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Cancer Pain

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Cancer Pain, Pain in Terminally Ill Patients, Pain at the End of Life

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