Chapter 46

In this chapter we present a broad overview of a variety of approaches including, but not limited to, anesthetic interventions. A roster of excellent clinicians and researchers discuss in prior chapters, in great detail a variety of approaches used in the management of pain in general. These prior approaches are used for the management of pain directly attributable to cancer as well as pain resulting from cancer treatment. We feel that it would be useful to the reader of this textbook — at the expense of some overlap with other chapters — to present a broad overview and synthesis of these approaches with emphasis on the unique attributes of cancer patients. Patients with cancer comprise a traditionally undertreated group. Even when the World Health Organization (WHO) guidelines for cancer pain treatment are followed (See Chapter 45, Medical Management of Cancer Pain), up to 30% of patients report inadequate analgesia.1,2 In addition, some patients with adequate analgesia may experience intolerable side effects from opioids and other pharmacologic treatments. This chapter first addresses the role of psychological and physical approaches to cancer pain management. Then, a variety of palliative procedures, including anesthetic, radiologic, and neurosurgical interventions, are presented.

Psychosocial aspects of cancer pain, often underestimated by clinicians who adopt a disease-centered rather than a patient-centered focus, have a profound impact on pain management.3 Nonpharmacologic methods used in conjunction with analgesics have as their goal to help the patient gain or maintain functionality and restore a sense of psychological control over their pain and their circumstances. These approaches ordinarily have no negative side effects. The perception of pain resides within the brain4 and is closely influenced by the patient’s ever-evolving emotions, behaviors, and attitudes toward pain. As mentioned previously, during the treatment of cancer pain one must be aware of the patient’s mood, coping strategies, family support structure, social beliefs, ability to express pain, cognitive level, and expectations regarding pain management.5 Pain is characterized not only by location, quality, and intensity, but also by affective, cognitive, and behavioral responses.6 Modifying these responses is part of treating pain. Although pain may diminish when the patient’s responses to it are optimized, there may remain issues of self-control, fear of death, dependency, and confusion about the meaning of pain.7 Adequate pain control is difficult to achieve without addressing these issues. Psychological interventions for cancer pain have continually demonstrated efficacy and are likely to be cost-effective8 (See Chapters 12, 13, 14, 15, and 16). It is important for health care providers never to conclude that if psychological interventions are of benefit, then the pain was purely psychogenic (“it was all in his head”).9

### Psychotherapy

Depression and adjustment disorder with depressed mood are common among cancer patients.10 They are often caused by, and usually interfere with, the management of pain.6,11 Derogatis et al studied ...

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