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CANCER PAIN

(Pathophysiology and Etiology)

Nuzirwan Acang

Bagian Ilmu Penyakit Dalam Fakultas Kedokteran


Universitas Andalas Padang

Pain as an unpleasant sensory and


emotional experience which we primarily
associate with tissue damage or describe in
terms of such damage, or both.
(The International Association for the Study
of Pain = IASP)
 This definition recognizes that pain is a
perception and not a sensation.


An estimated 6.6 million people from around


the world die from cancer each year.
Pain can occur at any point during the course
of the illness
The prevalence of pain
- At the time of cancer diagnosis : 50 %
- At advanced stages
: 75%
- In cancer survivors to be
: 33%
- Approximately 25% of those in nursing
homes

After curative treatment


: 33%
 Under anticancer treatment
: 59%
 Advanced/metastatic/terminal disease
: 64%
 Prevalence of pain was >50% in all cancer types
 Highest prevalence in head/neck cancer patients
: 51% to 88%).


(Annals of Oncology. 2007;18(9):1437-1449.)

Type of cancer and prevalence of pain:


Thoracic
52 %
Lung
45 %
Bone
85 %
Mouth
80 %
Gastrointestinal
40 %
Genitourinary tract (male)
75 %
Genitourinary tract (woman)
70 %
Lymphoma
20 %
Leukemia
5%
Oxford Textbook of Palliative Care, 2005

Unrelieved severe pain may associated with:


Disturbed sleep
Reduced appetite
Un-concentration
Irritability and depression

69% of severe cancer pain patient to cause


consideration of suicide.
(Wisconsin 1985)

Nociceptive pain: Ongoing tissue injury in


somatic structures
Neuropathic pain: Aberrant somatosensory
processing
Visceral pain: Damage of visceral structures

Nocious Stimuli
mechanical thermal chemical
electrical
Tissue damage
Release of mediators
Hydrogen and potassium ions,
neurotransmitters, kinins,
prostaglandins
Stimulation of nociceptors
Transmission to CNS
via afferent pathways

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Disease itself :
- localized
- Metastese
Cancer Treatment
- Surgery
- Radiotherapy
- Khemotherapy
- Hormonal therapy
Noncancer pain condition
- Low back pain
- Arthritis








Tumor expansion can cause pressure on


surrounding organs.
Proteolytic enzymes produced by tumor cells can
damage sensory and sympathetic nerve fibers
Tumors secrete inflammatory and
prohyperalgesic mediators.
Tumor infiltration in nerve plexuses and damage
to nerve tissue can cause neuropathic pain.
Metastatic spread of cancer to bone
Stretching of hollow viscera, distortion of the
capsule of solid organs, inflammation of the
mucosa, and ischemia or necrosis activate
visceral nociceptors, resulting in visceral pain.




Adverse effects of treatment :


- Joint pain following chemotherapy and hormonal
therapy
- Painful mucositis due to radiotherapy and
chemotherapy with certain agents.
- Neuropathic pain : postradiation plexopathies,
peripheral polyneuropathy after chemotherapy
- Opioid-induced hyperalgesia
Surgical interventions nerve damage and chronic
postoperative pain.
Procedures related to cancer pain ; biopsies, blood
draws, lumbar punctures, laser treatments

Painful peripheral neuropathy from


chemotherapeutic agents :
vincristine, platinum, taxanes, thalidomide,
bortezomib, and other agents; radiation-induced
neural
Damage of tissue :
- Radiation-induced brachial plexopathy
- Postradiation pelvic pain syndrome
- Postsurgical pain syndromes from
mastectomy, amputation, and thoracotomy.

Acute Pain
A. Due to procedures and therapies

- Acute pain associated with diagnostic


procedures
Lumbar puncture headache
Bone marrow biopsy
Lumbar puncture, Venepuncture
Paracentesis, Thoracentes

- Acute pain associated with analgesic techniques


Spinal opioid hyperalgesia syndrome
Acute pain after Strontium-89 therapy of
metastatic bone pain

- Acute pain associated with other


therapeutic procedures
Pleurodesis
Tumour embolisation
Nephrostomy insertion

B. Acute pain associated with chemotherapy









Pain from intravenous or intra-arterial


infusion
Intraperitoneal chemotherapy
Headache due to intrathecal chemotherapy
Painful oropharyngeal mucositis
Painful peripheral neuropathy

C. Acute pain associated with hormonal


therapy




Painful gynaecomastia
Luteinising hormone-releasing factor tumour
flare in prostate cancer
Hormone-induced acute pain flare in breast
cancer

D. Acute pain associated with immunotherapy




Arthralgia and myalgia from interferon and


interleukin

E. Acute pain associated with radiation therapy





Painful oropharyngeal mucositis


Acute radiation enteritis and protocolitis

Multifocal or generalised pain (focal metastases


or marrow expansion)
Base of skull metastases
 Pain syndromes of the bony pelvis and hip
 Tumour invasion of joint, or soft tissue, or
both


Paraneoplastic pain syndromes





Hypertrophic osteoarthropathy
Tumour-related gynaecomastia

Neoplastic involvement of viscera






Hepatic distension syndrome


Rostral retroperitoneal syndrome
Chronic intestinal obstruction and peritoneal
carcinomatosis
Chronic ureteral obstruction

Process of the pain disease

Acute pain + insufficient pain therapy


Collapse of the body's pain defenses
Central sensitization
Pain memory
Pain disease
Sandkhler, J.: Preventing Pain Memory. MMW 2002; Special
edition 2

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Adapted from Mundy G. Nature reviews cancer 2. 584593. 2002








Other somatic symptoms (chronic cough,


nausea, hiccup)
Knowledge and understanding of the patient
Feelings of frustrations, angry and
depression
Social factors (financial, partner, children)
Existential problems
Cultural factors

Pain is a common symptom of cancer, consist of


acute and chronic
Delineate type of cancer: nociceptive,
neuropathic, visceral
Local tumors cause spinal and supraspinal
hyperreactivity
Metastatic/spread of cancer produced Nociceptive
and visceral pain
Different tumors cause different pain reactivity

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UNIVERSITY
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