cancer pain

1. Dr. Md Mamun ur Rashid
DA , FCPS (ANAESTHESIA)
FIPM(Delhi)

2. CANCER PAIN : PREVALENCE &IMPACT
 More than 14 million cases of cancer were diagnosed
worldwide
 1 in 3 patients on average do not receive adequate
pain medication
 50% of patients undergoing treatment for cancer and
up to 90% of patients with advanced cancer have pain
 Cancer pain is multi focal, multi causal & dynamic.
Most patients have more than one type of pain

3. Barriers to effective pain
management
 lack of knowledge regarding pain
assessment and management
• misconceptions about the analgesic use
• Increased survival among persons with
cancer due to introduction of new
treatments
• govt restrictions on sale of opioids
• opiophobia

4. CLASSIFICATION OF
CANCER PAIN
1. Somatic : bone metastasis
2. Visceral : pancreatic carcinoma
3. Neuropathic : plexopathy
4. Sympathetically maintained pain :
reflex sympathetic dystrophy

5. Pain is a cornerstone of
cancer treatment:
• promotes an enhanced quality of life
• Avoids psychological effects of cancer
pain
• improves functioning
• means for patients to focus on their
lives
• Increased survival

6. CAUSES OF PAIN IN CANCER
1. Tumor infilteration
2. Involvement of nerves/plexus
3. Bony mets
4. Massive ascites, pleural effusion
5. Visceral and peritoneal infilteration
6. Related to cancer treatment –
mucosites, polyneuropathy,
Postsurgical chronic pain syndromes

7. ASSESSMENT OF PAIN INTENSITY
 Pain evaluation includes a detailed
oncologic, medical & psychosocial
assessment
 Wisconsin Brief Pain Inventory (BPI)
 Memorial Pain Assessment Card
 Edmonton Staging System
 Numerical Pain Rating Scale or VAS
 WHO QOL scores
 Eastern cooperative oncology group
performance scale & Karnofsky rating

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 Pediatric cancer pain assessment
includes use of the Beyer Oucher, Eland
Color Scale-Body Outline, Hester Poker
Chip Tool, and McGrath Faces Scale
 The BPI is a 15-minute questionnaire
that can be self-administered.
 It incorporates two valuable features of
the McGill Pain Questionnaire—a
graphic representation of the location of
pain and groups of qualitative descriptors

10. EVALUATION OF THE PATIENT WITH
CANCER PAIN
1. Oncologic history
• diagnosis and stage of disease
• History of implemented therapies -
chemotherapeutic agents used, types of
surgery, site of therapy
• radiotherapy
• outcome (including side effects)
• patient’s understanding of the disease
process and prognosis

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2. Pain history
for each new pain site-
• Onset and evolution
• site and radiation areas
• Pattern (constant, intermittent, or
unpredictable)
• Intensity (best, worst, average, current;
rating on a 0 to 10 scale)
• quality, exacerbating and relieving factors
• pain interference with usual activities
• neurologic and motor abnormalities
(including bowel and bladder continence)

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◦ vasomotor changes
• Current and past analgesics (use, efficacy, side
effects)
• Prior analgesic use, efficacy, and side effects
3.Psychosocial history
4. Medical history (independent of oncologic history)
• coexisting systemic disease
• Exercise intolerance
• allergies to medications
• current medications
• prior illness and surgery
5. Physical Examination
 The physical examination must be thorough

13. MANAGEMENT OF CANCER-
RELATED PAIN
 Basic principle :
• modifying its source (treatment of
cancer)
• interrupting its transmission
• modulating its influence at brain or
spinal cord sites (analgesics, anti
depressants, anxiolytics, neuraxial
analgesia)

14. GUIDELINES FOR CANCER PAIN
MANAGEMENT
1. WHO analgesic ladder
2. Pain treatment cantinuum

15. WHO analgesic ladder

16. PAIN TREATMENT CONTINUUM

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 ADVANTAGE:
 Effective pain relief
70-80% patients
 Simple to use
 assessment of cancer
pain
 DISADVANTAGE:
 less emphasis on
regional blocks
 Extra emphasis on
opioids, not easily
available especially
oral morphine

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 The most effective form of treatment of any
cancer related pain is treatment of the cancer
itself
 More than one treatment modality can be
employed at one time and one modality can
supersede another according to patients need

20. Treatment protocol for cancer pain managment

21. Consider other aetiologies and treatment

22. Pharmacologic Management
 Oral analgesics are the mainstay of
therapy for patients with cancer pain
 The noninvasive route should be
maintained as long as possible

1. Paracetamol & NSAIDS
 blocks synthesis of prostaglandins,
which activates nociceptive fibres
 Mild pain
 Opioid sparing
 Less side effects

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2. Cyclooxygenase 2 inhibitors
 Analgesic property lesser than NSAIDS
 Celecoxib 100-200mg OD/BD
Etoricoxib 90-120mg/day

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 3. Opioids
 1st line for moderate to severe cancer pain
 Effective pain control in 85% patients
 Easily titrable
 Good risk benefit ratio.
 Dosage
1. Morphine 10mg; q 3-4h (max 400mg/d) GOLD
STANDARD FOR MOD-SEVERE PAIN
2. Codeine 120-360 mg; q 3-4h

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3.Tapentadol 100-400mg/day NEW SYNTHETIC
OPIOID FOR SEVERE CANCER PAIN & LESSER
SIDE EFFECT
4.Tramadol 50-100mg; q8-12h(max 400mg/d)
5.Transdermal Fentanyl & transdermal
Buprenorphine.
 Opioid responsiveness : it is the probability of
adequate analgesia(satisfactory without
intolerable & unmanageable side effects) that
can be attained during gradual dose titration

26. Strategies for poor responsive patients

27. OPIOID ROTATION
 an approach to convert poorly responsive
patient to a responsive one
 guidelines :

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29. 4. ADJUNCT DRUGS
 1. ANTICONVULSANTS
 Moa: GABA receptors, pain transmission

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 2. ANTI DEPRESSANTS
 For neuropathic pain
 Potentiate analgesic properties of opioids

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 3. CORTICOSTEROIDS
 Mechanism:
• Reduction of inflammation
• Block C-fiber transmission
• Weak local anesth properties
• Reduce ectopic discharge from neuromas
• Action on dorsal horn cells

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4. Neuron Revitalizer :
 Methoxycobalamine: 500mcg TDS neuron
regeneration
5. Muscle Relaxants:
 For muscle spasm
 Tizanidine 2-6mg TDS
6. BISPHOSPHONATES
 used in multiple myelomas, bone mets
7. OSTEOCLAST INHIBITORS
 neuropathic & bone pain

33. Interventional Techniques for
Pain Management
 When pharmacologic therapy fails to
provide adequate analgesia or leads to
unacceptable side effects.
 A. Intravenous Infusion of Opioids with
Patient-Controlled Analgesia Devices
Indications
• severe pain
• need to titrate opioids rapidly
• oral route is not available because of
gastrointestinal (GI) obstruction,
malabsorption, uncontrolled nausea and
vomiting, dysphagia.

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 B. Intraspinal Analgesia
 Used when :
1. Systemic opioids provides pain relief but
with unacceptable side effects
2. Unsuccessful treatment with strong
opioids
3. Life expectancy > 3-6mnths opioid alone
or in combination with other agents such as
bupivacaine, clonidine(30-120mcg/day),
midazolam(1.2mg/day

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4.Intraspinal morphine is GOLD STANDARD
therapy (0.5 mg/day to 12.5mg/day)
5. pain relief is in a highly selective fashion
without motor, sensory, and sympathetic
effects
6. analgesia was potentially superior to that
achieved when opioids were administered
by other routes and, because the total
amount of drug administered is reduced,
side effects are minimal

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 C. NEUROLYTIC BLOCKS
 SOMATIC & SENSORY BLOCKS:
• Paravertebral block: CA lung, Rib
secondaries
• Intercostal nerve block : CA breast, rib
seconadries
• Mandibular & Maxillary nerve block : CA
cheek, salivary gland tumor
• Deep & superficial cervical blocks: nerve
tumors, thyroid CA.

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 SYMPATHETIC PLEXUS BLOCK:
• Stellate ganglion block: upper limb tumors
• Coeliac plexus block: CA liver, pancrease,
stomach
• Lumbar plexus block: pelvic & lower limb CA
• Superior hypogastric plexus block: pelvic CA,
cervix, body of uterus
• Ganglion Impar block: CA rectum

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 Limitations :
• New pathways develop
• Pain relief upto 60-70%
• Duration 3-4mnths
• Deafferentation pain synd
 Morbidity of procedure
D. INTRAVENOUS LIGNOCAINE INFUSION:
 central analgesia, 5mg/kg over 60mins
upto 3weeks

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 E. ADJUNCTS :
• Transcutaneous electrical nerve stimulation
• Cognitive behavioural intervention
• Relaxation
• Yoga, meditation