Treatment Plan for Cancer Pain

Treatment Plan To Treat Cancer Pain Involves Following Steps-

  • Diagnosis of cancer
  • Informed consent
  • Treatment choice

Treatment Plan for Cancer Pain

A. Diagnosis of Type of Cancer

Cancer is classified as benign or malignant disease. Benign cancer grows within capsule and does not infiltrate into surrounding tissue. Benign cancer causes pressure and compression of surrounding tissue and organ. Malignant cancer spreads locally into surrounding tissue and also to distant organ. Malignant cancer local growth is not restricted by capsule. Malignant cancer local growth is much faster than benign cancer and extensive. Spread of malignant cancer to distant organ is through blood or lymphatics.

Treatment approach to treat chronic pain for benign and malignant cancer is different. Prognosis and pain relief response depends on type of cancer like benign and malignant cancer.

B. Informed Consent 1

  1. List of Participants
  2. Mode and Distribution of Information
  3. Family Conference
  4. Legal Guardian
  5. Subject of Informed Consent Discussion

a. List of Participants –

  • Physician- Oncologist or Pain Specialist
  • Pain Coordinator- Registered nurse is trained to provide informed consent and answer to most of the questions patient may ask regarding informed consent.
  • Pharmacist2
  • Patient
  • Family Members
  • Legal Guardian.

b. Mode and Distribution of Information-

  • Verbal discussion is held between patient, relatives, physician and pain coordinator regarding choice of treatment to reduce pain.
  • Written information is provided.
  • Audio-visual presentation is presented during conference or following conference.

c. Family Conference-

  • Conference With Family Member Is Essential For Following Reason-
    • Family members of the patient are concerned about outcome of treatment and prognosis of cancer disease.
    • Family members suffer with emotional pain, fear and anxiety.
    • Spouse, parents and children suffer through severe anxiety and fear for not knowing the risk of treatment.
    • Family member do not want to see their loved one suffering with excruciating pain 24 hours and 7 days for several months.
    • Family members are worried of side effects of opioids medications. Side effects like drowsiness, sleepiness, nausea, vomiting and appetite loss are often significant during opioid therapy in terminal ill patient.
  • Who May Attend Family Conference-
    • Family conference is held between treating physician, pain coordinator and family members.
    • Family members participation depends on patient's approval.
    • Family members who may be concerned and want to know more details of treatment plan are spouse, children, siblings and parents.

d. Legal Guardian-

  • Single unmarried patient may appoint friend or acquaintance as a legal guardian.
  • Legal guardian often carries legal document and has a right to know about all treatment plan.
  • Legal guardian is treated like close family member.

e. Subjects of Informed Consent Discussion

  • Treatment Choice- Treatment choice to treat chronic cancer pain is discussed in detail.
  • Side Effects Of Opioids- Side effect caused by pain medication are discussed in details.
  • Side Effects Of Chemotherapy- Dosage, side effects and choice of chemotherapy is discussed in detail. Chemotherapy is advised to shrink the tumor mass if tumor mass is encroaching the nerve or the spinal cord.
  • Choice of Surgery and Complication Following Surgery- Choice of surgery, and surgery, is advised to remove the cancer mass as a treatment or to prevent spread to nerve, nerve plexus, or spinal cord.
  • Complications Following Radiation Therapy- Radiation therapy is often advised to treat malignant or benign cancer. Radiation shrinks the tumor mass and helps to eliminate or decrease pressure on surrounding organs and nerves.

C. Treatment Choice For Cancer Pain:

a. Treatment For Chronic Cancer Pain:

i. NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

  • Contraindications (avoid)-
    • History of gastric ulcer
    • Bleeding
    • Stomach pain
    • Most Common Prescribed NSAIDs-
      • Motrin, Naproxen and Celebrex

ii. Opioids

  • Contraindications (avoid)-
    • History of sleep apnea
    • Drowsiness
    • Severe constipation not responding to laxatives
  • Most Common Prescribed Opioids-
    • Hydrocodone for mild to moderate pain
    • Morphine, Dilaudid, Methadone and Fentanyl Patch for severe pain
    • Transdermal buprenorphine is used in high dosage, if alternative opioid is causing sleep apnea or drowsiness.3

iii. Oral Ketamine 4

  • Ketamine is used as an alternative to opioids as an analgesics (pain medications)
  • Ketamine prevents side effects like sleep apnea, addiction and dependence.

iv. Nerve Blocks and Nerve Ablations-Y

  • Nerve Block- Peripheral nerve block, epidural injection and intrathecal injection is performed for short-term pain relief.
  • Nerve Ablation- Nerve ablation or destruction procedure is performed using radiofrequency heat, cry probe freezing and chemical injections. Chemicals injected to destruct the peripheral and spinal nerves are phenol and alcohol.

v. Spinal Cord Stimulator

  • Electrode of Spinal Cord Stimulator is placed in epidural space and connected to generator, which is placed under the skin over abdomen or buttocks.
  • Segmental pain is effectively treated with spinal cord stimulator.
  • Spinal cord stimulator will eliminate pain when spread in 4 to 5 spinal dermatome.
  • Patient may need to take pain medications if pain is wide spread.

vi. Intrathecal Opioids

  • Catheter is placed in spinal fluid close to spinal cord. Free end of catheter floats in spinal fluid. The opposite end is connected to intrathecal delivery pump.
  • Pump is placed under the skin and connected to catheter. Pump sores opioid in reservoir and delivers opioids in spinal fluid.
  • Dosage required to reduce pain is 1/100th or less in comparison to oral same opioid pain medications.
  • Most common opioid used for intrathecal treatment is Morphine, Dilaudid and Fentanyl.

vii. Chemotherapy

  • Indication for chemotherapy is as follows-
    • Eliminate benign and malignant cancer growth
    • Restrict growth of benign and malignant cancer
    • Shrink the malignant tumor mass
  • Choice of Chemotherapy-
    • Depends on type of benign or malignant cancer.
    • Oncologist selects chemotherapy medications.

viii. Radiation Therapy

  • Indication for chemotherapy is as follows-
    • Eliminate benign and malignant cancer growth,
    • Restrict growth of benign and malignant cancer and
    • Shrink the malignant tumor mass
  • Dosage of Radiation-
    • Depends on type of benign or malignant cancer.
    • Radiation Oncologist selects radiation dosage.

ix. Surgery

  • Indication for surgery is as follows-
    • Remove benign and malignant cancer growth.
  • Types of surgery-
    • Depends on cancer type being benign or malignant cancer.

b. Treatment for Neuropathic Pain

i. Antidepressant Analgesics

  • Contraindications (avoid)-
    • Sleep apnea
  • Most common prescribed antidepressant for pain-
    • Elavil, Cymbalta and Seville

ii. Antiepileptic Analgesics

  • Contraindicated (avoid)-
  • Most common prescribed Antiepileptics for pain-
    • Neurontin and Lyrica

D. Treatment for Depression

  • Depression is mostly observed in patients suffering with malignant cancer and less often with benign cancer.
  • Depression associated with chronic pain is treated with Cymbalta or Seville.
  • Patient is also treated by psychiatrist and psychologist.

E. Treating Anxiety

  • Anxiety is observed in patients suffering with either benign or malignant cancer.
  • Anxiety is treated with antianxiety medications. Patient may need treatment for short period.
  • Anti-anxiety medication causes sedation and sleep apnea.
  • Close observation may be necessary if prescribed with heavy dosage of opioids.

Risk and Complications in Treatment of Cancer Pain:

  • Opioid Addiction
  • Opioid Dependence
  • Somnolence and Sleep Apnea- Combination of muscle relaxants, opioid, anti-anxiety and antidepressant may cause somnolence and sleep apnea.
  • Respiratory depression
  • Malnourishment- Loss of appetite, depression and sedation results is inadequate food intake causing malnourishment.
  • Dehydration- Loss of appetite and sleepiness may result in lack of fluid intake and dehydration.

References:

1. The valid informed consent-treatment contract in chronic non-cancer pain: its role in reducing barriers to effective pain management.

Compr Ther. 2004 Summer;30(2):101-4.

Jacobson PL1, Mann JD.

2. The pharmacists' role in patient-provider pain management treatment agreements.

Craig DS.

X. J Pharm Pract. 2012 Oct;25(5):510-6.

3. Pain management in palliative cancer patients: a prospective observational study on the use of high dosages of transdermal buprenorphine.

Clement PM1, Beuselinck B, Mertens PG, Cornelissen P, Menten J.

Z. Acta Clin Belg. 2013 Mar-Apr;68(2):87-91.

4. Nerve blocks in palliative care.

Chambers WA.

Y. Br J Anaesth. 2008 Jul;101(1):95-100. doi: 10.1093/bja/aen105. Epub 2008 May 20.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: June 14, 2014

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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