Pain control a necessary component of cancer treatment

An estimated one of three people undergoing treatment for cancer will experience pain during treatment.

The pain may result from chemotherapy, radiation therapy or surgery, all of which can result in painful scars or side effects such as mouth sores or nerve damage.

HemOnc Today spoke with Eduardo Bruera, MD, professor and chair of the department of palliative, rehabilitation and integrative medicine at The University of Texas MD Anderson Cancer Center, about the types of pain patients with cancer most frequently experience, as well as ways this pain can be treated.

Question: Can you offer tips for patients about the pain they may experience from cancer treatment?

Answer: Sometimes cancer treatment can cause swelling in the normal tissues — for example, with radiation therapy or chemotherapy. Also, some treatments can cause damage in the peripheral nerves and this can cause slight discomfort, such as pins and needles in the fingers and toes. Also, a patient may already have had pain before their cancer diagnosis, such as low back pain or other chronic pain. When the patient becomes weaker from the cancer, this pain becomes worse. It is important that the patient talks to their doctor about the pains they are having so he or she can figure out if the pain is related to the tumor itself or to the treatment, or if it is simply something that the patient had before.

Q: Who should raise the subject during office/hospital visits?

A: It is very useful for patients to let their doctor know what is giving them concern, and pain is always concerning. The best thing would be for the patient and the patient’s family to make sure they remember to mention aches and pains — especially those that were not there before the cancer treatment started.

Q: What kind of pain management options are out there for patients undergoing treatment for cancer?

A: Fortunately, there are many more pain management options than there were 10 to 15 years ago. Once a patient describes a pain he or she is having, we as physicians try figure out why the pain is there — whether it may be from swelling, a pinched nerve, if there is something in the bone or if there is nerve damage. We can then target and personalize the pain treatment to the mechanism. This may include things such as mild pain killers, opioid pain killers, radiation therapy or even medication for pinched nerves. The main treatment for the pain will be linked to the diagnosis that the patient is given.

Q: What recent research related to cancer treatment and pain have you found particularly compelling or informative?

A: We understand much more than we did before the different reasons why we experience pain, and we also have a much better understanding for how patients respond to pain killers — particularly how patients respond to opioid pain killers that are commonly used. The most recent research shows that switching from one pain killer to another is very wise. However, research previously suggested that opioids were all very similar and, therefore, changing from one to another was not useful. However, we now know that if one is not as effective or is causing side effects, we can change the type of opioids used and this may be very useful.

Q: What do you suggest for patients who are reluctant to take additional medications?

A: There are two things that are very useful to remember. One is that a patient needs to tell the doctor all the medications they are taking, whether they were prescribed by the oncologist or another doctor. It is then easy to identify a painkiller that will not interact with those medications. Many patients are worried about how a painkiller will interact with the medications they are already taking. Because we have many different painkillers, it is possible to find one that will have minimal or no interactions with existing medications. Also, it is more important to be able to function physically and socially, and if the patient does not take pain killers that allows them to do these things, it is not good for that patient. It makes them weaker and more tired, and it is easier for them to get infections. It is important for them to keep active, but if they are not dealing with the pain, keeping active is not a possibility.

Q: What are some of the biggest challenges with managing pain in a patient undergoing treatment for cancer?

A: Pain is unavoidable, especially after we all get to a certain age. We cannot avoid having some aches and pains. So when a patient is diagnosed with cancer, most will have some aches and pains. However, in a vast majority of cases, we can control those aches and pains to the point that they will not take over our mind and spirit and interactions with others. One of the challenges is to use painkillers in a way that will help us feel better and function better, but in a way that the painkiller does not become a problem, because if it causes a lot of side effects instead of helping, this is not a good thing. This balance between the type and dose of painkiller that allows us to function well and the type and dose that causes problems probably is the main challenge.

Q: Do you have any advice for the family and friends of a patient with cancer who is experiencing pain? Should they speak up on the patient’s behalf if he or she is not doing so?

A: It is very important to be vigilant and make sure that patients are reporting how they feel. If someone accompanies a loved one to the doctor and the patient is reluctant to disclose some of the symptoms, it does not hurt for the family member or friend to bring it up in the conversation. Sometimes, an expression of pain can be resulting from some new area where the tumor is located and they may be afraid of addressing this. Other times, the patient might feel a little more pain because he or she is more depressed or sad than before. The pain itself may not have changed but the perception of the pain may be different because they are depressed. I think family and friends should ideally encourage the patient to bring up the pain as part of the medical encounter.

Q: Do you find that patients are concerned about becoming addicted to pain medication? Does this contribute to their reluctance to talk about the pain they are experiencing?

A: I think a certain percentage of us are worried about losing control when we take opioid medications. It would be hard to say that this is not one of the concerns. If we have had generally no problems with these medications in the past, then the risk for addiction is low when working closely together with the doctor and the care team. In general, there is a great advantage to taking these medications because it makes patients feel better, allows them to endure the cancer treatment and helps them to function better. The best thing is for a patient to ask their doctor about the risk for addiction.

Q: What happens when a patient is prescribed pain medication that does not work? Is there room for flexibility and other pain medication options given the fact that they have cancer?

A: There are multiple medications for pain, but none of them is a gold standard. If a doctor gives a patient a painkiller and it does not work or there are a lot of side effects, it is important to not get discouraged. The patient should go back to their doctor and let him or her know and work together to identify a treatment that will make the pain much better with relatively low or no side effects. – by Jennifer Southall

For more information:

Eduardo Bruera, MD, can be reached at Department of Palliative Care and Rehabilitation Medicine, Unit 1414, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030.

Disclosure: Bruera reports no relevant financial disclosures.