GRACE :: Treatments & Symptom Management

Cancer Pain: Where Are We and Where Are We Going?

Pain is one of the most feared symptoms faced by cancer patients, particularly those with advanced disease.  The mainstay of treatment for cancer pain remains narcotic pain medications, though other treatments may be helpful and more are in development.

Studies have shown that, unfortunately, cancer pain is undertreated.  In a large study of more than a thousand patients with advanced cancer, more than a third of patients had pain to the point of impaired function, while nearly half were found to have inadequate pain control. (Cleeland et al NEJM 1994).  Risk factors for poor pain control include: female gender, minority race, older age and a discrepancy between the doctor’s perception of pain and the patient’s perception.

Measuring a symptom as complicated and varied as pain can be difficult.  It is important for a clinician to gather as many details about the pain as possible to come up with the best treatment regimen.  Patients should be asked the location of their pain, how often it occurs (or if it is constant), and what it feels like.  Some characteristics of pain sensation can include descriptions such as “gnawing” (characteristic of tissue damage), “aching” (may indicate bone pain) “burning” or “electric shock-like” (characteristic of nerve damage).  It may help to know what aggravates the pain or makes it better.  It is important to know how the pain affects quality of life: does the pain interrupt sleep? Does it prevent the sufferer from going out with friends or family?  Does it get in the way of day-to-day functioning?

Graphic of WHO's Pain Relief Ladder

WHO’s Pain Relief Ladder

Importantly, how is pain best treated?  The WHO uses a ladder to help visualize cancer pain management and strategies to treat it with the top of the ladder representing freedom from cancer pain.  Accordingly, mild pain is treated with medications such as acetaminophen or other anti-inflammatory drugs.  Moderate pain should be treated with a short acting opioid (such as oxycodone or morphine).  Severe pain likely requires a longer acting or timed release opioid for pain control.

Opioid medications have side effects that patients who take them need to be aware of.  One of the most difficult is constipation and prompt attention needs to be paid to bowel function when an opioid is started.  Most patients taking opioids will need medications to control their bowel function ranging from simple stool softeners to stronger laxatives.  Another distressing side effect is sedation and fatigue.  This can decrease as time goes on, but needs to be watched for safety reasons and to ensure that it does not significantly affect quality of life.  Other side effects to watch for include itching, difficulty urinating and nausea.

While opioids remain very important in the management of cancer pain, there are additional medications and procedures that may benefit patients suffering from cancer pain.  Anti-inflammatory medications such as ibuprofen are often helpful, particularly in bone pain.  Other adjunctive treatments include: warm packs or hot soaks, Lidoderm patches, acetaminophen, or massage.

For severe cancer pain, particularly pain that does not respond well to medications, procedures to control pain may be very helpful.  Such procedures are often done by an anesthesiologist, who may be specialized in pain management.  Procedures can include nerve blocks, which can temporarily or permanently deaden the nerve to a painful area.  Some patients will benefit from having a pump placed that delivers pain medication right to the spinal cord area.  Since it is directed in the spinal cord area, much less pain medication dose can be used with very effective pain relief.  Radiation therapy focused at a painful area of cancer can be very effective at providing pain relief, but may take time before the pain relief will be realized.

Picture of Puffer Fish

Puffer Fish

Opioids have been used in pain control dating back to 4000BC and improvements in pain control are desperately needed.  Fortunately, new drugs and pain control techniques are being developed.  One such therapy derives from the puffer fish.  TTX or tetrodotoxin is the neurotoxin found in puffer fish.  It blocks critical cellular channels required for the sensation of pain.  A derivative of this compound is currently in phase III testing in patients with cancer pain.  A new technique to treat cancer pain is also under development.  This uses MRI guidance to find the affected area and ultrasound waves to treat the pain (called MR guided focused ultrasound surgery or MRgFUS).  In a small study of patients with advanced cancer, 64% of patients had an improvement in their pain compared with 20% in the placebo arm.  (Hurwitz et al, JNCI March 2014).  This procedure shows promise and needs more study.

Cancer pain remains a difficult problem, but part of treating cancer is committing to optimal pain control for each patient.  Relief comes in the form of medications, simple measures such as massage and warm soaks or more invasive procedures such as epidural pumps.  Technology and newer medicines hold promise to expand our armamentarium to better treat cancer pain.


Hospice is HELP: Avoid it at Your Peril

I’m on call for my oncology group this weekend, and I’ve had the situation come up twice in less than 24 hours that a patient is in dire need of home-based symptom management, with plans for hospice just getting initiated in a mad scramble on a Saturday or Sunday.  In both cases, the patient is sick enough and far enough from the hospital that just evacuating them with a 911 call isn’t an effective way to solve the problem.  And so what could otherwise be a legal urgent delivery of pain medications to a hospice patient is a difficult night of toil and unnecessary suffering because there isn’t a mechanism to get medications or support for someone who will be enrolling on hospice tomorrow, after weeks of the patient and/or family resisting an appropriate and well-meaning recommendation to enroll earlier.

It’s a terrible shame that, in the US at least, hospice care is usually initiated at a point when death is just a few days or even hours away.  Too often it’s a race for hospice nurses to get to the patient in time to provide needed comfort and support in the last moments of a person’s life, after the patient and their family and friends have already struggled through the rapid changes and symptoms of dying.  If it isn’t “too little, too late”, it’s close.   But hospice teams can provide critical value and support if referrals are made long enough for the patients and families to develop a good relationship with the folks from hospice.

This seems to stem from a tendency to want to deny, to wish away, any acknowledgement that a person’s disease is terminal (sometimes by doctors, sometimes by families, sometimes by the patient himself or herself), as if avoiding the subject and the needed action will keep it from happening.  But a person will continue to decline, death will unfortunately ensue, and the only consequence of postponing to the point of critical distress and unavoidable recognition of the reality is that everyone experiences far, far more suffering and chaos than they would have otherwise.

It’s understandable that people don’t want to embrace a sad reality when death is becoming close enough to anticipate and plan for. In truth, death is rarely a beautiful experience, but it can often go from being terribly challenging and unpleasant to minimally so when there are people nearby who are equipped and motivated to help, and who have the experience to guide people.  I think it’s a very sad, regrettable mistake to not avail themselves of that help until it’s an absolute crisis.  


Dr. Harman on Depression and Cancer-Related Fatigue

 

 

Here is the last of four podcasts from Dr. Stephanie Harman’s terrific presentation on common cancer-related symptoms.  This one focuses on the common issues of depression and cancer-related fatigue.  Below you’ll find the audio and video versions of her presentation, along with the associated transcript and figures.

 

 

Dr. Harman Depression and Fatigue Audio Podcast

Dr. Harman Depression and Fatigue Figs 

Dr. Harman Depression and Fatigue Transcript 

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Dr. Stephanie Harman on Nausea and Management Options

 

The third installment from Dr. Harman covers nausea and options to manage it.  She discusses both chemotherapy-induced nausea and some other potential causes.  

Here is her talk in both video and audio podcast versions, along with the transcript and figures.

Dr. Harman Nausea Audio Podcast

Dr. Harman Nausea Transcript

Dr. Harman Nausea Figs

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Dr. Harman on Cancer Pain Management

Here’s the second part of Dr. Harman’s webinar on managing common cancer symptoms, in which she discusses the basic tenets of cancer pain management.  

Dr. Harman Pain Management Audio Podcast

Dr. Harman Pain Management Transcript

Dr. Harman Pain Management Figs

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