II. Approach: Goals of Cancer Pain Management
- Overall Strategy
- Palliative Care is active treatment, not passive
- Approach
- Identify the cause of pain
- Prevent the pain from recurring
- Erase the memory of the pain
- Maintain a clear sensorium and normal affect
III. Pathophysiology: Cancer Pain
- Address all components to achieve effective management
- Components
- Physical (biological) component 25%
- Psychological (emotional) component 25%
- Social Component 25%
- Spiritual Component 25%
IV. Symptoms
- Use a systematic approach to defining severity of pain (consistently use the same scale or assessment tools)
- Characterize the pain types and source
- Somatic Pain (aching or gnawing pain)
- Visceral Pain (cramping or shifting pain)
- Neuropathic pain (burning, shooting or shock-like pain)
- Distinguish pain related to terminal illness (e.g. Cancer Pain) from Chronic Pain from other cause (non-malignant)
- Treat Chronic Pain with focus on improving quality of life (but differentiating from the terminal illness related pain)
V. Differential Diagnosis
- Iatrogenic pain
- Cancer active treatment
-
Chronic Pain
- Exacerbation of Chronic Pain unrelated to cancer
- Consider new acute pain causes in cancer patients
- Pathologic Fracture, bone metastases or neoplastic Spinal Cord Compression
- See Metastatic Cancer involving Long Bones
- Lung Cancer, Breast Cancer and Prostate Cancer are most common
- Thyroid CancerKidney Cancer may also cause bone metastases
- Multiple Myeloma may cause lytic bone lesions
- Hemorrhage or direct invasion into region of tumor
- Hepatic capsule irritation (e.g. liver metastases, primary Hepatoma)
- Pancreatic Cancer local invasion
- Peritoneal irritation (cancer seeding, Ascites)
- Obstruction
- Ureteral obstruction
- Biliary duct obstruction
- Small Bowel Obstruction, abdominal adhesions or bowel perforation
- Muscle Cramps
- See Nocturnal Leg Cramp
- Electrolyte abnormalities (e.g. Diuretics, Uremia, Cirrhosis)
- Hypomagnesemia
- Hypocalcemia
- Elevated Creatinine Kinase
- Hypothyroidism
- Peripheral Nerve Injury from surgery or Radiation Therapy
- Neurotoxic Chemotherapy (e.g. Vincristine, Vinblastine, Cisplatin)
- Vincristine may cause Trigeminal Neuralgia (CN 5) as well throat pain (CN 9)
- Hormonal agents (e.g. Breast Cancer Management)
- Direct-invasion or metastatic disease related Peripheral Nerve invasion
- Pathologic Fracture, bone metastases or neoplastic Spinal Cord Compression
VI. Management
- See Cancer Pain Management
- See Cancer Pain Medications
- See Cancer Pain Opioid
- Specific management