Pain still under-treated in many men with mCRPC (even at the best centers)

Back in the 1970s and 1980s, before the availability of the PSA test (with all its flaws and benefits), it used to be the case that pain was one of the commonest symptoms leading to a diagnosis of prostate cancer … because the majority of men only got diagnosed when they already had advanced, metastatic disease.

Today, obviously, a much smaller percentage of men diagnosed with prostate cancer is initially diagnosed with such advanced disease, and the management of pain has become a less common factor in the general management of prostate cancer … but that does not mean it isn’t a real and serious issue, particularly for those men who progress while on androgen deprivation therapy because they become castration-resistant.

A new paper by Autio et al., just published in the Journal of Oncology Practice, has looked very carefully at issues related to the characteristics and management of pain in men with metastatic, castration-resistant prostate cancer (mCRPC) being treated at one of five different major prostate cancer centers belonging to the Prostate Cancer Clinical Trials Consortium. The authors used a standardized patient-reported outcomes (PRO) survey that took account of patients’ use of analgesics, the degree to which pain interfered with their daily activities, and incorporated the so-called Brief Pain Inventory or BPI.

Here are the key findings of the study:

  • 461 men with prostate cancer completed the survey.
    • 147/461 men (31.9 percent) had progressed to having mCRPC.
    • 89/147 men with mCRPC had received docetaxel-based chemotherapy.
    • 58/147 men with mCRPC were docetaxel-based chemotherapy-naive.
  • 84/147 men (57.1 percent) with mCRPC had some level of pain.
  • Among the men with mCRPC, pain was more common among those already treated with docetaxel-based chemotherapy.
    • 62/89 men with mCRPC who had been treated with docetaxel-based chemotherapy (70.0 percent) reported pain at any level.
    • 22/58 men with mCRPC who were docetaxel-based chemotherapy naive (37.9 percent) reported pain at any level.
  • A BPI score of ≥ 4 was also more common among those who had or had not been treated with docetaxel-based chemotherapy.
    • 34/89 men with mCRPC who had been treated with docetaxel-based chemotherapy (38.2 percent) had a BPI score ≥ 4.
    • 14/58 men with mCRPC who were docetaxel-based chemotherapy naive (24.1 percent) had a BPI score ≥ 4.
  • 23/58 men with a BPI score ≥ 4 (40 percent), reported no current prescription of a narcotic analgesic.

Autio and her colleagues conclude that:

  • The prevalence and severity of pain were both higher in men with mCRPC who had already been treated with docetaxel-based chemotherapy.
  • Analgesics were being under-utilized in the management of such men.

In other words, as is often found in the assessment of patients with several forms of advanced cancer, pain is still commonly under-evaluated and under-treated by physicians — particularly when there may be a real need for prescription of narcotic analgesics to manage breakthrough pain that cannot be effectively treated with non-narcotic forms of analgesia. Patients should be strongly advised to be clear with their doctors about pain associated with the cancer. This not something you need to be trying to “tough out”. Every man with mCRPC (and his caregivers) should be aware of the risks for severe bone-related pain and have access to appropriate drugs to manage such pain — inclusive of narcotic analgesic agents to deal with severe, breakthrough pain.

3 Responses

  1. Mike:

    My personal experience is: (1) I have developed bone pain while on ADT; (2) I have been treated with docetaxel (early on); and (3) the pain is becoming worse. However since nothing shows on the bone scans all my doctors completely ignore my complaints. I feel like a hypochondriac. Eventually I believe it will show up on the scans.


  2. “To cure sometimes, to treat often, to comfort always.” Still good practice.

  3. Bill,

    When Lyme tests were first developed my memory is something like 70 to 80% of those first tested had been sent to have their “emotional issues” treated. I wish you were a hypochondriac.

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