cancer pain2

8/21/2019 Cancer Pain2

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A Husni Tanra

Department of Anesthesiology, Intensive Care andPain Management

Faculty of Medicine Hasanuddin University

MAKASSAR

CANCER PAIN



A Patients perspective

“ One of the worst aspect of cancer pain is thatit`s a constant reminder of the disease and ofdeath ..

My dreams is for a medication that can relievemy pain while leaving me alert and with noside effects “

Jeanne Stover, 1992



Physicaldimension

Organic Pain

• unpleasant sensory• emotional experienced

Pain is “an unpleasant sensory and

emotional experience associated withactual or potential tissue damage ordescribed in term of such damage”

Definition of Pain (IASP 1979)

PAINhas 2 dimensions

Psycologicaldimention

PsychologicalPain



• Pain is extremely a major problem in cancer patients

• Pain is one of the most feared aspect in cancer patients

Unrelieved severe pain may associated with

• Disturbed sleep• Reduced appetite• Unrepaired concentration• Irritability and depression

• etc.• 69 % of severe cancer pain patient to cause consideration of

suicide.(Wisconsin 1985)

Problem of Cancer Pain



Prevalence of Cancer Pain

Bonica 1985

• + 50 % of patients of all stage reported pain• > 70 % with advanced cancer

Faley 1985

• 15 % of patients with non metastatic cancer hadsignificant pain

• 60-90 % of patient with advanced cancer reporteddebilitating pain

• 25% of all patients with cancer die in pain.WHO 1986

• 70 % of patient with advanced cancer had pain

• 3,5 million people suffering from cancer pain with or

without satisfacttory treatment every day



The Phenomena of Cancer Pain

COMPLEX and COMPLICATED

• ORGANIC PAIN

• PSYCHOLOGICAL PAIN• SUFFERING FROM PAIN

TOTAL PAIN

BIOPSYCHOSOCIOCULTUROSPIRITUAL

is the cumulative among :



TOTAL

PAIN

SOMATIC SOURCE

(ORGANIC PAIN)

ANXIETY

ANGERDEPRESSION

Non-cancer pathology

Cancer

Symptoms of debility

Side-effects of theraphy

Loss of social position

Loss of job prestige and income

Loss of role in family

Chronic fatigue and insomnia

Sense of helpessness

Disfigurement

Bureaucratic bungling

Friends who do not visit

Delay in diagnosis

Unavailable doctors

Irritability

Therapeutic failure

Fear of hospital or nursing home

Worry about family

Fear of death

Spiritual unrest

Fear of pain

Family finances

Loss of dignity and bodily control

Uncertainty about future

WHO 1986



Elisabeth K.Ross (1969) “on death

and dying”. BEHAVIOUR CHANGES IN CANCER PATIENTS

1. DENY2. ANGER

3. BARGAINING

4. DEPRESSION5. ACCEPTANCE



Pain

Somatic or

VisceralNociception

NeuropathicMechanisms

PsychologicalDisturbances

SufferingPsychologicalState and

Traits

Loss ofWork

PhysicalDisability

FearOf Death

FinancialConcerns

Social/Familial

Functioning

Pain In Cancer Patient



Mechanism of Cancer Pain

Can be divided into 2 catagories

1. ORGANIC PAIN

2. PSYCHOLOGICAL PAIN

ORGANIC PAINA. Nociceptive pain

1. Somatic pain(skin, muscle, bone, connective tissue)

2. Visceral pain

(thoracic and abdominal viscera)

B. Non nociceptive pain3. Neuropathic pain (deafferentiation pain) damage

of peripheral or central n.s.



Nociceptive Pain

Nociceptive pain means, pain with nociception

Nociceptive means, activity of afferent neurons

induced by a noxious stimulus

• TRANSDUCTION

• TRANSMISSION

• MODULATION

• PERCEPTION



Process whereby

noxious stimuli are

translated into

electrical activity at

the sensory endings

of nerves.

Heat

Chemical

TRANSDUCTION

Pressure



TRANSMISSION

Refers to the propagation

of impulses throughoutthe sensory nervous

system.

Transmission



MODULATION Process whereby endogenous

analgesic systems can modifynociceptive transmission. Theseendogenous systems (opioid,seretonergic, and noradrenergic)exhibit their inhibitory influenceat the dorsal horn.

Plays important role to the

individual perception.

Modulation



Pain

PerceptionBrain

PerceptionFinal process wherebytransduction,

transmission, andmodulation interact withthe uniqueness of theindividual to create the

final subjective feelingthat we call pain.



Organic pain in cancer

patients can be devided intothree types:

1. SOMATIC PAIN

2. VISCERAL PAIN

3. NEUROPHATICPAIN



Characteristic of Somatic Pain

• Example :

• Mechanisms :

• Management :

• Continous activation of nociceptors may producesensitization of N.S. (peripherally & centrally)

constant

aching, gnawing well localized

activation of nociceptors release algesic substances

(spesially prostaglandins)

bone metastasis. tumor of the soft tissue

Aspirin

Acetaminophen NSAID



Characteristic of Visceral Pain

• Mechanisms :

• Example :

• Management :

constant

deep or dull aching poorly localized usually with nausea and vomit often referred to cuttaneous sites

occational colicky or cramp

activation of nociceptors

pancreatic cancer

liver/lung metastasis with shoulder pain

Opioid (MS confine ®) Nerve block (e.g celiac plexus block)



Stimuli Sufficient To Cause

Visceral Pain Are:

1. Irritation of mucosal and serosal surfaces

2. Torsion and traction of mesentery

3. Distension or contraction of hollow viscus

4. Impaction of visceral organs



Characteristic of Neuropathic Pain(Deafferentiation Pain)

• Mechanisms :

• Example :

• Management :

burning pain paroxysmal shooting or electricalshock-like pain

spontaneus discharges of

peripheral or central n.s. loss of central inhibition

metastasis brachial or lumbosacralplexopathies

post herpetic neuralgia antidepressant or anticonvulsant nerve block etc



Classification of Cancer Pain

1. TEMPORAL2. TOPOGRAPHIC

3. ETIOLOGIC and

4. PATHOPHYSIOLOGIC

1. Pain associated with direct tumor

2. Pain associated with cancer therapy

3. Pain unrelated to cancer




Due to invasion of bone

• Base of skullOrbital syndromeParasellar sinus syndromeSphenoid sinus syndromeClivus syndrome

Jugular foramen syndromeOccipital condyle syndrome

• Vertebral body Atlantoaxial syndromeC7-T1 syndrome

L1 syndromeSacral syndrome

• Generalized bone painMultiple metastase




Due to invasion of nerves

Peripheral nerve syndromeParaspinal massChest wall massRetroperitoneal mass

Painful polynueropathyBrachial, lumbal, sacral plexopathiesLeptomeningeal metastaseEpidural spinal cord compression

Due to invasion of visceral Due to invasion of blood vessels

Due to invasion of mucous membranes



2. Pain associated with cancer therapy Surgery

Postthoracotomy syndrome

Postmastectomy syndromePostradical neck dissection syndrome

Postamputation syndromes

Chemotherapy

Painful polyneuropathyAseptic necrosis of bone

Steroid pseudorheumatism

Mucositis

Radiation

Radiation fibrosis of brachial or lumbosacral plexus

Radiation myelophaty

Radiation-induced peripheral nerve tumors

Mucositis

Radiation necrosis of bone



3.Pain indirectly related or

unrelated to cancer

Myofascial pains

Osteoporosis Postherpetic neuralgia

Debiliting (decubitus ulcer)

Etc



ABCDE Mnemonic for Pain

Assessment and Management

Ask about pain regularly

Believe the patient reports of pain

Choose pain control appropriately

Deliver in a timely, logical and coordinated

Empower patients and family



Three Step Ladder WHO, 1986

5 essential concepts

By mouth

By the clock

By the ladder

For individual

With attention to

detail

By this modality±

90% of cancer pain can be relieved



Pharmacologic Management of

Cancer Pain Individualize cancer pain management to the

patient

Use the simplest dosage schedules and theleast invasive means

An NSAIDs or acetaminophen should be usedin the pharmacologic management of mild tomodertae peripheral cancer pain, unless thereis a contraindication



Step I for MILD PAIN

NSAIDs may delay the need for escalatingopioid.

About 20% of patients were still taking NSAIDsin the last week of life.

NSAIDs have a potential opioid-sparing effect.

Caution is needed when using NSAIDs for

prolonged periods Risk factors such as aging, renal or GI diseases

should be considered.

It has ceiling effect.

Use paracetamol, aspirin or NSAID

f



Step Il for MODERATE PAIN

Combine Paracetamol/Aspirin/ NSAIDs + Codein

Formula

Constipation is the most common side effect ofcodein

Acetaminophen/

Aspirin 500 mg

Codein 10 mg

Dulcolax ¼ tab

mf pulv dtd XXX6 dd I cap

+ adjuvant

06.00 18.00

10.00 22.00

14.00 02.00 prn



Step lll for SEVERE PAIN

Oral morphine is the mainstay of severe cancerpain.

Strong pain needs strong analgesic.

It is a very safe drugs as long as given properly Morphine immediate release is not available in

Makassar.

MS contin is one of choice Sustained release

Long acting (twice a day)

Strong opioid

WHO A l i L dd



WHO Analgesic Ladder

Consider other treatment modalities when possible andappropriate

Radiotherapy, hormonal therapy, palliative chemotherapy, surgery

Consider nonpharmacologic modalities

Physiotherapy, psychotherapy, TENS, Accupucture, etc.

Address all aspects of suffering

Physical, psychosocial, cultural, and/or spiritual

STEP 1

Nonopioid

STEP 2

Weak opioid

+ nonopioid

STEP 3

Strong opioid

+ nonopioid

+ adjuvant



Adjuvant Drugs

Corticosteroids : Dexamethasone, Prednison Anticonvulsant : Carbamazepine, Gabapentin,

etc

Antidepressant : Amytriptiline, Doxepine Neuroleptics : Methotrimeprazine

Antihistamines : Hydroxyzine

Local anesthetic/antiarrhytmics : Lidocaine

Psycho-stimulans : Dextroamphetamine Laxatives : Bisacodyl, Lactulose, etc

Antiemetics : Droperidol, Metoclopropamide,etc

O F l i RSWS



Ours Formula in RSWS

Acetaminophen/Aspirin 500mg

Codein 20 mg

Dulcolax ¼ tab

mf pulv dtd XXX

6 dd I cap

+ adjuvant

06.00 18.00

10.00 22.00

14.00 02.00 prn

Moderate pain Severe pain

MST 5 - 10 mg

2 dd I tab

Celebrex 100 – 200 mg

2 dd I cap

+ adjuvant

06.00

18.00



If we could notable to cure the cancer patients,

never deny cancer pain, and let them die freeof pain and with IMAN

As a doctor, one should keep in mind :

To cure is sometimeTo treat is often, but…

To comfort is always



CONCLUSION1. Pain is a common problem and a major symptom

of cancer patients.

2. Pain is one of the most feared aspect and cancause to suicide

3. Cancer pain can be organic or psychological pain

4. Organic pain may be somatic, visceral orneuropathic pain or combined.

5. Total pain is aBIOPSYCHOSOCIOCULTUROSPIRITUALproblem.

6. CANCER PAIN management should be treated

integrated and comprehensive by multidisiplinedoctors.

cancer pain2

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