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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.
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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
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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 ...