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Cancer pain

What's new

Updated 2024 ASCO guidelines on cannabinoids for cancer pain.

Background

Overview

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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Guidelines

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 Society of Clinical Oncology (ASCO 2024,2022), the American Academy of Family Physicians (AAFP 2023), the American Society of Pain and Neuroscience (ASPN 2021), the European Society of Medical Oncology (ESMO 2021,2018), and the World Health Organization ...
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Diagnostic investigations

Clinical assessment: as per ESMO 2021 guidelines, assess the intensity of pain regularly, particularly using validated instruments to include patients with reduced consciousness or cognition.
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Medical management

General principles: as per ESMO 2021 guidelines, personalize and monitor pain management even in the last days of life.
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  • Non-opioid analgesics

  • Opioids

  • Ketamine

  • Cannabinoids

  • Corticosteroids

  • Osteoclast inhibitors

  • Radioisotope therapy

  • Management of cancer-related neuropathic pain

  • Management of delirium

Nonpharmacologic interventions

Alternative and complementary therapies, acupuncture: as per ASCO 2022 guidelines, 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)

Therapeutic procedures

Intrathecal analgesia
As per ASPN 2021 guidelines:
Consider offering 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

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

Follow-up and surveillance

Management of opioid side effects: as per ESMO 2018 guidelines, prescribe laxatives routinely for the prevention and treatment of opioid-induced constipation.
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