Elsevier

The Lancet

Volume 377, Issue 9784, 25 June–1 July 2011, Pages 2236-2247
The Lancet

Series
Treatment of cancer pain

https://doi.org/10.1016/S0140-6736(11)60236-5Get rights and content

Summary

In patients with active cancer, the management of chronic pain is an essential element in a comprehensive strategy for palliative care. This strategy emphasises multidimensional assessment and the coordinated use of treatments that together mitigate suffering and provide support to the patient and family. This review describes this framework, an approach to pain assessment, and widely accepted techniques to optimise the safety and effectiveness of opioid drugs and other treatments. The advances of recent decades suggest a future that includes increased evidence-based targeting of specific analgesic interventions within an individualised plan of care that is appropriate throughout the course of illness.

Introduction

Cancer subsumes many diseases, varied illness trajectories, and a rapidly changing therapeutic landscape. The burden of cancer-related illness is high for both patients and families, and symptom distress contributes substantially to this burden. Chronic pain is among the most important of symptoms in terms of prevalence and potential consequences, and integration of best practices for pain management into humane, effective, and affordable cancer care is a key challenge for health-care systems worldwide.

Key messages

  • The assessment and management of pain in populations with cancer is best considered as an essential component of the broad therapeutic approach known as palliative care

  • Pain assessment should characterise the pain complaint; take into account the status of the underlying disease; clarify the pain in terms of its cause, syndrome, and pathophysiology; and obtain details about other factors that contribute to illness burden

  • Pain can be addressed with primary disease-modifying treatment, most often radiotherapy, if this approach is available, feasible, and consistent with the goals of care

  • The mainstay symptomatic treatment for cancer pain is opioid-based pharmacotherapy, and all clinicians who provide care to patients with cancer should aim to optimise the positive outcomes from these drugs and minimise the risks associated with both side-effects and outcomes related to chemical dependency (misuse, addiction, and diversion)

  • Effective opioid treatment depends on appropriate selection of a drug and route, individualisation of the dose, consideration of so-called rescue dosing for breakthrough pain, and treatment of common opioid side-effects

  • The addition of a non-steroidal anti-inflammatory drug to opioid treatment can be helpful, especially in some painful conditions, but the gastrointestinal, cardiovascular, and renal risks of these drugs should be weighed against their benefits on a case-by-case basis

  • Adjuvant analgesic drugs, such as glucocorticoids, antidepressants, and anticonvulsants, have many uses as adjuvant analgesics when opioid treatment is not sufficient; clinicians should familiarise themselves with the common indications and agents

  • Many non-pharmacological treatments can be used to improve pain control, coping, adaptation, and self-efficacy; mind–body strategies have established benefit and can be used in a restricted but potentially useful manner by non-specialists

  • Interventions, including neural blockade and implanted therapies, play a small but important part in the management of refractory pain

In populations with solid tumours, the overall prevalence of clinically significant chronic pain ranges from 15% to more than 75%, depending on the type and extent of disease and many other factors.1 Many treatment guidelines have been published during the past quarter of a century,2, 3, 4, 5, 6, 7, 8, 9, 10 and few data and an extensive clinical experience suggest that adherence to these guidelines yields satisfactory relief for most patients.11 Unfortunately, as a result of many barriers to effective treatment, outcomes are not optimum.12 A review suggested that an average of 43% of cancer patients receive inappropriate care for pain.13 These data affirm the continuing need for professional education in this area.

This review discusses the management of chronic pain in populations with active cancer. Pain in cancer survivors—patients cured of cancer or living with cancer as a chronic illness—is poorly characterised, and there is no consensus about the therapeutic framework and best practices in this heterogeneous group.

Section snippets

Background

In patients who are medically ill, chronic pain is seldom an isolated problem. Most patients have several ailments, many symptoms, and other concerns.14 Distress can be worsened by psychological or social factors, or be heightened by spiritual or existential challenges. Communication between the patient, family, and health professionals can be limited, inaccurate, or constrained by cultural expectations, and this situation can lead to uncertainty about the goals of care, absence of advance care

Management of cancer pain

Treatment of chronic cancer-related pain should be individualised and balance benefits and burdens in relation to the broader goals of care. If the health system includes access to specialist palliative care teams, referral usually is considered when pain is difficult to control, is accompanied by other complex concerns, or occurs in the setting of very advanced illness and short prognosis.15 Some systems also support access to pain specialists, and patients with refractory pain might be able

Risk management

Although evidence-based clinical guidelines have expanded on the expert opinion originally described in the WHO approach,3, 4, 5, 6, 7, 10 much of conventionally accepted practice remains supported by clinical observations only. Existing guidelines need to be continually updated as new information emerges and clinical consensus shifts. An important example is the emerging emphasis on risk management in some countries.

In many countries, access to opioid treatment is limited by governmental

Non-opioid and non-traditional analgesic drugs

For patients with active cancer, paracetamol or a non-steroidal anti-inflammatory drug (NSAID) is conventionally used for mild or moderate pain; NSAIDs are usually preferred for bone pain. A recent systematic review concluded that paracetamol and the NSAIDs are efficacious, but there is only equivocal evidence that the combination of the non-opioid and opioid is more effective than an opioid alone.53

The decision to administer an NSAID for chronic cancer pain is strongly affected by safety

Other treatments for chronic cancer pain

Although most patients with cancer experience substantial benefit when pain and other symptoms are aggressively managed with systemic drug treatments, there is an important role for other modalities (panel 3). Some approaches are considered specifically for refractory pain. Among these are many interventional approaches, which consist of a large and varied group of injections, neural blockade approaches, and implant therapies.43, 61 Coeliac plexus block for pain due to upper abdominal

Conclusion

Although several decades of experience and research have not changed the consensus that opioid-based pharmacotherapy is the mainstay approach for the long-term treatment of chronic pain in populations with active cancer, there have been striking changes in the clinical approach to this problem. With analgesic strategies integrated into a palliative plan of care, there is increasing hope that patients can experience cancer with a minimum of suffering. Nonetheless, the treatments used have very

Search strategy and selection criteria

This review emphasises assessment and analgesic pharmacotherapy. Each topic was mainly assessed with systematic reviews or selected primary references from within the past 5 years. These references were largely accessed via a search of Medline (1966–2010). Several historically relevant narrative reviews also were included when appropriate and were obtained from Medline or from primary references. Keywords used to search included “cancer pain”, “pain assessment”, “opioid therapy”, “opioid

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