Cancer pain continues to be an under-recognized source of patient suffering and dissatisfaction within health care systems. Pain is one of the most common and feared symptoms of cancer, experienced by 30-50% of patients with cancer receiving treatment and 70-90% of patients with advanced disease.

For some patients, the prevalence and severity of pain increases as the cancer progresses. In addition, patients may experience pain of several sites at the same time, each pain may have a different mechanism, and each pain may occur in distinct patterns.

To address these concerns, the National Comprehensive Cancer Network (NCCN) developed guidelines to better direct cancer pain assessment and management. A recent study found that a substantial number of cancer inpatients were receiving treatment for their pain that was not adherent to the NCCN guidelines during the first 24 hours of admission. Those patients whose regimens were adherent to NCCN guidelines compared with those not adherent were significantly more likely to have better pain control.

Decades after the publication of the World Health Organization’s (WHO) analgesic ladder, cancer pain still is a major cause of suffering. It affects millions of cancer patients worldwide and because of the increasing incidence of cancer it is a major international public health problem.  

In a report released in January 2003, the Institute of Medicine listed pain control in advanced cancer as one of 20 health care areas in need of substantial quality improvement. The report cited:

  • many with cancer experience substantial pain throughout the course of their illness and that pain is widely dreaded
  • cancer-related pain affects 20% to 50% of patients at the time of their diagnosis and during subsequent treatment; while 55% to 95% of those experience substantial pain in the advanced stages of their disease
  • living with overwhelming pain is demoralizing, removes dignity, and interferes with daily  life activities.

FACTS

-The American Cancer Society estimated that about 585,720 Americans are expected to die of cancer in 2014, almost 1,600 a day. Cancer is the second most common cause of death in the U.S., exceeded only by heart disease. In the U.S., cancer accounts for one of every four deaths. Approximately 1.665 million new cases of cancer are excepted to be diagnosed in the U.S. in 2014.

-According to the International Association for the Study of Pain, an estimated 6.6 million people around the world die from cancer each year. Pain can occur at any point during the course of the illness.

-Estimates of the prevalence of cancer pain have varied widely, mainly because of a lack of standardization in definitions of pain and in the measures used to assess it, and because of the similarity of related pain conditions. Other factors contributing to the wide variation in results include the heterogeneity of cancer diagnoses (breast, lung, etc.) and the types of treatment settings in which the studies were conducted (outpatient, inpatient, or community settings).

-One strategy for evaluating the prevalence of pain in cancer patients is to consider the following categories: pain related to the cancer, to it’s treatment, or to unrelated causes.

-American Cancer Society Facts about Cancer Pain Treatment 

  • cancer pain can almost always be relieved or lessened
  • controlling your cancer pain is part of your cancer treatment
  • keeping pain from starting or getting worse is the best way to control it
  • you have a right to ask for pain relief
  • side effects from pain medicines can be managed and often even prevented
  • your body does not become immune to pain medicine

-The American Pain Society 2005 Updated and Expanded Recommendations for improving the Quality of Acute and Cancer Pain Management

  • recognize and treat pain promptly (emphasis on comprehensive assessment and importance of preventative and prompt treatment based on evidence for neuroplasticity)
  • involve patients and families in pain management plan (emphasis on customization of care and participation of patient in treatment plan)
  • improve treatment patterns (eliminate inappropriate practices, provide multimodal therapy)
  • reassess and adjust pain management plan as needed (respond not only to pain intensity but to functional status and side effects)
  • monitor processes and outcomes of pain management (new standardized Ql indicators and comments about forthcoming national performance indicators)

CANCER PAIN AND SURVIVORSHIP

-Pain and survivorship is an important issue. The American Cancer Society estimates that nearly 13.7 million Americans who have ever had cancer were alive on January 1,2012.

-In general, the prevalence of pain at the time of cancer diagnosis and early in the course of disease is estimated to be approximately 50%, increasing to 75% at advanced stages. A recent review found the prevalence of pain in cancer survivors to be 33%, an important quality of life consideration.

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-Persisting pain after cancer treatment is drawing increased attention given the growing number of cancer survivors, and the documented challenges identifying and treating long-term consequences of cancer treatment. A study evaluating pain in can survivors found that 32.4% reported moderate to severe pain six months after cancer diagnosis. The pain intensity ratings ranged from 0 to 10; 35.3% reported pain intensity of “5” or worse.

-Concerns about the impact of pain on daily activities, work and enjoyment as well as moderate to high intensity of pain continued unabated at 12 to 18 months following a diagnosis.

-At six months post diagnosis, younger adults described higher levels of pain interfering with activities, work, and enjoyment of life than did older adults. Similarly, younger adults described higher levels of pain intensity on a 0-10 scale than did older adults. Considered as a percentage, 42.4% of younger adults reported moderate to severe pain impacts, whereas 20.5% of older adults did.

-One study of cancer patients with amputations found the prevalence of phantom pain was 46.7%, phantom sensation 90.7%, and surgical stump pain 32.0%.

-limb amputations resulting from cancer most commonly involved the lower limb; above-knee and below-knee amputations alone account for more than a third 36% of all cancer-related amputations

-The prevalence of severe persistent postsurgical pain (PPP) following breast cancer surgery and lung cancer surgery are 13% and 4-12%, respectively. The consequences of PPP include severe impairments of physical, psychological, and socioeconomic aspects of life. The pathophysiology underlying PPP consists of a continuing inflammatory response, a neuropathic component, and/or a late reinstatement of postsurgical inflammatory pain.

-Additionally, 23-90% of cancer patients also experience breakthrough pain (BTP) – sudden, at times excruciating, flares that occur even when pain medication is used to control a generally-consistent level of pain. One study found that cancer patients who reported pain that was not associated with their cancer had higher rates of BTP.

CANCER PAIN AND AGE

-One study of cancer pain in children found that they reported pain 56% of the time, while their nurses only reported it 23% of the time. The children also consistently reported higher intensity of pain compared with nurses’ documentation. Nurses noted ethnicity-related differences with higher pain levels for Caucasian children, who received analgesics more frequently.

-The most frequent location of pain reported by the children was the head (indicated in 31% of all interviews). Other locations that were reported from 20% to 30% of the time by all children included the abdomen, lower back, legs, and the feet.

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-Among older cancer patients, one study found that discrimination was a significant indicator of satisfaction with pain treatment, where those who perceived being discriminated against being less satisfied with their treatment for cancer pain. Data showed an overwhelming number of Caucasians cited age as the main reason for their experienced discrimination, whereas African Americans reported race as the primary reason. This is important because studies have shown that the more satisfied patients are with their management of pain, the more likely they are to comply with the advice of their health care provider, refrain from destructive behaviors that do not improve or maintain health, miss fewer medical appointments, and adhere to their medical treatment.
-Lack of knowledge, knowledge gaps, misconceptions about pain self-management, and difficulties putting pain management strategies into practice hinder the efficacy of pharmacological and non-pharmacological interventions in cancer patients. In a survey of older adults presenting with outpatient cancer treatment, low education, being African American, and physician mistrust were significant predictors in serving as barriers to pain management.

CANCER PAIN AND CAREGIVERS

-A study of 24 family caregivers of advanced cancer patients uncovered the following four themes of distress as they tried to manage the patient’s pain. The family caregivers’ own words are used to illustrate these themes:

  • “like being in a prison” (overwhelmingly responsible)
  • “flying blind” (unprepared)
  • “lambs to the slaughter” (unsupported)
  • “it hurts to watch somebody you love suffer” (helpless)

-In addition, these four themes were interrelated as participants often expressed distress in multifaceted way, with distress in one area leading to distress in another.

-Metastatic breast cancer can be challenging for couple given the significant pain and distress caused by the disease and its  treatment. One study of 191 couples surveyed found that when patients engaged in high levels of catastrophizing and had high levels of pain, both patients and partners reported significantly higher levels of depression than when patients engaged in high levels of catastrophizing but had low levels of pain.

ADDITIONAL RESOURCES

American Cancer Society
www.cancer.org

American Cancer Society Cancer Action Network
www.acscan.org

American Pain Society
www.americanpainsociety.org

Cancer Care
www.cancercare.org

Cancer Hope Network
www.cancerhopenetwork.org

Cancer Support Community
www.cancersupportcommunity.org

LIVESTRONG Foundation
www.livestrong.org

National Coalition for Cancer Survivorship
www.canceradvocacy.org