The management of pain in patients with end-stage prostatic malignancy
Pain produced by prostatic malignancy is a pain that usually does not have a well-defined time of onset, and although it has a definable cause, it is persistent and not associated with the physical signs of autonomic nervous system activity usually associated with acute pain discomfort. The physician, managing the patient with pain secondary to prostatic malignancy, has few objective signs that will substantiate the patient's complaint of pain. The physician, upon encountering the patient with malignant disease, must accept the patient's report of pain. Although the patient may not 'look' as if he is in pain, there usually are associated changes in personality, life-style, and functional ability characterized by the signs and symptoms of depression, such as helplessness, hopelessness, the loss of libido and weight, and sleep disturbances. Patients with metastatic prostate carcinoma should not be treated with placebo to determine if their pain complaint is 'functional' in an attempt to receive sympathy from their surrounding environment. A response to placebo occurs commonly in most patients. Thus, a positive analgesic effect from either intramuscular or oral placebo does not provide useful information with respect to the origin or severity of the pain. Most patients will obtain temporary relief from their pain when provided a placebo even when therre is a documented organic basis for the pain disorder. The patient who has widespread prostatic carcinoma should be viewed as having real pain that requires definitive treatment. Patients with pain secondary to prostatic malignancy usually require treatment directed at the symptoms, not the cause. However, in patients with widespread prostatic malignancy, treatment may be directed at the cause if they have not previously received androgen deprivation therapy.
