At Nazha Cancer Center Cancer Center, pain management is one component of a broad symptom-management approach for patients at every stage of treatment. Pain can be managed effectively in most patients with cancer or with a history of cancer. An accurate diagnosis of the cause and type of pain is key to finding the most effective treatment.
Types of Cancer Pain
Pain has been defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Not all cancer patients experience pain, but it is one of the most common symptoms associated with cancer. Approximately one quarter of newly diagnosed cancer patients have some degree of pain, as do one third of patients undergoing cancer treatment and three quarters of patients with advanced
Pain is a highly subjective experience. The same physical stimulus may cause greater or lesser amounts of pain in different people and even in the same person in different situations. Nonphysical stressors, such as emotional, financial, and spiritual difficulties, can influence the patient's experience of pain.
Over the past 25 years, scientific advances in molecular biology, neuroscience, pharmacology, and anesthesiology have led to a better understanding of the
anatomy and physiology of pain. Pain receptors and mediators have been identified and duplicated in the laboratory, and medications and methods of treatment have been improved.
Types of Cancer Pain
Accurate diagnosis of the cause and type of pain is key to finding the most effective treatment. Neuropathic and nociceptive pain, for example, respond very differently to pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, antidepressants, and anticonvulsants.
Acute, Chronic & Breakthrough Pain
Cancer pain may be acute (relatively short-term) from tumor growth, injury, and certain treatments and procedures; or chronic (continuing over several weeks or months). Both types can be of varying severity. Breakthrough pain is a sudden temporary flare in pain intensity. Breakthrough pain can occur even when a patient takes the proper pain medication, and a doctor may prescribe a special dose or treatment to use when pain breaks through normal pain medication.
Cancer pain can be caused by injury to or compression of nerves or other components of the nervous system, in which case it is termed neuropathic.
Pain may also be caused by an inflammatory response to ongoing nerve-tissue damage. This pain, called nociceptive, can be defined further by site of origin:
- Visceral Pain
Visceral pain is caused by injury to an internal organ such as the liver. Such pain is often hard to pinpoint and can be throbbing, aching, or sharp.
- Somatic Pain
Somatic pain primarily involves bone. It can usually be pinpointed and can also be throbbing, aching, or shar
Patients with cancer can have pain from the tumor itself or as a side effect of treatment.
- Cancer pain can be directly related to tissue damage from tumors that destroy or press on tissues, bones, and nerves or block hollow structures such as parts of the digestive system, blood vessels, and lymph vessels.
- Pain can also result from cancer treatment, most typically after surgery but sometimes after chemotherapy, immunotherapy, or radiation therapy.
- Muscle aches can develop from physical inactivity that sometimes occurs during or after treatment.
Pain can also occur completely independent of cancer or its treatment, as when anyone has headache, backache, arthritis, or other common pains.
Treating Cancer Pain
Pain can be managed in most patients with cancer or with a history of cancer. Although cancer-related pain cannot always be relieved completely, therapy can lessen pain for nearly all patients. Effective management of pain and other symptoms improves quality of life throughout all stages of the disease.
Assessment of Pain
Because patients vary in diagnosis, stage of disease, responses to pain and treatments, and personal likes and dislikes, management of cancer pain needs to be individualized if it is to be effective.
All patients with cancer should be screened for the presence of pain each time they are seen, in both inpatient and outpatient settings. At Nazha Cancer Center, clinicians monitor pain as a "fifth vital sign" -- with regular assessments in each day's treatment plan.
Patients are encouraged to report to their nurse or doctor when pain occurs, and its intensity is assessed on a scale of 0 to 10, with 0 representing "no pain" and 10 representing "the worst pain imaginable." Every
effort is made to provide patients with adequate analgesia and ongoing assessment.
Management of Pain
Combination therapy has advanced to the degree that no cancer patient should suffer unmanageable pain. Cancer-related pain may be treated through one or more of the following approaches:
- Removal or Reduction of the Underlying Cancer
- Surgery, radiation therapy, chemotherapy, and immune therapy all may provide substantial relief from pain as they rid the body of the underlying cancer. Surgery may also be used to prevent or control pain-causing complications of cancer such as bowel obstruction, compression of the spinal cord or peripheral nerves, or compression of organs. The chief purpose of most of these therapies is to treat the cancer, however,
and not primarily to provide pain relief; also sometimes these therapies may themselves be a source of pain. For that reason, effective cancer treatment encompasses several other approaches primarily directed at relieving pain.
- Pharmacologic & Anesthetic Approaches
Pain-relieving medicines can be prescribed to meet various kinds of cancer-related pain. They can also be administered by different routes, depending on a patient's individual needs and preferences. Analgesics are given orally, rectally, transmucosally, intravenously, intrathecally, epidurally, subcutaneously, or transdermally. They may also be delivered by means of patient-controlled analgesia (PCA), in which patients
help control the amount of pain medication by pressing a button on a computerized pump.
Mild to Moderate Pain
Non-opioid drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen provide relief for many types of mild to moderate pain, including muscle pain, bone pain, and the pain of some incisions. Non-opioid analgesics may be prescribed in combination with opioids and other therapies for greater pain relief.
Moderate to Severe Pain
Opioids (such as morphine, fentanyl, codeine, oxycodone, and others) are highly effective medicines for relieving cancer pain. Opioids may be combined with non-opioid drugs such as acetaminophen or NSAIDs for treatment of moderate pain, and used alone or in combination with other drugs (adjuvant analgesics) and therapies for severe pain. Patients rarely become addicted when powerful pain medications such as opioids are prescribed for cancer-related
pain and taken appropriately. Depending on need, opioids may be prescribed at any stage of treatment.
There is no need to "tough it out" early in treatment out of concern that strong pain medicines won't be effective if needed later on. Patients may receive increasing doses of opioids for years without becoming addicted, or psychologically dependent. When the need for pain relief subsides, physical dependence can usually be managed without withdrawal symptoms
by tapering the opioid before discontinuing. Patients with cancer very rarely seek drugs beyond what is needed to control pain.
A doctor may prescribe a quick-acting potent analgesic called a "rescue medication" such as oral morphine to have available for times when pain "breaks through" normal pain control. These rescue doses act quickly and clear the body relatively soon, and are usually prescribed in addition to the dose taken regularly for persistent pain.Adjuvant Analgesics
Several drugs besides non-opioid and opioid analgesics have been found to provide pain relief in specific situations and may be prescribed to help manage cancer-related pain. Many of these drugs are well known for their primary indications for conditions other than pain. A growing number of drugs, including antidepressants, anticonvulsants, and steroids as well as local anesthetics, are being used with excellent results. Some of these agents have been found to help
relieve specific types of pain such as "tingling" and "burning" sensations, and pain caused by inflammation (swelling).
For acute and postoperative pain and some chronic pain problems, temporary nerve blocks (neural blockades) can provide temporary relief. In this procedure, a physician injects a local anesthetic into or around nerves or below the skin in the area where there is pain. The anesthetic interrupts transmission of pain signals to the brain and may provide relief for up to several hours. In a procedure called a neurolytic block (neurolysis), a physician injects a substance,
most often ethyl alcohol or phenol, into a nerve or into the spinal fluid so that nerve tissue in the pain pathway is destroyed. This technique usually has a long-lasting or permanent effect.Epidural & Intrathecal Pumps
Nerve blocks work best for pain that occurs over a limited area involving one or two specific nerves. For pain that is more widespread, it is possible to interrupt pain signals using epidural or intrathecal pumps. ("Epidural" refers to the space just outside the spinal cord's outer membrane; "intrathecal" refers to the space between the sheaths covering the spinal cord.) These pumps are either carried in a pouch or placed under the skin and can
deliver medication continuously to broad areas. Further, depending on the type of pump, patients can obtain additional medication by pushing a button. By delivering medicine directly to the nerves causing pain, less medication may be needed. For many patients, this can mean better pain relief with fewer side effects.
Most cancer-related pain can be effectively managed with medication, but when drug therapy does not provide adequate relief or when the side effects of medications become a problem, nonpharmacologic approaches are often effective.
In some instances when pain is not controlled by more conservative means, pain pathways can be cut or interrupted (ablated) by neurosurgery. Neurosurgical techniques are also sometimes used to implant drug-delivery devices and to stimulate
nerve fibers to inhibit pain.
Focused psychological interventions are an important component of effective pain management. Short-term psychotherapy, structured support, and cognitive-behavioral therapy can help provide useful coping skills to enhance the effectiveness of other treatments. Relaxation and imagery, cognitive distraction (focusing attention on stimuli other than pain), support groups, and pastoral counseling are now widely used to help patients manage pain.Complementary Therapies
During all phases of cancer treatment, complementary approaches to pain relief may be integrated into therapy. These complementary therapies include relaxation techniques, meditation, movement therapies, and massage to supplement medical pain-control methods. These techniques can help relieve acute pain during some procedures, acute post procedural pain, and some forms of chronic pain.
Management of Side Effects
The side effects of opioids and other analgesics have been well studied and can be managed. Because many common side effects of pain medicines are also symptoms of other conditions -- including, sometimes, the underlying cancer -- an interdisciplinary approach to symptom management is important.
This common side effect of opioids can often be lessened by an increase in fluids, an increase in dietary fiber (if your condition permits), and moderate exercise (with the advice of your cancer care team). If constipation occurs, your cancer care team can usually help remedy it with the addition of laxatives or stool softeners.
Nausea and vomiting sometime occur in the first day or two of opioid medication. Report nausea and vomiting to your nurse or doctor.
Your cancer care team can prescribe anti-nausea therapies to control these effects.
- Sedation, Drowsiness, Clouded Thinking
Sometimes opioids can cause sedation, drowsiness, or sleepiness when first administered or for a day or so after a dose is increased. Some people find that they become confused or disoriented, or simply absent-minded, after receiving an analgesic. If such effects become pronounced, tell your physician immediately. She or he may be able to adjust the dose, switch to another drug, or add an adjuvant drug.
- Slowed Breathing
Opioids can slow breathing, particularly at high doses. The condition usually resolves as your body becomes used to the medication. Respiration and other vital signs are closely monitored throughout your hospital stay; still, inform your cancer care team if slowed breathing becomes uncomfortable or otherwise troublesome. Adjuvant drugs may be prescribed to treat this effect.
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