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Cancer-Related Pain
Researchers/reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.
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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.
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.
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.
From: National Comprehensive Cancer Network (NCCN); 2007. 31 pages. Access checked 1/14/08.
From: National Comprehensive Cancer Network (NCCN); 2007. 31 pages. Access checked 1/14/08.
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.
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.
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.
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.
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
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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.
For additional and more specific cancer-related pain documents, see the following sections….
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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.
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.
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.
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.
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.
