This document provides brief guidelines for cancer pain management. It discusses the magnitude of the cancer pain problem, with 30-50% of cancer patients experiencing pain during active therapy. It then covers cancer pain classification, assessment, the WHO three-step approach, and recommendations for managing pain in opioid-naive patients versus those already taking opioids. Interventional strategies like nerve blocks and surgical procedures are also reviewed. The document provides an overview of guidelines for comprehensive cancer pain management.

1. Cancer Pain Management
Brief Guidelines
Prof. Shad Salim Akhtar
MBBS, MD, MRCP(UK), FRCP(Edin), FACP(USA)
Consultant Medical Oncologist & Medical Director
Prince Faisal Oncology Center, KFSH
Professor of Clinical Medicine
Qassim Medical University
Buraidah, Al-Qassim

2. IARC Globocan 2002, Figures based on 1998-2002 prevalence
Burden
of
Cancer

3. Magnitude of the Problem-
Future looks GRIM
New cases in 2020

5. Cancer Pain
30-50% of cancer pts are on active therapy
5 million or more cancer patients are
suffering from pain
 With or without adequate therapy
57% patients perceive cancer death painful
69% consider committing suicide due to pain

6. Cancer Related Pain
At diagnosis 25%
Advanced disease 75%
During therapy 30%
Goudas LC et al: Cancer Invest 2005;23:519

7. Barriers to Pain Management

8. Neurophysiology
Nociceptive receptors
 Myelinated fibres
 Noxious mechanical stimuli
 Rapid conduction
 A delta fibres- sharp stinging pain
 Unmyelinated fibres
 Chemical stimuli
 Mechanical stimuli
 Thermal stimuli
 C fibres- dull burning aching pain

9. Cancer Pain Classification
Nociceptive (skin, viscera, muscles,
connective tissue)
 Somatic pain
 Most common type
 Bone metastasis most common cause
 Visceral pain
 Commonly refd to cutaneous sites
Neuropathic pain
 Injury to peripheral or CNS
Caraceni A et al: Oncology 2001;15:1627

10. WHO Three - Step Approach

11. New Concepts of Management
Assessment of pain
Individualization of therapeutic approach
Continual reassessment
Simplest approach
Continuing communication
Define goals
Assurance of availability of expertise

12. Universal Screening
Screen for pain
Quantify pain
Pain >0 comprehensive pain
assessment
 Pain=0 repeat screening at each subsequent
visit

13. Clinical Assessment of Pain
Believe the patients complaint
Careful history
Characteristics of each pain
List and prioritize each pain complaint
Evaluate response to previous therapy
Psychological state evaluation
Alcohol or drug dependence

14. Comprehensive Pain
Assessment
Intensity
At rest
With movement
Interference with activities

15. Pain Intensity Numerical Scale
Verbal: “How much pain are you having?”
from 0 (no pain) to 10 (worst imaginable
pain)
Written: “Circle the number that describes
how much pain you are having.”
0 1 2 3 4 5 6 7 8 9 10
No pain Worst imaginable pain
Wong DL et al:2001; Mosby Inc Ess Ped Nurs

16. Pain Intensity Wong-Baker
Faces
Wong DL et al:2001; Mosby Inc Ess Ped Nurs

17. Pain Intensity Categorical
Scale
None (0)
Mild (1–3)
Moderate (4–6)
Severe (7–10)
Wong DL et al:2001; Mosby Inc Ess Ped Nurs

18. Comprehensive Pain
Assessment
Location
Pathophysiology (Character)
Somatic: pain in skin, muscle, bone described
as aching, stabbing, throbbing, pressure
Visceral: pain in organs or viscera described
as gnawing, cramping, aching, sharp
Neuropathic: pain caused by nerve damage
described as sharp, tingling, burning, shooting

19. History of Pain Other Points
Onset
Duration
Course
Referred pain, radiation
Aggravating & alleviating factors
Associated symptoms
Response to current and prior treatment
including reasons for discontinuing

20. Etiology (Pain syndromes)
 Associated with tumour infiltration
 Associated with cancer therapy
 Unrelated to cancer therapy
Medical history
 Current medications including prescribed,
over the counter
 Complimentary and alternative therapies
 Oncologic
 Other significant medical illnesses
Comprehensive Pain
Assessment

21. Psychosocial Aspects of Pain
Patient distress
Family and other available support
Psychiatric history including current or prior
history of substance abuse
Special issues relating to pain
 Meaning of pain for patient/family
 Patient/family knowledge and beliefs surrounding
pain
 Cultural beliefs toward pain
 Spiritual or religious considerations

22. Clinical examination
Appropriate diagnostic procedures
Treat pain as necessary for work up
Individualize diagnostic and therapeutic
approach
Continuity of care
Reassess patient for response
Discuss advance directive with the pt &
family
Clinical Assessment of Pain

24. Pain not related
to an Oncologic
emergency
Patient not
taking opioids
Patient taking
opioids

25. Opioid Naive Patient Severity 7-10
Rapidly titrate short-acting opioid
 Begin bowel regimen
Recognize and treat side effects
Co-analgesics as indicated
Provide psychosocial support
Begin educational activities
Repeat comprehensive assessment in 24 hrs

26. Titrate short-acting opioid
 Begin bowel regimen
Recognize and treat side effects
Co analgesics as indicated
Provide psychosocial support
Begin educational activities
Repeat assessment in 24-48 hrs
Opioid Naive Patient Severity 4-6

27. Consider NSAID or acetaminophen without
opioid if patient is not on analgesics or
Consider titrating short-acting opioid
 Begin bowel regimen
Recognize and treat side effects
Co analgesics as indicated
Provide psychosocial support
Begin educational activities
Repeat assessment in 72 hrs
Opioid Naive Patient Severity 1-3

28. Approximate Opioid Doses
The appropriate dose is the dose that relieves the patient’s pain
throughout its dosing interval without causing unmanageable
side effects.
Pain 7-10 Consider increasing dose by 50%-100%
Pain 4-6 Consider increasing dose by 25%-50%
Pain 1-3 Consider increasing dose by 25%

32. Pain with Oncological Emergency
 Bone fracture or impending fracture of weight
bearing bone
 Brain metastases
 Epidural metastases
 Leptomeningeal metastases
 Pain related to infection
 Perforated viscous
 (acute abdomen)
 Analgesics as specified by pathway
 Specific treatment for oncological emergency as clinically
indicated
 (eg, surgery, steroids, RT, antibiotics)

33. Consider conversion to SR when 24 hr
opioid requirement is stable
Extended-release morphine sulfate tablets
every 8-24 h depending on brand.
Capsules every 8-24 h
Extended-release oxycodone hydrochloride
tablets every 8-12 h
Transdermal fentanyl delivery system every
48-72 h
Provide rescue short acting opioids
Maintenance Therapy

34. Interventional Strategy
Pain likely to be relieved with nerve block
 Pancreas/upper abdomen
 Celiac plexus block,
 Lower abdomen
 superior hypogastric plexus block,
 Intercostal nerve block
 Peripheral nerve block

35. Interventional Strategy
Failure of response without side effects
 Intraspinal agents
 Blocks
 Spinal cord stimulation
 Destructive neurosurgical procedures
 Neurolysis
 Thoracic splanchnicectomy
 Midline myelotomy
 Cordotomy

36. Surgical Procedures for Pain Control

37. Specific Pain Problems
Inflammation
 NSAIDS
 Corticoides
Bone pain
 Bisphosphonates
Neuropathic pain
 Tricyclic
 Anticonvulsants
 Topical agents
Cancer chemotherapy/radiotherapy

38. Additional therapeutic modalities
Physiotherapy
Hypnosis
Acupuncture
Alternative therapies