Assess and Manage Cancer-Related Pain

October 10, 2017 by Elisa Becze BA, ELS, Editor

Despite the findings that more than 90% of cancer pain can be controlled with routine interventions, many patients continue to experience pain throughout their cancer diagnosis and treatment. The average pain score for patients on inpatient oncology units is 5.87 on a 0–10 scale, and 25% of patients spend more than 50% of the time in constant or severe pain (https://cjon.ons.org/cjon/21/3/supplement).

A special supplement to the June 2017 issue of the Clinical Journal of Oncology Nursing (https://cjon.ons.org/cjon/21/3/supplement) discussed how oncology nurses can assess and manage cancer-related pain in patients, improving quality of life and patient outcomes.

Assessing Pain in Patients With Cancer

Conducting a comprehensive pain assessment is critical when patients report experiencing pain. See Figure 1 for the components of a comprehensive pain assessment.

Pain intensity should be monitored using a numerical or categorical scale, and several are available for oncology nurses to use, including the Faces Pain Rating Scale, Brief Pain Inventory, Patient-Reported Outcomes Measurement Information System, and the McGill Pain Questionnaire.

Unfortunately, no tools are currently widely validated for diagnosing breakthrough pain. It can be either predictable or unpredictable, and oncology nurses should take a careful history to identify the type and frequency of breakthrough cancer pain episodes to best understand the types of treatments that would be effective for a specific patient’s breakthrough pain.

Comprehensive Pain Assessment

Location: Many patients have more than one pain site. Ask where the pain is located or if pain exists in more than one area. Have patients point to where they feel pain.
Intensity: Pain is a subjective experience, so patient self-report is the current assessment standard. Have patients rate their pain on a standardized scale.
Quality: Pain is categorized into different types.
Neuropathic: caused by nerve disorders; described as burning, tingling, shooting, radiating, lancinating, or numbness. Patients can experience phantom neuropathic pain in an area of the body no longer present.
Somatic: a type of nociceptive pain that occurs in the skin, tissue, or muscle; described as achy, throbbing, or dull and well localized. It can accompany arthritis, bone or spine metastases, lower back pain, and orthopedic procedures.
Visceral: a type of nociceptive pain that varies in different phases of pathology; described as squeezing, pressure, cramping, distention, dull, deep, or stretching. It commonly manifests after abdominal or thoracic surgery or secondary to liver metastases or bowel or venous obstruction.
Temporality: Is the pain intermediate, chronic, or breakthrough?
Additional factors: Determine whether psychosocial factors (e.g., patient distress, family caregiver support, psychiatric history), risk factors for undertreatment (e.g., history of addiction), cultural or religious considerations, or other factors may be influencing patients’ pain experience.

Managing Pain in Patients With Cancer

As part of its Putting Evidence Into Practice (PEP) resources (https://www.ons.org/practice-resources/pep/pain), ONS project teams have evaluated evidence in the literature to support treatment recommendations for various types of cancer-related pain. Following are the treatments that are classified as “recommended for practice” or “likely to be effective” for acute, chronic and refractory, and breakthrough pain.

Acute Cancer Pain

Recommended for practice: Epidural analgesia and local anesthetic infusion are recommended for practice in treating acute cancer pain. Studies have shown significant reductions in pain scores, use of analgesics, and acute postoperative pain in patients treated with epidural analgesia. Similarly, infusions of local anesthetics (e.g., ropivacain, bupivacaine, dexmedetomidine, lidocaine) have shown a significant reduction in pain or lower intake of systemic opioids with their use. However, postoperative pain was not significantly reduced with local anesthetic infusions.

Likely to be effective: Although the evidence is less rigorous, use of gabapentin, parecoxib, intraspinal analgesia, oral tramadol, nefopam, and naproxen for colony-stimulating factor-related bone pain are all classified as likely to be effective, according to the PEP project team. Additionally, the nonpharmacologic interventions of music and music therapy as well as hypnosis and hypnotherapy are likely to be effective based on available evidence.

Chronic and Refractory Cancer Pain

Recommended for practice: According to the supplement authors (https://cjon.ons.org/cjon/21/3/supplement), “Opioids are the mainstay of chronic cancer pain and are recommended for practice." Evidence specifically supports the use of methadone, extended- and sustained-release opioids, transdermal fentanyl, buprenorphine, oxycodone and naloxone, and tramadol and tapentadol. Additionally, anesthetics, bone-modifying agents, gabapentin combinations, and nonsteroidal anti-inflammatory drugs are all recommended for chronic cancer pain control.

Likely to be effective: Initiating opioids as first-line therapy for mild pain has shown positive results in the literature. Other adjuvants and coanalgesics likely to be effective are abiraterone, antidepressants (specifically tricyclic antidepressants and serotonin nonspecific reuptake inhibitors, most notably duloxetine), cannabinoids, and radiopharmaceuticals.

Breakthrough Cancer Pain

Recommended for practice: Oral opioids are recommended, and the preferred varieties should have a rapid onset and short duration. Also recommended are opioids given at proportional doses to basal dose, and the supplement gives this example (https://cjon.ons.org/cjon/21/3/supplement): “If the daily, 24-hour, long-acting morphine dose is 200 mg, the breakthrough cancer pain dose would be estimated at 20–40 mg for each dose." Finally, evidence supports the recommendation for use of transmucosal immediate-release fentanyl.

No interventions were found that could be classified as likely to be effective for breakthrough cancer pain.

Nonpharmacologic Cancer Pain Interventions

Recommended for practice: Two procedural interventions, celiac plexus block and radiation therapy, are recommended based on the available evidence. Celiac plexus block is used for chronic cancer pain, and radiation therapy is recommended for metastatic bone pain.

Likely to be effective: Only psychoeducational interventions were classified as likely to be effective, many of which can be directly delivered by oncology nurses, such as nurse-led educational sessions, interactive cognitive-behavioral therapies, telehealth interviews, psychosocial interventions, structured education with a booklet, tailored education, and coaching. These can be delivered individually or in groups, in person, by phone, or online, and they were found most effective for chronic cancer pain.

For more information on assessing and managing cancer-related pain, refer to the full supplement to the June 2017 issue (https://cjon.ons.org/cjon/21/3/supplement) of the Clinical Journal of Oncology Nursing.

This monthly feature offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes the cancer-related pain supplement to the June 2017 issue of CJON. Questions regarding the information presented in this article should be directed to the CJON editor at CJONEditor@ons.org. Photocopying of this article for educational purposes and group discussion is permitted.

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