You should not have to accept pain as a normal part of having cancer.

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 doctor should discuss and investigate other causes of the pain that you are experiencing.

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 tell your doctor. 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 doctor 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 you will be able to control your pain effectively.

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. Dealing 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. Speak to your doctor about how you are feeling, emotionally, and seek out a Malecare support group.

How is pain assessed?
How you describe your pain to your doctor is very important in helping find the best treatment for you. Your doctor will try to gather as much information as possible about you and your pain.
Before you see your doctor, 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.

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

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:
• Pain-relieving drugs.
• Hormone therapy.
• Steroids.
• Palliative radiotherapy.
• Chemotherapy.
• Medicines called bisphosphonates.
• Other therapies for example nerve blocks or Transcutaeneous Electrical Nerve Stimulation (TENS) machine.
• Complementary therapies.
• Emotional support.
• Treatments for other causes of pain, for example antibiotic therapy, which can be very effective for pain caused by an infection.

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 doctor may be able to try something else. Tell your doctor about any new pain. This may or may not be related to your cancer.
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 doctor may use a guide called a ‘pain relief ladder’ 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 opiods such as codeine.

Step 3 Severe pain
Strong opioids such as morphine. By using this approach, your doctor 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 doctor.
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 nflammation 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-relievingdrugs described above include:
• Difficulty emptying your bowel (constipation) – this can be very uncomfortable so your doctor 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 doctor 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. 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 buprofen are enough to control their pain.

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 doctor may prescribe additional tablets to help to protect your stomach.

It is important not to stop taking steroids suddenly as this can make you very ill. Instead you could discuss reducing your dose gradually.

Palliative 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 radiotherapy, often referred to as palliative radiotherapy. This is different from having radiotherapy to treat cancer that has not spread outside the prostate gland (local 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.

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.
Ask your doctor about treating and preventing bone problems with 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.

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 stabilize the area of affected bone.

Transcutaeneous Electrical Nerve Stimulation (TENS)
Some pain clinics and doctors 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.

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.

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, but some people have found them helpful.