Pain and advanced prostate cancer
You can download this page as a PDF file.
This page is for men with advanced prostate cancer who are having problems with pain. We hope that it will help you understand more about cancer 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 fact sheet as a general guide and ask your specialist team for more details about the care you will receive. This sheet also lists other sources of support that may help you cope with pain.
- What does having advanced prostate cancer mean?
- Do all men with advanced prostate cancer have pain?
- What causes pain in men with advanced prostate cancer?
- What happens when prostate cancer spreads to the bones?
- How much pain might I have?
- How will having pain make me feel?
- How might my pain affect my friends and family?
- How is pain measured?
- Talking about pain
- How is pain treated?
- What are the side effects of these treatments?
- Will I need to take pain-relieving drugs?
- Will I become addicted to morphine?
- What are the side effects of pain-relieving drugs?
- What other things can I do to help control my pain?
- Where can I get support?
- Questions to ask your doctor
What does having advanced prostate cancer mean?
Having advanced cancer means that your cancer has spread from where it began to other parts of your body. Your cancer isn't curable but treatment can keep it under control for months or years. Treatment can also help to control symptoms, such as pain.
Many men live for years with advanced prostate cancer. It can spread to any part of the body, but most commonly to the bones and lymph nodes. When cancer spreads it can cause symptoms that need controlling. One of these might be pain.
Do all men with advanced prostate cancer have pain?
No, some men won't have any pain at all and others will have varying amounts. As we now have a much better understanding about the causes of cancer pain, with the right treatment, pain can be relieved most of the time.
It is natural to feel very upset about your cancer spreading and causing pain. Having pain should not be accepted as a normal part of having cancer. So let your medical team know about your pain as soon as you can. Don't try and put up with it. The earlier you ask for help the easier it will be to get it under control.
What causes pain in men with advanced prostate cancer?
This depends on how advanced your cancer is and where it has spread to. You may have more than one type and cause for your pain 1. Possible causes include:
- The cancer itself – for example, the tumour may be pressing on the nerves, or it may have spread to the bones
- Problems related to the cancer, such as constipation or muscle tension
- Another medical condition, such as arthritis
- Side effects from your treatments - for example, chemotherapy or radiotherapy.
In men with advanced prostate cancer, pain is most common when the cancer spreads into the bones 2. Doctors call these areas of spread ‘bone metastases' or ‘bony secondaries'. The growth of the cancer within the bone damages the tissue and causes the pain. About eight out of ten men (80%) with advanced prostate cancer will have bone metastases 3.
Another possible cause of pain is a rare condition called ‘spinal cord compression'. This means that your cancer is pressing on your spinal cord. This is a serious condition which needs treating as soon as possible. Tell your doctor if you have any new pain in your lower back and your legs feel weak. The most common treatments are radiotherapy, steroids, bed rest and pain-relieving drugs, which usually work very well to relieve the pain. In some situations you may have surgery.
What happens when prostate cancer spreads to the bones?
The most common place that prostate cancer spreads is to the bones (bone metastases or bony secondaries). This means that the cancer cells from the prostate have made their way to your bones. This is called secondary prostate cancer, not bone cancer. The cancer cells affect the normal strength and functioning of your bones, leading to pain and weakening of the bone.
Finding bone metastases early helps your doctor work out the best way to treat and prevent these complications. When the cells first spread they tend to move to nearby areas. This means that the first bony areas to be affected are those closest to your prostate including your pelvic bone, lower spine and upper thighs (hips). 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 dull aching or stabbing.
There are several effective ways of treating pain caused by bone metastases. For example, pain-relieving drugs, hormone therapy, radiotherapy and a group of drugs called bisphosphonates. For more information on how to treat bone pain, read ‘How is pain treated?'.
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 very difficult as pain is a very individual experience and we all feel it in our own way. Trust your own feelings. If you think that your pain is bad it is important to let your doctors and nurses know this so that they can plan care to suit your individual needs.
How much pain you will have can depend on several factors including:
- Where the pain is and what is causing it
- How quickly you tell your doctor that you are in pain and get treatment
- How well you respond to treatment
- Whether or not you take pain-relieving drugs as often as your doctor prescribes, and
- Other factors such as how well you are feeling, if you are anxious and whether or not you feel well supported with your pain
Remember with the right treatment and management, your doctor is very likely to be able to control your pain. The first step is to tell your medical team as much as you can about your pain. How often if comes, where it is and how bad it is. Different types of pain are treated in different ways. So your doctor needs this information before they can choose the best treatment for you.
It is also very important to let your doctor know as soon as your pain starts. The sooner you tell them the quicker they will be able to control it. If your doctor orders pain-relieving drugs to help with your pain, take them as often as prescribed. Leaving out doses just because you are not in pain, or worry about taking too much, is not the best way to control pain. Pain-relieving drugs work best when you take them regularly, before your pain gets too intense. There is more information about pain-relieving drugs and their side effects below.
How will having pain make me feel?
We are all unique and will feel and react to pain differently. This means that only you can describe how your pain feels and how severe it might be. Another person with the same illness may not feel pain in the same way as you do. Your needs for managing your pain are very individual as well.
The fear of having pain is very 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 ever 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.
Poorly controlled pain is very likely to affect your mood and what you can do each day. Research has shown that people who have pain for long periods of time can become depressed 4. Feeling depressed or ‘low' only increases your awareness of how much pain you are in.
However your pain is making you feel, the important thing is to let your medical team know as soon as possible. Don't put up with it until it gets worse as it then takes longer to control.
How might my pain affect my friends and family?
Close friends and relatives often say that it is extremely hard to watch a loved one in pain; they can feel helpless and have trouble coping.
If you or those close to you need support and information, call our confidential Helpline on 0800 074 8383 . We also provide a ‘friends and family' forum on our online message boards.
How is pain measured?
Before your doctor can manage your pain effectively they will want to gather as much information as possible about you and your pain. They will ask you questions to determine where your pain is, how bad it is, the type of pain, how often it happens and if anything in particular relieves it, like a change of position or hot 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 2 . It often helps if you can bring along someone close to you to help you answer the questions.
Your doctor will also need to examine you to see if there are any obvious physical reasons for your pain. This will help them decide whether you need any tests or investigations, such as blood tests or an X-ray.
Talking about pain
You may find it difficult to talk about your pain but the earlier you tell someone about it, the easier it will be to control. So do try and ask for help – and keep asking until you feel comfortable with how your pain is being managed.
The best motto to have is ‘treat and prevent your pain early'. If you are someone who has trouble talking about your pain try to think of it like this – when you are in pain you are more likely to feel anxious, depressed, tired and angry. You may have trouble sleeping, eating, staying in a good mood with those close to you or enjoying intimacy. When you let someone know about your pain and it is managed well, things become easier.
How is pain treated?
Deciding on the best way to manage and treat your pain will depend on its cause, how severe it is and what works best for you as an individual. You may have one or more of the treatments we mention here. Pain-relieving drugs are commonly given alone or alongside one of the treatments. If one type of treatment doesn't work for you, then your doctor will most likely be able to try something else.
The treatments we write about here focus mainly on treating bone pain. This is because it is the most common type of pain that men have in the advanced stages of prostate cancer.
If you want more specific information about how best to treat the type of pain you are having it is best to speak to your doctor. You can also call our confidential Helpline on 0800 074 8383 for support and information.
Hormone therapy
One of the best ways to treat pain due to prostate cancer that has spread is with hormone therapy. Read our Hormone Therapy fact sheet for information about the types of hormones that you may be given.
You may take one type of hormone drug on its own or two together. They work by starving the cancer cells of the male sex hormone testosterone. This hormone is what prostate cancer cells need to grow. By lowering testosterone levels in your body this can shrink or slow down the growth and spread of your cancer. It can help prevent and relieve your pain. This kind of treatment usually works well for a certain length of time but should it stop being effective your doctor will need to suggest other treatments. You may hear your doctor call this ‘hormone refractory' prostate cancer. The effectiveness of hormone therapy varies between men but your medical team will keep a close eye on this.
Radiotherapy
If treating your bone metastases with hormone therapy is not completely controlling your pain or is no longer working then your doctor may suggest a course of radiotherapy. Radiotherapy may also be given alongside hormone treatment. For many men this can work very well. In general, between eight and nine out of every ten men (80-90%) get some degree of pain relief from radiotherapy. You may hear your doctor call this palliative radiotherapy. The treatment can take a few weeks to work and will not cure your cancer. But it can give you a better quality of life for longer.
There are two ways of giving radiotherapy to help treat bone pain: external beam radiotherapy and internal radiotherapy. The aim of both these treatments is to shrink the cancer in the bones which will stop it pressing on nerves and causing pain. It may also kill off cancer cells that are growing, which gives your bones time to repair and strengthen.
External radiotherapy
External radiotherapy is the most common way of giving radiotherapy to help treat bone metastases that are causing pain in a specific spot. It is done by aiming the radiation beams directly at the painful areas. The pain-relieving effect starts within a few days of treatment and lasts for an average of four months. Nine out of ten men get some pain relief from this treatment and between three and six out of ten men get total pain relief in the treated area 5 .
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. You have to be quite fit to have this treatment.
Internal radiotherapy (radioisotopes)
Another way of treating cancer that has spread to many areas of bone is with internal radiotherapy. This is given using an injection of a very small amount of a radioactive substance called strontium 89 (Metastron). This drug makes its way directly to your bones. It can take between one and two weeks to start working and lasts for an average of four to six months. Around seven out of ten men find that this treatment partially or completely relieves their pain 5.
Steroids
Steroids can help to reduce inflammation, which sometimes occurs around a tumour. This inflammation may cause bone pain. If the tumour is on the spine, it can cause problems due to the tumour pressing on the nerves.
Bisphosphonates
Bisphosphonates are a group of drugs that help to prevent and slow down the destruction of bone in men with advanced prostate cancer. They are used to treat bone problems such as fractures, pain and high levels of calcium in the blood (hypercalcaemia) 6. There are several bisphosphonates on the market but one common one you may have is zoledronic acid (Zometa). This is given as an injection into the veins every three to four weeks.
Chemotherapy
Some men may benefit from a course of chemotherapy, but research is ongoing in this area 7. The aim of this treatment is to shrink the cancer. This can stop tumours pressing on nerves and causing you pain. It doesn't cure the cancer but it can give you a better quality of life.
Surgery
This is rare, but if doctors are sure that there is only one area of bone affected by your cancer, they may decide to remove it using surgery. They then strengthen your bone with a metal pin or use a false part (prosthesis) to replace it.
What are the side effects of these treatments?
All treatments can have side effects. The type of side effects that you may have will depend on things like the type and dose of treatment that you have. Some of the very general side effects that can happen after having cancer treatments include:
- Feeling and being sick (nausea and vomiting)
- Tiredness
- Feeling emotional
- Temporary effect on your bone marrow causing anaemia and an increase in your risk of getting an infection
- Bowel problems (constipation or diarrhoea)
There are other side effects that you may have. Your medical team should discuss with you all the possible side effects of the specific treatment you are having before you start it. Other medicines can often be given to help control many of the side effects.
Will I need to take 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. You may only need one type of drug. But it is not uncommon to be given two or three drugs to help keep your pain under control. Which drugs you have will depend on the cause of the pain and how it is affecting you. You may start with some of the mild pain-relieving drugs such as paracetamol. If these don't help then your doctor may order something a bit stronger such as codeine. If this stops working then you may need a stronger type of drug called opioids. These include the morphine drugs. These are usually the best drug to help relieve bone pain.
There are also a group of drugs called non steroidal anti-inflammatory drugs (NSAIDs), which include Ibuprofen (Nurofen) and diclofenac (Voltarol). These can help to reduce any swelling that may be causing your pain.
Will I become addicted to morphine?
This is a common worry for a lot of men. Research has shown that if you are taking morphine for the right reasons (pain) then addiction is very unlikely 8. Most men do need to keep taking some type of pain-relieving drugs for a while. However, if you have been using morphine, you may be able to reduce the dose over time if radiotherapy has successfully helped control your pain. You may even be able to stop taking it but this should not be done suddenly. Your doctor will discuss this with you if necessary.
What are the side effects of pain-relieving drugs?
All pain-relieving drugs can cause side effects. The main one is constipation. This is common when you are taking codeine-based drugs or opioids such as morphine. Constipation can be very uncomfortable so your doctor should prescribe laxatives for you to take regularly. It also helps to drink plenty of water and eat a high fibre diet.
Morphine-based drugs can also make you feel drowsy when you first begin taking them. Try not to worry too much about this. It usually settles down after a few days when your body has become used to having it. You may also have problems with feeling sick (nausea). Again, this usually only lasts a short time and can be controlled with anti-sickness drugs. It is important that you discuss with your doctor about whether or not it is safe for you to drive when you are taking pain medications that cause drowsiness.
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:
- Use music, reading or television to try and take your mind off your pain
- 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
- Have a chat with someone close to you either on the phone or ask them around to chat or read a book to you – this may take your mind of things for a short while
- Some people find it helps to use complementary therapies such as acupuncture, aromatherapy, reflexology and hypnotherapy.
These suggestions are not magic cures but they may help some men feel more in control of their pain.
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 as well. Feeling more in control of your emotions can help make you feel better. It is very important not to feel alone with your pain. You may find it helps to talk to your doctor or a specialised cancer nurse such as a Macmillan or Marie Curie nurse. Many of these nurses have counselling training and can help you work through some of your concerns. They also know a lot about cancer pain and how to manage it. A great deal of your anxiety may go if you know what to expect. It is important that you know your options so that you can make informed decisions about your care. If you don't already have contact with one of these nurses you can ask your GP to refer you to their services.
Questions to ask your doctor
- What is causing my pain?
- How long will my pain last?
- Who will assess my pain?
- Does having pain mean that my cancer is getting worse?
- What treatments are available to help treat my pain?
- Who is the best person to talk to about my pain?
- Will I need to take pain-relieving drugs?
- Are pain-relieving drugs addictive?
- What else can I do to help with my pain?
More information
The Prostate Cancer Charity
This fact sheet is part of the Tool Kit, which includes a Glossary which explains some of the words and phrases used in this sheet.
Cancerbackup
3 Bath Place, Rivington St, London EC2A 3JR
Freephone 0808 800 1234 Mon-Fri 9am-8pm
Information on cancer including booklets on prostate cancer.
Macmillan Cancer Support
89 Albert Embankment, London SE1 7UQ
Macmillan cancerline: 0808 808 2020 Mon - Fri 9am - 10pm
Practical, emotional and financial support for people with cancer, family and friends.
Marie Curie Cancer Care
89 Albert Embankment, London SE1 7TP
Phone: 020 7599 7777
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.
National Comprehensive Cancer Network (NCCN)
This American website gives information for patients on the diagnosis and treatment of pain. Click on ‘treatment guidelines for patients’.
Pain Concern
PO Box 13256, Haddington EH41 4YD
Telephone: 01620 822 572
Information about managing pain plus telephone contact with others who have experience of pain. References to sources of information used in the production of this fact sheet are available on our website.
Sources used in the compilation of this page
1: Souhami R, Tobias J. Cancer and its management. 5 th ed. Oxford : Blackwell; 2005.
2: Prodigy Guidance. Palliative care – pain. NHS National Library for Health. Clinical Knowledge Summaries; 2006. [cited 2007 Feb 1]. http://www.prodigy.nhs.uk/palliative_care_pain/view_whole_guidance
3: Twycross R, Wilcock A. Symptom management in advanced cancer. 3 rd ed. Abingdon: Radcliffe Medical; 2002.
4: Spiegel D, Sands S, Koopman C. Pain and depression in patients with cancer. Cancer 1994; 74(9): 2570-2578.
5: Jager PL , Kooistra A, Piers D.A. Treatment with radioactive 89 strontium for patients with bone metastases from prostate cancer. BJU Int. 2000; 86(8): 929-934.
6: British Association of Urological Surgeons, The Prostate Cancer Charity. The BAUS Guidelines for the management of metastatic prostate cancer: an overview. London : The Prostate Cancer Charity; 2005. http://www.prostate-cancer.org.uk/news/features/baus_1.asp
7: National Institute for Health and Clinical Excellence. Interventional procedures overview – Docetaxel for the treatment of hormone-refractory metastatic prostate cancer. London : NICE; 2006 [cited 2007 Feb 1]. http://www.nice.org.uk/guidance/TA101
8: Royal College of Physicians. Principles of pain control in palliative care for adults. [Consensus statement on the Internet]. London : Royal College of Physicians; 2000. http://www.rcplondon.ac.uk/pubs/wp/wp_pc_home.htm
Reviewed by:
- Debra Gordon, Clinical Nurse Specialist Palliative Care, Edinburgh Cancer Centre
- Anne McGee, St Catherine’s Hospice, West Sussex
- Melanie Solieri, Nurse Manager, Chronic Pain Management Service, Southend Hospital
- Anna-Marie Stevens, Clinical Nurse Specialist Palliative Care, Royal Marsden NHS Foundation Trust
- Dr John Zeppetella, Medical Director, St Clare Hospice, Essex
- The Prostate Cancer Charity Information Volunteers
Written by: Annie Angle, Specialist Oncology Nurse Writer
Edited by: Debbie Clayton, Information Manager, The Prostate Cancer Charity
The Prostate Cancer Charity makes every effort to make sure that its services provide up-to-date, unbiased and accurate facts about prostate cancer. We hope that these will add to the medical advice you have had and will help you to make any decisions you may face. Please do continue to talk to your doctor if you are worried about any medical issues.
© The Prostate Cancer Charity January 2003, revised February 2007. To be reviewed February 2009