Cancer-Related Pain
Summary of Key Points
Treatment
• In 85% of patients, pain can be well palliated using simple, inexpensive, “low-technology,” oral analgesics.
• The addition of appropriate adjuvant pain medications, alternate routes of opioid administration, antineoplastic therapy, nonpharmacologic approaches, neurostimulatory techniques, regional analgesia, and neuroablative procedures provides excellent palliation for nearly all patients with pain relating to cancer.
1. A 58-year-old man presents with unrelenting epigastric pain radiating to his back. Tests reveal unresectable pancreatic cancer. His pain is not controlled with morphine or hydromorphone administered at doses that cause sedation and confusion. Which of the following would you recommend?
A Radiation directed at the pancreatic cancer
C An intrathecal pump delivering opioids to the cerebrospinal fluid (CSF)
2. A 35-year-old mother of three was diagnosed with breast cancer (8/10+ nodes, decreased estrogen receptor) 18 months ago. She completed surgery, radiation, and chemotherapy and now presents with low back pain radiating down her right leg that began after a fall on ice 4 weeks ago. The pain continues to increase in intensity and is interfering with her sleep and daily activities. Her neurologic examination is normal, but spinal radiographs reveal multiple lytic lesions in the thoracic and lumbar spine. What would you recommend?
A Oral opioids with follow-up in 1 week
B A nonsteroidal antiinflammatory drug for bone metastases
C Radiation for spinal metastases
D Dexamethasone and urgent spinal magnetic resonance imaging
3. A patient with locally advanced head and neck cancer has a tracheostomy. He is unable to swallow, and thus a feeding tube has been placed, and he is receiving radiation and chemotherapy as an outpatient. He reports 8/10 pain in the area being treated with radiation. What would you recommend?
A Escalating doses of liquid morphine placed down the feeding tube
B A transdermal fentanyl patch
C Home patient-controlled analgesia using intravenous hydromorphone
4. A 40-year-old man was recently found to have melanoma metastatic to the liver, lungs, ribs, spine, pelvis, and right femur. He now reports right upper quadrant and right leg pain. He has a long history of heroin use, but for the past 3 years he has been taking methadone and has worked full-time as a computer programmer. What would you do?
1. Answer: D. A celiac plexus block is a relatively safe outpatient procedure that is highly likely to reduce pain intensity scores and opioid requirements.
2. Answer: D. This patient has a high likelihood of having an epidural cord compression (vertebral metastases large enough to be visible on plain spine radiographs with pain) that should be ruled out urgently.
3. Answer: A. The initial goals are to determine if the pain is opioid sensitive and what dose of opioids are required to provide adequate relief. Escalating doses of liquid morphine administered via the feeding tube will answer these questions.
4. Answer: B. This patient will require opioids to adequately control pain from his widely metastatic and progressive melanoma. Despite his drug abuse history, he is in a methadone program and has been employed and drug free for years, and thus he is at lower risk for abuse than a patient who is actively abusing opioids. Changing his methadone dose is likely to exclude him from the drug abuse program that provides him psychosocial support, and thus this medication should probably not be adjusted. Because he is tolerant to opioids, his dose requirements will be higher than in opioid-naïve patients.
