Elsevier

The Lancet

Volume 353, Issue 9165, 15 May 1999, Pages 1695-1700
The Lancet

Series
Management of cancer pain

https://doi.org/10.1016/S0140-6736(99)01310-0Get rights and content

Summary

Patients with cancer have diverse symptoms, impairments in physical and psychological functioning, and other difficulties that can undermine their quality of life. If inadequately controlled, pain can have a profoundly adverse impact on the patient and his or her family. The critical importance of pain management as part of routine cancer care has been forcefully advanced by WHO, internationlal and national professional organisations, and governmental agencies. The prevalence of chronic pain is about 30–50% among patients with cancer who are undergoing active treatment for a solid tumour and 70–90% among those with advanced disease. Prospective surveys indicate that as many as 90% of patients could attain adequate relief with simple drug therapies, but this success rate is not achieved in routine practice. Inadequate management of pain is the result of various issues that include: undertreatment by clinicians with insufficient knowledge of pain assessment and therapy; inappropriate concerns about opioid sideeffects and addiction; a tendency to give lower priority to symptom control than to disease management; patients under-reporting of pain and non-compliance with therapy; and impediments to optimum analgesic therapy in the healthcare system. To improve the management of cancer pain, every practitioner involved in the care of these patients must ensure that his or her medical information is current and that patients receive appropriate education.

Section snippets

Assessment of cancer pain

The management of cancer pain depends on a comprehensive assessment that characterises the symptom in terms of phenomenology and pathogenesis, assesses the relation between the pain and the disease, and clarifies the impact of the pain and comorbid conditions on the patient's quality of life. This assessment requires the use of a standard nomenclature and an approach that explores the many dimensions of pain and other features of cancer.

Because pain is inherently subjective, a patient's

Cancer pain syndromes

Recognition of pain syndromes can help identify the specific aetiology responsible for the pain, guide the need for additional evaluation, suggest specific therapies, or assist in assessments of patients' outcome. Although most acute pain syndromes are caused by common diagnostic or therapeutic interventions2 (panel 1), acute flare ups of pain are also common among patients with chronic pain. Up to two-thirds of patients with well-controlled chronic pain have transitory breakthrough pains.3 The

Other issues in assessment of cancer pain

Most patients with cancer who experience chronic pain also develop other physical and psychological symptoms. Studies have shown that pain, fatigue, and psychological distress are the most common symptoms in patients with cancer.6, 7, 8 A broad assessment of symptoms is an essential part of the management of cancer pain.

Assesment of pain and symptoms, in turn, is only one of a range of issues that contribute to the suffering of the patient and the family.9 Suffering has been compared to overall

Management of cancer pain

Although the mainstay approach for the management of cancer pain is opioid-based pharmacotherapy, a range of potential strategies should be considered for each patient. In many cases, the assessment of pain indicates an intervention targeted at the aetiology of pain. Radiation therapy is commonly used for pain, and palliative chemotherapy is occasionally given with the major goal being analgesia. Recently, the US Food and Drug Administration approved two chemotherapeutic drugs, gemcitabine and

Opioid therapy

Given its effectiveness and safety, opioid therapy should be administered routinely to patients with moderate to severe cancer pain. The “analgesic ladder” approach of WHO is widely accepted as the basis for treatment guidelines.3, 15, 16 Although this approach originally emphasised the role of morphine, it is now recognised that individual patients vary greatly in their response to different opioids. Sequential opioid trials (so-called opioid rotation) may be needed to identify the drug that

Conclusion

Cancer pain occurs mostly in the context of a progressive illness that may result in multiple other physical and psychological symptoms, functional decline, spiritual or existential distress, family disruption, financial worries, and many other issues that may undermine the quality of life of the patient and his or her family. Optimum management of pain should be viewed from the broad perspective of palliative care that aims to maintain quality of life throughout the course of disease and

References (29)

  • EB Curtis et al.

    Common symptoms in patients with advanced cancer

    J Palliat Care

    (1991)
  • C Saunders

    The philosophy of terminal care

  • EJ Cassell

    The nature of suffering and the goals of medicine

    N Engl J Med

    (1982)
  • NI Cherny et al.

    Suffering in the advanced cancer patient: a definition and taxonomy

    J Palliat Care

    (1994)
  • Cited by (597)

    • Pain Management in Lung Cancer Rehabilitation

      2022, Lung Cancer Rehabilitation
    View all citing articles on Scopus
    View full text