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Cancer pain

Definition
Cancer pain is a common symptom associated with cancer and its treatment, and is defined as an unpleasant, multidimensional, sensory, and emotional experience related to actual or potential tissue damage.
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Pathophysiology
Cancer pain can be broadly divided into pain secondary to the cancer itself (spinal cord compression, bony metastases), pain due to chemotherapy (peripheral neuropathy, mucositis, stomatitis), pain due to radiation therapy (skin burns, mucositis) and pain associated with surgical treatment.
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Disease course
Cancer pain is associated with anxiety, poor QoL and performance, and increased morbidity in cancer patients.
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Prognosis and risk of recurrence
Severe pain in non-small cell lung cancer is associated with reduced survival (HR 1.39, 95% CI 1.02-1.87).
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Key sources
The following summarized guidelines for the evaluation and management of cancer pain are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the American Society of Clinical Oncology (ASCO 2022), the American Society of Pain and Neuroscience (ASPN 2021), the European Society of Medical Oncology (ESMO 2018), and the World Health Organization (WHO 2018).
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Guidelines

1.Diagnostic investigations

Clinical assessment: monitor pain intensity regularly using the VAS or NRS, using the question: "What has been your worst pain in the last 24 hours?".
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2.Medical management

General principles: initiate analgesic treatment with drugs indicated by the WHO analgesic ladder appropriate for the severity of pain.
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  • Non-opioid analgesics

  • Opioids

  • Ketamine

  • Corticosteroids

  • Osteoclast inhibitors

  • Radioisotope therapy

  • Management of cancer-related neuropathic pain

  • Management of delirium

3.Nonpharmacologic interventions

Alternative and complementary therapies, acupuncture: consider offering acupuncture in patients experiencing general pain or musculoskeletal pain from cancer.
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  • Alternative and complementary therapies (massage)

  • Alternative and complementary therapies (reflexology)

  • Alternative and complementary therapies (progressive muscle relaxation)

  • Alternative and complementary therapies (yoga)

  • Alternative and complementary therapies (hypnosis)

  • Alternative and complementary therapies (music therapy)

4.Therapeutic procedures

Intrathecal analgesia
As per ASPN 2021 guidelines:
Consider administering intrathecal analgesia using an implantable pump in patients with cancer-related pain not responding to or developing side effects from conventional medical management.
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Consider trialing before intrathecal pump implantation for cancer-related pain at the discretion of the physician and patient, recognizing that it is not a requirement.
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  • Neurolysis

  • Nerve block

  • Percutaneous radiofrequency ablation

  • Radiofrequency lesioning

  • Spinal cord stimulation

  • External beam radiation therapy

5.Surgical interventions

Cordotomy: as per ASPN 2021 guidelines, consider offering cordotomy for uncontrolled unilateral nociceptive pain after failure of more conservative options.
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  • Myelotomy

  • DREZ-otomy

  • Cingulotomy

  • Vertebral augmentation

6.Follow-up and surveillance

Management of opioid side effects: prescribe laxatives routinely for the prevention and treatment of opioid-induced constipation.
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