Cancer Pain Management

Ramani Vijayan
University Malaya Medical Centre
Kuala Lumpur, Malaysia

World Cancer Burden

Number of patients with cancer is increasing
Estimated 11 million new cancer cases / year
More than one half in the developing world
Incidence of pain at various stages 50%
Increases to 75% in advanced cancer
Most patients with advanced cancer have two or
more types of cancer related pain
Ground S et al. J Pain Symptom Manage 1994;9:372-382

Successful Cancer Pain

Management
Comprehensive Assessment
A Multidisciplinary Approach
Participation of patients and their families

Pain in patients with cancer can

be:
Cancer related
Treatment related
Unrelated to cancer or treatment

Cancer related pain examples

Cancer
Infiltration
Muscle/Soft
tissue

Metastasis

Bone / ribs

Bone

Skin

Brain

Liver

Other organs

Pathophysiology of Lesions associated

with cancer pain
Nociceptive
Somatic
Visceral

Neuropathic

Nociceptive / Inflammatory
Somatic Pain
Character is aching, stabbing or throbbing and
usually well defined
Examples are bone metastasis, breast cancer with
skin infiltration

Nociceptive Visceral Pain

Character Diffuse, difficult to localize and
may be referred
May be cramping when there is an
obstruction of a hollow viscus
Examples : Intestinal obstruction from ca
colon, liver metastases

Metastases in the liver, stretching the

capsule and causing pain

Neuropathic Pain
Defined as pain as a result of injury to the
somatosensory system either in the peripheral or
central nervous system
Character is burning, pricking, electric shock like,
shooting
Pain may be associated with loss of sensation
Allodynia may be present

Mets in the vertebrae can

cause nerve compression
Large lymph nodes compressing the cervical
plexus neuropathic pain

Assessment - Is the Pain

Due to the tumour?
Or is it due to metastases?

Pancoasts tumor

Brain metastases

Treatment related
Chemotherapy induced phlebitis or extravasations
Immunosuppression
Radiotherapy
Surgery

Herpes
Zoster
infection

Post-mastectomy Syndrome

Lymphoedema

Management of Cancer Pain

Assessment of the patient
Pain
Accurate diagnosis of the cause of the pain

A focused Pain History is the most

important part of management

When a patient with pain presents:

Introduce yourself and explain the purpose of the
interview
Ask the patient about his or her pain
You can use the acronym PAIN

For each focus / area of pain

Place

Where is the pain?

Aggravating factors

What makes the pain worse?

Intensity / Severity

If 0 is no pain and 10 is the worst pain

imaginable:
- What is your pain score now?
- What is the worst level of pain you
experience in a day?
- What is the least pain (score) you
experience in a day?

Nature

Describe your pain aching, throbbing,

burning, shooting, stabbing, dull, deep,
radiating etc.

Neutralizing factors
What relieves the pain?

Establish
What pain relieving medications are being
used?
Names?
- Time and dose
- Are they effective?

Do these medications have Side effects ?

- Drowsiness
- Nausea / vomiting
- Gastric irritation
- Constipation
What is the effect of pain on
Function
Quality of life?

Pain Assessment
A whole person approach to assessment can be
assisted by considering the four components of the
pain experience
The stimuli that cause it
The minds perception to these stimuli
The persons interpretation of these unpleasant
sensations
The impairment of function that they produce

The Stimuli that caused it

What is the Pain generator?
Tumour

Secondaries

Incident pain

Neuropathic pain

Visceral pain

 Tumour Infiltration of nerves

Carcinoma of breast brachial plexus
Neuropathic pain

Pain as a result of therapy

Postoperative pain
Severe oral mucositis radiotherapy

Pain as a result of prolonged inactivity

Musculo-skeletal pain

Pain as a result of immuno-compromise

Herpes zoster

Causes of Pain in Cancer

Assessment of Pain Intensity

Usually self assessment
Visual Analogue or Numerical rating scale

Detailed pain history

Assists in determining the pathophysiology of pain
Is it nociceptive pain?
Is it neuropathic pain?
Is it a combination of both which in common in patients with
cancer

It also helps establish what strategy/drug has been

used earlier for pain relief

Patient assessment
continued..
Medical History

Cancer history
History of cancer treatment
Prognosis
Others peptic ulcer disease, arthritis etc

Attention to psychological problems

Depression, Insomnia, fear, tiredness

Family / Social history

Including financial issues

Pain Interpretation

Is influenced by prior experiences, knowledge,

cultural values

Influenced by misconceptions resulting in unrealistic

fears and expectations with increased suffering

People put pain into a framework they can

understand which gives meaning to their suffering

Impairment that comes with pain

Physical impairment

Impairs relationships

Ability to continue
normal activities

Reduces one sense of

self

What is the worst thing about this pain?

Strategies for Total Pain Management

Regular Analgesia as per the WHO Ladder

Appropriate pharmacological and nonpharmacological adjuvant therapies

A wide range of strategies to improve mood,

morale, general health and resilience

Open discussions to assist in appropriate pain

interpretation
Interventions to overcome impairment in
relationships, normal activities of daily living and a
sense of self capacity

Multimodal Therapeutic management

Neurosurgery

Palliative
Surgery

Orthopaedic Surgery

Chemotherapy

CANCER PAIN

Nerve Blocks

Radiation
Therapy

Pharmacotherapy

Others
Psychological
Nursing care
Physiotherapy
Alternative modalities
End of Life issues

Guiding principles
Individualize the approach to the patients needs
Consider the risks and benefits of various treatment
options
Discuss with patients and family regarding treatment
goals
Base therapy on the expected life expectancy

Pharmacotherapy Mainstay
WHO Analgesic Ladder
First published in 1986
Based on a small number of
relatively inexpensive drugs

WHO Analgesic Step-Ladder

Potent Opioids NSAIDs
Step 3
Weak Opioids NSAIDs

Step 2
NSAIDS
Step 1

Adjuvants can be added at each

step - when indicated
WHO. Cancer Pain Relief. Geneva

Management
Accurate diagnosis of the cause of pain
Formulate a plan
Review treatment-plan frequently
Adequacy of pain relief
Side effects

Principles
By the Mouth
when possible
alternative routes rectal, transdermal,
sublingual, subcutaneous, intravenous, spinal

By the Clock
By the Ladder
For the Individual

Potent opioids available in Malaysia

Morphine
Aqueous morphine 2 mg / ml
Morphine Tablets (SR) 10, 30, 60 mg

Fentanyl as Transdermal fentanyl

Oxycodone
Sustained Release (SR)
Immediate Release (IR)
PETHIDINE should not be used for chronic
cancer pain potential toxic metabolites

How to use opioids?

Start with immediate release morphine (aqueous

morphine
Four hourly 5-10 mg Regularly
Add a PRN dose for breakthrough pain
Titrate upwards if there are numerous doses of breakthrough
When stable change to SR morphine

Patients may have sedation / nausea initially

Reduces with continued use ( they develop tolerance)

Always prescribe laxatives for constipation

Transdermal - fentanyl

Chronic stable pain

Better compliance
When oral intake is not possible
Less constipation
Is increasingly being used as first
line after morphine titration

Morphine in Cancer Pain Management

The magic of pain relief with opiates had been
known for centuries
YET
By the middle of the twentieth century, there was
a lot of reluctance by the medical establishment
to prescribe morphine

MYTHS
Regular administration leads to addiction
Tolerance to morphine is a major problem
Oral morphine is ineffective
Morphine acts by causing indifference to pain

WHO guidelines - Validated in several

studies
Ventrafridda et al.
Cancer 1987; 59: 850-865

Schug et al.
J Pain Symptom Manage 1990; 5: 27-32

Zech et al.
Pain 1995; 63: 65-76

Up to 80% of cancer pain can be effectively

controlled

Adjuvant drugs
Anticonvulsants

Neuropathic pain

Antidepressants

Neuropathic pain

Corticosteriods
Raised intracranial pressure, spinal
cord compression
Spasmolytics

Colicky pain

Anxiolytics, hypnotics
Laxatives
Bisphosphonates
Calcitonin
Lignocaine viscous
Anti-emetics
NMDA antagonist

Anxiety, insomnia

Constipation
Bone metastasis
Bone metastasis
Oral mucositis
Nausea / vomiting
Ketamine

Neuropathic pain
Antidepressants
Amitriptyline (tri-cyclic)
Duloxetine (SSNRI)

Anti-convulsants

Gabapentin
Pregabalin
Sodium valproate
Carbamazepine

Sodium channel blocker

Lignocaine Also now available as a patch
Mexilitine

Adjuvant Therapy continued.

Total Pain
Dame Cicely Saunders defined the concept of total
pain as the suffering that encompasses all of a
persons
Physical
Psychological
Social
Spiritual struggles

A diagnosis of a life-threatening illness jars open a

door of awareness, allowing thoughts of death
For many people the opening of this door precipitates
a crisis and an acute encounter with great total pain

The Four Domains of Total Pain

Management of Total Pain

Requires a holistic approach to the patient

Multi-disciplinary approach
Involving the family
Social worker
Psychological counselling

Discussion about End-of Life issues

It is not easy but proper management can be
rewarding

Factors contributing to the undertreatment of cancer pain

Inadequate pain assessment
(Von Roenn. Ann Intern Med 1993; 119: 121-126; Larue et al. BMJ 1995;
310: 1034 37)

Under diagnosed
(WHO 1990; Bruera et al. J Pain Symptom Manage1989;4:112

Inadequate access to Morphine

(In Developing Countries where the majority of newly diagnosed cancer
patients reside)

Availability/use of morphine in developing

countries is very low

Morphine consumption in kg in 1999, E/INCB/2002/2, Part 4, Table IX

Morphine: Distribution of consumption - 2002

OTHERS ( 79%)
Japan( 2.2%)
Australasia (0.4%)
3% 6%
4%

31%
Europe (13.2%)

56%
North America
(5.2%)

Statistics International Narcotics Control Bureau (INCB)

Country (%) Percentage of the world population ( I.e. 79% of the
population uses only 6% of morphine consumed

Reasons for low demand

Very strict laws and regulations with
regard to the import and distribution of
potent opioids
Fear of diversion of potent opioids for illicit
use
Not only in Asia but also in Africa and Latin
America ( personal communication)

Effect of excessive regulations - India

1985 - the Narcotic Drugs & Psychotropic Substances
(NDPS) Act was passed
to prevent diversion of narcotics

715 kg

18 kg

(INCB 1989 / 1999)

Other barriers underutilization of

morphine
Lack of knowledge among health care
professional
Medical and nursing school curricula inadequate

Myths surrounding the use of morphine

Fear of addiction!!

Doctors / nurses alike

Patients

Antiquated teaching at medical schools

Inadequate patient education fatalistic

attitude

Despite appropriate use of guidelines

and availability of opioids :
Up to 30% of patients have poor pain
control

Main risk factors for poor pain

control
Neuropathic pain
Incidental pain
Tolerance
Psychological distress (Total Pain)
Alcohol or drug abuse
It is important to identify such patients
with poor prognostic pain syndromes
More complex approaches

When Pharmacotherapy is
inadequate
Administer the opioids via the CNS

Ketamine infusion
Low dose ketamine infusion
IV / subcutaneous infusion 0.1 0.2 mg / kg /
hr
NMDA antagonist
Reduces hyperalgesia
Opioid infusions can be reduced
Successfully used even in children
J Paediatr Hematol Oncol 2004 26(10): 678 - 80

Non Pharmacological techniques to

reduce opioid requirements
Neurolytic procedures
Rehabilitative
Bracing
TENS

Hypogastric plexus block

Psychological
Complimentary
Acupuncture etc

Epidural phenol

Palliative Treatment of
underlying cancer - Pain control
Chemotherapy
Radiotherapy
Hormonal therapy
Others

Chemotherapy

Chemo-port implanted

Hickman's line

Peripheral line

Radiation therapy
Radical
Palliative
Systemic radiation therapy

Systemic irradiation

Referral to other disciplines

Surgeon
Orthopaedic
General/colorectal
Neurosurgeon

Nuclear physician
Anaesthesiologist
Physiotherapist
Palliative care physician
others

Neurosurgeon

Exclude cord
compression

Colorectal surgeon

Typical apple core

appearance of
colorectal cancer on
barium enema
Intestinal obstruction
may ensues with this
barium enema picture

Orthopedic surgeon

Stabilize the bone with

intramedullary rod and
screws

Irradiation of femur

Nuclear physician

Bone seeking radioisotope like strontium

or samarium

In Conclusion

Cancer pain can be challenging

A holistic approach is important taking the patients

wishes into consideration

The physical component of pain requires

pharmacotherapy

Addressing the psychological, social and spiritual

components of pain is just as important

In advanced disease
It gives meaning and closure to those who are left behind
When there is good and peaceful death

Iguazu Falls - Argentina