Pain Management & Supportive Care
In the most recent statistics published, 327,174 new cases of cancer have been reported in England alone in 2019.1 Patients who have been diagnosed with cancer may suffer from pain as a symptom which is often caused by tumours pressing on bones, nerves, or other organs.2 However, pain experienced in cancer patients may also be caused by treatments i.e., chemotherapy and radiotherapy.3
Incidence of cancer pain in England
Of the 327,174 new cases of cancer reported in 2019 incidence rate for males was 23% higher than in females.1 Patients that were aged 70 and above at diagnosis accounted for approximately half of those that were diagnosed.1 Within those aged 65 and above the incidence rates were around 50% higher in men than in women.1 Conversely, in those that were diagnosed between the ages of 15-54 the incidence rate was higher in women than in men.1
More than 50% of cancers can be put down to four types which include prostate, breast, lung and colorectal cancer.1
Figure 1: Demonstrates the incidence of pain with respect to the type of cancer which has been diagnosed.6 Adapted from Breivik et al. 2009
Upon diagnosis of cancer, pain has been identified as a common symptom associated with the disease. Within the UK, there are between 72,000 to 89,600 patients who are diagnosed with advanced incurable cancers, evidence suggests that approximately 45-56% of these patients will suffer from moderate to severe pain before death.7
Figure 2: Demonstrates the prevalence of cancer pain at different stages of the disease.
How is cancer pain diagnosed?
Precise and systematic pain assessment is required to make the correct diagnosis and determine the most efficacious treatment plan for patients presenting with pain.4 Where an individual is competent and able to communicate, this will be the most reliable source of information in the assessment of pain.5
Establishing the underlying cause of pain is essential in assessing pain. This could be difficult where there may be multiple causes or sites of pain. This is where reviews of medical histories can allow healthcare professionals to determine current malignancies and their location. For example, pain from certain areas of where the cancer is located may indicate a secondary spread of the cancer.5
The severity of the pain can be assessed using a structured pain assessment tool. This can be done via a numerical scale e.g. 0 for no pain to 10 which is the worst pain.5 Other tools may include visual scales where a 10cm line can be used one end representing no pain and the other end representing the worst possible pain, a mark may be made on this line by the patient to describe their pain.5 A score can then be coupled to the severity of pain, for example:
- Mild pain: For patients scoring less than 35
- Moderate pain: For patients scoring between 3-65
- Severe pain: For patients scoring more than 65
Figure 3: Demonstrates the European Society of Medical Oncology (ESMO) Guidelines recommendations for assessing pain.3
Patients should also be assessed for external factors which may influence the perception of pain such as psychological, social and spiritual factors.5
Figure 4: Demonstrates the European Society of Medical Oncology (ESMO) Guidelines recommendations for identifying interference of pain.3
What is the impact of pain on quality of life (QoL)?
Pain experienced due to cancer can greatly impact a patient’s quality of life.12 Pain is characterised by being either acute or chronic. Acute pain occurs when there is damage caused by an injury which tends to subside over a short period of time.3 Whereas chronic pain is a sensation which is experienced over a much longer period of time (> 3 months). Examples of chronic pain include pressure being exerted on nerves by tumours or even tumours releasing chemicals that stimulate pain.13
Figure 5: Illustrates a meta-analysis of three phase 2 and phase 3 trials (“Hector”, Topotecan phase III” and “TRIAS”) where data was gathered to investigate the impact of pain on QOL and survival in 1226 patients with gynaecological cancer including recurrent ovarian cancer. 952 patients out of the 1226 patients provided data on pain.12
What is an individualised approach to pain management?
Different types of pain require specific treatments, to treat pain in the most appropriate way, it is important that the type and the cause of the pain is established by a doctor.
The type of pain coupled with the severity of pain raises the need for an individualised approach to ensure pain is treated appropriately. This is because the type of cancer that has been diagnosed, the location of the cancer and the stage of the cancer will all play differing roles into how pain is perceived in different patients.
External factors such as lack of sleep, anxiety and depression may also influence how pain is perceived in different patients.3
1) Baker C. Cancer: Summary of statistics (England) 2021. Available from: https://researchbriefings.files.parliament.uk/documents/SN06887/SN06887.pdf [Accessed June 2022]
2) British Pain Society. Cancer Pain Management 2010. Available from: https://www.britishpainsociety.org/static/uploads/resources/files/book_cancer_pain.pdf [Accessed June 2022]
3) Fallon M, Giusti R, Aielli F, Hoskin P, Sharma M, Ripamonti C. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines 2018. Available from: https://www.annalsofoncology.org/article/S0923-7534(19)31698-9/pdf [Accessed June 2022]
4) Pain Assessment: Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans https://emedicine.medscape.com/article/1948069-overview [Accessed June 2022]
5) NICE CKS. Palliative cancer care – pain: Scenario: Assessment of pain 2021. Available from: https://cks.nice.org.uk/topics/palliative-cancer-care-pain/management/assessment-of-pain/ [Accessed June 2022]
6) Breivik H, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes 2009. Ann Oncol;20:1420–1433.
7) Bennett M, Miller B, Weiss A, Wilkinson P, Davies A, Tillett T, Toy E. Framework For Provision Of Pain Services For Adults Across The UK With Cancer or Life-Limiting Disease 2019. Faculty of Pain Medicine.
8) World Cancer Research Fund. Worldwide cancer data. Available from: https://www.wcrf.org/cancer-trends/worldwide-cancer-data/ [Accessed June 2022]
9) Bennett MI, et al. Standards for the management of cancer-related pain across Europe – A position paper from the EFIC Task Force on Cancer Pain. 2019. Eur J Pain;23(4):660-668
10) van den Beuken-van Everdingen MHJ, et al. Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. 2016. J Pain Symptom Manage; 51(6):1070-1090
11) Deandrea S, et al. Prevalence of breakthrough cancer pain: a systematic review and a pooled analysis of published literature. 2014. J Pain Symptom Manage;47(1):57-76
12) Woopen H, et al. The prognostic and predictive role of pain before systemic chemotherapy in recurrent ovarian cancer: an individual participant data meta-analysis of the North-Eastern German Society of Gynecological Oncology (NOGGO) of 1226 patients. 2020. Support Care Cancer;28(4):1997-2003
13) Causes and types of cancer pain; Cancer Research. Available from: https://www.cancerresearchuk.org/about-cancer/coping/physically/cancer-and-pain-control/causes-and-types
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