Cancer Pain

Despite all the advances that have occurred in understanding the pathophysiology and treatment of pain, cancer pain remains a very prevalent and serious public health problem. Pain precludes a satisfactory quality of life. Repeatedly many health surveys have found a high incidence of pain related to cancer, and its treatment. Several barriers have been identified that help explain these statistics. These barriers fall into three categories:

• Patient
• Health care professionals
• Societal

Patient barriers include:

1. Patient's reluctance to report pain
2. Patient's reluctance to follow treatment recommendations
3. Patient's fear of tolerance and addiction
4. Patient's concern about side-effects
5. Patient's belief that pain is an inevitable consequence and must be accepted
6. Patient's fear of disease progression
7. Patient's fear of injections

Health care professional barriers include:

1. Lack of appreciation of the extent and impact of a patient's pain
2. Poor patient assessment skills
3. Knowledge deficits on the appropriate approach to the management of cancer pain
4. Lack of knowledge of the long term effects of opiates
5. The lack of time committed to pain as a priority

Societal barriers include:

1. Perceived and real regulatory barriers to the use of controlled substances
2. The lack of priority to fund research and treatment for pain
3. The lack of understanding of the scope of the problem and the availability of treatment options

The key to successful pain management is accurate and reproducible assessment of a patient's pain. Factors that are important in assessment include:

1. The onset of pain
2. Classification of the pain to either neuropathic or nociceptive
3. Exacerbating and relieving factors
4. Temporal pattern
5. Exact onset
6. Associated signs and symptoms
7. How the pain interferes with daily activities
8. The impact of the pain on a patient's psychological state
9. The response of lack of to previous analgesic therapies
10. The etiology of the pain
11. A thorough physical examination

Following an accurate assessment of a patient's pain, a diagnosis and treatment plan should be formulated. Many cancer pain syndromes have been identified. Examples of these are numerous and can be related to the location of the original cancer, its treatment or systemic effects of the tumor. These systemic effects are now gradually being discerned and research is beginning to identify these systemic factors.

The WHO has formulated treatment guidelines, which since has been validated. These guidelines are a three-step process that suggests treatment approaches for a patient's pain. These steps are:

1. Step one for mild to moderate pain. Often a non-opiate with or without and adjuvant be used for this type of pain. Pain in this stage is often managed by short acting analgesic on an as needed basis.
2. Step two for mild to moderate pain. Treatment for this stage is usual a weak opiate with or without a non-opiate analgesic and an adjuvant. Traditionally patients in this category have been treated with short acting analgesics. Experience suggests longer acting timed-release formulations are preferred even in this stage by patients. Several timed-release formulations are now available and under development.
3. Step three for moderated to severe pain. Treatment for this stage is usual a strong opiate with or without a non-opiate analgesic and an adjuvant. Morphine like agonists is widely used for this stage. There is no evidence of any preferred opiate with which to start from. Personal experience and patient response are most important. For more information, please see the opiate section of this web site.

Studies have shown that these WHO guidelines can relieve cancer pain in 80% of patients. For pain that is non-responsive, or with patients with intolerable side-effects many other therapies including interventional techniques are available. These are described elsewhere.

Alternative medicine has been shown to be capable of relieving many of the distressing symptoms of patients with cancer. Relaxation therapies, acupuncture, and other psychosocial treatments are often used with benefit.

Treatment for pain should begin when it first becomes apparent. The long term use of opiates has not been shown to lead to more refractory pain problems later. Uncontrolled pain leads to a poorer prognosis and should be an integral part of every patient's treatment plan. For more information about specific topics see areas of this web site.

The pain management center of the Brigham and Women's Hospital has the necessary expertise and resources to supply the entire treatment continuum including alternative therapies that a cancer patient may need.