Most of this document talks about ways to remove or to destroy prostate cancer cells or to slow their growth. But maintaining your quality of life is another important goal. Don't hesitate to discuss pain, other symptoms, or any quality of life concerns with your cancer care team. Pain and most other symptoms of prostate cancer can often be treated effectively. If the treatments listed above don't help with symptoms, there are several other options.
Pain medicines
When properly prescribed, pain medicines (ranging from aspirin to opioids) are very effective. You may worry about addiction with opioids, but this is almost never a problem if the drug is being used as directed to treat cancer pain. Symptoms such as drowsiness and constipation are likely but can usually be treated by changing the dose or by adding other medicines.
Bisphosphonates
Bisphosphonates are a group of drugs that can help relieve bone pain caused by cancer that has spread (metastasized). These drugs may also slow the growth of the metastases and prevent fractures. Bisphosphonates also help to strengthen bones in men who are also receiving hormone therapy. The most commonly used bisphosphonate is zoledronic acid (Zometa®), which is approved for use in bone metastases from prostate cancer. It is given as an intravenous (IV) injection. Other bisphosphonates have been approved for other uses, and some doctors use these "off label" (to treat a condition for which they have not been approved by the Food and Drug Administration) to treat prostate cancer.
Bisphosphonates can have their own side effects, including flu-like symptoms and bone pain. They can also lead to kidney problems, so patients with poor kidney function may not be able to be treated with these medications. A rare but very distressing side effect of bisphosphonates is something called osteonecrosis of the jaw (ONJ). With this condition, the blood supply to an area in the bone stops, and that part of the bone dies. This can lead to tooth loss and infections or open sores of the jaw bone that won't heal. There is no really good way to treat this, other than to stop the drug and give supportive care. Doctors don't know why some people develop ONJ while on bisphosphonates, but it seems to come up more often after dental work (such as having a tooth pulled) is done while on this medicine. That is why many cancer doctors recommend that a patient who will be starting a bisphosphonate have a dental checkup and have any tooth or jaw problems treated before they start taking the drug. Maintaining good oral hygiene by flossing and brushing, making sure that dentures fit properly, and having regular dental checkups may also help prevent this condition.
Denosumab
Denosumab (Xgeva™) is another drug that can help when prostate cancer spreads to bone. When prostate cancer cells spread to the bones, they can turn on the cause cells that the body uses to break down bone (called osteoclasts). Denosumab blocks the osteoclasts from being turned on by blocking a substance called RANK ligand. Studies have shown that it can help prevent problems like fractures in men with bone metastases better than zoledronic acid. It also can be helpful when zoledronic acid is no longer working.
This drug is given as an injection under the skin every 4 weeks. Men given this drug are often urged to take a supplement containing calcium and vitamin D to prevent problems with low calcium levels. Like the bisphosphonates, denosumab can cause ONJ, so doctors recommend taking the same precautions (such as having tooth and jaw problems treated before starting the drug).
Steroids
Some studies suggest that corticosteroids (such as prednisone and dexamethasone) can help relieve bone pain in some men.
External radiation therapy
Radiation therapy can help reduce bone pain, especially if the pain is limited to one or only a few areas of bone. Radiation can be aimed at tumors on the spine, which can help relieve pressure on the spinal cord in some cases. Radiation therapy may also help relieve other symptoms by shrinking tumors in other parts of the body.
Radiopharmaceuticals: Strontium-89 (Metastron®) and Samarium-153 (Quadramet®) are drugs that contain radioactive elements. They are injected into a vein and collect in bones. Once there, the radiation they give off kills the cancer cells and relieves some of the pain caused by bone metastases. About 80% of prostate cancer patients with painful bone metastases are helped by this treatment at least for a while.
These drugs are used to treat bone pain caused by metastatic prostate cancer -- they are not for early stage prostate cancer. These drugs are especially helpful when prostate cancer has spread to many bones, since external beam radiation would need to be aimed at each affected bone. In some cases, one of these drugs will be used together with external beam radiation aimed at the most painful bone metastases.
The major side effect of this treatment is a lowering of blood cell counts, which could place you at increased risk for infections or bleeding, especially if your counts are already low.
It is very important that your pain be treated effectively. This will help you feel better and allow you to focus on the people and activities that are most important to you. There are many ways to treat your pain, so be sure and tell members of your entire prostate cancer care team about your symptoms.
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