Understanding and Managing Cancer
Pain is the most common complaint in medicine. In cancer practice,
it often heralds the presence of a tumor. Any new complaint
of pain in a known cancer patient should be considered a recurrence
until ruled out. Cancer patients frequently associate worsening
of pain as a sign of a deteriorating condition, while its
lessening may indicate a resolving, or an improving condition.
Large sums of money are earmarked for research to develop
innovations in cancer therapy, yet precious little time and
resources are devoted to the study and treatment of this singular,
most common complaint. At present, less than 1% of National
Cancer Institute grants are used to fund pain-related research.
Despite this lack of funding, advances have been made in improving
the cancer patients’ battle with pain.
While obviously influenced by the underlying cancer responsible
for the discomfort, pain per se is associated with significant
personality changes and dramatically affects quality of life.
Cancer patients commonly require combinations of medications
to achieve pain relief and are expected to self medicate appropriately
as needed. This is becoming more common and is appropriate
when one understands the multitude of chemical receptors that
are involved in the development of pain. Drugs such as antiepileptics
and antidepressants are commonly used as
supplemental pain therapy in some types of pain. But these
medications do not just serve as pain relieving adjuncts.
Denial, depression and anxiety are not uncommon [nor should
they be surprising] findings in the cancer patient. These
need to be addressed medically and behaviorally as the entire
patient needs treatment in order to achieve the best possible
Opioids (e.g., morphine and related compounds)
continue to remain the mainstay of cancer pain management.
There are a multitude of different preparations as well as
a variety of routes in which they may be administered. Patient
prescriptions need to be individualized and a specific program
tailored to each patient’s specific needs and tolerance.
While oral medications are by far the most popular, other
routes are increasingly being used. Transdermal, oral transmucosal
and spinal delivery of opioids are frequently included in
the treatment armamentarium. Other, less commonly used routes
include the rectal, inhaled, subcutaneous and intravenous
routes, which have their indications and may be of benefit
in selected patients.
Interventional Techniques to relieve pain
are becoming more prevalent. Dr. Ricardo Plancarte’s
group from the Cancer Institute of Mexico City has long renowned
as pioneers in interventional approaches to cancer pain relief.
The use of chemical neurolysis (i.e., alcohol
or phenol to destroy nerves) has a long history of use in
the cancer patient. Dr. Plancarte’s group has developed
new techniques (e.g., superior hypogastric plexus neurolysis
[pelvic pain], ganglion impar block [perineal pain], thoracic
transdiscal splachnic [upper abdominal pain] nerve blocks)
to treat pain more effectively, with fewer side effects. As
long as patients are selected appropriately and there is understanding
of the risks and possible post-procedural sequelae, it is
an attractive option for analgesia in the cancer patient.
Spinal catheters and implanted pumps are
also options available for pain control using a fraction of
the amount of medications that need to be administered by
the oral route. A myriad of catheters and pumps exist, progressively
more sophisticated that improve pain relief, functionality
and may affect longevity. Each has their accompanying indications
and drawbacks which need to be taken into consideration but
are largely appropriate options to any cancer patient.
Bony metastases are common therapeutic dilemmas
faced by many cancer patients. Multidisciplinary approaches
into their management are essential in order to obtain optimal
control. Stabilization and prevention of a spinal catastrophe
are as important, if not more so, than pain control and need
to be addressed quickly, in order that maximum neurological
function may be preserved.
Barriers to effective pain relief exist. Some of these originate
at the treating physician level, where the knowledge base
may not be sufficient to adequately treat complex pain problems.
Other barriers exist at the patient or caregiver level, where
they may be reluctant to take opioid medication for fear of
addiction or loss of faculties. Another great impediment to
effective, widespread pain relief is real or perceived regulatory
scrutiny. Examples of these are recent actions by the DEA
supporting regulations, such as triplicate prescriptions.
In these, a copy of each controlled substance prescription
goes to the physician and the other two to the pharmacist,
who keeps one and forwards the other to the respective State
Department of Health. There has been no comprehensive evaluation
of these programs for efficacy, yet millions of dollars are
spent each year to operate them. While enormous strides have
been made in the last 2 decades in improving pain management,
the prescribing physicians and patients should take the lead
role in contacting their legislators and encouraging them
to enact legislation aimed at combating obstacles towards
adequate pain relief by early pain diagnosis, appropriate
referrals, and strident opposition to questionable regulatory
scrutiny. Legislators nationwide are finally realizing the
importance of pain relief, especially in cancer patients.
Recent studies have added to the perception that improved
pain control with greater functionality is associated with
greater longevity in cancer patients, largely by minimizing
the use of larger doses of opioids, which may affect vitality.
Cancer appears to be flourishing in our Society. Its diagnosis
is made earlier and more consistently, making curative intervention,
or at the very least a longer life, more commonplace. Cancer
and its therapeutic strategies, such as surgery and radiation,
may induce pain syndromes. In the final stages of life, most
cancer patients have come to terms with their mortality. Their
main concern may not be unrealistic expectations of survival,
but rather a very clear request that their remaining days
not be ones in pain. It is a request that demands our full
and undivided attention.
“We must all die. But that I
can save him from days of torture, that is what I feel is
my great and ever new privilege. Pain is a more terrible lord
to mankind than death itself”
Albert Schweitzer, M.D.
Rafael Miguel, M.D.
Professor of Anesthesiology
Program Director, Pain Medicine
Department of Anesthesiology
University of South Florida
Interventional Pain Program
H. Lee Moffitt Cancer Center
* * *
Readers may send questions to our
email address. This column is for informational purposes
only and is not a substitute for professional or medical advice.
* * *