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Cancer Pain: Successful Management of Patients’ Fears

Appropriate assessment is essential to treatment planning and successful management of the patient’s pain.
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When asked about their cancer experience, patients often echo, “My greatest fear was pain.” Most fear that they will have pain and suffer, while others associate the presence of pain with disease progression and nearing death. Oncology clinicians have available the necessary knowledge, skills, techniques, and clinical guidelines to relieve most patients’ pain and therefore quiet their fears. As clinicians, we have a moral obligation to do so.

Cancer does not automatically result in pain, but if it does occur, the pain can be effectively managed. Appropriate assessment is essential to treatment planning which often involves a combination of pharmacotherapy, cognitive behavioral techniques, and invasive and noninvasive procedures. Cancer patients do not need to suffer in pain, and they should expect their health care provider to help them achieve satisfactory pain control.

Pain is experienced by 30 to 60 percent of cancer patients during treatment and by more than two thirds of those with advanced disease. A series of studies identified pain in 28 percent of newly diagnosed cancer patients, pain in 50 to 70 percent of patients currently receiving treatment, and pain in 64 to 80 percent of patients with advanced disease.1-11

Cancer pain has a significant impact on the patient’s quality of life, leading to discomfort and suffering. Patients with uncontrolled pain have problems with physical, psychologic, and social functioning. Physical effects include decreased strength, limited mobility, and difficulty sleeping. Psychologic effects are related to increased anxiety, fear, depression, and a decrease in overall enjoyment of life. Socially, the patient’s ability to form and maintain relationships with others is diminished, and increased demands are placed on caregivers.12

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue injury.13 Cancer patients experience acute pain related to diagnostic procedures, surgery, acute pressure, obstruction, or invasion of normal tissues by the tumor. However, most cancer pain is chronic, variable in intensity, and caused by the cancer itself or as a side effect of its treatment. Cancer pain may be visceral, from pain involving organs; somatic, as in that involving bone; or neuropathic, which is caused by injury to or compression of the structures of the central or peripheral nervous system.14

Pain, as perceived by the individual, is highly variable and the patient is therefore the expert in assessing his or her own pain. The high prevalence of cancer pain requires clinicians to be knowledgeable about cancer pain and have the appropriate skills to assess and diligently manage it. All cancer patients have a right to effective pain relief.

Cancer Pain Assessment

The effective treatment of cancer pain relies on a careful assessment of the patient’s pain as emphasized by recent clinical practice guidelines.15,16 The assessment clarifies the characteristics of the pain, including its impact on function and emotional well being; identifies the cause of the pain and any underlying disease; and characterizes any concurrent physical, psychologic, or social problems that may add to the patient’s distress. In its 1994 guidelines, the Agency for Health Care Policy and Research (AHCPR) outlined a comprehensive pain assessment for clinicians (See Table 1).

Table 1 Initial Pain Assessment

Pain Intensity and Character

  • Onset and temporal pattern — When did your pain start? How often does it occur? Has its intensity changed?
  • Location — Where is your pain? Is there more than one site?
  • Description — What does your pain feel like? How would you describe your pain?
  • Intensity — On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine how much does it hurt right now? How much does it hurt at its worst? How much does it hurt at its best?
  • Aggravating and alleviating factors — What makes your pain better? Worse?
  • Previous treatment — What types of treatments have you tried to relieve your pain? Were they and are they effective?
  • Effect — How does the pain affect physical and social function?


  • Effect of the cancer diagnosis and cancer treatment on the patient and the caregiver
  • The meaning of the pain to the patient and the family
  • Significant past instances of pain and their effect on the patient
  • The patient's typical coping responses to stress or pain
  • The patient's knowledge of and expectations about pain management methods
  • The patient's concerns about using controlled substances
  • The economic effect of the pain and its treatment
  • Changes in mood that have occurred as a result of the pain (e.g., depression, anxiety)

Physical and Neurologic

  • Examine site of pain and evaluate common referral patterns
  • Perform pertinent neurologic evaluation:
    —Head and neck pain — cranial nerve and fundoscopic
    —Back and neck pain — motor and sensory function in limbs;
    rectal and urinary sphincter function


  • Evaluate disease recurrence or progression or tissue injury related to cancer treatment (e.g., electromyography) testing
  • Perform appropriate radiologic studies and correlate with
    physical/neurologic exam
  • Recognize limitations of diagnostic studies
    —Bone scan — false negatives in myeloma, lymphoma,
    previous radiotherapy sites
    —CT scan — good definition of bone/soft tissue but difficult
    to image entire spine
    —MRI scan — bone definition not as good as CT; better
    images of spine and brain

Source: AHCPR, 1994

All cancer patients should be asked, “Do you have pain?” When patients report pain, the intensity can be measured by using a relatively simple but useful pain assessment tool to help them objectively describe their pain. A common method is a numerical scale that uses scores ranging from 0 to 10 with 0 being no pain and 10 being the worst possible pain. Other pain scales include the visual analog scale, categorical scale, or the pain faces scale.15,16

Last updated on: September 27, 2012
First published on: September 1, 2001