Pain in Cancer

Comments · 84 Views

Pain is the most common symptom leading people to seek medical attention. When pain is controlled, quality of life improves. Pain may even shorten life. Reported pain in a group of ovarian cancer survivors was associated with markers of inflammation, a known driver of cancer and other dise

Pain

Pain, which can range from mild to severe, is the most common symptom leading people to seek medical attention. Both our experience and research tell us that when pain is controlled, quality of life improves dramatically. Uncontrolled pain, on the other hand, creates unnecessary suffering, "not only by causing immediate physical suffering, but also by increasing the anxiety level and the fear about the future and future problems."1 Pain may even shorten life. Reported pain in a group of ovarian cancer survivors was associated with markers of inflammation, a known driver of cancer and other diseases.2

Types of Pain

Pain can be acute or persistent:

  • Acute pain is short-term and usually ends after the source of the pain is addressed and the painful area heals—for example, incision pain after surgery.
  • Persistent pain is present frequently or constantly most of the day and persists beyond the period of time when the painful area is expected to heal. In persistent pain, the cause of the pain may not be able to be addressed.

Many cancer patients fear that they will have persistent pain, but many don’t usually experience such pain except perhaps with advanced cancer.

If you have pain, first understand that cancer pain can be managed, often with relatively simple treatments such as oral pain medications. Become educated about cancer pain, how to communicate your pain, where to get help, and what to do next if you’re not satisfied.

Pain may be a side effect of many medications, such as statins. Before pursuing treatments for pain, check with your doctor or pharmacist to see if any of your prescription medications may contribute to pain and whether adjustments can be made.

Reporting Pain

A critical step is reporting pain to your doctor. To learn how to talk with your doctor about pain, see NCI’s booklet: Pain Control. If your doctor is not trained in cancer pain management and is unable to help you relieve your pain satisfactorily, consider asking for a referral to a healthcare professional trained in managing cancer-related pain. These professionals often have a point of view that pain is an “emergency”, encouraging patients to report unmanaged pain promptly. In addition to medical oncologists (who are usually very knowledgeable about cancer pain management), doctors and nurses trained in palliative care are experts in helping people manage symptoms related to chronic illnesses such as cancer. These palliative care specialists often work in hospice or palliative care programs.

Myths and Truths about Pain

Fears about pain and pain treatment are common. Perhaps your fears come from experience with someone with cancer whose pain caused suffering, and you are afraid that will happen to you. Many people are also afraid that if they take opiates such as morphine, they will become addicted or will be confused, incoherent or “out of it” all the time. Many may fear that if they take an opiate now, it won’t work later if the pain gets worse.

Many of the common fears people have about cancer pain management are often unfounded. Allow space for the probability that you will not have persistent pain, and that if you do, you will have knowledge of and access to expert help for managing your pain.

Some truths:

  1. Unreported, uncontrolled pain will make you weak.
  2. Addiction is not common if you are taking your pain medication as your doctor prescribes and you don’t have have the disease of addiction or high risk for addiction (see at right).
  3. The risk of opiod-related death is very low in cancer patients.
  4. Pain dampens your thinking abilities. When opiates effectively control pain, cognitive function usually improves over time.
  5. Raising the dose of opiate as needed or even switching to another opiate can achieve good pain management with minimal side effects.
  6. Most opiate side effects can be prevented or controlled.
  7. Some people with cancer misuse opioids by using without a prescription or for a reason other than as directed by a physician (such as to create euphoria). Misuse also includes using opioids in greater amounts, more often or longer than prescribed,7 often because of insufficient pain control.

Even though addiction is not common overall, a study of women undergoing mastectomy with reconstructive surgery as part of cancer treatment investigated use of opioids and sedative-hypnotic drugs. These women are at particularly high risk of becoming dependent on opioids following surgery, with about 13 percent of women who had not used an opioid for the year before surgery becoming a chronic user in the year following surgery. More than 6 percent of women became chronic users of sedative-hypnotic drugs. The researchers recommend women work closely with the prescribing provider to attempt to minimize risk of dependence.8

If you are not getting good pain management, report this to your physician as soon as possible rather than adjusting the dose or frequency on your own. Misusing opioids, even for what you consider a good reason, may possibly lead to mistrust between you and your doctor and less effective care.

Finally, bear in mind that complete obliteration of physical pain is not usually a realistic objective; however, a realistic goal is to manage the pain so that it is tolerable and frees you up to achieve your own goals of living well.

Managing Pain

Clinical Practice Guidelines

The 2016 American Society of Clinical Oncology clinical practice guideline for management of chronic pain in survivors of adult cancers makes these recommendations regarding complementary approaches:10

TherapyRecommendation
An individualized exercise program
  • Based on intermediate quality evidence
  • Benefits outweigh harms
  • Strength of recommendation: moderate
Acupuncturemassage or music therapy
  • Based on low quality evidence
  • Benefits outweigh harms
  • Strength of recommendation: weak
Cognitive behavioral therapy, mindfulness, relaxation, distraction, or guided imagery
  • Based on intermediate quality evidence
  • Benefits outweigh harms
  • Strength of recommendation: moderate

Conventional Approaches

Opiates are currently the mainstay of treating moderate to severe cancer pain. The non-opioid analgesic acetaminophen/paracetamol (brand name Tylenol in the US) can be effective against mild to moderate pain. Non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin can reduce pain caused by inflammation. Your doctor may prescribe both acetaminophen and an NSAID for mild to moderate pain if inflammation is involved. Advil Dual Action combines analgesic and anti-inflammatory effects in one pill, but a similar effect can be achieved by alternating an analgesic (acetaminophen/paracetamol) with an NSAID, with the added benefit of tailoring the NSAID to your specific needs and condition (see Aspirin and Other Non-steroidal Anti-inflammatory Drugs (NSAIDs) for cautions related to each type of NSAID). Because each type of pain reliever carries risks of adverse reactions and interactions with other therapies, we encourage you to consult your physician before use.

We can often further manage pain with other kinds of medication, such as anticonvulsants and antidepressants. Chemotherapy, surgery or radiation therapy may also be part of your pain-treatment plan.

Pharmacologic treatment of pain does not always meet patients’ needs and may produce difficult side effects.

Complementary Approaches

Many non-drug techniques—complementary therapies—can also be remarkably helpful in controlling your pain. Persistent pain often is best managed with an integrative approach, combining conventional medications and treatments with complementary approaches. The Society for Integrative Oncology clinical practice guidelines list integrative therapies with evidence for addressing pain:12 

  • Massage therapy from a therapist trained in oncology massage
    • The presence of depression or higher baseline psychological symptom frequency impacts the effect of massage therapy on pain, interference of pain, quality of life, 60-second heart and respiratory rates, and physical distress among people with advanced cancer13
  • Mind-body approaches including these:
    • Cognitive-behavioral stress management
    • Cognitive-behavioral therapy (CBT)
    • Hypnosis
    • Music therapy
    • Relaxation training
    • Support groups
    • Supportive/expressive therapy
  • Acupuncture
  • Therapies based on a philosophy of bioenergy fields such as these:
  • Medical cannabis or cannabinoids can be highly effective with fewer concerns than opiods.14
  • Bioelectromagnetically based therapies:
    • Pulsed electromagnetic fields (PEMF): Several studies and reviews show reduced pain, opioid use and inflammation after surgery.15
    • Transcutaneous electrical nerve stimulation (TENS): A review and meta-analysis showed reduced blood levels of proinflammatory cytokines,16 and a clinical trial found reduced pain intensity, lower opioid use and fewer requests for chest radiographs after coronary artery bypass surgery.17 A review found improved postoperative pain in urology patients.18
    • Electroacupuncture: Randomized trials showed evidence of reduced pain after thoracic surgery.19
    • Transcutaneous electrical acupoint stimulation (TEAS): A randomized study found that TEAS use with general anesthesia led to stable blood pressure during surgery, reduced analgesic use and better pain relief compared to general anesthesia alone..20

Some of these methods may relieve pain directly, while others may improve your ability to cope with the mental, emotional and spiritual discomforts that often accompany and aggravate physical pain.

Research shows that mind-body interventions can reduce or relieve pain in cancer patients, whether from the disease itself or from side effects of treatments, and allow patients to participate in their own care.22

Earlier bedtimes (before midnight) were also associated with less pain than later bedtimes in a group of ovarian cancer survivors.23

Integrative Programs, Protocols and Medical Systems

Comments