Management of Cancer Pain

Prof. Dr. Başak Oyan-UluçYeditepe Üniversitesi Hastanesi

Medikal Onkoloji Bölümü

Cancer pain

At diagnosis % 20-50

During treatment % 30-40

Advanced stage %75-90

Physiological effects of Pain

• Decreased limb movement: increased risk of DVT/PE

• Respiratory effects: shallow breathing, tachypnea, cough suppression resulting increased risk of pneumonia and atelectasis

• Tachycardia and elevated blood pressure

• Increased catabolic demands: poor wound healing, weakness, muscle breakdown

• Increased sodium and water retention (renal)

• Decreased gastrointestinal mobility

Psychological effects of Pain

• Negative emotions: anxiety, depression

• Sleep deprivation

• Existential suffering

• Patient questions the very foundations of their life:

whether their life has any meaning, purpose or

value

Immunological effects of Pain

Decrease natural killer cell counts

Tolerance to chemotherapy decrease. infection

Cancer pain

Physiological effects

Psychological effects

Immunological effects

Decreased quality of life

Shorter survival

What Does Pain Mean to Patients?

• Poor prognosis or impending death

• Particularly when pain worsens

• Decreased autonomy

• Impaired physical and social function

• Decreased enjoyment and quality of life

• Challenges to dignity

• Threat of increased physical suffering

Causes of Cancer-Related Pain• Tumor / Mass effect (70%)

• Bone metastases, soft tissue infiltration, nerve infiltration

• Treatment related (20%)• Post-chemotherapy• Post-radiation (mucositis, enteritis , etc)• Post-surgical (mucositis, neuropathy, G-CSF related bone

pain, etc)

• Other (10%)– Decubitis ulcers, constipation – Postherpetikc neuralgia

Types of pain

• Somatic pain

• Visceral pain

• Neuropathic pain

Somatic Pain

• Generally described as musculoskeletal pain• Dull, sometimes sharp• Intermittent or continuous• Well-localized: Because many nerves supply the

muscles, bones and other soft tissues, somatic pain is usually easier to locate than visceral pain.

• Related to tumor / mass effect

• Example: Soft tissue infiltration, bone metastases

Patient with head and neck cancer: Large right sided mass causing somatic pain

Visceral Pain

• Infiltration, compression, extension, or stretching of the thoracic, abdominal, or pelvic viscera

• Pressure, deep, squeezing, cramps

• Not well-localized or referred pain

• Intermittent or continuous

• Example: Intraabdominal metastases

Colorectal cancer with liver metastases:Visceral pain

Neuropathic Pain

• Causes:

• Cancer compressing or infiltrating nerves/nerve roots/blood supply to nerve

• Nerve damage from treatments

• Types:

• Dysestetic: Burning, “pins & needles”

• Ex: Postherpetic neuralgia

• Neuralgic: Sharp, shooting and paroxysmal pain along the course of a nerve

• Ex: Trigeminal neuralgia

Neuropathic Pain

• Chemotherapy-induced neuropathies: symmetrical polyneuropathy – localized in hands and feet

• Cisplatin, Oxaliplatin

• Paclitaxel, Thalidomide

• Vincristine, Vinblastine

• Surgical Neuropathies

• Phantom limb pain

• Post-mastectomy syndrome

• Post-thoracotomy syndrome

Most cancer pts have some sort of combination of somatic, visceral pain and neuropathic pain

Patient with cervival cancer

• Visceral pain due to peritoneal carcinomatosis

• Somatic pain: Due to vertebral metastasis

• Neuropathic pain from nerve root involvement

Assessment of cancer pain

Assessment of Pain

• Pain history

• Onset / duration

• Severity of paiN

• Site(s) of pain/radiation

• Type of pain

• What aggravates or relieves pain?

• Impact on sleep, mood, activity

• Effectiveness of medication

Non-verbal signs of pain• Autonomic changes

– Hypertension, tachycardia, sweating

• Patients with organic brain syndrome: Agitation or confusion

• Patients with cognitive dysfunction: Apathy, inactivity, irritability– Refuse eating– Avoidance of painful site– Painful expression on face

Principles of Assessment

• A (Ask) Assess and REASSESS

• B (Believe) the patient and care-givers

• C (Choose) Use methods appropriate to cognitive status and context

• D (Deliver)

• E (Empower) Include the family

• Pain scales– Numeric– categoric– Facial expression pictures

• Body maps

• Pain queries

Assessment of severity of pain

MUST BE FİLLED BY THE PATIENT

TREATMENT

MAXIMUM PAIN CONTROL

MINIMUM SIDE EFFECT

INCREASED QUALITY OF LIFE

No pain at rest No pain with activity

No interrruption of sleep due to pain

Aims of Cancer Pain treatment

Modalities of treatment• Pharmacological Management

• Radiation / Nuclear Medicine

• Non-Pharmacologic Management

• Interventions– Blocks– Epidural or intratecal pain pumps– Palliative surgery (ablative neurosurgery)– Nerve Blocks

Pharmacological Treatment

Pharmacologic Management

• WHO Ladder

• Non-opioid therapy / Co-analgesics

• Opioids

WHO Ladder

(1-3)

(4-6)

(7-10)

Oral

By the clock

Step by step4. Basamak:

Invasive modalities

Non-Opioids NSAIDS Acetaminophen (Paracetamol) Topicals

Lidocaine, Capsaicin

For mild pain Ceiling effect: increasing doses of a given medication to have

progressively smaller incremental effect Can be combined with opioids-> Opioid dose lower No tolerance and no addiction risk

NSAID: Gastointestinal, renal and hematological side effects

Adjuvants

• Primary indication other than pain, but have some analgesic properties in some painful conditions

• Usually coadministered with other analgesics

Benzodiazepines Antispasmodics Muscle relaxants NMDA-blockers Systemic local

anesthetics

Antidepressants Anticonvulsants Corticosteroids Neuroleptics Alpha2 – agonists

Adjuvants for special pain types

• Neuropathic pain: Antidepresants, Anticonvulsants, GABA agonists, etc

• Bone pain: Osteoclast inhibitors (bisfosfonates), radiopharmaceuticals, corticosteroids

• Musculoskeletal pain: Muscle relaxants

OpioidsStep 2 opioids

Codeine, Oxycodone, tramadol

Step 3 opioids Oxycodone, morphine, fentanyl

AVOID: Meperidine

If pain constant/chronic – use long-acting opioids with short-acting for breakthrough pain

Principles of analgesic treatment• Patient –specifc treatment: Dose, route

• By clock: Analgesics should be administered at regular intervals, not as needed

• Appropriate dose

• Consider renal and liver functions

• When changing to and other opioid or the route of adb-ministration, use “equal analgesic conversions” guides

• Avoid placebo

Principles of analgesic treatment

• Be aware of drug side effects and prevent side effects

• Monitor development of tolerance

• DO NOT USE MEPERİDİNE (Dolantin) for cancer pain– Toxic metabolite is normeperidine –> highserum levels can cause

seizures– Short-acting

Side effects of opioids

Physiological side effectsSedation

Constipation

Nausea-vomiting

Urinary retention

Supression of cough

Toxic side effects

Lethagy

Hallusination

Myoclonik jerks

Supression of respiration

Tolerance to Nausea-vomitingand sedation: Early

Tolerance to constipation: Late

Success rate of Cancer pain Treatment

• Oral /Transdermal• Administer by clock• Step by step• Patient-specific

• Appropriate– Dose– Route– Dose interval

• Treatment of breakthrough pain

• Treatment od side effects

Success rate>%80

Reasons for failure to relieve cancer pain

• Inadequate dose of opioids– No ceiling dose for agonist opioids like morphine

– Only dose-limiting factor: Side effects

• In young patients, dose should be higher

Seminars in Oncology, Vol 27. No.1 February 2000: pp 45-63Seminars in Oncology, Vol 27. No.1 February 2000: pp 45-63

Torkey

Mean: 0.0872

World: Rank number 44

EURO zone Rank number 33

Torkey

Mean: 0.1763

World: Rank number 106

EURO zone Rank number 42

http://www.ascopost.com/media/175223/3.8.37_chart.jpg

Reason for inadequate doing of opioids?

• Physicians’ lack of information about opioids

• Patients’/Relatives’ lack of information about opioids

• Exaggeration of risks

• Side effects

• Risk of addiction

• Legal factors

Non-Pharmacologic Management

Acupuncture Yoga Guided imagery Cold/heat Massage Vibration TENS units

Exercise programs Hypnosis Music Pet therapy

Intervensions

Palliative surgery

Nerve Blocks

Kyphoplasty/Vertebroplasty

Epidural

Intrathecal pain pumps

Celiac Plexus Block

Kyphoplasty/Vertebroplasty

Intrathecal Pain Pumps

Conclusion Cancer pain can effect quality of life and mortality

Ask the patient about pain and REASSESS!

Choose non-opioid / adjuvants carefully paying close attention to side effect profile

Use WHO ladder guidelines when titrating pain medications

Use long-acting opioids for chronic cancer pain

Recognize “4th step” in WHO ladder and utilize your multidisciplinary resources