Cancer pain

1. ADULT CANCER PAIN
Dr. Chinmayee Agrawal
Moderator: Dr. Sadashivan Iyer
Dr. Santhosh K.D.
19.02.2021
References Used:
1. DeVita, Hellman, and Rosenbergs Cancer Principles
and Practice of Oncology – 11th Edition
2. Perez & Brady's Principles and Practice of Radiation
Oncology, 6th Edition
3. NCCN Guidelines 2021

2. OVERVIEW
 Definition of pain
 Types of pain
 Measurement of pain
 Pain Syndrome
 Management of Cancer pain
 WHO Ladder
 Non opioid analgesics
 Opioid analgesics
 Adjuvant therapies

3. DEFINITION OF PAIN
INTERNATIONAL ASSOCIATION FOR THE STUDY
OF PAIN
 An unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage
 Subjective experience

4. EPIDEMIOLOGY
 19 million new cases diagnosed each year world
wide
 7 million cancer death per year, many suffer from
cancer pain
 Pain due to direct tumor involvement: 85%
 Pain associated with cancer therapies: 15-25%
 Chronic pain, cancer survivors: 5-40%

5. PHYSIOLOGY OF PAIN
Painful or noxious stimulus
Sensory nerve endings called
nociceptors
Nerve impulse
Travels from the sensory
nerve ending to the
spinal cord and brainstem
Brain
Pain

6. PERIPHERAL SENSITIZATION
Peripheral sensitization occurs in response to the
release of inflammatory molecules
(Histamine, prostaglandins, pro-inflammatory
cytokines)
sensitize nociceptors
inflammatory environment
enhances pain sensitivity
reducing threshold of nociceptors activation

7. CENTRAL SENSITIZATION
 In central sensitization, nociceptive-specific
neurons may progressively increase their response
to repeated non-painful stimuli, develop
spontaneous activity, and increase the area of the
body that is involved with the pain.
 The hyperalgesia of central sensitization usually
develops as part of ongoing pathology (i.e, damage
to peripheral or central nerve fibers, cancer,
rheumatoid arthritis) and is considered maladaptive

9. TYPES OF PAIN
SOMATIC PAIN
 Nociceptors are activated in cutaneous or deep
tissues
 Characterized by dull or aching but well localised
pain
 Examples:
 Bone pain
 Post surgical incision pain
 Myofascial and musculoskeletal pain

10. VISCERAL PAIN:
 Activation of nociceptors due to infiltration, compression,
extension or stretching of thoracic, abdominal or pelvic
viscera.
 Poorly localised, deep, squeezing and pressure like
 Associated with autonomic dysfunction, including
nausea, vomiting and diaphoresis
 Example- Intraperitoneal metastasis

11. NEUROPATHIC PAIN:
 Injury to the central or peripheral nervous system
 Consequence of tumor compression or infiltration of
peripheral nerves or the spinal cord or from chemical
injury to the peripheral nerve or spinal cord
 Example: Brachial and Lumbosacral plexopathies
 Peripheral neuropathies
 Post mastectomy
 Post thoracotomy
 Phantom limb pain

12. ACUTE PAIN
 Well defined temporal pattern of pain onset
 Associated with subjective and objective physical
signs
 Hyperactivity of autonomic nervous system

13. CHRONIC PAIN
 Chronic pain is pain that persists for more than 3
months with a less well defined temporal aspect
 Autonomic nervous system adapts and chronic pain
patients lack the objective signs common to those
with acute pain
 Significant changes in personality, lifestyle and
functional ability

14. BASELINE PAIN:
 Average pain intensity experienced for 12 or more
hours during a 24hr period
BREAKTHROUGH PAIN:
 Transient increase in pain to greater than moderate
intensity that occurs on a baseline pain of moderate
intensity or less

15. TOTAL PAIN
PHYSICAL
SPIRITUAL
PSHCHOLOGICAL
SOCIAL

16. INTENSITY OF PAIN
 Numerical Rating Scale:

17. FACE PAIN RATING SCALE

19. COMMON PAIN SYNDROME
 Tumor related chronic pain syndrome
 Bone pain
 Headache and facial pain
 Tumor involvement of Peripheral nervous system
 Pain syndromes of viscera and Miscellaneous
tumor related syndrome
 Paraneoplastic Nociceptive Pain syndrome

20.  Treatment related Chronic pain syndrome
 Post chemotherapy pain syndrome
 Chronic pain associated with Hormonal therapy
 Chronic post surgical pain syndrome
 Chronic post radiation pain syndrome

21. CLINICAL ASSESSMENT OF PAIN
 Believe the patient’s complaint of pain
 Take a careful history of the patient’s pain complaint
 Evaluate the patient’s psychological state
 Perform careful medical and neurologic examination
 Order the appropriate diagnostic studies and personally
review the results
 Treat the pain to facilitate the appropriate workup

22.  Reassess the patient’s response to therapy
 Individualise the diagnostic and therapeutic
approaches
 Discuss advance directives with the patient and
family

23. MANAGEMENT O CANCER PAIN
 WHO Ladder
 Non opioid analgesics
 Opioid Analgesics
 Anesthetics
 Neurosurgical approaches

24. WHO LADDER

25. WHO LADDER
 STEP I:
 Analgesic drug therapy for mild-moderate pain
 Non opioid analgesic that may or may not be
combined with an adjuvant drug
 STEP II:
 Moderate pain
 Not relieved on non opioid analgesic
 Combination of non opioid with low dose of opioid
i.e. <60mg Oral morphine equivalent

26.  STEPIII:
 Severe pain or moderate pain inadequately
managed at second step
 Opioids >60mg oral morphine equivalent

27. NON OPIOID ANALGESICS
Mechanism of action:
 Inhibiting activation of peripheral nociceptors
 Prevention of the formation of prostaglandin E2
Difference:
 Duration of analgesic action
 Pharmacokinetic profile

30. TOXICITIES: CARDIAC TOXICITIES
 NSAIDs with aspirin:
Reduce effectiveness
Avoid or take separately
 Treatment: Discontinue NSAID
If congestive heart failure develops
Hypertension develops or worsens

31. HEMATOLOGIC TOXICITIES
 When combined with anticoagulants
- Risk of bleeding complications
 Treatment:
- Avoid combination
- Topical NSAIDs such as diclofenac gel or
or patch

32. RENAL TOXICITIES
 High risk:
Age>60yrs
Compromised fluid status
Multiple myeloma
Diabetes
Interstitial nephritis
Papillary Necrosis
Concomitant nephrotoxic drugs
Renally excreted chemotherapy
 Treatment: Re-evaluate NSAID use
Renal function deteriorates
Hypertension develops or worsens

33. GI TOXICITIES
 High Risk:
>60 yrs
History of peptic ulcer disease
Significant alcohol use
Major organ dysfunction
High dose NSAIDs for long period
Concomitant steroid use
Daily aspirin

34.  Treatment:
Discontinuing NSAIDs
Changing to selective COX-2 inhibitors
Adding Misoprostol or PPIs
LFT >1.5 times increase: Discontinue

35. OPIOIDS
 3 types of opioid receptors : mu, delta, and kappa.
 Mu opioid receptors are thought to give most of
their analgesic effects in the CNS, as well as many
side effects including sedation, respiratory
depression, euphoria, and dependence.
 Most analgesic opioids are agonists on mu opioid
receptors

36. TYPES OF OPIOIDS
 Weak opioids: Codeine, Tramadol
 Strong opioids: Morphine, Methadone
 Alternatives of Morphine: Fentanyl patch,
Buprenorphine, Oxycodone

39. CONVERTING ORAL MORPHINE TO FENTANYL
PATCH
 200mg/day oral morphine = 100mcg/hr Fentanyl
patch
Example:
 Patient is taking 30mg SR oral morphine
 60mg/day
 60mg Morphine = 30mcg Fentanyl patch
 Closest round of  25mcg
(Fentanyl patch- 12,25,50,75 and 100 mcg)

40.  Opioid Tolerance: With Repeated therapeutic dose
of morphine or its surrogates, there is gradual loss
in effectiveness.
 Opioid Dependence: Characteristic withdrawal or
abstinence syndrome when a drug is stopped or an
antagonist is administered.
 Opioid Addiction: Euphoria, indifference to stimuli
and sedation, especially when injected i.v. tend to
promote their compulsive use.

41. MANAGEMENT OF OPIOID TOXICITIES
CONSTIPATION
 Preventive measures:
 Educating patient about bowel movement
 Prophylactic medications:
 Stimulant Laxatives
 Dose: Senna: 2 tab every morning (Max 8 tablets per
day)
 Polyethylene glycol: 1 heaping tablespoon in 8 oz water
PO twice daily
 Increase dose of laxative when increasing dose of
opioids

42.  Maintain adequate fluid intake
 Adequate dietary fibre intake
 Supplemental medicinal fibre such as psyllium
unlikely to control and may worsen constipation
 Docusate may not provide benefit
 Exercise, if feasible

43. If Constipation develops:
 Assess cause and severity
 Rule out obstruction
 Titrate laxatives as needed with one non forced
bowel movement every 1-2 days
 Consider Adjuvant analgesics to reduce opioid dose

44. If Constipation persists:
 Reassess the cause and severity
 Rule out bowel obstruction/impaction
Treatment:
 Magnesium hydroxide 30-60ml daily
 Bisacodyl 2-3 tablets daily
 1 Rectal suppository daily
 Lactulose 30-60ml
 Sorbitol 30ml every 2 hours x 3
 Magnesium citrate 8oz PO daily
 Polyethylene glycol

45.  Enema using Sodium phosphate, saline or tap
water
 PAMORAs
 Peripherally acting mu-opioid receptor antagonists :
Methylnaltrexone
Naloxegol
Naldemedine
Lubiprostone
Intractable chronic constipation: opioid rotation to
transdermal fentanyl or methadone

46. Nausea:
 Prochlorperazine 10mg PO every 6 hrs
 Metoclopramide 1-15mg PO 4 times daily
 Haloperidol 0.5-1mg PO every 6-8 hrs
 Alternatives:
 Serotonin antagonists: Ondansetron 4-8mg TDS
Granisetron 2mg PO
 Olanzapine
 Scopolamine

47. Pruritus:
 Antihistaminics:
Cetrizine 5-10mg PO once daily
Diphenhydramine 25-50mg
Promethazine 12.5-25mg
Hydroxyzine 25-50 mg every 6 hrs

48. Delirium:
 Olanzapine 2.5-5mg PO or sublingually
 Risperidone 0.25-0.5 mg 1-2 times per day
Respiratory Depression:
 <10 breaths per minute : Early sign
 Naloxone: Dilute 1 ampule of naloxone into 9ml of
NS for a total volume of 10ml
 Give 1-2ml every 30-60 seconds until improvement
in symptoms

49. ROLE OF ADJUVANT THERAPY

50. ADJUVANT THERAPIES
 1st line: Anti-depressants
 Anti-convulsants
 Tri-cyclic antidepressants:
 Amitriptyline
 Imipramine
 Nortryptyline
 Desipramine
 SNRIs: Duloxetine
 Venlafaxine

51.  Anti-convulsants: Gabapentin
Pregabalin
 Topical agents: Lidocaine patch
 Corticosteroids: Dexamethasone
 Bisphosphonates: Zoledronic acid

53. ROLE OF ANESTHETIC

55. ROLE OF NEURO-SURGERY

57. NCCN GUIDELINES