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Ospital ng Maynila Medical Center

Hospital Tumor Board

 

Statements on Certain Cancer Issues

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.

 

Unified Concept on Cancer Pain Control Program

 

“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 and mental 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.

 

 

What is the OMMC’s Cancer Pain Control Program?

 

Goal: Satisfactory control of cancer pain for all clients consulting OMMC.

 

Strategies:

 

  1. Formulation and continual updating of clinical practice guidelines in cancer pain control.
  2. Continual education of staff on cancer pain control program and clinical practice guidelines for proper implementation.
  3. Insurance of provision of facilities to make all needed analgesics, particularly morphine, always readily available in and accessible from the hospital pharmacy.
  4. Continual monitoring and assessment of cancer pain control in all clients, particularly, admitted patients.

 

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.