Managing Cancer-Related Pain: A Look at Alternative Approaches
Pain continues to be the most important undertreated symptom in end-stage cancer patients, with 50% to 90% of patients experiencing cancer-related pain.1,2 Cancer pain can be multifaceted, involving somatic, visceral, and neuropathic components. The ability to effectively assess a patient’s pain and know different ways of providing pain relief are essential not only for healthcare providers but for all those involved in the care of cancer patients. Unfortunately, cancer pain management tends to focus solely on biomedical issues, with the primary emphasis on medications.
Despite the fact that nonpharmacologic therapies have significant evidence of benefit and potential for pain relief and quality-of-life improvements, they still are not widely incorporated into palliative-care models for cancer patients. Cancer affects millions of individuals and their families. The aim of this article is to increase awareness of different ways to cope with cancer-related pain, whether this is through medication or complementary interventions. Ultimately, the goal is to help cancer patients feel like they once again have a life worth living.
As noted, pharmacologic management is considered the first line of treatment for cancer-related pain. In 1986, the World Health Organization (WHO) established guidelines for pain relief in cancer patients; these guidelines remain the standard of care to this day.3 Understanding the fundamentals expected of healthcare providers in treating cancer pain is essential before alternative treatment approaches are explored. WHO outlined a 3-step ladder, involving a progression from nonopioids (eg, aspirin and nonsteroidal anti-inflammatory drugs) to “weak” opioids, and from adjuvant therapies to strong opioids (eg, morphine) until the patient is theoretically pain free (Figure 1).3,4
A patient’s medical management is based on the current severity of pain in relation to the stage of disease. These drugs are usually administered every 3 to 6 hours instead of on an “as needed” basis. Consequently, if a patient reports inadequate pain relief, a provider can determine if the dosing and associated intervals are appropriate. Similarly, the intensity and frequency of pain can be correlated with the WHO ladder to see if the patient is being undertreated. The WHO recommendations are clear and have been implemented with quantifiable success in different clinical settings.5-7
When practiced appropriately, the WHO guidelines provide a good foundation for pain relief. Ideal medical management of pain also involves tracking patient progress, assessing and reassessing the patient’s pain, and monitoring side effects of different therapeutic modalities. If patients are experiencing neuropathic pain, an existing medication schedule can be supplemented with antidepressants (eg, tricyclic antidepressants), anticonvulsants (eg, gabapentin, pregabalin), and topical agents (eg, lidocaine patch). Medication side effects, fear of addiction, and the development of tolerance can weigh down on patients and make them noncompliant or averse to the pharmacologic pain management. The search then begins for nonpharmacologic ways to cope with pain.
If the cancer is potentially curable, surgery, radiation, and/or systemic therapy can be used to durably alleviate cancer pain. A subset of patients with limited metastases have long-term survival following definitive treatment. More commonly, patients with distant metastases require supportive care and palliative treatment.
Radiation therapy can be safely performed in 1 to 10 treatments, is 65% to 70% effective at relieving pain, and reduces the need for opioid medications and the subsequent risk of pathologic fractures.8 Painful metastases may respond to radiation, chemotherapy, hormonal therapy, and/or regional nerve blocks. Interestingly, pain is not necessarily associated with lower survival odds in patients with advanced cancer.9
Individuals with poor performance status, extensive disease, and inadequate nutrition generally have a worse prognosis and may be better candidates for supportive therapy alone. For this poor-prognosis cohort, potential side effects of treatment may outweigh any palliative benefit.
Relaxation Techniques And Psychosocial Support
Interventions geared toward relaxation in cancer patients can also be used to reduce reactivity to pain. The relaxation techniques discussed here involve the use of deep breathing and imagery. On a basic level, consciously pairing muscle tension with inhalation and muscle relaxation with exhalation assists a patient in using breathing to control pain. More specifically, deep breathing is thought to help the patient concentrate better, soothe the nervous system, and balance the mind-body connection—this is especially true when used during activities like yoga, meditation, and tai chi.10
Jon Kabat-Zinn, PhD, established the mindfulness-based stress reduction (MBSR) meditation technique that has been studied for its effect on psychological stress and pain in cancer patients. MBSR is an 8-week, structured program that includes sitting meditation, silent body scanning, and simple yoga postures.11 A recent study by CA Lengacher, RN, PhD, and colleagues of breast-cancer survivors revealed improvements in physical functioning, pain, and emotional well-being in patients who regularly practiced the MBSR technique.12
Imagery in the context of cancer is defined as having patients use positive visualizations to substitute for the feeling of pain. Imagery and relaxation training have been found to decrease the intensity of cancer-related pain, possibly through an interruption in the pain/muscle tension/anxiety cycle.13,14 Sloman and colleagues studied the use of imagery and relaxation training in intermediate- to advanced-stage cancer patients and, in addition to the above, they noted a decreased need for non-opioid analgesics in managing pain.15