000; 86(8): 929-934.

7: Robb Karen A, Bennett Michael I, Johnson Mark I, Simpson Karen J, Oxberry Stephen G Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006276

8: Bardia A, Barton D L, Prokop L J, Bauer B A, Moynihan T J. Efficacy of complementary and alternative medicine therapies in relieving cancer pain: a systematic review. Journal of Clinical Oncology. 2006 Dec 1;24(34)

9: Carr D, Goudas L, Lawrence D, et al. Management of cancer symptoms: pain, depression and fatigue. Systematic Review. Rockville: Agency for Healthcare Research and Quality. 2002

Page last updated: March 4th 2009