Prostate cancer: 10. Palliative care

The main side effect of strontium-89 is suppression of bone marrow function. Because a patient may already have a reduced reserve of bone marrow as a result of previous external-beam radiotherapy, myelosuppressive chemotherapy or tumour infiltration of the bone marrow, it is imperative to assess carefully the patient's eligibility for strontium-89 treatment. Systemic radionuclide therapy is not recommended for those with inadequate bone marrow reserves or inadequate renal function, nor for patients whose main symptomatic lesions show inadequate uptake on bone scanning. It is also contraindicated as the sole treatment in patients with fracture or impending fracture and compression of the spinal cord or a nerve root. As strontium-89 is aBeta emitter and is excreted in the urine, its use in men who are incontinent or who have indwelling catheters poses greater radiation safety concerns and is thus contraindicated.zo Because strontium-89 must be used in the appropriate context and only after an evaluation of the patient's overall status, previous therapy and possible future treatments, an oncologist with expertise in the overall management of the prostate cancer should be involved in its use. This patient has pain because of metastatic bone lesions. Continuous bone pain responds well to opioid analgesics. Most patients will experience good analgesia with a combination of acetaminophen plus codeine or oxycodone. After several weeks or months, this man will likely require stronger opioid agonists such as morphine or hydromorphone (drugs with similar effectiveness and toxicity).22 The initiation of opioid analgesics represents a major hurdle for some patients, in terms of fears of addiction or uncontrolled pain and the symbolic message that their illness has become serious enough that such agents are necessary. Physicians should be aware of these concerns and address them directly. In particular they should reassure patients that addiction is not an issue and that adequate pain control can be achieved in most cases. Patients should always undergo titration to good pain control with short-acting opioids every 4 hours before being switched over to a maintenance dose of a slow-release opioid preparation. Slow-release preparations of morphine (once or twice a day), hydromorphone, codeine, oxycodone and fentanyl (transdermal patches every 3 days) are currently available in Canada. Patients receiving long- or short-acting opioids should have access to extra doses of ap