Chapter 93

1. Cancer pain remains a significant problem. Studies show approximately 30% of ambulatory cancer patients suffer moderate to severe pain. With progressive disease, the incidence is far higher. Incident pain or episodic severe pain often is problematic for cancer patients.

2. Elucidation of the painful syndrome helps guide effective treatment. In most cases, cancer pain stems from the tumor itself. Tumors cause pain due to invasion of bone, soft tissues, muscle, and nervous structures. A less frequent cause of cancer pain is treatment-related pain, including postchemotherapy neuropathic pain, postsurgical pain syndromes, and postradiation pain syndromes.

3. Neuropathic pain is usually more difficult to treat. Neuropathic pain is seen with chemotherapy-induced painful peripheral neuropathies, postherpetic neuralgias, phantom limb pain, and others. Nociceptive pain syndromes typically are opioid responsive, whereas in neuropathic pain states, adjuvant analgesics may be needed to obtain adequate analgesia.

4. Treat opioid-related side effects aggressively. In some patients, opioid doses are limited by intolerable side effects, including sedation, confusion, constipation, nausea, and pruritus. These side effects are best managed by changing opioids, adding agents to treat the side effect, or using neuraxial, neural blockade, or other interventional pain techniques to lower systemic opioid doses.

5. Stick with the basic tenets of cancer pain management. These include the use of oral opioids whenever possible, often with combinations of long-acting opioids for constant pain with short-acting opioids for incident pain. It also includes the use of adjuvant coanalgesics, including nonsteroidal anti-inflammatory drugs, anticonvulsants, antidepressants, and topicals to minimize opioid doses and concomitant opioid-related side effects.

6. Treat constipation and nausea prophylactically.

7. Advance to interventional therapies when the risk-to-benefit ratio is favorable. Interventional options for pain control include nerve blocks, parenteral infusions, neuraxial infusions, palliative radiotherapy, palliative chemotherapy, and surgery in combination for optimal patient quality of life. The optimal blend of these techniques currently is empirical and based largely on availability of services.

8. Cancer pain management is rewarding. In most cases, adequate pain and symptom control can be obtained through regular assessment and application of the relatively straightforward principles outlined.

The American Cancer Society reports that the cancer death rate for men and women combined decreased by 1.6% per year during the period 2001 to 2006, in keeping with the steady downward trend that started in the early 1990s. New diagnoses for all types of cancer combined also decreased, approximately 1% per year. Men saw greater declines, but overall death and incidence rates still are much higher among men than women. Rates of the most common cancer types in men (prostate, colorectal, and lung) are falling, but unfortunately others are rising: kidney, liver, esophageal, myeloma, melanoma, and leukemia.

Among women the rates for breast and colorectal cancer has declined, but lung, thyroid, pancreatic, bladder, kidney, myeloma, melanoma, and leukemia have increased.1

Approximately 11.1 million Americans live with cancer, and an estimated 1.48 million new cases were diagnosed in 2009. The 5-year survival rate for all cancers has increased to 66% due to earlier ...

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