In a recent poll of the American people, cancer was cited as the disease that most Americans (53%) feared would end their lives. Even though heart disease is 50% more likely than cancer to cause an American to die, it is the concern of only 37% of Americans. Among the African-American community, 78% believe that cancer is a major problem, and 17% believe it is a minor problem. Of American women, 40% are very worried that they may develop breast cancer.
Considering the chilling statistics that one in three American women and one in two American men will develop cancer in their lifetime, the threat is real. But why are Americans so afraid of cancer? Many people say that they do not fear death, but they do fear cancer. The answer can be summarized in one word: “pain.” People do not fear death; they fear the agony that precedes it. Heart disease is thought to result in a quick, nearly painless death, whereas death from cancer is widely perceived to be agonizing. Although not necessarily true, these perceptions are confirmed by generations of experience and the media.
Only recently has the medical profession focused its energy on pain management. It will take many years to improve the science of pain control in cancer patients, and many more years to convince the public that pain can and will be managed effectively.
Many treatments are now available to relieve the pain and anguish associated with cancer. The medical profession has a responsibility not only to learn more about the basic science and causes of pain but also to disseminate knowledge about effective pain control methods. We must do a better job in using currently available, effective treatments for cancer pain and finding more effective ones.
Pain in the Context of Quality-of-Life Issues
With that background, the paper by Olson and Pienta is a very important addition to the literature. In fact, I would strongly encourage the dissemination of this information to our urologic colleagues.
Pain is more than just the physical stimulation of nerves that is interpreted by the brain as a negative feeling, however. It is the poor quality of life that is associated with a serious or terminal disease. It is the psychological trauma of knowing that there is no hope, and the separation anxiety stemming from leaving a family behind. It is also the total loss of control that comes when a disease overtakes the body. The patient’s mind may yearn for time, control, and a sense of well-being, but the disease inexorably marches on until it claims its victims’ strength and hope and, subsequently, life.
Several studies have measured pain threshold and its effect on people. These studies have shown that individuals who believe that pain is a necessary passageway to better health are better able to tolerate that pain, and it is easier to control. However, when the patient interprets pain as a precursor to death, it is more difficult to control.
Thus, quality-of-life issues in prostate cancer patients, as discussed in a previous article in oncology,[1] are an integral part of overall management. Within this context, special emphasis must be placed on controlling pain (both physical and psychological).
Importance of Early Intervention
Olson and Pienta describe the various regimens employed to treat pain in prostate cancer patients and explain the scientific basis for their use. This is very helpful. However, the importance of early intervention needs to be emphasized. Education of the patient, family, and health care provider is crucial. The patient and family must be aware of the early signs and symptoms of
metastatic disease, which do not necessarily involve pain. Fatigue and its fellow-traveler, depression, often can predate and exacerbate pain.
Equally important, the clinician needs to view the patient as a total human being, not just a disease or particular symptom to be treated. This whole person needs constant encouragement, education, empathy without sympathy, and communication.
Summary
This excellent article needs to be read and reread by those caring for patients with prostate cancer. Only through a fundamental understanding of the physical and psychological pain that many patients experience can the health care provider confer the expert advice that the patient and family desperately desire. Only through an understanding of the concerns and needs of the patient can the provider have the satisfying experience of knowing that the patient has received the finest care available, based on science and humanism.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
