Nearly 40% of cancer patients experience moderate to severe pain due to the disease or aggressive forms of treatment. This pain can cause anxiety, depression, insomnia, loss of appetite, and decreased mobility for patients.
For the first time since 1996, the World Health Organization (WHO) updated its guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents in 2018. Yoshihisa Matsumoto, MD, PhD, of the Japanese Foundation for Cancer Research at the Cancer Institute Hospital in Tokyo, presented an overview of these updated pain management guidelines at the 2022 Asia Conference on Lung Cancer.
“The goal of optimum management of pain is to reduce pain to levels which allow an acceptable quality of life,” Dr. Matsumoto said.
One of the significant revisions to the WHO guidelines was directed toward the use of a three-step analgesic ladder in treatment. He explained that while a cancer pain management ladder is beneficial as a teaching tool and a general guide to pain management, it cannot replace individualized therapeutic planning based on a careful assessment of each individual patient’s pain.
For the initiation of pain relief, the WHO recommends nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol/acetaminophen, and opioids. After the initial pain management efforts, opioids should continue to be administered to provide maintenance for pain relief. Clinicians can either use regularly dosed immediate-release opioids or regularly dosed slow-release opioids with immediate-release opioids in cases of urgent need.
“The guidelines do recommend discontinuation of opioids if a patient has developed physical dependence,” Dr. Matsumoto added.
Steroids are strongly recommended as adjuvant medicine related to cancer pain. Dr. Matsumoto clarified that there is moderate-quality evidence to support this care strategy. However, antidepressants and anticonvulsants are not recommended due to an absence of high-quality evidence specific to treating tumor-related neuropathic pain.
Bisphosphonates and radiotherapy are strongly recommended for pain management related to bone metastases.
“Single-dose radiotherapy probably has beneficial effects on treatment coverage, waiting times, and financial savings,” Dr. Matsumoto explained.
According to Dr. Matsumoto, in the future, there will likely be situations where the use of analgesics will have to be withheld. This means a multimodal analgesic approach to treating pain may be needed more than ever. Interventional procedures such as acupuncture, which is significantly associated with reduced cancer pain and the decreased use of analgesics, will likely be more routinely integrated into patient care strategies.
While the underutilization of specialists, a lack of training, and gaps in knowledge related to these interventional procedures are barriers that must be overcome, efforts are being made to address these concerns.
“The Japanese government introduced a policy to establish a system to provide interventional procedures for cancer pain this year,” Dr. Matsumoto said.
Providers must also recognize that individuals experience and express pain differently. For some patients, psychosocial and spiritual care should be utilized in addition to pharmacological treatments.
In 2020, the International Association for the Study of Pain (IASP) revised its definition of pain to account for the fact discomfort cannot be inferred solely from activity in sensory neurons. Pain can be present even when there is no evidence of actual or threatened tissue damage or lesions of the somatosensory system causing the pain. According to the IASP, since pain is a personal experience that can be influenced to varying degrees by biological, psychological, and social factors, a person’s report of discomfort should always be respected.