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Pain in cancer patients has numerous possible causes. The vast majority of pain syndromes are caused by direct tumor involvement of pain-sensitive structures, a smaller number are treatment-related, and fewer than 10% are unrelated to the cancer. Metastatic disease may invade bone, obstruct a hollow viscus, and compress nerve or spinal cord. Radiation treatment may cause fibrosis of nerve or spinal cord. Chemotherapeutic agents may cause peripheral neuropathy, aseptic bone necrosis, and predispose to painful opportunistic infections. Surgical treatment leads to acute postoperative pain, and may cause deafferentation pain if major nerves or nerve plexi are cut. In any given patient, one or more of these factors may be in play, and more than 50% of cancer patients with pain have more than one source of pain.1


Primary care physicians and oncologists should be able to recognize and treat most of cancer-related pain. They should be able to initiate treatment for the more common causes with opioids and non-opioid analgesics. More than 70% of patients can be treated effectively with simple analgesics and adjuvant drugs. Effective pain relief, without intolerable side effects, is occasionally difficult to obtain with the use of conventional analgesics. When this occurs, consultation with a specialist in pain management may be necessary.


Daut and Cleeland found that while 36% of 286 patients with nonmetastatic cancer reported pain, 59% of 381 with metastatic disease did.2 Cleeland and colleagues found that 67% of 1308 outpatients with metastatic cancer had pain, and 62% of those had severe pain. Thirty-six percent reported disability due to pain, and 42% of those with pain reported inadequate analgesia.3 Terminal pain, refractory to escalating opioid administration, is a more challenging problem. Depression, uncontrolled pain, the adverse effects of opioids, and fear of pain may precipitate suicidal thoughts or requests for aid in dying.4,5 Pain also adds to the discomfort experienced by those caring for the dying patient.


The likelihood of pain associated with cancer depends on the type and stage of disease. Foley, in a 1-week survey of 540 patients hospitalized at Memorial Sloan-Kettering Cancer Center, showed that the prevalence of pain requiring analgesic drugs varies by cancer type (Table 44-1).6 In contrast, among 1308 outpatients with metastatic cancer, Cleeland and colleagues did not find variation in pain prevalence according to cancer type.3

Table Graphic Jump Location
Table 44-1 Prevalence of Pain in Hospitalized Cancer Patients 

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