Cancer Pain Treatment Guidelines for Patients – Version II, August 2005

Introduction

This report shows patients how cancer pain is treated at the nation’s leading cancer centers. Originally devised for cancer specialists by the National Comprehensive Cancer Network, these treatment guidelines have now been “translated” for the general public by the American Cancer Society. For a printed copy of these guidelines as well as to learn more information about cancer-related topics, call the American Cancer Society at 1-800-ACS-2345 or the National Comprehensive Cancer Network at 1-888-909-NCCN. Or visit these organizations’ web sites at www.cancer.org (ACS) and www.nccn.org (NCCN).

Since 1995, health professionals have looked to the National Comprehensive Cancer Network for guidance on the highest quality, most effective advice on treating cancer. The Network has brought together experts from 20 of the nation’s leading cancer centers.

After studying the research results on cancer pain, a panel of these experts has agreed upon specific, state-of-the-art recommendations for treating individuals with cancer-related pain. Every year the panel updates their recommendations based on advances in medical science.

For more than 90 years, the public has turned to the American Cancer Society when it needed information about cancer. The Society’s books and brochures have provided comprehensive, current, and understandable information to hundreds of thousands of patients, their families, and friends. This collaboration between the National Comprehensive Cancer Network and the American Cancer Society provides a reliable and understandable source of cancer treatment information for the general public.

Making Decisions About Cancer-Related Pain

About one-third of patients being treated for cancer have pain. More than two-thirds of patients with advanced cancer (cancer that has spread or recurred) have pain. For these patients, controlling pain and managing symptoms are important goals of treatment.

Pain affects all aspects of quality of life. Patients who have chronic pain (pain ranging from mild to severe and present for a long time) may not be able to participate in their regular activities as much, may have sleeping and eating problems, and may be frustrated that family and friends do not always understand how they feel.

Cancer pain is a common problem, but it is one that your cancer care team can treat. Your team may include a social worker, psychologist, oncology nurse, pastor, psychiatrist, medical oncologist, surgeon, pain specialist, and anesthesiologist. The cancer care team will consider each person’s medical situation. Remember, each patient is unique and treatment will be developed based on each person’s specific pain.

Questions to Ask Your Doctor about Pain Control:

• What can be done to relieve my pain?
• What can we do if the medicine doesn’t work?
• What other options do I have for pain control?
• What side effects may happen with the pain medicines?
• What can be done to manage the side effects?
• Will the treatment limit my activities (i.e., working, driving, etc.)?

To make an informed decision about treatment, patients need to understand the medical terms the doctor uses. This report includes background information on cancer pain, explanations of what causes pain, what may prevent effective pain control, and treatments used to treat pain. We've also provided a glossary. Words in blue italics are defined in the glossary; you can access their definitions in a small pop-up window by clicking on them.

What Is Pain?

Pain is a sensation that hurts. Normally, pain alerts us to a bodily injury or illness. Everyone feels pain differently so it is important for patients to be able to describe their pain to the doctor or nurse. Patients should explain where the pain is, when it began, how long it lasts, how much it hurts, what it feels like, what makes it better, what makes it worse, and how it affects their life.

Types of Pain

Acute pain is severe and lasts a relatively short time. It is usually a signal that body tissue is being injured and the pain generally disappears when the injury heals.

Chronic or persistent pain may range from mild to severe and is present to some degree for long periods of time. Some people with chronic pain that is controlled by medicine can have breakthrough pain, which is moderate to severe pain that “breaks through” the regular pain medicine given for chronic pain. It is felt for a short time. Breakthrough pain may occur several times a day, even though the proper dose of pain medicine is given for the chronic or persistent pain.

What Causes Pain?

People with cancer may have pain for a variety of reasons. The most common cause of pain in cancer patients is the cancer itself. Pain is caused when cancer spreads into soft tissues (muscle, connective tissue, etc.), organs, or bone; by nerve injury; when cancer is pressing on a nerve; or by increasing pressure in the head. Surgery, radiation therapy, and chemotherapy can also cause pain. This is referred to as treatment-related pain. Patients who have had an arm or leg removed may still be able to feel pain (called phantom pain) in the missing limb. This pain is real, but doctors are not sure why it occurs. Several chemotherapy agents cause numbness, tingling, and burning, while radiation can cause painful skin irritation.

Sometimes the pain has nothing to do with the cancer or its treatment. Patients with cancer can have headaches, muscle strains, and other aches and pains just like anyone else.

There are three main types of pain: visceral, somatic, and neuropathic.

• Visceral pain involves organs. Pain caused by tissue damage in an organ such as the liver is usually pain that cannot be pinpointed and may be described as gnawing, cramping, aching, or sharp.
• Somatic pain involves the skin, muscle, or bone and is usually in a specific area. It is described as stabbing, aching, throbbing, or pressure.
• Neuropathic pain is caused by injury to, or compression of, the structures of the peripheral or central nervous system. Nerve injury or compression can be due to an injury of a peripheral nerve, injury to the central nervous system such as the spinal cord, or a combination of injury to both a peripheral nerve and central nervous system. It is often described as sharp, tingling, burning, or shooting.

It is important to know the type of pain present because different pain is treated differently.

What Are the Obstacles to Cancer Pain Relief?

Although most cancer pain can be relieved, controlling cancer patients’ pain effectively continues to be a problem. The reasons for this are related to knowledge, beliefs, and fears.

Fear of addiction. Many patients fear that taking opioids (narcotic-like medications), like morphine, will lead to addiction. But this very rarely happens. Just as patients with diabetes have changing needs for insulin, patients with cancer have changing needs for their pain medicines.

Fear of side effects. Patients often take less than the prescribed dose of pain medicines because they are concerned about the side effects that may occur. Most side effects, however, can be prevented or relieved.

Inadequate knowledge. Doctors’ and nurses’ personal beliefs interfere with adequate management of chronic cancer pain. In the past, doctors and nurses were not well trained to care for patients with chronic pain. They did not always know what medicines were used to control pain and were not familiar with other procedures to control or eliminate pain. They also were afraid of the possibility that patients would become addicted.

Inadequate pain assessment. Patients often do not mention pain unless asked about it. Some patients believe they must be strong and “tough it out.” Patients may not report their pain when they are asked for fear of what the presence of pain may mean. Because they don’t mention it, many patients’ pain may go unrelieved.

Legal obstacles. When prescribing opioids, especially doses that some might consider high, doctors, pharmacists, and nurses fear actions by drug enforcement agencies. These actions may be exaggerated by professionals and should not be an obstacle to pain relief.

How Will the Doctor Know About the Patient's Pain?

Before starting a plan to manage cancer pain, the doctor needs to know a lot of information about the patient’s pain. Collecting this information is called pain assessment or finding out about the patient’s pain. This information comes from the patient’s physical examination, answers to questions about the patient’s medical history, and from family members and friends, especially when the patient is too uncomfortable or too tired to talk.

Patients are asked the following questions about their pain:

• How much does the pain hurt?
• Where is the pain?
• How does the pain affect your daily activities, including movement and rest?
• Is the pain
  • somatic – such as pain in skin, muscle, or bone described as aching, stabbing, throbbing, or pressure?
  • visceral – pain in organs or tissue described as gnawing, cramping, aching, or sharp?
  • neuropathic – pain caused by nerve damage described as sharp, tingling, burning, or shooting?
• When did it start?
• How long has it lasted?
• Has the pain changed in any way?
• Is there anything that makes the pain worse or better?
• Is the pain caused by cancer, cancer treatment, or something else?
• Are there any symptoms or side effects from treatment present?
• Do you have a support system available?
• Do you have a history of any mental health problems?
• What do you know or believe about pain and pain control?

After all questions are answered and the physical examination is done, x-rays, MRI, and blood tests are done if needed to give more information about the pain and to help determine how to treat the pain. For example if the pain is bone pain and a fracture could be present, an x-ray of the bone is done.

The entire report is also available as a PDF file:

nccn_pain_guidelines.pdf 336 k

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PAIN ASSESSMENT

The mutual goal of the National Comprehensive Cancer Network® (NCCN®) and the American Cancer Society (ACS) partnership is to provide patients and the general public with state-of-the-art cancer treatment information in understandable language. This information, based on the NCCN's Clinical Practice Guidelines, is intended to assist you in the dialogue with your physician. These guidelines do not replace the expertise and clinical judgment of your physician. Each patient's situation must be evaluated individually. It is important to discuss the guidelines and all information regarding treatment options with your physician. To ensure that you have the most up-to-date version of the guidelines, consult the web sites of the ACS (www.cancer.org) or NCCN (www.nccn.org). You may also call the NCCN at 1-888-909-NCCN or the ACS at 1-800-ACS-2345 for the most recent information.

NCCN Clinical Practice Guidelines were developed by a diverse panel of experts. The guidelines are a statement of consensus of its authors regarding the scientific evidence and their views of currently accepted approaches to treatment. The NCCN guidelines are updated as new significant data become available. The Patient Information version will be updated accordingly and will be available on-line through the NCCN and the ACS web sites. To ensure you have the most recent version, you may contact the ACS or the NCCN.

© 2005 by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reproduced in any form for commercial purposes or downloaded and stored in any information-retrieval system without the express written permission of the NCCN and the ACS. Single copies of each page may be printed out for personal, noncommercial use only.