A Husni Tanra

Department of Anesthesiology, Intensive Care and

Pain Management
Faculty of Medicine Hasanuddin University
MAKASSAR
CANCER PAIN
A Patients perspective
One of the worst aspect of cancer pain is that
it`s a constant reminder of the disease and of
death ..
My dreams is for a medication that can relieve
my pain while leaving me alert and with no
side effects

Jeanne Stover, 1992
Physical
dimension
Organic Pain
unpleasant sensory
emotional experienced
Pain is an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage or
described in term of such damage
Definition of Pain (IASP 1979)
PAIN
has 2 dimensions
Psycological
dimention
Psychological
Pain
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 had
significant pain
60-90 % of patient with advanced cancer reported
debilitating 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
ANGER DEPRESSION
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. DENY
2. ANGER
3. BARGAINING
4. DEPRESSION
5. ACCEPTANCE
Pain
Somatic or
Visceral
Nociception
Neuropathic
Mechanisms
Psychological
Disturbances
Suffering Psychological
State and
Traits
Loss of
Work
Physical
Disability
Fear
Of Death
Financial
Concerns
Social/
Familial
Functioning
Pain In Cancer Patient
Mechanism of Cancer Pain
Can be divided into 2 catagories
1. ORGANIC PAIN
2. PSYCHOLOGICAL PAIN
ORGANIC PAIN

A. Nociceptive pain
1. Somatic pain
(skin, muscle, bone, connective tissue)
2. Visceral pain
(thoracic and abdominal viscera)
B. Non nociceptive pain
3. 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 throughout
the sensory nervous
system.
Transmission
MODULATION
Process whereby endogenous
analgesic systems can modify
nociceptive transmission. These
endogenous systems (opioid,
seretonergic, and noradrenergic)
exhibit their inhibitory influence
at the dorsal horn.
Plays important role to the
individual perception.
Modulation
Pain
Perception
Brain
Perception
Final process whereby
transduction,
transmission, and
modulation interact with
the uniqueness of the
individual to create the
final subjective feeling
that we call pain.
Organic pain in cancer
patients can be devided into
three types:
1. SOMATIC PAIN
2. VISCERAL PAIN
3. NEUROPHATIC
PAIN
Characteristic of Somatic Pain


Example :

Mechanisms :
Management :
Continous activation of nociceptors may produce
sensitization 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 electrical
shock-like pain
spontaneus discharges of
peripheral or central n.s.
loss of central inhibition
metastasis brachial or lumbosacral
plexopathies
post herpetic neuralgia
antidepressant or anticonvulsant
nerve block
etc
Classification of Cancer Pain
1. TEMPORAL
2. TOPOGRAPHIC
3. ETIOLOGIC and
4. PATHOPHYSIOLOGIC
1. Pain associated with direct tumor
2. Pain associated with cancer therapy
3. Pain unrelated to cancer
1. Pain associated with direct tumor
Due to invasion of bone
Base of skull
Orbital syndrome
Parasellar sinus syndrome
Sphenoid sinus syndrome
Clivus syndrome
Jugular foramen syndrome
Occipital condyle syndrome
Vertebral body
Atlantoaxial syndrome
C
7
-T
1
syndrome
L
1
syndrome
Sacral syndrome
Generalized bone pain
Multiple metastase
1. Pain associated with direct tumor
Due to invasion of nerves
Peripheral nerve syndrome
Paraspinal mass
Chest wall mass
Retroperitoneal mass
Painful polynueropathy
Brachial, lumbal, sacral plexopathies
Leptomeningeal metastase
Epidural 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 syndrome
Postradical neck dissection syndrome
Postamputation syndromes
Chemotherapy
Painful polyneuropathy
Aseptic 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 the
least invasive means
An NSAIDs or acetaminophen should be used
in the pharmacologic management of mild to
modertae peripheral cancer pain, unless there
is a contraindication
Step I for MILD PAIN
NSAIDs may delay the need for escalating
opioid.
About 20% of patients were still taking NSAIDs
in 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
Step Il for MODERATE PAIN
Combine Paracetamol/Aspirin/ NSAIDs + Codein
Formula







Constipation is the most common side effect of
codein
Acetaminophen/
Aspirin 500 mg
Codein 10 mg
Dulcolax tab
mf pulv dtd XXX
6 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 cancer
pain.
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 Analgesic Ladder
Consider other treatment modalities when possible and
appropriate
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

Ours Formula in RSWS
Acetaminophen/
Aspirin 500
mg
Codein 20 mg
Dulcolax 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 100200 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 free
of pain and with IMAN

As a doctor, one should keep in mind :
To cure is sometime
To treat is often, but
To comfort is always










CONCLUSION
1. Pain is a common problem and a major symptom
of cancer patients.
2. Pain is one of the most feared aspect and can
cause to suicide
3. Cancer pain can be organic or psychological pain
4. Organic pain may be somatic, visceral or
neuropathic pain or combined.
5. Total pain is a
BIOPSYCHOSOCIOCULTUROSPIRITUAL
problem.
6. CANCER PAIN management should be treated
integrated and comprehensive by multidisipline
doctors.