Potential Contribution of Nonmalignant Etiologies to Back Pain in Patients With Metastatic Prostate Cancer

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In a single-institution study reported in JCO Oncology Practice, Ruppert et al found that nonmalignant etiologies contribute to back pain in many men with metastatic prostate cancer who experience pain in areas where spinal metastases are known to occur.

Study Details

The study consisted of retrospective review of findings in 53 men with metastatic disease treated at Memorial Sloan Kettering Cancer Center who reported pain in an area of known spinal metastases. Patients were evaluated in a joint medical oncology and physiatry clinic.

Data included disease extent, hormonal status, sites of spread, pain characteristics, physiatric examination findings, imaging, and recommended management. Patient pain descriptions were categorized as activity-related, biologic, mechanical, and radicular based on the literature for nonspecific back pain (activity-related, mechanical, radicular) and as classic pain types described in spinal metastases (biologic, mechanical, radicular).

Along with these classifications, data on disease state, precancer history or current presence of non–cancer-related conditions that might contribute to back pain, physical examination abnormalities, and imaging data were used to determine a pain diagnosis. The final categorizations of pain were malignant pain, mixed pain due to both cancer-related and non–cancer-related causes, and nonmalignant pain.  

Key Findings

Among the 53 patients, 35 (66%) had castration-resistant disease and 34 (64%) had a precancer history of back pain. Presenting pain symptoms were assessed as activity-related in 22 patients (42%), radicular in 8 (15%), transitional movement–related in 7 (13%), biologic in 5 (9%), and multifactorial in 11 (21%).

Pain was considered to have malignant etiology in 20 patients (38%, including 5 with castration-sensitive and 15 with castration-resistant disease), nonmalignant etiology in 12 (23%, including 4 with castration-sensitive and 8 with castration-resistant disease), and mixed etiology in 21 (40%, including 9 with castration-sensitive and 12 with castration-resistant disease).

The investigators concluded, “Nonmalignant etiologies contributed significantly to back pain at sites of metastatic spread for 33 [of] 53 (62%) patients with metastatic prostate cancer assessed by medical oncology and physiatry. We recommend multidisciplinary care for patients with metastatic prostate cancer and back pain to address nonmalignant etiologies that contribute to functional compromise.”

Lisa Marie Ruppert, MD, of the Rehabilitation Medicine Service, Department of Neurology, Memorial Sloan Kettering Cancer Center, is the corresponding author for the JCO Oncology Practice article.

Disclosure: The study was funded by the National Cancer Institute and others. For full disclosures of the study authors, visit

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