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Cancer pain - General factors (3.6.1 - 3.6.6)

Updated: Mar 7, 2022




3.6.1 - Sociocultural influences on experience of cancer

Sociocultural influences such as diet, life habits and environmental factors may contribute to 85-90% of cancer incidence


Lifestyles across the world emanate from cultural beliefs, values and practices

Cancer incidence is similar across the world but the different types varies widely


Cultural factors influence risk factors for cancer but also determine the meaning of cancer for different persons


Healthcare providers who learn the nuances of cultural factors are more effective in managing the pain of their patients. They are also better equipped to assist patients and families


Putting pain into words is subjective - and therefore how this is communicated is coloured by the cultural background of the patient. Even the term 'palliative care' can mean different things to different individuals and communities


For example, in some cultures discussing death may be seen as inappropriate and culturally insensitive. In some cultures families may ask that healthcare providers do not disclose a terminal diagnosis to the family member as they want to avoid emotional suffering and preserve hope.


Buddhists may refuse medications that cloud the mind close to death

Taiwanese believe that talking about impending death brings bad luck


Religion and spirituality may have a tremendous impact upon healthcare decisions made by patients but many healthcare providers do not factor this, or its functional impact, into their assessment and management.


A palliative care founder of the modern-day hospice movement, Dame Cecily Saunders, described 'spiritual pain' and said it can come from a feeling of meaninglessness.


Even the meaning of pain can be different.

  • Chinese cultures view pain as an imbalance of Yin and Yang.

  • Some cultures believe they should endure pain bravely and serve as a role model to improve their standing after death.

  • Some cultures are very stoic regarding pain such as American Indian and Black and may maintain a neutral face despite being in severe pain

  • Some religions believe they should suffer pain as this is a test of faith or a penance for past sins

  • Some cultures believe they should deal with pain individually whereas others believe the community should share the burden

How does this affect pain management?

  • Many cultures may not accept the use of opioids

  • Some may believe this is the same as euthanasia, and need further education

  • Some believe opioid use means death is imminent

  • They may believe that its use early means less effect later

  • Fear of addiction

Alternative therapies can be used where they do not cause harm

Family involvement may or may not be useful/important

Language barriers need to be considered and interpreters utilised

Pain medicine may be seen as a weakness in some cultures


"Two people, with the same faith tradition and cultural upbringing, may have different end-of-life issues that create pain, challenge, or distress. This may be because of the choices made in their lives and/or the circumstances that surround them.” (Spiritual Care in a multi-religious context. Lunn JS, Journal of Pain & Palliative Care Pharmacotherapy, 2003)


Cultural management

- Healthcare professionals may need to dispel myths and gently explore barriers

- Patients need to be taught about pain relief, its role, and how it may affect quality of life


Questions can be used like:

  1. How important is staying mentally alert to you in the final days before death?

  2. What pain level are you willing to endure?

  3. What type of pain medicine or alternatives should be considered?

Rachel Naomi Remen M.D. once said: “Our power to heal is far less limited than our power to cure. Healing is not a relationship between an expert and a problem. It is a relationship between human beings.”


Barriers to appropriate cancer analgesia therapy:

  • Societal changes

  • System and regulatory barriers to prescribing

  • Clinician barriers such as reluctance to prescribe

  • Patient barriers

  • Health care disparities

Reference:

Givler A, Bhatt H, Maani-Fogelman PA. The Importance Of Cultural Competence in Pain and Palliative Care. [Updated 2020 Dec 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493154/

 

3.6.2 - Compare and contrast assessment and management of persons with cancer pain with those with chronic non-cancer pain


The term 'cancer pain' is relatively new - appearing only in the last 30 years

Arguably pain mechanisms do not support a difference between cancer and non-cancer pathophysiology.


Cancer patients are now living longer and their original pain generators may become chronic pain in and of itself, which is then little different from patients without cancer


There may also have been political motivations as relieving the suffering of cancer is seen as essential


Cancer pain:

  • Opioids are used more readily. Initially, because patients were suffering and the prognosis usually meant only short term use

  • Mechanisms may be different - for example, bone pain may be exacerbated by the local creation of RANK-L and acid-forming environment

  • Treatments available for cancer pain may well be different than non-cancer pain - for example radiation therapy and chemotherapy and this comes with its own problems

 

3.6.3 - Cancer survivors who have persistent pain


Pain after cancer is increasingly common

  • 39% of patients after curative intent living with chronic pain

  • 55% after receiving anticancer treatments

  • 66% in metastatic, advanced or terminal disease

More than 40% of patients are now living longer than 10 years after a cancer diagnosis

These patients may either be cured or managing a relapsing and remitting disease process

Clearly chronic pain is debilitating and can also significantly impact activity and QOL


Causes of pain

Pain can be from:

  • The tumour itself

  • Anticancer treatments (e.g. chemotherapy, radiotherapy, surgery, stem-cell transplants)

  • Comorbid diseases

ICD-11 currently recognised this increasing cohort of chronic pain sufferers with a specific code/diagnosis - Chronic Cancer pain


Postsurgical pain

PSP is more common after major cancer operations than general operations

They are also more commonly associated with sensory abnormalities


Chemotherapy-induced peripheral neuropathy

Can commonly occur after chemotherapy with one report suggesting

- 68.1% in first month after chemotherapy

- 60% at 3 months

- 30% at 6 months


The pathophysiology of CIPN is not fully understood

Symptoms are often distal sensory neuropathy with sensations such as numbness, paraesthesia, tingling, and neuropathic pain.

Different chemotherapy agents have different risks for the development of CIPN


Hormone treatment-related pain

Widespread persistent joint pains and stiffness can occur in up to 50% of women taking aromatase inhibitors often leading to reduce exercise capacity and may be a factor in 20-40% of women ceasing therapy early


Radiotherapy-related pain

Radiotherapy dose is calculated using a radiation unit - Gray's (Gy)

The fractionation is how many sessions are used to provide the total Gray amount

Fractionation is done because tumour cells have less propensity to repair between treatments

It is done in three ways - Definitive (highest amount), Adjuvant (mid therapy), Palliative (to shrink a tumour)


Radiation therapy by

1. Directly by damaging DNA and regulatory proteins that repair DNA

2. Indirectly by the production of reactive oxygen species which further damage tissue DNA


Abdominal foci can cause pain, diarrhoea and rectal bleeding

Side effects can often be either acute or late (occurring 90 days+ after treatment)

GI and urological toxicity, muscular and pelvic pain are possible complications

Serious complications include:

  • Haemorrhagic cystitis (bladder pain and blood in urine)

  • Anterior urinary fistula from bladder to skin of pubic ramus (prostate cancer)

Corticosteroid induced osteonecrosis

Children with leukaemia have VERY intensive chemotherapy regimes

Bone damage can persist due to high doses of corticosteroids used in these regimes

Avascular or osteonecrosis can occur in between 2 and 4% of patients


Management of chronic pain in cancer


All the typical agents can be used as per the WHO analgesic ladder (paracetamol, NSAIDs and then upwards etc).

 

3.6.4 - Discuss the WHO ladder for analgesia in cancer

Written initially in 1986 for the management of cancer pain, it is widely used by doctors for the management of all types of pain.


Principle is simple - start low and go slow.

 

3.6.5 - Discuss end-of-life symptoms including:


  • Pain


The palliative care college considers pain in a slightly different way. They split it into different factors


Painful stimuli

  • Pain due to effects of the cancer (organ infiltration, remote effects)

  • Pain syndromes from cancer therapy (Radiation, surgery, chemotherapy)

  • Pain unrelated to cancer (Low back pain etc.)

Strategies for pain management in palliative care:

Regular analgesic as per the WHO ladder


For an opioid-naive patient at the end of their life, morphine 2.5 - 5 mg morphine given hourly is often sufficient


Breakthrough pain - occurs when pain 'breaks through' the base level of analgesia

Incident pain - Pain on movement or activity (never added to regular daily dose)

Spontaneous pain - Can occur intermittently

Rescue doses - This is the medication that can be given in breakthrough or incident pain (1/6th of daily OMED - ?short acting fentanyl)


Effects on cognition

- Often mild and will settle. Need to not drive when initiating or increasing the dose


Opioid toxicity - Pinpoint pupils, hallucinations, drowsiness, vomiting, respiratory depression, confusion, and myoclonic jerks


This is more likely to occur with: Doses increasing too rapidly, renal impairment is present, patient is poorly responsive to opioids and high doses are used to try and get a response, adjuvants have been added that give pain relief but base morphine has not been reduced


Respiratory depression can be reversed with naloxone 20 micrograms every 2 minutes until respiratory rate improves. If the naloxone is titrated to RR and consciousness then an acute pain crisis is unlikely


NB: Fentanyl patch often takes 12-24 hrs to start working. Takes 6 days to reach maximal effect

It also takes 12-24 hrs for it to stop working too!


Corticosteroids can be used as an adjunct. Their exact dosing is unclear however


When converting from oral to sub-cut morphine always go to 1/3rd the normal dose due to increased bioavailability


Nausea/Vomiting

Constipation is inevitable. They recommend movicol early

N&V - Two-thirds of patients will experience this early but often resolves

Antiemetics can be used such as:

  1. Haloperidol 0.5-1.5 mg at night (first line)

  2. Metoclopramide (particularly if gastric stasis) 10 mg TDS. Short term use only

  3. Cyclizine 25-50 mg TDS - if brain tumour related

(They don't use ondansetron because of constipating effect - strong)


Respiratory distress

  • Simple first - sit bed upright, oxygen if hypoxia, hand-held or free-standing fan, controlled breathing techniques and the management of anxiety

  • Try to treat the cause e.g. anaemia - transfusion

  • Low doses of morphine suppress excess respiratory drive - doses are very slowly titrated e.g. 2.5 mg morphine every 4 hrs

  • Benzodiazepines can be used to have a calming and muscle relaxant effect. Diazepam 5 mg or lorazepam 1 mg. SL lorazepam can be used for rapid effect

Cough

  • Can be associated with dyspnoea or be separate

  • Treatable causes should always be sought first

  • Dry cough

  1. Pholcodine (30 mg loading dose (because it has a long half-life) then 5-10 mg QID)

  2. Oral morphine 2.5 mg QID

  3. Codeine 15-30 mg TDS

  4. Dexamethasone can be used if tumour related - 6-8 mg daily

  5. ? Bisolvon

Productive cough

  • Expectorant

  • Nebulised saline

  • Physiotherapy

  • Cough suppressants are generally avoided if wet cough

  • Anti-muscarinic (Hyoscine hydrobromide) may help reduce secretions

Pruritis

  • Can be difficult to treat

  • Pain and itch common share pathways

  • Cholestatic and uraemic itch is thought to be mediated by opioid receptors

  • Morphine can also contribute to itch in a similar way

  • Reversible causes should be sought considering endocrine disease, iron deficiency, drug allergy, and lymphoedema

Management

- Cooling agents to the skin such as menthol

- Using a soap substitute

- Oral antihistamine

- Bile sequestrant if indicated (cholestyramine 6-8 mg)

- Rifampicin for chronic cholestasis

- Anxiolytics

- H2 antagonists

- Paroxetine


Reference:

 


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