CANCER PAIN,

The Management
Syafruddin Gaus, M.D,Ph.D
anesthesiologist

Department of Anesthesiology and ICU

Faculty of Medicine Hasanuddin University
Makassar
PREVALENCE OF CANCER PAIN
Bonica (1985):
 50% of patient of all stage reported pain
 >70% with advanced cancer

Faley (1985):
 50% of patient with non metastatic cancer had
significant pain
 60-90% of patient with advanced cancer reported
debilitating pain
WHO (1986):
 70% of patient with advanced cancer has pain
 3,5 million people suffering from cancer pain with
or without satisfactory treatment every day
NATURE OF CANCER
 1/3 PREVENTABLE
 1/3 TREATABLE
[Early detection]
 1/3 PALLIATIVE CARE
[Pain is one of the most common]
NATURE OF CANCER PAIN
Pain is one of the major symptoms in cancer
patients:
 During active treatment
 Advanced and terminal stage

Pain is:
 One of the most common symptoms
leading to medical evaluation
 One of the most feared consequences of
cancer patient
NATURE OF CANCER PAIN
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)
In general PAIN is defined as (IASP 1979):
“ an unpleasant sensory and emotional
experience associated with actual or
potential tissue damage or described
in term of such damage ”
 unpleasant sensory
 emotional experienced

PAIN
Physical Psychological
dimension dimension

• Motivational affective
ORGANIC PAIN • Cognitive evaluation
• The meaning of pain
THE PHENOMENOM of CANCER
PAIN is VERY
COMPLEX and COMPLICATED
is the cumulative among:
• ORGANIC PAIN
• PSYCHOLOGICAL PAIN
• socioeconomic, cultural and spiritual

TOTAL PAIN

BIOPSYCHOSOCIOCULTUROSPIRITUAL
 WHO 1986
Symptoms of debility Non-cancer pathology
Side-effects of therapy Cancer

Loss of social position SOMATIC SOURCE Bureaucratic bungling

Loss of job prestige and income Friends who do not visit
TOTAL
Loss of role in family DEPRESSION ANGER Delay in diagnosis
PAIN
Chronic fatigue and insomnia Unavailable doctors
Sense of helplessness Irritability
ANXIETY
Disfigurement Therapeutic failure

Fear of hospital or nursing home Fear of pain

Worry about family Family finances
Fear of death Loss of dignity and bodily control
Spiritual unrest Uncertainty about future
BEHAVIOR CHANGES IN
CANCER PATIENTS
1. Deny
2. Anger
3. Depression
4. Bargaining
5. Acceptance
Elizabeth Roos (1996), On Death and Dying
 PAIN IN CANCER PATIENT
Neuropathic Mechanisms
Somatic or Psychological
Visceral Disturbances
Nociception
Pain

Psychological Suffering Social/

State and Familial
Traits Functioning

Loss of Financial
Work Concerns

Physical Disability Fear of Death

American Cancer Society 1988

CANCER PAIN
Can be divided into 2 categories:
1. ORGANIC PAIN
2. PSYCHOLOGICAL PAIN
ORGANIC PAIN
1. Nociceptive pain:
 Somatic pain
(skin, muscle, connective tissue)
 Visceral pain
(thoracic and abdominal viscera)
2. Non nociceptive pain:
 Neuropathic pain (deafferentiation pain)
damage of peripheral or CNS
MECHANISM of NOCICEPTIVE PAIN
Nociceptive pain means pain with nociception

Nociception means activity of afferent neurons

induced by a noxious stimulus

 TRANSDUCTION
 TRANSMISSION
 MODULATION
 PERCEPTION
1. TRANSDUCTION
Transduction
Process whereby
Pressure
noxious stimuli
are translated in-
to electrical acti- Heat
vity at the senso-
ry endings of Chemical
nerves.
 Transmission
2. TRANSMISSION
Refers to the pro-
pagation of impul-
ses throughout the
sensory nervous
system.
3. MODULATION
 Process whereby endo- Modulation
genous analgesic sys-
tems can modify noci-
ceptive transmission.
These endogenous sys-
tems (opioid, seretoner-
gic, and noradrenergic)
exhibit their inhibitory
influence at the dorsal
horn.
 Plays important role to
the individual perception.
4. PERCEPTION
Final process where- Perception
by transduction, trans- Pain
Perception Brain
mission, and modula-
tion interact with the
uniqueness of the in-
dividual to create the
final subjective feeling
that we call pain.
Organic pain in cancer
patients can be divided into
three types:
1. SOMATIC PAIN
2. VISCERAL PAIN
3. NEUROPHATIC PAIN
SOMATIC PAIN
 constant
 aching, gnawing
 well localized
Mechanisms:
 activation of nociceptors
 release algesic substances (specially PGｓ)
Example:
 bone metastasis
 tumor of the soft tissue
Management:
 Aspirin
 Acetaminophen
 NSAID
Continuous activation of nociceptors may
produce sensitization of N.S. (peripherally
& centrally)
VISCERAL PAIN
 constant
 deep or dull aching
 poorly localized
 usually with nausea and vomit
 often referred to cutaneous sites
 occasional colicky or cramp
Mechanisms:
 activation of nociceptors
Example:
 pancreatic cancer
 liver/lung metastasis with shoulder pain
Management:
 Opioid (MS contin®)
 Nerve block (e.g celiac plexus block)
STIMULI SUFFICIENT TO CAUSE
VISCERAL PAIN ARE:
1. Irritation of mucosal and serosal
surfaces
2. Torsion and traction of mesentery
3. Distension or contraction of
hollow viscus
4. Impaction of visceral organs
NEUROPHATIC PAIN
(DEAFFERENTIATION PAIN)
 burning pain
 paroxysmal shooting or electrical
shock-like pain
Mechanisms:
 spontaneus discharges of peripheral or
central n.s.
 loss of central inhibition
Example:
 metastasis brachial or lumbosacral plexo-
pathies
 post herpetic neuralgia (PHN)
Management:
 antidepressant or anticonvulsant
 nerve block
 etc
NEUROPATHIC PAIN
CLASSIFICATION OF CANCER PAIN
1. TEMPORAL
2. TOPOGRAPHIC
3. ETIOLOGIC
4. PATHOPHYSIOLOGIC

1. Pain associated with direct tumor

2. Pain associated with cancer therapy
3. Pain unrelated to cancer
1. Pain associated with direct tumor
 Due to invasion of bones
 Base of skull:
- Orbital syndrome
- Parasellar sinus syndrome
- Sphenoid sinus syndrome
- Clivus syndrome
- Jugular foramen syndrome
- Occipital condyle syndrome
 Vertebral body:
- Atlantoaxial syndrome
- C7-Th1 syndrome
- L1 syndrome
- Sacral syndrome
 Generalized bone pain:
- Multiple metastase
1. Pain associated with direct tumor
 Due to invasion of nerves
 Peripheral nerve syndrome:
- Paraspinal mass
- Chest wall mass
- Retroperitoneal mass
 Painful polyneuropathy
 Brachial, lumbal, sacral plexopathies
 Leptomeningeal metastase
 Epidural spinal cord compression

 Due to invasion of visceral

 Due to invasion of blood vessels
 Due to invasion of mucous membranes
2. Pain associated with cancer therapy
 Surgery
 Postthoracotomy syndrome
 Postmastectomy syndrome
 Postradical neck dissection syndrome
 Postamputation syndromes
 Chemotherapy
 Painful polyneuropathy
 Aseptic necrosis of bone
 Steroid pseudorheumatism
 Mucositis
 Radiation
 Radiation fibrosis of brachial or lumbosacral plexus
 Radiation myelophaty
 Radiation-induced peripheral nerve tumors
 Mucositis
 Radiation necrosis of bone
3. Pain indirectly related unrelated to
cancer
 Myofascial pains
 Osteoporosis
 Postherpetic neuralgia
 Debiliting (decubitus ulcer)
 Etc
What anesthesiologist can
do for cancer pain patient
1. Neurolitic Block
- Alcohol 100%
- Phenol glycerin 15%
2. Epidural/Spinal opioid
3. Celiac Ganglion Block
4. Neural Blockade
5. Etc
MANAGEMENT OF CANCER PAIN
PATIENT
 Is called “PALLIATIVE TREATMENT”
(any treatment which may increase the
quality of life)
 Palliative treatment may be:
 Surgical
 Radiation
 Chemotherapy
 Pain management
BASIC PRINCIPLE OF
PAIN MANAGEMENT
 Knowing the CHARACTERISTIC of
PAIN
 Type and the level of cancer pain is very
important in order to provide optional
management of cancer pain
 Distinguishing the type of pain should be
done before starting the “Three Step
Ladder” of WHO
 When we use:
 NSAID
 Opioid (weak or strong)
 Adjuvants
Three Step Ladder WHO
 THREE STEP LADDER
Basic principle of three step ladder,
drugs should be given by:
 the patients him/herself
 the mouth/oral
 the clock
 the ladder
Started with step one, two than
three
 Type of Pain Medicine
• For mild to moderate pain:
- Nonopioids (acetominophen, aspirin & NSAIDs:
ibuprofen)
• For moderate to severe pain:
- Opioids (morphine, hydromorphone, oxycodone,
hydrocodone, codeine, fentanyl, methadone)
• For tingling and burning pain:
- Antidepressants (amitriptyline, doxepin, trazodone)
- Antiepileptics (gabapentin)
• For pain caused by swelling:
- Steroids (prednisone and dexamethasone)
How Pain Medicine is Taken
• Rectal suppositories
• Transdermal patches
• Injections
• Subcutaneous
• Intravenous
• Epidural or intrathecal
• Subdermal and intramuscular
Side Effects of Pain Medicine
• Constipation
• Nausea and vomiting
• Sleepiness
• Slowed breathing
• Itching
 Common Concerns About Pain
Treatment
• Concern 1:
I can only take medicine or other treatments
when I actually have pain
• Concern 2:
I will be come addicted to pain medicine
• Concern 3:
If I take too much medicine, it will stop working
• Concern 4:
If I complain too much, I am not being a good
patient
CONCLUSION
1. Pain is common problem and a major symptom of
cancer patient.
2. Pain is one at most feared aspect and can cause
to suicide.
3. Cancer pain can be organic or psychological pain.
4. Organic pain may be somatic, visceral or
neuropathic pain or combined.
5. Basic principle of cancer pain treatment in RSWS
following WHO guidelines.
6. Total pain is a BIOPSYCHOSOCIOCULTUROSPIRI-
TUAL problem.
7. CANCER PAIN management should be treated
integrated and comprehensive include spiritual
approach.
If we fail to treat
cancer patients, let
them died free of
pain with “iman“