prof nusirwan acang pembicara ii
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CANCER PAIN(Pathophysiology and Etiology)
Nuzirwan Acan
Bagian Ilmu Penyakit Dalam Fakultas Kedokteran
Universitas Andalas Padang
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Pain as “an unpleasant sensory andemotional experience which we primarilyassociate with tissue damage or describe in
erms o suc amage, or o .(The International Association for the Studyof Pain = IASP)
This definition recognizes that pain is aperception and not a sensation.
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An estimated 6.6 million people from around
the world die from cancer each year. Pain can occur at any point during the course
of the illness
The prevalence of pain- At the time of cancer diagnosis : 50 %
- At advanced stages : 75%
- In cancer survivors to be : 33%
- Approximately 25% of those in nursing
homes
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After curative treatment : 33% Under anticancer treatment : 59%
Advanced/metastatic/terminal disease : 64%
Highest prevalence in head/neck cancer patients
: 51% to 88%).
(Annals of Oncology. 2007;18(9):1437-1449.)
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Type of cancer and prevalence of pain:Thoracic 52 %
Lung 45 %
Bone 85 %
Gastrointestinal 40 %
Genitourinary tract (male) 75 %
Genitourinary tract (woman) 70 %Lymphoma 20 %
Leukemia 5 %
Oxford Textbook of Palliative Care, 2005
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Unrelieved severe pain may associated with:Unrelieved severe pain may associated with:Unrelieved severe pain may associated with:Unrelieved severe pain may associated with:
◙ Disturbed sleep◙ Reduced appetite
◙ Un-concentration
rr ta ty an epress on
69% of severe cancer pain patient to cause69% of severe cancer pain patient to cause69% of severe cancer pain patient to cause69% of severe cancer pain patient to cause
consideration of suicide.consideration of suicide.consideration of suicide.consideration of suicide.(Wisconsin 1985)(Wisconsin 1985)(Wisconsin 1985)(Wisconsin 1985)
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Nociceptive pain: Ongoing tissue injury insomatic structures
Neuropathic pain: Aberrant somatosensoryprocessing
Visceral pain: Damage of visceral structures
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NociousNociousNociousNocious StimuliStimuliStimuliStimuli
mechanical thermal chemicalelectrical
Tissue damageTissue damageTissue damageTissue damage
Release of mediatorsRelease of mediatorsRelease of mediatorsRelease of mediators
Hydrogen and potassium ions,neurotransmitters, kinins,
prostaglandins
Stimulation of nociceptorsStimulation of nociceptorsStimulation of nociceptorsStimulation of nociceptors
Transmission to CNSTransmission to CNSTransmission to CNSTransmission to CNS
vvvvia afferent pathways
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Disease itself :
- localized- Metastese
Cancer Treatment-- Radiotherapy- Khemotherapy- Hormonal therapy
Noncancer pain condition- Low back pain- Arthritis
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Tumor expansion can cause pressure on
surrounding organs. Proteolytic enzymes produced by tumor cells candamage sensory and sympathetic nerve fibers
Tumors secrete inflammatory andpro ypera ges c me a ors.
Tumor infiltration in nerve plexuses and damageto nerve tissue can cause neuropathic pain.
Metastatic spread of cancer to bone
Stretching of hollow viscera, distortion of thecapsule of solid organs, inflammation of themucosa, and ischemia or necrosis activatevisceral nociceptors, resulting in visceral pain.
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Adverse effects of treatment :- Joint pain following chemotherapy and hormonal
therapy- Painful mucositis due to radiotherapy and
chemotherapy with certain agents.- europa c pa n : pos ra a on p exopa es,
peripheral polyneuropathy after chemotherapy- Opioid-induced hyperalgesia
Surgical interventions nerve damage and chronicpostoperative pain.
Procedures related to cancer pain ; biopsies, blooddraws, lumbar punctures, laser treatments
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Painful peripheral neuropathy fromchemotherapeutic agents :
vincristine, platinum, taxanes, thalidomide,bortezomib, and other agents; radiation-induced
Damage of tissue :- Radiation-induced brachial plexopathy
- Postradiation pelvic pain syndrome
- Postsurgical pain syndromes frommastectomy, amputation, and thoracotomy.
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Acute PainAcute PainAcute PainAcute PainA. Due to procedures and therapies
- Acute pain associated with diagnosticprocedures
Lumbar puncture headache
Bone marrow biopsyLumbar puncture, VenepunctureParacentesis, Thoracentes
- Acute pain associated with analgesic techniques
Spinal opioid hyperalgesia syndromeAcute pain after Strontium-89 therapy of
metastatic bone pain
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- Acute pain associated with othertherapeutic procedures
Pleurodesis
Tumour embolisationNephrostomy insertion
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B. Acute pain associated with chemotherapy
Pain from intravenous or intra-arterialinfusion
Intraperitoneal chemotherapy
ea ac e ue o n ra eca c emo erapy Painful oropharyngeal mucositis
Painful peripheral neuropathy
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C. Acute pain associated with hormonal
therapy Painful gynaecomastia Luteinising hormone-releasing factor tumour
flare in prostate cancer Hormone-induced acute pain flare in breast
cancer
. cute pa n assoc ate w t mmunot erapy Arthralgia and myalgia from interferon and
interleukinE. Acute pain associated with radiation therapy Painful oropharyngeal mucositis Acute radiation enteritis and protocolitis
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Multifocal or generalised pain (focal metastases
or marrow expansion)
Base of skull metastases
Pain syndromes of the bony pelvis and hip
umour nvas on o o nt, or so t t ssue, orboth
Paraneoplastic pain syndromes
Hypertrophic osteoarthropathy Tumour-related gynaecomastia
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Neoplastic involvement of viscera Hepatic distension syndrome
Chronic intestinal obstruction and peritonealcarcinomatosis
Chronic ureteral obstruction
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Process of the pain disease
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Acute pain + insufficient pain therapyAcute pain + insufficient pain therapyAcute pain + insufficient pain therapyAcute pain + insufficient pain therapy
Central sensitizationCentral sensitizationCentral sensitizationCentral sensitization
Pain memoryPain memoryPain memoryPain memory
Pain diseasePain diseasePain diseasePain disease
Collapse of the body's pain defensesCollapse of the body's pain defensesCollapse of the body's pain defensesCollapse of the body's pain defenses
Sandkühler, J.: Preventing Pain Memory. MMW 2002; Special
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Adapted from Mundy G. Nature reviews cancer 2. 584-593. 2002
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Other somatic symptoms (chronic cough,nausea, hiccup)
Knowledge and understanding of the patient
Feelings of frustrations, angry anddepression
Social factors (financial, partner, children)
Existential problems Cultural factors
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Pain is a common symptom of cancer, consist of
acute and chronic Delineate type of cancer: nociceptive,
neuropathic, visceral
Local tumors cause spinal and supraspinalhyperreactivity
Metastatic/spread of cancer produced Nociceptive
and visceral pain
Different tumors cause different pain reactivity
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ANDALAS
UNIVERSITYHOSPITAL