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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
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