Palliative Care & Pain Management: Treating Cancer Pain

It is possible to manage pain effectively in most patients with cancer or with a history of cancer. Although cancer-related pain cannot always be relieved completely, therapy can lessen pain for nearly all patients. Effective management of pain and other symptoms improves quality of life throughout all stages of the disease.

Patients should not hesitate to tell their physicians or nurses if they are feeling pain. In fact, pain can interfere with the effectiveness of cancer treatment, so it is very important that patients tell a member of their medical team about any pain they may be experiencing.

Assessment of Pain

Because the diagnosis, stage of disease, response to pain and treatments, and personal likes and dislikes are different for each patient, management of cancer pain at Memorial Sloan Kettering is tailored to the individual patient in order to be as effective as possible.

All patients of Memorial Sloan Kettering are regularly screened for the presence of pain in both inpatient and outpatient settings. Inpatients are asked every four hours if they have pain, and they are encouraged to report it to their nurse or doctor whenever it occurs. Intensity is assessed on a scale of 0 to 10, with 0 representing “no pain” and 10 representing “the worst pain imaginable.” Every effort is made to provide patients with adequate analgesia and ongoing assessment, and patients are encouraged to tell their nurse or doctor whenever pain occurs.

Management of Pain

Much progress has been made in understanding and treating pain over the past three decades due to scientific advances in molecular biology, neuroscience, pharmacology, and anesthesiology. Researchers have identified pain receptors and clarified the process by which pain signals are transmitted to the brain. These findings in the laboratory have translated into more effective therapies for treating pain in cancer patients.

Cancer-related pain may be treated through one or more of the following approaches:

Removal or Reduction of the Underlying Cancer

Video

Pain specialist Paul Glare explains the causes of cancer-related pain, and describes strategies to help manage it.

(29:00)

Surgery, radiation therapy, chemotherapy, and immune therapy may provide substantial relief from pain by ridding the body of some or all of the underlying cancer. In addition, new methods of interventional radiology allow for minimally invasive treatments that destroy tumors without surgery.

Palliative Surgery/Radiation Therapy

In addition to removing or reducing the cancer responsible for the pain, surgery and radiation therapy also can be performed strictly for palliative purposes, reducing pain and other symptoms and allowing patients to sustain quality of life. Surgery may be used to prevent or control pain-causing cancer complications such as bowel obstruction, compression of the spinal cord or peripheral nerves, or compression of organs. Palliative surgery and radiation are focused on patient comfort rather than survival and are used primarily for patients with advanced cancer.

Pharmacologic & Anesthetic Approaches

Pain-relieving medicines can be prescribed for various types of cancer-related pain. These medications are given in different ways, depending on a patient's individual needs and preferences. These include:

  • Orally (by swallowing)
  • Transmucosally (held in the mouth briefly until absorbed)
  • Rectally
  • Intravenously (by needle into a vein)
  • Subcutaneously (injected just under the skin)
  • Transdermally (absorbed through the skin)
  • Epidurally or intrathecally (delivered by pump into the space around the spinal cord)

Typically, a nurse will administer these medications, but they may also be delivered by means of patient-controlled analgesia, or PCA, in which the patient helps determine the amount of pain medication that is given by pressing a button on a computerized pump.

Mild to Moderate Pain

Non-opioid drugs such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs, or NSAIDs, such as aspirin and ibuprofen, provide relief from many types of mild to moderate pain, including muscle pain, bone pain, and the pain caused by some incisions. Non-opioid analgesics may be prescribed in combination with opioids and other therapies for greater pain relief.

Moderate to Severe Pain

Opioids (such as morphine, fentanyl, codeine, oxycodone, hydromorphone, and methadone) are highly effective medicines for relieving cancer pain. (Despite widespread belief, morphine is not the most powerful opiod. Patients sometimes fear its potency or worry about becoming addicted but it is a safe, well-tolerated drug.) When pain arises, doctors usually start with an immediate-release medication and then switch to an extended-release form that needs to be taken only twice a day.

Opioids may be combined with non-opioid drugs such as acetaminophen or nonsteroidal anti-inflammatory drugs for treatment of moderate pain, and used alone or in combination with other drugs (adjuvant analgesics) and therapies for severe pain. Patients rarely become addicted when powerful pain medications such as opioids are prescribed for cancer-related pain and taken appropriately. Depending on need, opioids may be prescribed at any stage of treatment. For cases in which the doctor wishes to reduce the amount of opiod used, it may be possible to manage pain sufficiently by placing a lidocaine patch over the painful area.

There is no need to “tough it out” early in treatment out of concern that strong pain medicines won't be effective if needed later on. Patients may receive increasing doses of opioids for years without becoming addicted or psychologically dependent. When the need for pain relief subsides, physical dependence can usually be managed without withdrawal symptoms by tapering the opioid before discontinuing. Patients with cancer very rarely seek drugs beyond what is needed to control pain.

Breakthrough Pain

Sometimes, a doctor may prescribe a quick-acting, potent analgesic called a “rescue medication,” such as oral morphine, for the patient to have available in the event that pain “breaks through” normal pain control. These rescue doses act quickly and leave the body relatively soon. They are usually prescribed in addition to the medication taken regularly for persistent pain.

Adjuvant Analgesics

Several drugs besides non-opioid and opioid analgesics have been found to provide pain relief in specific situations and may be prescribed to help manage cancer-related pain. Many of these drugs — including antidepressants, anticonvulsants, and steroids — are better known for treating conditions other than pain but now are being used with excellent results. Some of these agents have been found to help relieve specific types of pain, such as “tingling” and “burning” sensations and pain caused by inflammation (swelling).

Nerve Blocks

For acute and postoperative pain and some chronic pain problems, temporary nerve blocks (neural blockades) can provide temporary relief. In this procedure, a physician injects a local anesthetic into or around nerves or below the skin in the area where there is pain. The anesthetic interrupts transmission of pain signals to the brain and may provide relief for up to several hours. In a procedure called a neurolytic block (neurolysis), a physician injects a substance — most often ethyl alcohol or phenol — into a nerve or into the spinal fluid so that nerve tissue in the pain pathway is destroyed. This technique usually has a long-lasting or permanent effect.

Epidural & Intrathecal Pumps

Nerve blocks work best for pain that occurs over a limited area, involving one or two specific nerves. For pain that is more widespread, it is possible to interrupt pain signals using epidural or intrathecal pumps. (“Epidural” refers to the space just outside the spinal cord's outer membrane; “intrathecal” refers to the space between the sheaths covering the spinal cord.) These pumps are either carried in a pouch or placed under the skin to deliver medication continuously to broad areas. Some pumps have a button that the patient can push to receive additional medication. By delivering medicine directly to the nerves causing pain, less medication may be needed. For many patients, this can mean better pain relief with fewer side effects.

A powerful new drug, ziconotide, is now commonly used in epidural and intrathecal pumps. Derived from the toxin of a cone snail, this drug was approved by the Food and Drug Administration in 2004 for use in severe, chronic pain. It is effective in up to 50 percent of patients, but may not be appropriate for everyone.

Neurosurgical Approaches

Most cancer-related pain can be effectively managed with medication, but when drug therapy does not provide adequate relief or when the side effects of medications become a problem, nonpharmacologic approaches are often effective.

In some instances in which pain is not controlled by more conservative means, pain pathways can be cut or interrupted (ablated) by neurosurgery. The most common procedure, called a cordotomy, disables nerves in the spinal cord that are responsible for conducting pain impulses to the brain. Neurosurgical techniques are also sometimes used to implant drug-delivery devices and to stimulate nerve fibers to inhibit pain.

Psychological Approaches

Focused psychological interventions are an important component of effective pain management. Short-term psychotherapy, structured support, and cognitive-behavioral therapy can help patients develop useful coping skills to enhance the effectiveness of other treatments. Memorial Sloan Kettering's Department of Psychiatry and Behavioral Sciences pioneered the development of psychiatry in the cancer setting and is committed to the psychological and psychiatric care of cancer patients and their families. The department provides evaluation and management of the major psychiatric complications of cancer and its treatment, as well as counseling services for the problems of coping with cancer.

Patients and family members who would like to have a consultation with a psychologist who specializes in coping with pain can call 646-888-0200.

Complementary Therapies

Complementary approaches to pain relief may be integrated into therapy at any stage of treatment. These complementary therapies include relaxation techniques, meditation, movement therapies, acupuncture, and massage to supplement medical pain-control methods. Techniques such as these can help relieve acute pain during certain procedures, acute post-procedural pain, and some forms of chronic pain.

Memorial Sloan Kettering's Integrative Medicine Service offers individual therapies and group classes using the best of these complementary approaches. Services and programs offered by the Integrative Medicine Service are open to all cancer patients. Memorial Sloan Kettering inpatients can arrange for services by calling 646-888-0888.