cancer pain its causes and management

1. Cancer Pain Management
Brief Guidelines
Prof. Shad Salim Akhtar
MBBS, MD, MRCP(UK), FRCP(Edin), FACP(USA)
Consultant Medical Oncologist & Medical Director
Prince Faisal Oncology Center, KFSH
Professor of Clinical Medicine
Qassim Medical University
Buraidah, Al-Qassim

2. IARC Globocan 2002, Figures based on 1998-2002 prevalence
Burden
of
Cancer

3. Magnitude of the Problem-
Future looks GRIM
New cases in 2020

5. Cancer Pain
30-50% of cancer pts are on active therapy
5 million or more cancer patients are
suffering from pain
 With or without adequate therapy
57% patients perceive cancer death painful
69% consider committing suicide due to pain

6. Cancer Related Pain
At diagnosis 25%
Advanced disease 75%
During therapy 30%
Goudas LC et al: Cancer Invest 2005;23:519

7. Barriers to Pain Management

8. Neurophysiology
Nociceptive receptors
 Myelinated fibres
 Noxious mechanical stimuli
 Rapid conduction
 A delta fibres- sharp stinging pain
 Unmyelinated fibres
 Chemical stimuli
 Mechanical stimuli
 Thermal stimuli
 C fibres- dull burning aching pain

9. Cancer Pain Classification
Nociceptive (skin, viscera, muscles,
connective tissue)
 Somatic pain
 Most common type
 Bone metastasis most common cause
 Visceral pain
 Commonly refd to cutaneous sites
Neuropathic pain
 Injury to peripheral or CNS
Caraceni A et al: Oncology 2001;15:1627

10. WHO Three - Step Approach

11. New Concepts of Management
Assessment of pain
Individualization of therapeutic approach
Continual reassessment
Simplest approach
Continuing communication
Define goals
Assurance of availability of expertise

12. Universal Screening
Screen for pain
Quantify pain
Pain >0 comprehensive pain
assessment
 Pain=0 repeat screening at each subsequent
visit

13. Clinical Assessment of Pain
Believe the patients complaint
Careful history
Characteristics of each pain
List and prioritize each pain complaint
Evaluate response to previous therapy
Psychological state evaluation
Alcohol or drug dependence

14. Comprehensive Pain
Assessment
Intensity
At rest
With movement
Interference with activities

15. Pain Intensity Numerical Scale
Verbal: “How much pain are you having?”
from 0 (no pain) to 10 (worst imaginable
pain)
Written: “Circle the number that describes
how much pain you are having.”
0 1 2 3 4 5 6 7 8 9 10
No pain Worst imaginable pain
Wong DL et al:2001; Mosby Inc Ess Ped Nurs

16. Pain Intensity Wong-Baker
Faces
Wong DL et al:2001; Mosby Inc Ess Ped Nurs

17. Pain Intensity Categorical
Scale
None (0)
Mild (1–3)
Moderate (4–6)
Severe (7–10)
Wong DL et al:2001; Mosby Inc Ess Ped Nurs

18. Comprehensive Pain
Assessment
Location
Pathophysiology (Character)
Somatic: pain in skin, muscle, bone described
as aching, stabbing, throbbing, pressure
Visceral: pain in organs or viscera described
as gnawing, cramping, aching, sharp
Neuropathic: pain caused by nerve damage
described as sharp, tingling, burning, shooting

19. History of Pain Other Points
Onset
Duration
Course
Referred pain, radiation
Aggravating & alleviating factors
Associated symptoms
Response to current and prior treatment
including reasons for discontinuing

20. Etiology (Pain syndromes)
 Associated with tumour infiltration
 Associated with cancer therapy
 Unrelated to cancer therapy
Medical history
 Current medications including prescribed,
over the counter
 Complimentary and alternative therapies
 Oncologic
 Other significant medical illnesses
Comprehensive Pain
Assessment

21. Psychosocial Aspects of Pain
Patient distress
Family and other available support
Psychiatric history including current or prior
history of substance abuse
Special issues relating to pain
 Meaning of pain for patient/family
 Patient/family knowledge and beliefs surrounding
pain
 Cultural beliefs toward pain
 Spiritual or religious considerations

22. Clinical examination
Appropriate diagnostic procedures
Treat pain as necessary for work up
Individualize diagnostic and therapeutic
approach
Continuity of care
Reassess patient for response
Discuss advance directive with the pt &
family
Clinical Assessment of Pain

24. Pain not related
to an Oncologic
emergency
Patient not
taking opioids
Patient taking
opioids

25. Opioid Naive Patient Severity 7-10
Rapidly titrate short-acting opioid
 Begin bowel regimen
Recognize and treat side effects
Co-analgesics as indicated
Provide psychosocial support
Begin educational activities
Repeat comprehensive assessment in 24 hrs

26. Titrate short-acting opioid
 Begin bowel regimen
Recognize and treat side effects
Co analgesics as indicated
Provide psychosocial support
Begin educational activities
Repeat assessment in 24-48 hrs
Opioid Naive Patient Severity 4-6

27. Consider NSAID or acetaminophen without
opioid if patient is not on analgesics or
Consider titrating short-acting opioid
 Begin bowel regimen
Recognize and treat side effects
Co analgesics as indicated
Provide psychosocial support
Begin educational activities
Repeat assessment in 72 hrs
Opioid Naive Patient Severity 1-3

28. Approximate Opioid Doses
The appropriate dose is the dose that relieves the patient’s pain
throughout its dosing interval without causing unmanageable
side effects.
Pain 7-10 Consider increasing dose by 50%-100%
Pain 4-6 Consider increasing dose by 25%-50%
Pain 1-3 Consider increasing dose by 25%

32. Pain with Oncological Emergency
 Bone fracture or impending fracture of weight
bearing bone
 Brain metastases
 Epidural metastases
 Leptomeningeal metastases
 Pain related to infection
 Perforated viscous
 (acute abdomen)
 Analgesics as specified by pathway
 Specific treatment for oncological emergency as clinically
indicated
 (eg, surgery, steroids, RT, antibiotics)

33. Consider conversion to SR when 24 hr
opioid requirement is stable
Extended-release morphine sulfate tablets
every 8-24 h depending on brand.
Capsules every 8-24 h
Extended-release oxycodone hydrochloride
tablets every 8-12 h
Transdermal fentanyl delivery system every
48-72 h
Provide rescue short acting opioids
Maintenance Therapy

34. Interventional Strategy
Pain likely to be relieved with nerve block
 Pancreas/upper abdomen
 Celiac plexus block,
 Lower abdomen
 superior hypogastric plexus block,
 Intercostal nerve block
 Peripheral nerve block

35. Interventional Strategy
Failure of response without side effects
 Intraspinal agents
 Blocks
 Spinal cord stimulation
 Destructive neurosurgical procedures
 Neurolysis
 Thoracic splanchnicectomy
 Midline myelotomy
 Cordotomy

36. Surgical Procedures for Pain Control

37. Specific Pain Problems
Inflammation
 NSAIDS
 Corticoides
Bone pain
 Bisphosphonates
Neuropathic pain
 Tricyclic
 Anticonvulsants
 Topical agents
Cancer chemotherapy/radiotherapy

38. Additional therapeutic modalities
Physiotherapy
Hypnosis
Acupuncture
Alternative therapies