Cancer-Related Pain

Pain is one of the most common and most feared symptoms in patients with cancer. It affects about one-third of patients being treated for cancer and more than two-thirds of those with advanced disease. Toward the end of life up to 80% of patients with cancer may experience severe pain. Cancer-related pain may be due to active cancer itself, to cancer treatments, and/or to comorbidities arising from cancer. It is important to understand the nature of the pain experienced by individual patients and to distinguish between its various causes and contributing factors. Documents in this section focus on pain control and associated symptom management via pharmacotherapies, nonpharmacologic strategies, and/or complementary approaches during cancer care.

Researchers/reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.
Graphic depicts dividing cancer cells - modified from University of Birmingham, 2007.

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For additional and more specific cancer-related pain documents, see the following sections….

• Clinical Guidelines: <Click Here>
• Systematic Reviews: <Click Here>
• Position/Policy Statements: <Click Here>
• CME Courses: <Click Here>

For more general information on pain, see "Overview - Pain Management & Tx" under Clinical Concepts:<Click Here>

For your patients see the Patient Resources tab section for special educational materials: <Click Here>

Management of Pain in the Older Person With Cancer

Part 1: Pathophysiology, Pharmacokinetics, and Assessment

By: Delgado-Guay MO, Bruera E. Cancernetwork.com; 2008. Reprinted in full-text from Oncology. 2008(Jan);22(1):56-61. Access checked 3/11/08.

See HTML article at: http://www.cancernetwork.com/display/article/10165/1147001

Pain management in older cancer patients requires a multidisciplinary team approach using pharmacologic and nonpharmacologic interventions. Studies have shown that cancer pain in aged patients is frequently undertreated due to a variety of barriers. This article reviews appropriate assessment options for older patients, reviews the pathophysiology of pain, and examines special issues related to alterations in pain perception and pharmacokinetics.

Part 2: Pharmacologic Approaches to Treating Pain

By: Delgado-Guay MO, Bruera E. Cancernetwork.com; 2008. Reprinted in full-text from Oncology. 2008(Feb);22(2): Early online publication prior to print. Access checked 3/11/08.

See HTML article at: http://www.cancernetwork.com/display/article/10165/1146781

Appropriate treatment for relief of cancer pain in older patients can require a multidisciplinary approach using pharmacologic and nonpharmacologic interventions. The authors estimate that 20% of cases require careful assessment and the use of adjuvant medications and/or complementary therapy to effectively control pain. This review discusses the special considerations of nonopioid and opioid analgesic therapy for the elderly patient; however, nonpharmacologic treatments are merely mentioned along with minimal research as evidence of their efficacy.

Adult Cancer Pain

From: National Comprehensive Cancer Network (NCCN); 2007. 31 pages. Access checked 1/14/08.

PDF available for download: http://www.nccn.org/professionals/physician_gls/PDF/pain.pdf

This NCCN guideline is presented in a concise, easy-to-use format that includes algorithms for assessment, follow-up, and decisions related to referral for interventional therapies. Prescribing and titration tables for opioids, non-opioid dosing, and a guide for the management of opioid adverse effects are all summarized in an at-a-glance format. Some guidance is offered for specific pain problems, specialty referrals for complementary therapy, and patient education.

Pediatric Cancer Pain

From: National Comprehensive Cancer Network (NCCN); 2007. 31 pages. Access checked 1/14/08.

PDF available for download: http://www.nccn.org/professionals/physician_gls/PDF/pediatric_pain.pdf

The Pediatric Cancer Pain guideline is written in the same easy-to-use format as the NCCN adult guideline (above). Algorithms for screening, initial treatment, and follow-up treatment are presented. Additionally, there is a conversion table for fentanyl transdermal administration and a titration algorithm for both slow and rapid administration of short-acting opioids. A guide to reducing the pain and anxiety of procedure-related pain as well as the management of opioid adverse effects in children is included. The NSAID table contains information on the risk of toxicity in pediatric patients.

Cancer-Related Pain and Its Pharmacologic Management in the Patient With Bone Metastasis

By: Slatkin N. Journal of Supportive Oncology. 2006(Feb);4(2 Suppl 1):15-21. Access checked 1/23/08.

PDF available for download: http://www.supportiveoncology.net/journal/articles/0402s115.pdf

The pain of bone metastasis, common in patients with advanced malignant disease, can present specific challenges due to its multifocal, progressive nature and the high incidence of bone fracture. The authors stress the need for a thorough understanding of the extent of the disease as well as associated complications and risks. The characteristics that distinguish cancer-related pain from other types of chronic pain are matched to the most suitable pharmacologic management approaches.

Pharmacologic Management of Cancer Pain

By: Pharo GH, Zhou L. Journal of the American Osteopathic Association. 2005(Nov);105(11 Suppl 5):S21-S28. Access checked 1/23/08.

PDF available for download: http://www.jaoa.org/cgi/reprint/105/suppl_5/S21

This article begins with a review of the World Health Organization’s (WHO) stepladder approach to the treatment of cancer pain and reports that numerous studies have shown that 90% of patients are pain-free when the WHO guidelines are followed. A review of the mechanism of action, basic dosing information, and adverse effects for non-steroidal anti-inflammatory drugs (NSAIDs), Cox-2 Inhibitors, opioids, and adjuvant drugs is presented. A brief discussion reports on the use of local anesthetics for neuropathic pain and adjuvant analgesia that has been shown to be effective for bone pain.

Management of Cancer Pain in Geriatric Patients

By: Balducci L. Journal of Supportive Oncology. 2003(Sep-Oct);1(3):175-191. Access checked 1/10/08.

PDF available for download: http://www.supportiveoncology.net/journal/articles/0103175.pdf

The authors review the physiology of aging, including associated systemic and organ-related changes, as a starting point to a discussion of the pharmacological considerations in pain management. In addition to the standard information regarding assessment, the Vulnerable Elders Survey 13 (VES-13) is presented as a valuable tool to evaluate the aging patient’s level of health deterioration. A discussion of the variations in the perception and manifestations of pain in the aged includes a good summary of the best pain assessment tools for this population.

Note: Vioxx, a Cox-2 inhibitor recommended in the section on “Analgesic Drugs” and the section summarizing the pain guidelines from the American Geriatric Society, was withdrawn from the market in 2004. It is also important to remember that recent studies on non-steroidal anti-inflammatory drugs (NSAIDs) have shown an increase in the risk of heart disease or stroke in certain patients who use these products.
For more information on safety issues related to NSAIDs, please see the special Pain-Topics.org section at:
http://pain-topics.org/non_opioid_therapies/nsaids.php#NSAIDs

Opioid Rotation in the Management of Refractory Cancer Pain

By: Indelicato RA, Portenoy RK. Journal of Clinical Oncology (from American Society of Clinical Onology - ASCO). 2003(May Suppl);21(9):87s-91s. Access checked 1/23/08.

PDF available for download: http://www.westmeadanaesthesia.org/pain/documents/OpioidrotationPortenoy.pdf

The authors use a case-study approach as a discussion guide to safe, effective concepts in opioid rotation. A step-by-step approach to strategies for treating the patient who demonstrates poor responsiveness to initial opioid therapy is offered. Dose conversion guidelines, including exceptions, and an equianalgesic dosing table are the foundations of a detailed explanation of opioid rotation. Exact opioid administration details, including dosing and timeframes, are presented for a 59-year-old woman with increasing pain due to metastatic bone cancer.

For more information on the administration and safe use of opioid analgesics in pain management, please see the special Pain-Topics.org section at: http://pain-topics.org/non_opioid_therapies/nsaids.php#NSAIDs

Management of Cancer Pain: Safe, Adequate Analgesia to Improve Quality of Life

By: Hartmann LC, Zahasky KM, Grendahl DC. Postgraduate Medicine Online. 2000(Mar);107(3). Access checked 1/23/08.

See HTML article at: http://www.postgradmed.com/issues/2000/03_00/hartmann.shtml

Barriers to effective pain management are created by patients as well as healthcare professionals. This article begins with a review of the basic principles of effective pain relief and the World Health Organization’s 3-step approach to cancer pain management. A brief discussion explores the types of barriers that continue to prevent adequate pain relief in patients with cancer. And, acknowledging that opioids are the drug of choice for moderate to severe cancer pain, a table of equianalgesic dosing is combined with a discussion of dose titration. Due to the age of this publication, the drug costs quoted in the text will be inaccurate.

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