Cancer Pain Management: Chemotherapy, Radiation, Surgery, Interventional Pain Therapy
Normally when the cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. This growing accumulation of extra cells forms a mass of tissue called tumor or cancer. Many cancers are identified by the name of the tissue that the abnormal cells originated from, e.g. breast cancer, lung cancer, colon cancer, mouth cancer, brain cancer, skin cancer etc. The collections of abnormal cells are called cancer or tumor growth.
Types of Cancer
- Benign Cancer- Grows slow and enclosed within capsule.
- Malignant Cancer- Grows faster, spreads and infiltrate in surrounding normal tissue.
Characteristics of Cancer Growth
- Cancer is the condition when cells in the body divide and grow uncontrollably and start spreading and infiltrating to other parts of the body.
- Cancer is the uncontrolled growth of abnormal cells anywhere in a body.
- The majority of cancer patients experience pain at some time or another.
- The pain results from the cancer itself or from side effects of chemotherapy (cancer medication).
- In some cases, people who have been cured of their cancer also continue to suffer from pain.
Characteristics of Cancer Pain
- The symptoms of cancer pain differ from person to person.
- Pain and other symptoms depend on the type of cancer, the stage of cancer, the extent of the cancer and the patient's pain threshold (tolerance for pain).
- Pain can range anywhere from mild to severe and occasional to constant.
- Pain or discomfort from the benign cancer is easy to manage but malignant cancer is often difficult to treat.
- Cancer pain is treated with medications, interventional pain therapy or surgery.
- Pain in the beginning is acute nociceptive pain and responds to pain medications.
- Cancer pain is caused due to many reasons but most cancer pain occurs when a tumor presses on nerves or body organs or when cancer cells invade bones or body organs.
- Cancer treatments such as chemotherapy, radiation, or surgery also may cause pain.
Symptoms of Benign And Malignant Cancer
Symptoms and signs of benign and malignant cancer are as follows-
- Warning Symptoms
- Deceptive Symptoms
- Common Symptoms
- Specific Symptoms
- Cognitive Symptoms
1. Warning Symptoms Of Cancer
- Often early and specific.
- Early investigation of warning symptoms results in early diagnosis of cancer.
- Warning symptoms are nausea, vomiting, constipation, fever, dizziness, loss of appetite, generalized weakness and pain.
2. Deceptive Symptoms Of Cancer
- Symptoms are caused by normal disease.
- Symptoms are treated like warning symptoms.
- Symptoms are often caused by viral infection resulting in fever, cough, nausea or vomiting.
- Leads to unnecessary expensive investigations
3. Common Symptoms of Cancer
- Common symptoms are observed in all cancer
- Symptoms like fatigue, pain, weight loss, sweating, loss of appetite, loss of weight are considered common symptoms.
4. Specific Symptoms Of Cancer
Specific symptoms are diagnostic symptoms and demands further investigations. Specific symptoms are associated with common symptoms. Common symptoms associated with specific symptoms are pain, weight loss, night sweating and fever.
Specific Symptoms Are As Follows-
- Blood in Saliva: Caused by cancer of oral cavity, tonsil, pharynx and larynx.
- Hoarseness: Caused by cervical lymph node, cancer of larynx.
- Non healing ulcer and/or white or red patch in oral cavity: Caused by cancer of tonsil, tongue and gum.
- Repeated infections such as bronchitis, sinusitis : Caused by cancer of lungs, trachea and bronchi.
- Persistent cough, blood in mucus : Caused by cancer of lungs, trachea and bronchi.
- Constipation and/ or Obstruction : Large Intestine, rectum cancer.
- Continuous diarrhea, pencil thin stools : Colon cancer.
- Multiple bowel movements with no stool : Cancer of small intestine.
- Blood in stool, Anemia : Cancer of small or large intestine.
- Anal itching, pain : Anal or rectal cancer.
- Anemia and Flank pain : Cancer of Kidney.
- Abnormal discharge, breast lump : Breast cancer.
- Swelling and painless mass over testicles : Cancer of Testicles.
- Male urinary infection, enlarged prostate : Cancer of Prostate
- Pelvic pain : Ovarian cancer.
- Blood in urine, frequency, pressure feeling, urinary infection : Cancer of Urinary Bladder.
- Heartburn, Barrett esophagus, difficulty swallowing : Cancer of Esophagus
- Vaginal bleeding, discharge, postmenopausal bleeding : Cancer of uterus
- Itching, skin discoloration, infection like psoriasis, non healing sores : Skin cancer.
- Moles- multicolored, irregular edges, bleeding, larger moles : Melanoma.
- Deceptive and misleading symptoms : May or may not be associated with cancer.
- Regurgitation, epigastric pain : Esophageal ulcer or varices.
- Hemorrhoid, diarrhea, fissure : Rectal bleeding
- Gastric or stomach pain : Gastric Ulcer
- Anemia : Iron deficiency.
- Varicocele, epididymitis : Testicle vascular disease or infection.
- Urinary infection : Bladder stone.
- Vocal cord polyp : Larynx.
- Wart mole : Skin Cancer.
- Ulcer, psoriasis : Skin.
- Symptoms secondary to spinal cord compression
- Tingling, Numbness and weakness in extremities.
5. Cognitive Symptoms Observed With Chronic Pain In Cancer Patients Are:
- Fatigue and Tiredness
- Feeling of loneliness and isolated
- Memory Lapse
- Attention Deficit
Treatment Of Cancer Pain
- Interventional Pain Therapy
- Treatment of Cognitive symptoms.
- Alternative Treatment
1. Analgesics for Cancer Pain
a. Treatment of Mild to Moderate Chronic Pain :
- NSAIDs: Nonsteroidal anti-inflammatory drugs e.g. Naproxene, Advil.
- Adjuvant pain medications like Cymbalta (antidepressants) and Neurontin (antiepileptic).
b. Treatment of Severe Intractable Chronic Pain :
- Opioids, if not responding to NSAIDS.
- Adjuvant pain medications like Cymbalta (antidepressants) and Neurontin (antiepileptic).
2. Chemotherapy for Cancer Pain
- Chemotherapy is prescribed to shrink cancer tumor mass.
- Chemotherapy is indicated when serious pain symptoms are not responding to conservative treatment and analgesics.
- Chemotherapy is suggested when tumor is pressing on peripheral nerve, nerve plexus, epidural space, foramina, spinal cord and viscera.
3. Radiation Therapy for Cancer Pain
- Radiation shrinks normal viscera as well as cancer tumor mass.
- Radiation is targeted to reduce tumor mass to prevent complications.
- Radiation is indicated when serious pain symptoms are not responding to conservative treatment and analgesics.
- Radiation is suggested when tumor is pressing on viscera and peripheral nerves.
4. Surgery for Cancer Pain
- Surgery is performed to remove entire tumor mass or partial tumor mass.
- Benign tumor causing pressure on surrounding nerves causes severe pain. Benign tumor can be completely excised and excision may cure cancer growth.
- Malignant tumor can be removed in early stage but once tumor is infiltrated in surrounding soft tissue, complete removal is not possible.
- Partial removal of malignant tumor is performed when peripheral tumor mass is causing pressure on the nerve resulting in pain.
5. Interventional Pain Therapy for Cancer Pain
- Nerve block is performed to relieve pain and inflammation.
- Nerve ablation is used to destruct the nerve, which is causing pain. Nerve ablation is performed by using radiofrequency and cryotherapy.
- Spinal cord stimulator is performed to neuromodulate spinal cord. Neuromodulation of spinal cord helps to block the transmission of pain impulses to brain.
- Programmable pump is inserted to deliver opioids intrathecally close to spinal cord.
6. Treatment Of Cognitive Symptoms
- Medication- Antidepressants and anti-anxiety medications are prescribed for depression and anxiety disorder.
7. Alternative Treatment for Cancer Pain
- Herbal Medication
- Massage Therapy
- Vitamin Pills
- Social and Spiritual Communication
Why Cancer Pain Is Difficult To Treat:
- Resistance to pain medication
- Increased tolerance to pain medication or opioids
- Emotional suffering of patient and family
- Denial of cancer treatment by patient
- Secondary Gain: Patient does not want to get better because of secondary gain. Secondary gain could be patient getting more attention from family members, patient's family is receiving the benefits due to his illness.
- Apprehensive Family: Family members interfering with the suggested treatment.
Adequate Pain Relief:
- Achieving adequate control of pain with minimum side effects is sometimes difficult.
- Side effects end up with poor quality of life, exhaustion, lethargy, somnolence and drowsiness.
- In spite of inadequate pain relief and several side effects, often oral, intramuscular or intravenous opioid treatment is continued for chronic cancer pain instead of intrathecal route of opioid treatment.
- Although cancer pain can be relieved, surveys have shown that pain is often undertreated in many patients.
- Patients may be reluctant to report their pain to avoid opioids; patients may be reluctant to use morphine and other opioids for pain control because of fear of addiction.
- Addiction is extremely rare in people with cancer.
Service Providers For Cancer Pain Treatments Are
- Lab technician
- Social worker
Informed Consent With Patient
- Informed Consent is a communication between patient and treatment provider. Communication is direct verbal explanation or providing documentation in audio-visual or written format.
- Communications should be explained in detail the proposed treatment and choice of treatment or procedures.
- Informed consent for procedures or surgery requires signature by patient and physician service provider.
- Patient's choice to have minimum pain relief must be respected.
Verbal Informed Consent Also Includes Families When Necessary
- Exhausted, terminally ill patients, may not wish to be involved in making pain management decisions.
- Patient may delegate such choices to their physicians or legal guardian.
- The patient's participation in ongoing treatment is essential, but could be counterproductive if patient is confused and disoriented.
- Family should be informed of any change in treatment and possible outcome of the treatment when necessary and approved by patient.
- Families could be spouse, children, parents and close relatives.
- Family members or group of family members suffer with emotional pain.
- Emotional pain becomes predominant when spouse, children, parents and family members are very close to patient.
- Pain coodinator is trained as registered nurse (RN) preferably with master degree or physician assistant (PA) trained in pain management.
- Pain coordinator has an important role in explaining the change of treatment if needed or observation of any complications.
- Pain coordinator should be available at short notice during working or off hours.
- Pain Coordinator is mostly in close contact with patient, family and physician.
- Goal is to achieve less pain and suffering.
- Adequate pain relief with minimum side effects.
- Avoid inadequate pain relief and continuation of suffering.
- Obtain informed consent from the patient or legal guardian if life threatening side effects such as bradycardia, hypotension, somnolence and apnea are expected in achieving optimum pain relief.
- Objective is to prevent life threatening side effects in underweight terminally ill patients.
- Objective is to reduce pain to tolerable level, keep patient attentive as much as possible. Patient could thus communicate with families and travel short distance as permitted by disease and side effects.
- Daily follow up and detailed history should identify patient's need of pain.
- Loss of income.
- Enormous cost to patient as out of pocket expense and health care.
- Loss of productivity at work.
- Annual expenses for treatment and lost income are close to 200 billion dollars a year.
- Impaired daily living of patient causes hardship at home involving entire family.