Despite advances in modern medicine, cancer remains a common occurrence throughout the world. By the age of 85, 1 in 2 of us in Australia, both male and female, will be diagnosed with cancer. Of concern to all doctors involved in the treatment of pain and cancer, is how commonly pain still occurs.
There is a lot of room for improvement in the treatment of pain in patients diagnosed with cancer, but there is a significant amount of help available.
CAUSES OF CANCER PAIN
There are unfortunately a number of different causes of pain in patients with cancer and so a number of different ways of describing it. The pain experienced depends on the type and stage of the cancer and the treatment. Pain can occur as a result of the tumour itself, e.g. the tumour pressing on nerves, or damaging other structures such as bones. Also, treatments used in managing cancer such as surgery, chemotherapy or radiotherapy can also be painful.
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HOW PAIN IN CANCER IS DESCRIBED
Pain is described in a number of different ways, one of the most common ways being due to the cause as outlined above. Other descriptions are based on time and or symptoms.
Pain will vary in time both in the long and short term. Broadly speaking, pain is considered acute if it lasts for less than 3-6 months and chronic if it lasts longer. On a more short-term basis, pain that is provoked by an action such as getting out of bed, which is severe and short lived, is considered an incident pain. This differs from background pain experienced for longer during a day or night.
Pain can be diagnosed as normal (nociceptive) pain, nerve related pain (neuropathic), or pain due to organ damage (visceral).
This is what we all understand and have experienced as pain. The pain from an injury like a cut, sprain, break, bruise etc. This usually feels like an ache and if it flares up or is a new injury can be very sharp.
When nerves get damaged they aren’t able to perform their normal functions appropriately. A nerve will normally tell us about sensation eg the feel of something against our skin and a nerve will make us move our hand away from a hot object (motor function). When a nerve is damaged, these actions are damaged so sensations that were previously normal become painful. Examples include a burning feeling, the feeling of short-lived electric shocks of pain for no apparent reason, pain from even the lightest sensation like a blanket on your feet at night and, bizarrely, pain in an otherwise numb area.
Viscera is a term that essentially means your internal organs such as the gut or uterus. A stomach ache is an example of a visceral pain. This kind of pain is difficult to localise, often a crampy feeling and frequently causes feelings of nausea or even vomiting.
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WHO GETS CANCER PAIN?
Anyone can get pain during their cancer journey. Pain is commonly the symptom that causes people to see their doctor in the first place and before they get diagnosed. Pain can then occur during treatment for cancer and after successful treatment. It is estimated for instance that up to 40% of patients after successful cancer treatment may still have nerve pain 5 years after their treatment ends. It is also unfortunately common if someone’s cancer treatment is not successful for them to experience pain.
WHAT CANCER PAIN TREATMENT IS AVAILABLE?
The most important thing for anyone experiencing pain during cancer treatment to do is tell their doctor. Pain is managed during this time by a large number of people – G.P’s , Oncologists, Pain Specialists and Palliative Care Specialists to name a few. It is normal to not tell your doctor or specialist if pain is an issue. Patients can have concerns about reporting pain such as what the pain might mean or will it take the focus away from the treatment. However, your medical team want to know. They want you to be comfortable.
There are a large number of different medications available for the treatment of pain. These range from the simple tablets such as panadol to the strong “opiate” medication such as morphine. The right choice of medication depends on the type and severity of your pain, any other medical problems you might have such as allergies and your response to medications. If your pain is not responding to simple medications ensure your medical team know. Nerve pain for instance is a common reason some “pain killers” are not effective . Nerve pain is not well controlled by the simple pain killers or “opiate” medication and require other pain relieving tablets.
Many of the treatments provided by oncologists will also help pain, so again, its vital to let your g.p. and specialist know. Both chemotherapy and radiotherapy are used to help pain severity and not just to treat the cancer itself.
Allied health is a term that refers to a very diverse, highly skilled and qualified group of practitioners. Included in this group are physiotherapists, psychologists, occupational therapists etc. These professionals are enormously helpful in the management of pain from cancer. Your doctors may suggest a referral to a physiotherapist to improve your conditioning after recovering from surgery or to see a psychologist if understandably your mood has got a bit low due to illness. It is very important not to underestimate the importance of this group.
Both Pain Specialists and Palliative Care Specialists are highly trained in managing pain. Pain specialists and palliative care specialists are able to provide advanced management where simple pain relief is not effective enough.
WHAT CAN PAIN SPECIALISTS OFFER?
In some types of pain other medications than normal pain-relieving medications can be really helpful. Pain Specialists are experienced in the use of these in conditions such as nerve pain.
SIMPLE INJECTION TREATMENTS
As outlined above, nerve pain is common in the cancer journey. In some situations nerve blocks can be performed as simple day case procedures. These act to temporarily numb the nerve. Often, the benefit of these is short lived so longer-acting nerve techniques can be used. These act to reorganise the nerve so it is less sensitive to sending pain signals and their benefit can last for many months. There are two forms – pulsed radiofrequency and radiofrequency ablation. In many instances of cancer pain a pulsed procedure is used which does not damage the nerve but instead reorganises the nerve to stop it sending severe pain signals. Radiofrequency ablation is used less often and “cauterises” the nerve.
If pain is chronic or severe and not responsive to medications or simple treatments then there are a number of options available that should be considered. These are not common and not suitable to all the types of pain but can provide excellent pain relief. The two main advanced treatments are spinal cord stimulation and intrathecal pump. In cases of severe or chronic nerve pain these are invaluable. The second option – the intrathecal pump- is a way of providing strong pain relieving medication to the spine when normal medications aren’t working or causing too many side effects. Both involve careful planning, minimally invasive techniques and short hospital admissions but can provide excellent pain relief in the right situation
HOW TO GET RELIEF FROM CANCER PAIN
Getting relief starts with reporting your pain. Tell your medical team and they can help.
Overall, if simple pain-relieving medications aren’t helping, see (or ask your oncologist/GP about seeing) a pain specialist. Pain Specialists have the qualification FFPMANZCA after their name, and those specialised in cancer pain will have experience in cancer hospitals and in working with palliative care teams. Pain specialists will work closely with the team of GP and oncologist to ensure the best pain management options at the correct time.