Cancer-related pain doesn’t always stop when active treatment ends. Patients with stabilized disease or in remission are living longer due to earlier detection and better treatments. Managing chronic pain (six months or longer) is increasingly important. About 5% of the U.S. population are cancer survivors, 15.5 million people, according to “Pain in Cancer Survivors: How to Manage,” June 2019, Current Treatments in Oncology. Cancer-related pain can be from the disease itself, or due to treatment. Most cancer patients will experience pain at some point during their illness, says Jacob Strand, MD, chair of palliative care medicine at the Mayo Clinic in Rochester, Minnesota. About 80% to 90% of those with metastases, who are incurable, will have cancer-related pain, Strand says, as will up to 40% of cancer survivors overall.
Ideally, treating pain involves a multi-prong approach. That might mean some combination of physical therapy, behavioral therapy, blocks/injections, and medication. Not all health insurance covers an extensive approach, though undertreating pain impacts a patient’s health and quality of life substantially. As patients live longer after active treatment, oncologists see the patients less, leaving pain management in the hands of primary care physicians (PCP), who may not feel equipped to treat it.
Cancer pain assessment
A typical assessment for pain management includes pain assessment, functional assessment, and then risk assessment, says Judith Paice, PhD, RN, director of the Cancer Pain Program in the Hematology-Oncology division at Northwestern University in Chicago.
The risk assessment is newer and still not performed by most oncologists, Paice says. It includes questions about smoking, alcohol use, and prescription substance use not as prescribed. It also includes a family history of substance abuse to give a “crude understanding of genetic risk” and to understand what substance issues might exist in the home. She takes all the answers into account, while trying to determine if their pain is likely to respond to opioids, and if they’re at risk for abuse.
A cancer patient can suffer from various types of pain. Tumor-related pain can be from a tissue injury, like a mass effect from the tumor pressing against the bone or nerves. Pain can be treatment-related, like pain after surgery, or associated with radiation therapy. As radiation gets more precise, patients are experiencing less pain. “Unfortunately, pain associated with chemotherapy is increasing, as more and more agents are causing peripheral neuropathy,” Paice says. Steroid use can cause avascular necrosis and bone fragility. Aromatase inhibitors and hormonal therapies for prostate and breast cancers can cause pain. “If one in eight women with breast cancer are estrogen positive, they’re likely on aromatase inhibitors for five to 10 years,” Paice says. Stem cell transplant can lead to graft versus host disease. With new treatments always arising, pain management is a moving target, she says.