Cancer Pain

Cancer pain is an insidious force that increasingly threatens the functional capability and psychological well-being of the cancer patient as disease progresses. Because of unrelieved pain, many cancer patients spend the last weeks, months or even years of their lives in needless discomfort and disability (Bonica, 1990, Jacox et al., 1994).

Although many people think of cancer pain as a focal crisis that emerges in advanced stages of the disease, it is a complex, extensive problem. Bonica (1990) pointed out that cancer patients suffer with pain from direct tumor involvement, from anticancer therapy, from cancer-related physiologic and biochemical alterations, and from still other causes. Foley (1990) found that among 143 cancer patients referred for pain therapy, pain resulted from the disease in 78%, from treatment in 19% and was unrelated to either in 3%. Because cancer pain is multi-causal, multi-focal and dynamic, its management requires efforts directed toward both prevention and relief.

The scope of the cancer pain problem is greater than most of us realize. Approximately 15.1 million persons throughout the world have cancer at any given time. The mean incidence of pain in a sample of 5,410 patients (22 studies) in various stages of cancer was 51%, whereas among 9,007 patients (38 studies) with advanced metastatic or a terminal phase of cancer, the mean incidence was 74% (Bonica, 1990). A large proportion of health care providers deals with cancer patients from time to time. Most are poorly prepared to undertake pain management.

Tragically, the extensive suffering caused by cancer pain is unnecessary. Gains in knowledge about pain and its control and technological advances in pain management now enable informed physicians to relieve up to 90% of cancer pain (Levy, 1985, Portenoy, 1989). The reality, however, is that many cancer patients with straightforward pain problems continue to get inadequate relief (Cleeland et al., 1994).

In sum, pain is a very large medical and social problem, compounded by the lack of knowledge on pain mechanisms and treatment among Health care providers as well as by the general ignorance of the public as a whole with regard to the nature of pain and its prevention or relief. Clearly pain research and the education of Health care providers in pain control address a great deficit in American medicine.

Fortunately, much progress has taken place in the last quarter century. The founding of the IASP in the early 1970s at Dr. Bonica's instigation began the process. The American Pain Society emerged as a child organization of the IASP shortly thereafter. These organizations called attention to pain problems and fostered numerous research funding directives and public policy changes. In recent years AHCPR has produced three practice guidelines concern with pain: Acute Pain (1992), Cancer Pain (1994) and Acute Low Back Pain (1994).

AHCPR. Management of Cancer Pain, Clinical Practice Guideline, Agency for Health Care Policy and Research, 1994

Acute Low Back Problems in Adults, Clinical Practice Guideline, Agency for Health Care Policy and Research, 1994

Acute Pain Management, Clinical Practice Guideline, Agency for Health Care Policy and Research, 1992

Bonica, JJ The Management of Pain, (2nd Ed), Philadelphia: Lea and Febiger, 1990.

Cleeland, C.S., Gonin, R., Hatfield, A.K., Edmonson, J.H., Blum, R.H., Stewart, J.A., and Pandya, K.J. "Pain and its treatment in outpatients with metastatic cancer", New England Journal of Medicine, 330, pp. 592596, 1994.

Foley, K.M. "Pain syndromes in patients with cancer", J.J. Bonica (Ed), Advances in pain research and therapy, Vol 2, Raven Press, New York, 1990.

Jacox, A., Carr, D.B., and Payne, R. "New clinical practice guidelines for the management of pain in patients with cancer", New England Journal of Medicine, 330, pp. 651-655, 1994.

Levy, M.H. "Pain management in advanced cancer", Semin Oncol., 12, pp. 394-410, 1985.

Portenoy, R.K. "Cancer pain: epidemiology and syndromes", Cancer. 63, pp. 2298-2307, 1989.