4. • Blood pressure
• Temperature
• Pulse
• Respiration
• Oxygen saturation
• Pain
PAIN : Six vital signs
5. Cancer Pain Prevalence
For many patients pain is the first sign of cancer.
• 30 – 50 % of all cancer patients will experience
moderate to severe pain
• 75 – 95 % of patients with advanced stages will
experience severe pain
• 45 % of cancer patients have inadequate pain
control
• 10 % requires invasive action
• 25 % Will die in pain.
Nature Reviews Cancer March 2002
6. Prevalence of Pain in Patients With Cancer:
Systematic Review and Meta-Analysis
Based on the data of 122 articles, Pain
prevalence rates were
39.3% after curative treatment; 55.0% during
anticancer treatment;
66.4% in advanced, metastatic, or terminal
disease and 50.7% in all cancer stages.
J Pain Symptom Management. 2016 Jun;51(6):1070-1090.e9.
7. Pain is an unpleasant sensory and emotional
experience associated with, or resembling that
associated with, actual or potential tissue
damage. (The International Association for the study
of pain )
Pengalaman sensoris dan emosional yang tidak menyenangkan
yang terkait dengan kerusakan jaringan aktual atau potensial,
atau dijelaskan dengan istilah cedera tersebut
PAIN
8. Cancer management is a multidimensional and
requires an interdisciplinary approach.
The various pharmacological (like chemotherapy) and
non-pharmacological (surgical, radiation) intervention
for diagnostic and therapeutic purposes have
associated adverse effects and pain is one of them.
Pain is a complex phenomenon and remains to be
one of the feared symptoms in cancer patient leading
to poor quality of life.
CANCER PAIN
9. Nashed MG, et al. Current Pain and Headache report 2014 18(1):384
10. Pain is a personal experience that can be different for
everyone
It's important to remember that all pain can be
treated.
Cancer pain may not always be completely relieved,
but could be to control and lessen it as much as
possible.
CANCER PAIN
Garg R. J Anesth Crit Care Open Access 2016, 4(3): 00136
11. Classification Of Cancer Pain
• Nociceptive Pain
Somatic pain arises from the skin or deep
tissues.
Visceral pain arises from smooth muscle and
organs.
• Neuropathic Pain
Originates from the nervous system due to
lesions or dysfunction.
12. CANCER PAIN
DIAGNOSTIC
PROCEDURE TUMOR RELATED
Nerve
pain
Bone pain Soft tissue
pain
Referral
pain
TREATMENT RELATED
Surgery
pain
Phantom
pain
Side
effect
chem/radi
otherapy
Etiology cancer pain
15. THE ONCED OF
CANCER PAIN
ACUTE PAIN
CHRONIC PAIN
BREAKTHROUGH
PAIN
The ONCED of Cancer Pain
16. Acute Cancer Pain
The acute cancer pain syndrome is usually due to a definable acute
injury or illness.
This could be secondary to cancer disease events such as
hemorrhage into a tumor, pathological fracture, acute intestinal
obstruction or perforation of a viscous.
Acute cancer pain has a definite onset and its duration is limited
and predictable.
It is associated with clinical signs of sympathetic over activity such
as tachycardia, hypertension, sweating, papillary dilatation and
pallor.
17. Chronic Cancer Pain
Chronic cancer pain can result from the same
causes as acute pain but is differentiated by its
longevity. is defined as constant or continuous
pain of long duration.
Background pain refers to pain persisting for more
than 12 hours per day.
It often has a gradual or ill-defined onset with the
potential to progress in severity.
18. Breakthrough Cancer Pain (BTCP)
Breakthrough pain has been defined as a
transitory exacerbation of pain in patients
receiving chronic opioid therapy with acceptable
analgesia.
Breakthrough cancer pain can either have rapid or
gradual onset and can vary in duration from a few
minutes to a few hours.
19.
20. Acute pain : Acute pain is usually severe, comes on
quickly, and lasts a fairly short time.
Chronic or persistent pain : Chronic or persistent pain
can come on quickly or slowly, and can range from
mild to severe
Breakthrough : Breakthrough pain is a flare of pain
that might happen even though who are taking pain
medicine regularly for chronic pain.
The ONCED of cancer pain
21. A holistic and multidisciplinary approach including
pharmacological, interventional, physical, psychological,
rehabilitative, and alternative modalities
This is essential as these syndromes have the propensity to
continue as chronic pain and becomes difficult to treat.
Requires aggressive management at its initial presentation.
The pain management needs to be individualized based on
etiology.
Management CANCER Pain
22. Management CANCER Pain
Respond by being present as soon as able
Make a rapid clinical assessment (etiology)
Establish the intensity of the pain experienced (severity)
Treatment
Evaluation
23. Cancer Pain Management
Treatment of the
underlying of disease
(ETIOLOGY)
No-Drug
Treatment
Radiation
Physiotherapy
Acupuncture
others
Drug
Treatment
analgesics
Therapy adjuvant
others
24. ETIOLOGI CANCER PAIN
Tumor
Related
Fracture
Brain meta
Pleuritic pain
Diagnostic
procedure :
Thoracocentesis,
Biopsy etc
Treatment
Surgery related :
Chemotherapy /
Radiation
Related
Palliative for
Chronic pain
Breakthrough
pain
Infection
Management CANCER Pain (ETIOLOGY)
33. • How it responds to analgesics
• Whether the daily dose of administration is
appropriate
• Is there a need to increase the dose of opioids
(breaktrough pain >3x/day)
• Whether to switch to opioids therapy
Management CANCER Pain (EVALUATION)
34. 90% of Cancer Pain can be managed by
using WHO Step Ladder
36. Recommendations:
The opioid of first choice for moderate to severe cancer pain is
oral morphine [I, A].
The average relative potency ratio of oral to i.v. morphine is
between 1:2 and 1:3 [II, A].
The average relative potency ratio of oral to s.c. morphine is
between 1:2 and 1:3 [IV, C].
Use of Opioids
Fallon et al. Annals of oncology 2018
37. • How it responds to analgesics
• Whether the daily dose of administration is
appropriate
• Is there a need to increase the dose of opioids
OPIOID TITRATION
42. Doses Convertion
Codein oral Morphine oral (1:10) Dose
codein / 10/24 jam
Tramadol oral Morphine oral ( 1:5) Dose
tramadol/5/24 jam
Morphine oral Morphine subkutan (1:3) Dose
morphine oral/3/24 jam
Morphine oral Morphine subkutan (1:3) Dose
morphine oral/2/24 jam
Morphine oral Morphine iv ( 1:2) Dose
morphine oral/2/24 jam
Morphine sc Morphine iv (1:1) Same dose
Morphine sc/iv Morphine oral (2:1) Dose
morphine X2/24 jam
Opioid Switch
43. Morphine oral
(Dosis per 24 jam)
Fentanyl transdermal
(Dosis mcg/jam)
< 90 mg 25 mcg
90 – 134 mg 37 mcg Used 25 mcg
135-189 mg 50 mcg
190-224 mg 62 mcg Used 50 mcg
225-314 mg 75 mcg
315-404 mg 100 mcg
Opioid Switch
46. Common Adverse Effects of Opioids
• Sedation – common in the beginning, but resolves
soon.
• Nausea & Vomiting – Nausea is common initially.
Metoclopramide (10mg 8hrly) effective.
• Constipation – fairly common. Prophylactic laxatives
– Senna 15mg ON, Lactulose 30ml/day.
• Dry mouth – can be troublesome. Frequent sips of
cool drinks or frozen fruit pieces like pineapple help.
47. Opioid Toxicity Signs And Symptoms
• Clinical triad of central nervous system (CNS)
depression, respiratory depression, and
pupillary miosis.
• Respiratory depression - most specific sign.
• Acute delirium.
• Myoclonus.
• Seizures.
• Hyperalgesia.
• Hallucinations.
47
48. Morphine Myths:
• Respiratory depression – Experimental pain
stimulates respiration and attenuates morphine-
induced respiratory depression – Pain 64, 1996.
• Addiction (Psychological Dependence) – Very rare
in cancer patients. One case seen in study of 550
cancer patients over 22,525 days.
• Physical Dependence – Withdrawal symptoms
normal and expected physiologic response when
opioids are discontinued.
48
49. Take Home Message
• Opioid therapy is the mainstay treatment in
cancer pain with 90% effectiveness
• Opioid is not a life threatening drug if you use it
properly
• Be confident of using opioid when it’s necessary
• Do palliative care concept with good palliation
of symptom
Iranian Journal of Cancer Prevention: 10 (1): e7902
