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7 Articles in Volume 1, Issue #5
Accidentally Speaking
Breaking Down the Barriers of Pain: Part 5
Cancer Pain: Successful Management of Patients’ Fears
Emergency Medicine: Emergency Department Protocols
Magnets & Medicine
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 3
Thinking About Pain

Cancer Pain: Successful Management of Patients’ Fears

Appropriate assessment is essential to treatment planning and successful management of the patient’s pain.

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?

Psychosocial

  • 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
    evaluation
    —Back and neck pain — motor and sensory function in limbs;
    rectal and urinary sphincter function

Diagnostic

  • 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

Once the intensity of the patient’s pain has been assessed, the National Comprehensive Cancer Network (NCCN), a network of 18 major comprehensive cancer centers, recommends the clinician rule out an oncologic emergency, such as a fracture or impending fracture of weight-bearing bone; bowel obstruction/perforation; epidural or leptomeningeal metastases; and pain related to an infection. If one of these is present, treatment focuses on resolving the underlying problem. If no underlying problem exists, pharmacologic treatment is started based on the intensity of pain. The pain intensity is reassessed on an ongoing basis to determine satisfactory relief of pain, and treatment plans should be adjusted if the patient’s pain level changes. If the patient’s pain is not relieved, the clinician should reevaluate the underlying cause.16

Cancer Pain Management

The majority of cancer patients will have satisfactory pain relief with a treatment plan that incorporates primary therapy, such as chemotherapy, surgery, or radiotherapy directed at the tumor; systemic pharmacologic analgesia; and psychologic techniques. Patients whose pain does not respond to this regimen may gain relief with more invasive anesthetic or neurosurgical approaches.

Primary Therapy

The clinician may decide after assessing the pain that it can be relieved best by treating the underlying disease. Primary therapies include surgery to remove a tumor; chemotherapy to reduce the size of a tumor; radiotherapy to relieve bone pain; or antibiotic therapy to relieve pain caused by complications such as cellulitis, pelvic abscess, or other infection.

Systemic Analgesic Pharmacotherapy

The use of analgesic medications is the mainstay of cancer pain treatment. Analgesic medications are classified as nonopioid analgesics, opioid analgesics, and adjuvant analgesics, with the latter acting along with analgesics to increase the likelihood of effective pain relief for specific types of pain.

The analgesic ladder, developed by the World Health Organization (WHO), utilizes a three-step approach to the treatment of chronic cancer pain. It uses a scale with levels 1, 2, 3 indicating mild, moderate, or severe pain. For level 1, the guideline recommends the use of a nonopioid analgesic with or without an adjuvant medication if indicated. If the pain persists or increases to a level 2, an opioid is prescribed in combination with non-opioid analgesics and adjuvants as indicated. If pain worsens or becomes a level 3, stronger opioids are used and adjuvant and nonopioid medications are continued.17

Nonopioid Analgesics. Aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) are often effective for mild to moderate pain. They also are used in combination with opioids when pain is moderate to severe. They are a heterogeneous group of medications with different mechanisms of action and different side effects. A minimum effective analgesic dose, ceiling dose, or toxic dose for the cancer patient is not known. Doses may be higher in cancer patients because recommended therapeutic doses are often established in healthy individuals with a variety of underlying causes for their pain.18

Opioid Analgesics. Cancer patients with moderate to severe pain should be treated with opioid analgesics. The administration of opioids requires that the clinician have a good understanding of the principles of opioid pharmacology, including routes of administration, drug selection, dosing and dose titration, and prevention and management of side effects. Commonly used opioids include codeine, fentanyl, hydrocodone, hydromorphone, levorphanol, morphine, meth-adone, oxymorphone, and oxycodone. In practice it is often useful for the clinician to become familiar with one member of the different classes of opioids. The response to particular drugs can vary greatly from patient to patient. So, if a particular analgesic is not effective in relieving pain, another one might be.

Route of administration. When feasible, the oral route of administration is preferred. Parenteral or intravenous administration is considered for patients who cannot take an oral medication, for those who need a rapid onset of pain relief, or for those who may not be able to manage the logistics or side effects associated with the oral route.19

One unique route of administration is transdermal delivery. This approach uses a drug reservoir with a drug delivery control device, which slowly releases the analgesic to the skin surface at a constant amount per unit of time. Fentanyl is the one opioid available for administering via transdermal patches. This drug is also available in a transmucosal formulation that provides rapid absorption and achieves blood levels comparable to the parenteral form of fentanyl.

Continuous intravenous or subcutaneous infusion of analgesics is also feasible for patients who cannot tolerate oral forms of opioids. Continuous infusions are also used when the dose of opioid is sufficiently high to render the oral form impractical.

Dose titration. The adjustment of the opioid dose is essential to the success of opioid therapy. The dose should be adjusted at the start of therapy and throughout the course of treatment as needed. Clinicians who do not frequently treat cancer pain are often surprised by the amount of opioid needed to relieve some patients’ pain. Patients vary greatly in their opioid dose, and some patients require very high doses of opioids to achieve pain relief.

Patient-controlled analgesia (PCA) is a technique of intravenous or subcutaneous drug administration that allows patients to titrate the rate of drug administration to meet their pain needs. The system delivers a bolus of drug pre-established by the clinician but regulated by the patient.

Side effects. The goal of cancer pain therapy is to provide the maximum benefit to the patient with the fewest side effects. Virtually all pain medications have some side effects that require management. The use of preventive measures, diligence in surveillance, and anticipatory planning are essential components for minimizing adverse effects. For example, a prevention care plan for constipation with opioid use recommended by the NCCN includes increased fluid intake, increased dietary fiber, exercise, laxatives, and stool softeners when opioid therapy is begun.16 Treatment guidelines also address other common side effects such as nausea, mental confusion, and sedation.

Adjuvant Analgesics. Adjuvant analgesics are drugs that have a primary indication other than pain treatment but assist in providing analgesia. When an analgesic is not effective, an adjuvant can be combined with the analgesic to obtain an enhanced response. Acetaminophen and NSAIDs are often used as adjuvant analgesics. Adjuvant analgesics used in cancer pain management are listed in Table 2.

Table 2 Commonly Used Adjuvant Analgesics
Drug Category Indication Preferred Drugs
Antidepressants Continuous neuropathic pain; pain complicated by depression or insomnia Amitriptyline, doxepin, imipramine, desepramine, nortriptaline, paroxetine
Anticonvulsants Lancinating, neuropathic pain Gabapentin,carbamazepine, phenytoin, valproate, clonazam, baclofen
Oral local anesthetics Neuropathic pain Mexiletine, tacainide
Neuroleptics Pain complicated by delirium, nausea; refractory neuropathic pain Fluphyenazine, haloperidol, methotrimeprazine
Muscle relaxants Acute musculoskeletal Carisoprodol, chlorzoxazone, methocarbamol,cyclobenzaprine
Antihistamines Pain complicated by anxiety or nausea Hydroxyzine
Corticosteroids Pain from infiltration of neural structure compression; bone pain; pain in patients with advanced disease Dexamethasone
Bisphosphonates Bone pain Pamidronate, clodronate
Radiopharmaceuticals Bone pain Strontium-89
Miscellaneous Bone pain Calcitonin

Adapted from Cherny, NJ. Cancer Pain: Principles of assessment and syndromes. In Berger, Portenoy, Weissman, eds (1998) Principles and practice of supportive oncology. Lippincott-Raven. Philadelphia.

Patients vary greatly in their response to adjuvant analgesics. Patient characteristics, such as advancing age or coexistent major organ disease, may complicate the selection of an adjuvant.18

Psychosocial Support for the Person with Cancer Pain

Support for adequate pain management

  • Psychosocial support is an important part of effective pain control.
  • Pain can usually be managed by the primary health care provider.
  • Pharmacy and pharmaceutical companies should be contacted for financial support if payment is a problem for the patient.
  • Families may have to speak up and ask for pain management if the patient is not able to.

Emotional support

  • Emotional support reassures the patient that pain is a problem to be addressed.
  • Emotional responses to the pain experience are normal.
  • The team will work with the patient and family to address the pain problem.
  • A care plan will be developed tailored to the patient's needs.
  • The cancer care team is committed to relieving the patient's pain.
  • There is always something else that can be done to try to manage the patient's pain.

Skills Needed

  • Coping skills to manage emotional responses, provide pain relief, and enhance personal control.
  • Coping skills for pain emergency such as breathing exercises and distraction techniques.
  • Coping skills for pain which includes the above plus relaxation techniques, guided imagery, and hypnosis.

Source: ACS/NCCN Cancer Pain Treatment Guidelines for Patients. American Cancer . 2001. No. 9488-HCP.

Other Noninvasive Analgesic Techniques

Psychologic and psychiatric techniques can be effective in relieving cancer pain and improving the patient’s ability to function and carry out usual activities. These therapies include distraction, imagery, massage, relaxation, physical therapy, use of heat and cold, transcutaneous electric nerve stimulation (TENS), orthotic devices, pneumatic compression pumps, learning to position for comfort, learning coping skills, cancer pain education, and emotional support and counseling.

Invasive Techniques

Most patients satisfactorily manage their pain by using the approaches outlined previously. However, studies show that 10 to 30 percent of patients with cancer pain do not have satisfactory relief from standard management approaches.18 For these patients, anesthetic and neurosurgical techniques may provide relief. These methods include: epidural, intrathecal, and intraventricular opioids; intrapleural local anesthesia; celiac plexus block; sympathetic blocks for visceral pain and somatic structures; rhizotomy for neuropathic pain; and cordotomy.

The use of anesthetic and neurosurgical techniques should be based on the duration of pain relief required, the immediate and long-term risks of the procedure, likely survival time, availability of the necessary expertise to perform the technique, and anticipated hospital length of stay.

Important Messages for Patients and Families
  • Your doctor and nurse are concerned about your pain.
  • There is no benefit to suffering with pain.
  • Pain can usually be well controlled with medicines taken by mouth.
  • If these medicines do not work, many other options are available.
  • Morphine or morphine-like medicines are often used to relieve pain. When these drugs are used to treat cancer pain, addiction is rarely a problem. If these are used now, they will still work later.
  • Communication with the doctors and nurses is critical.
  • Doctors and nurses cannot tell how much pain you have unless you tell them.
  • Doctors and nurses want to know about any problems the pain medicine might be causing, since there are probably ways to make these better.
  • The doctor or nurse wants to know if there are any problems getting the medicine or if you have concerns about taking them. They have dealt with these issues before and can help.

Source: ACS/NCCN Treatment Guidelines for Patients. American Cancer Society. 2001. No. 9489-HCP.

Breakthrough Cancer Pain

Breakthrough cancer pain, a specific type of cancer pain, occurs when episodes of moderate to severe pain “break through” the persistent pain that is otherwise controlled by appropriate analgesia.20,21 As many as one half of patients with cancer pain experience breakthrough pain. It usually has a rapid onset and becomes severe quickly. It may result from a change in activity but often the patient does not recognize the cause. Patients can have as many as three to four episodes in one day. Because it can occur at the time of the next scheduled dose for treating persistent pain, breakthrough pain must be differentiated from end-of-dose pain. Rapid-acting opioids are needed for relief. Those that are effective in relieving this pain quickly are oral transmucosal fentanyl citrate and oral immediate-release morphine.

Addiction in Cancer Patients

In spite of the great fear among patients and in some instances among caregivers, addiction in cancer patients is extremely uncommon. In one large study of 11,882 patients who received at least one opioid while in the hospital, only four patients became addicted.22 In a prospective study of 550 cancer patients who were treated with morphine for over six weeks, only one patient developed problems related to addiction.23 These studies, as well as others, should be reassuring to both patients and physician, that addiction in cancer patients is extraordinarily rare when managed appropriately.

Conclusion

The goal of cancer pain therapy is to provide the maximum relief to the patient with minimum side effects. Success of effective pain management depends on an accurate assessment of the patient’s pain. Effective treatment techniques and treatment guidelines are now widely available which allow clinicians to provide pain relief for the vast majority of patients with cancer. However, like all areas of medicine there is sometimes a need to refer patients to specialists if the complexity of pain management required exceeds the physician’s experience.

Last updated on: September 27, 2012
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