Overview
When it comes to cancer, a vast majority of patients (70% - 90%) suffer from pain during their course of the disease and treatment. Cancer pain is multifactorial, so it is important to recognize the pain early so that it can be managed with the help of an expert physician along with the management of the disease.
Causes of Cancer Pain
Pain in cancer patients may arise due to many reasons. It may be:
- related to cancer itself. Pain is often the presenting complaint leading to the diagnosis of cancer.
- due to local spread of the disease, destruction to the adjacent structures or from distant spread (metastases) from the disease.
- a later presentation due to side effects of various tests and treatments undertaken for chemotherapy, radiotherapy or surgery.
- a result of extra stress placed on other body parts such as shoulder pain due to using a stick for walking.
- due to neuropathic pain which can occur if nerves are affected by cancer.
- totally unrelated coincidental problems such as arthritis.
- ‘Phantom Pain’ which occurs from the surgically removed diseased part.
Signs & Symptoms of Cancer Pain
- Neuropathic/Nerve pain: This is a burning, shooting, electric shock-like or stabbing pain with associated tingling or numbness.
- Visceral pain: It originates from viscera (organs in body cavity) and is generally described as a deep aching, squeezing and cramping sensation.
- Bone pain: This is an aching, throbbing sensation, increasing with particular movements or weight bearing.
Expertise in Pain Management for Cancer Patients
Max Institute of Cancer Care offers integrated Pain & Palliative Care management services for a wide variety of conditions, including cancer pain, palliative care issues, supporting patients undergoing disease directed treatments & also during end of life care. Our expert pain & palliative consultants assess the patient in a holistic way and also guide them to reachout to physiotherapists, psychologists, occupational therapists, dieticians and Ayurveda & wellness specialists, to work together as a team to maximize your health gains. We do provide non-surgical alternatives using a multidisciplinary approach and coordinated care customized to suit individual needs.
Our experienced team will give you complete guidance, advice and support in implementing lifestyle modifications to help sustain the benefits. We work with you not only to reduce the pain but also the impact of pain on your life.
Max Healthcare’s cancer pain management and support services include:
- Managing physical problems: management of pain, breathlessness, non-healing ulcers, oral ulcers, nausea, vomiting and other distressing symptoms in patients undergoing disease directed treatment.
- Managing psychosocial problems: Like depression, anger or denial in response to the illness, emotional isolation etc.
- Managing spiritual pain and integrating the psychological and spiritual aspects of patient care.
- Offering a support system to help patients live as actively as possible.
- Providing terminally ill patients with end of life care.
- Offering a support system to help the family cope during the patient's illness and in their own bereavement.
Postive Approach Towards Cancer Pain Management
Cancer patients must receive adequate pain relief as it helps them eat, sleep and remain active during the day time and allows them to enjoy time with family and friends. This prevents them from falling into depression and helps adhere to the treatment as advised.
Accordingly, cancer pain relief at Max Institute of Cancer Care is individually tailored depending on the cause, severity and duration of the pain. In most cases, reasonable control is achieved by using a combination of methods. Our multimodal, multidisciplinary approach provides the opportunity to maximise pain relief. Besides physical symptoms like pain, nausea, vomiting, fatigue, our palliative care team will also support you and your family for emotional, social and spiritual needs.
Additionally, patients can choose from the following types of palliative care services:
- Outpatient basis: You may come to the front desk and ask for a Palliative Care Physician for consultation.
- Virtual consultation : Max healthcare has a virtual consultation platform, My healthcare plus application, which can be used to consult our pain & palliative care specialists from the comfort of your home.
- Inpatient services: You may require admission into the hospital for appropriate management of your condition.
- Home care: Liasioning with the home care teams to guide them for supportive care at home.
- Available on request: Patients and their families can request for specialized palliative care services at any time during a severe illness.
- Patients can be referred: Physicians and medical staff at hospitals or other healthcare facilities will refer a patient or request that the hospitalized patients be evaluated for services by the hospital's palliative care team.
Cancer Pain Management Options
The various options offered by Max Institute of Cancer Care for cancer pain management are:
A) Medications Management: This involves using different classes of medications to optimize pain control. A combination of drugs helps minimize side effects and maximize the benefits.
The drugs that are used to cancer pain management are called analgesics and broadly classified as follows:
- Non-opioids/Non-Steroidal Anti-Inflammatory Agents: These are a class of drugs used to control mild to moderate pain and inflammation.
- Opioids: Also known as narcotics, opioids can only be procured with a duly prescribed form by a registered medical practitioner. They are used for the management of moderate to severe cancer pain. Opioids are the mainstay of cancer pain management worldwide.
- Adjuvants: Include antidepressants, anticonvulsants and steroids. They are used along with non-opioids and opioids to manage cancer pain. Antidepressants and anticonvulsant drugs are used to manage tingling and burning pain due to involvement of nerves. Steroids help whenever there is swelling involved with pain.
- Nerve blocks – Majority of nerves can be targeted safely e.g. Pudendal Nerve for perineal or rectal pain, Suprascapular Nerve for shoulder pain, Pectoral Nerve for chest wall pain.
- Neurolytic procedures - These include Celiac Plexus, Splanchnic Nerves, Hypogastric Plexus, Lumbar Sympathetic, Ganglion Impar, etc.
- Radiofrequency procedures - Here conventional/ pulsed radiofrequency waves are used for neurolysis.
- Drug infusions- For breaking pain cycle, titrating opioids & decreasing central & peripheral sensitization.
- Spinal and joint injections - For patients with cancer presenting with chronic back pain & joint pains.
Second Opinion Regarding Cancer Pain Management
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Frequently Asked Questions
What is Pain/Cancer Pain?
According to the International Association for the Study of Pain (IASP), pain is described as "an unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage." To put it plainly, whenever someone says they're hurting—whether it's emotional, psychological, physical, or mental—it's considered as experiencing 'pain'.As we go through the journey of a patient with cancer, one experiences pain due to the disease, its treatment or a combination of both. Patients with cancer also complain of pain before the diagnosis, during the evaluation process such as biopsy, and while undergoing treatment modalities such as surgery, chemotherapy, immunotherapy or radiotherapy.
Why is it important for patients with cancer to have adequate relief of their pain?
Patients with cancer must receive multidimensional integrative care for adequate pain relief. Integrative care goals are to manage pain and increase physical and mental function, improving the quality of life of patients and bringing the shift towards:
- Relaxed/Feeling good.
- Better/normal posture.
- Improved mobility.
- Healthy socialisation.
- Improved quality of life where dignity is ensured.
What are the types of cancer pain? How can we classify it?
Cancer pain can be classified based on:
- Chronicity as acute pain (<3 months) and chronic pain(> 3 months).
- Episodic pain, such as breakthrough pain (flare-up pain) and incidental pain with relation to activity.
- Mechanism-based neuropathic pain (associated with the nervous system) and Nociceptive (stimulation of pain receptors).
It is also associated with emotional and psychological distress, which may potentiate the overall pain of the patient. As palliative care specialists, we talk about the concept of Total Pain, which may encompass the components of pain other than physical pain, such as emotional, psychological, spiritual, financial and as well as physical components.
How is cancer-associated pain assessed?
Cancer pain is assessed using a pain scale and questionnaire-based approach, which would measure the impact of your pain in your day-to-day life. Patients are also encouraged to keep a pain diary to monitor the pain relief and to encourage judicious use of pain medications, especially opioids.
How do I approach my doctor and talk about pain?
It is very important for your well-being that you seek help for disease (cancer) and also manage pain associated with cancer.
To help your doctor understand your pain, they may ask the following questions:
- Where does it hurt?
- How long have you been experiencing this pain?
- How much pain do you have on a scale of 0-10?
- What does the pain feel like, in your words? For example, is it aching, burning, throbbing or stabbing?
- What makes the pain better or worse?
- Is your pain affecting your ability to work, sleep, eat, do household chores, socialise, or perform other everyday actions?
- How do you feel with your current pain medications?
What is included in integrated pain management services for patients with cancer?
Integrated services include pain medications, interventional pain management techniques, radiation therapy and complementary therapies. To our knowledge, disease-directed therapies like chemotherapy, immunotherapy and surgical management, as indicated, definitely benefit the overall disease as well as the associated symptoms. The usual integrative approach does include :
- Pain Medications and Adjuvant Medications: Following the guidance of the WHO step ladder approach and other guidelines of cancer pain management based on evidence are to be followed.
- Interventional Pain Management Techniques: Early interventions to manage cancer pain are supported by the pain and palliative care physicians and are recommended whenever it is required.
- Psychology: Cancer is accompanied by anxiety, depression and fear of uncertainty. Our psychologists help analyse these thoughts rationally and develop a positive behavioural approach. They may teach relaxation techniques and coping strategies, thereby reducing the effect of cancer on patients & their families.
- Physiotherapy: Guided mobilisation and exercises improve functionality and decrease the incidence of chronic pain. Post-surgical and post-admission for critical event-associated pain states are phases in the disease trajectory where you would benefit the most with expert guidance.
- Complementary and Alternative Therapies: These could include meditation, acupuncture, transcutaneous electrical nerve stimulation (TENS), and wellness.
You can approach a pain and palliative medicine specialist to discuss and make an individualised care plan for yourself or your loved ones.
What are the pain medications used for pain management in cancer?
Cancer pain management involves using different classes of medications to optimise pain intensity and have better pain control. Many times, a combination of drugs helps minimise side effects and maximise the benefits. The drugs that are used to manage pain are called analgesics and are broadly classified as follows:
- Non Opioids/Non-Steroidal Anti-Inflammatory Agents: These drugs control mild to moderate pain and inflammation. Non-opioids include acetaminophen & Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like diclofenac, which are sometimes available over the counter, which is why they are prone to non-medical use (overuse).
- Medical Opioids: Also known as narcotic drugs, these may be used to manage moderate to severe cancer-related pain. Worldwide, opioids are the mainstay of cancer pain management. They can only be procured with a duly prescribed form by a registered medical practitioner.
- Adjuvants: Adjuvants include antidepressants, steroids and anticonvulsants. They are used with opioids and non-opioids to manage cancer pain. Antidepressants and anticonvulsant drugs help manage tingling and burning pain due to the involvement of nerves. Steroids are sometimes helpful whenever there is inflammation involved causing the pain.
What are the Interventional Pain Management procedures for Cancer-related pain?
Interventional pain management requires an individualised approach and can include interventions like nerve blocks or injections for pain management or using advanced pain management techniques such as intrathecal morphine pumps and spinal cord stimulators. A comprehensive list of the methods are given below:
- Nerve Blocks - A majority of nerves can be targeted when carrying pain signals.
- Neurolytic procedures such as Celiac Plexus, Splanchnic Nerves, Hypogastric Plexus, Lumbar Sympathetic, Ganglion Impar, etc., where there is some evidence for interventional pain management.
- Radiofrequency procedures include conventional and pulsed radiofrequency waves used for neurolysis.
- Drug Infusions - To break the pain cycle, titrating opioids and decreasing central and peripheral sensitisation may be considered.
- Spinal and joint injections are used for individuals with cancer presenting with chronic back pain & joint pains.
Your pain and palliative care physician works with you to individualise the plan and medication dose and better manage the side effects to bring relief to the severe pain.
How do I request cancer pain relief services for my patient?
You can approach pain and palliative care services in the following ways:
- Outpatient Basis: You may approach the front desk and ask for a pain & palliative care physician for consultation or book your consultation online.
- Virtual Consultation: Max Healthcare offers a virtual consultation on the Max my Health app. It can be used to consult pain & palliative care specialists from the comfort of your home.
- Inpatient Services: When you require admission into the hospital for appropriate management of your pain condition and titration of pain medications.
- Home-based Palliative Care: Liasioning with the Max@Home care teams to guide them for pain alleviation & to provide palliative and supportive care services at home.
Is morphine always used for pain relief?
Not always. It is important that the type of pain is identified and the appropriate intervention and drugs are used. Morphine is seldom used alone. Here are some common myths:
- Can a patient on morphine be sedated for the rest of life?
- No, certainly not, if used in the appropriate dose by an expert.
- Will morphine not cause addiction?
- No, not if used properly. A physician-supervised plan is needed to avoid diversion and prevent addiction. Patients with cancer-related pain might need morphine.
- If morphine is taken for pain currently, will it be ineffective later when the pain gets worse?
- Not at all. Morphine continues to be effective throughout the pain course; patients might also sometimes need opioid rotation to change over to a different opioid.
- What is the risk of respiratory depression with oral morphine?
- Very rare when used in the right dose under the supervision of a pain & palliative specialist.
Reviewed by Dr. Gaurav Chanana, Senior Consultant - Pain & Palliative Medicine, Pain Management, Cancer Care / Oncology, Palliative Care.
Other Conditions & Treatments
- Headaches
- Heel Spurs and Plantar Fasciitis
- Joint Pain
- Low Back Pain and Sciatica
- Neck and Shoulder Pain
- Neuropathic Pain
- Widespread Body Pain/Fibromyalgia