Ospital ng Maynila Medical
Center
Hospital Tumor Board
April 24, 2003
Objective:
To promote a unified and
consensual concept on cancer issues among OMMC staff that will be used as a
guide in management of patients with cancer in OMMC and that will serve as
OMMC’s public health information and education on cancer.
“We
must all die. But that I can save him from days of torture, that is what I feel
as my great and ever new privilege. Pain is a more terrible lord of mankind
than even death himself.”
Dr.
Albert Schweitzer
What is cancer pain?
Cancer
pain is defined as pain that
is attributable to cancer or
its therapy.
What is pain?
Pain, as defined by the International Association for the
Study of Pain, is the “unpleasant sensory and
emotional experience associated with actual or potential tissue damage or
described in terms of such damage”.
Pain is whatever the experiencing person says it is, and
exists whenever he says it does.
Whatever definition is used, pain is a sensation that hurts,
and it has both physical and emotional aspects to consider.
What
are the different types of pain?
Physical pain is due to the occurrence of an injury or
disease affecting the nerves (neuropathic pain), internal organs (visceral
pain), and supporting structures (somatic pain).
Mental pain is due to the anxiety and depression of having a
health problem or disease.
Acute and chronic and
breakthrough pain
Acute pain usually starts suddenly and often triggers visible bodily reactions such as sweating, an elevated blood pressure, and more. It is generally a signal of rapid-onset injury to the body and it resolves when pain relief is given and/or the injury is treated.
Pain is considered chronic when it lasts beyond the normal
time expected for an injury to heal or an illness to resolve. Sometimes called
persistent pain, it can be very stressful for both the body and the soul, and
requires careful, ongoing attention to be appropriately treated.
Along with chronic cancer pain, sometimes people have acute flares of pain when not all pain is controlled by the medication or therapy. This pain is usually called breakthrough pain.
How common is cancer pain?
Pain is common in people with cancer, although not all people with
cancer will experience pain.
Approximately 30% to 50% of people with cancer experience pain while undergoing treatment, and up to 95% of people with advanced cancer experience pain.
What are the more common causes
of cancer pain?
Cancer pain is a highly personal
experience and depends on many factors such as the type of cancer, its stage,
its effect on the body structure, and a person's own resistance or threshold to
pain.
The incidence may be dependent on the type of cancer.
|
Type
of cancer |
Incidence of cancer pain (%) |
|
Primary Bone Tumor |
85 |
|
Oral cavity Tumor |
80 |
|
Genitourinary tumor |
70-75 |
|
Breast Cancer |
50 |
|
Lung Cancer |
45 |
|
Gastrointestinal cancer |
40 |
|
Lymphomas |
20 |
|
Leukemia |
5 |
The pain may be due to cancer itself (70%), to treatment of the cancer (20%), to something unrelated to the cancer or its treatment (10%), and to the psychological or emotional problems that a cancer patient may be experiencing (100%).
What are examples of pain caused
by the cancer itself?
Pain
caused by a cancer invading bone, nerves, blood vessels, mucous membranes or skin.
Pain
caused by a cancer
obstructing a hollow
viscus or duct.
Pain
caused by a cancer compressing on a normal body structure.
What are examples of pain caused
by the treatment of cancer?
Pain
resulting from a surgical
or invasive medical procedure used to treat a cancer.
Pain
resulting from the side-effects of radiation therapy [mouth sores (mucositis),
swelling of arms and legs (lymphatic obstruction)].
Pain
resulting from the side-effects of chemotherapy [mouth sores (mucositis),
numbness and sometimes painful sensations in the feet, legs, fingers,
hands and arms (peripheral neuropathy), diarrhea, constipation, nausea,
vomiting]
How should cancer pain be
managed?
Management starts
with a definite diagnosis of cancer (nature and extent) and whether the cancer
is associated with pain or not.
If the cancer
pain is present, the nature (physical, mental or in combination), cause
(invasion, obstruction, compression), type (somatic, visceral, neuropathic),
and severity (mild, moderate, severe) should be determined as accurately as
possible.
Treatment of
cancer pain is primarily directed towards the cancer itself (curative goal as
much as possible, if not, palliative goal) in the hope that resolution of the
pain will just follow. However, when treatment of the cancer is deemed not
feasible for one reason or another, then the objective of treatment should
focus on the relief of the cancer pain.
The treatment
modalities for cancer pain include non-pharmacologic, pharmacologic, and
interventional therapies, singly or in combination. The choice of a specific treatment regimen will be dependent on
the comprehensive diagnosis of the cancer and the cancer pain (see above) and
its track records of success in resolving a specific cancer situation.
Below are some
general guidelines in the selection of treatment modalities:
1.
Since practically
all patients with cancer will have various degrees of anxiety and depression,
in other words, mental pain, psychotherapy and psychosocial support should be
integrated into the treatment of the physical pain all throughout the course of
management.
2.
Selection of a
specific treatment regimen should be made after an objective and systematic
comparison of the benefit, risk, cost, and availability data on the different
options.
3.
All patients
should be given opportunities to make informed consent or refusal for all
recommended treatment regimen.
What constitutes a non-pharmacologic therapy
in cancer pain control?
Anything that
does not fall under the categories of pharmacologic and interventional
therapies are non-pharmacologic therapy.
This may consist of massage, hydrotherapy, ultrasound, transcutaneous
electrical nerve stimulation and psychotherapy without the use of drugs.
What constitutes a pharmacologic therapy in
cancer pain control?
Pharmacologic
therapy utilizes drugs. Drugs may be used for the control of the physical pain
caused by the cancer itself as well as pain occurring in the process of
treatment of the cancer. Drugs may also
be used for the control of the mental pain experienced by cancer patients.
See below the
pharmacologic therapy being recommended by the World Health Organization and
the Department of Health for a cancer pain control program.
What constitutes an interventional therapy
in cancer pain control?
Interventional
therapy utilizes invasive procedures in the control of cancer pain. This may
consist of nerve block, nerve ablation, and intraspinal analgesia.
With 70-90%
responding to pharmacologic therapy, nowadays, interventional therapy is rarely
used.
What is the pharmacologic
therapy being recommended by the Department of Health – Cancer Pain Control
Program (DOH-CPCP)?
The DOH-CPCP
adopts the World Health Organization’s analgesic ladder approach with some
modifications.
The WHO has devised a three-step analgesic ladder outlining
the use of nonopioid analgesics, opioid analgesics, and adjuvant medications
for progressively severe pain.
A nonopioid analgesic, with or without an adjuvant agent, is tried first (step 1).
If pain persists or increases on this regimen, the patient is switched to a weak opioid plus a nonopioid agent, with or without an adjuvant medication (step 2).
If pain continues or intensifies despite this change in
therapy, a strong opioid analgesic is prescribed, with or without a nonopioid
and/or an adjuvant agent (step 3).
Modifications of the WHO 3-step analgesic ladder are done because of problems of availability of codeine and high-cost of weak opiods in the Philippines. Thus, a modification is a 2-step analgesic ladder omitting step 2 of giving weak opioids.
What are the essential concepts
of WHO’s pharmacologic therapy for cancer pain control?
-
By the
mouth - if the patient can
swallow, oral administration is the route of choice
-
By the
clock - analgesics should be given regularly and prophylactically
-
By the
ladder – tritration using non-opiod analgesics followed by opiod
analgesics and lower dose to higher dose
How should cancer pain be
managed in the terminally-ill cancer patient?
Total control of pain as much as possible with the goal of
improving or maintaining an acceptable quality of life and quality of dying.
Goal:
Satisfactory control of cancer pain for all clients consulting OMMC.
Strategies:
Evaluation
criteria:
All
enabling objectives and strategies are accomplished by end of 2003 and
sustained thereafter.
Every
year, at least 90% of admitted cancer patients have achieved pain score of 3 or
less prior to discharge.