Andrew Siegel MD 1/25/2020
Despite what you may have heard about prostate cancer being “a slow growing malignancy” and that “most older men have prostate cancer,” the hard truth is that prostate cancer is the second leading cause of cancer death in men in the USA (>30,000 deaths estimated in 2020). The good news: the death rate has dropped over the years and the vast majority of men with prostate cancer fare well, with about 3 million prostate cancer survivors in the USA. To put this in perspective: if you have prostate cancer, you are more likely to die of heart disease than of the cancer itself.
Those patients with advanced prostate cancer who are destined to die of the disease often value their quality of life as much as their quantity of life. “Palliative management,” a.k.a. “supportive care,” aims not to treat the advanced prostate cancer, but to provide comfort to the patient to improve their quality of life. This holistic approach addresses the patient as a whole and not just the disease. It includes management of pain from bone metastases, neurological issues that may result from bony compression of the spinal cord and/or nerves, and urinary tract obstruction. Efforts are directed at improving symptoms without curing the disease.
Image by truthseeker08 from Pixabay
Localized bone pain
Patients with isolated bone metastases that are symptomatic typically have unrelenting, well-localized pain. The pain may be effectively treated with localized radiotherapy to the area of concern, often referred to as “spot radiation.”
Pathological fractures—as distinguished from “traumatic” fractures—are broken bones due to bone weakness from normal cells having been replaced by cancer cells. If a pathological fracture from the prostate cancer involves a weight-bearing bone, orthopedic surgery (in addition to radiation) may be necessary to stabilize the bone. The most common pathological fracture site from prostate cancer is the hip.
Denosunab (Xgeva) is a monoclonal antibody that effectively can delay skeletal related events. It has largely replaced Zometa because it is more easily administered (subcutaneous injection), does not have the same issues with kidney impairment, and has outperformed it in terms of effectiveness. Both medications rarely can cause jaw osteonecrosis (loss of bone integrity of the jawbone).
Diffuse bone pain
For symptomatic patients with extensive bone metastases, systemic radionuclide therapy using radio-pharmaceuticals can be helpful. Xofigo is one such drug approved by the FDA in 2013 for bone-metastatic CRPC. It mimics calcium and forms complexes at sites of increased bone turnover. It contains the radioactive material radium 223, which emits radiation at the sites of bone metastases. Xofigo has replaced the previous generation agents, Strontium and Samarium, because of an improved survival benefit and less bone marrow toxicity.
Spinal cord compression
Cord compression is a serious emergency that may occur in men with metastatic prostate cancer. When weakened by prostate cancer the vertebral column can collapse, compressing the spinal cord and/or nerves, leading to severe back pain, leg weakness, altered sensation and bowel and bladder functional issues. Even in the absence of vertebral collapse, the spinal cord and nerves can be affected by metastases, causing pain and neurological symptoms.
Vertebral metastatic disease is an emergency that requires rapid evaluation with MRI imaging of the spine and treatment with high-dosage intravenous steroids and radiotherapy to the involved vertebra. Neurosurgical intervention may be necessary if there are progressive symptoms during radiation therapy or if there is a recurrence after radiation. If androgen deprivation therapy has not been previously used, it needs to be instituted immediately.
Urinary tract obstruction
Lower urinary tract obstruction can occur as the prostate growth occludes the urethra (urinary channel leading out from the bladder). At times, this needs to be treated with surgery to create a channel through the obstruction to restore normal urinating.
Upper urinary tract obstruction can occur if the ureters (tubes that drain urine from the kidneys to the bladder) are compressed by local infiltration of the prostate cancer directly into the bladder base or by pathologically enlarged lymph nodes. This can be managed with ureteral stenting (placement of a small catheter within the ureter to alleviate the obstruction) or percutaneous nephrostomy (placement of a small catheter directly into the kidney from the flank to alleviate the obstruction).
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours).
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: Andrew Siegel MD, bone metastases, bone pain, CRPC, palliative management, prostate cancer, Prostate Cancer 20/20, spinal cord compression, urinary obstruction
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