Despite multiple guidelines from national and international organizations,1,2 the quality of current cancer pain management remains inadequate. The World Health Organization’s three-step analgesic dosing ladder forms the foundation of these guidelines.3 Yet, as noted by William S. Rosenberg, MD, FAANS, Medical Director of the Center for the Relief of Pain, the effectiveness of the analgesic ladder has not been rigorously evaluated.
Clinical observations and consensus support the use of the analgesic ladder for a selection of pharmacologic treatment for cancer pain based on pain severity. For mild pain (rated 1–3 on a 0–10 scale), non-opioid analgesics are recommended; for more intense pain (rated as 4 or greater), the ladder approach recommends different opioids, such as codeine and tramadol, for moderate pain; and for severe pain, the ladder recommends morphine, for example.
The Analgesic Ladder as a First Step
The analgesic ladder is a first step—effective pharmacologic management of cancer pain requires delivery of the appropriate drug, in the right dose, by the best route of administration, with consideration for a “rescue medication” for breakthrough pain and prevention and treatment of analgesic side effects. Unfortunately, multiple studies demonstrate the inadequacy of our pharmacologic treatment for cancer pain.
A recent review assessing the adequacy of analgesic therapy reported that about one-third of patients still do not receive pain medication proportional to their pain intensity.4 However, when analgesics appropriate to the pain intensity are prescribed, there is now some evidence that pain management outcomes improve.5
As highlighted by the roundtable discussion reported in this issue of The ASCO Post, control of cancer pain may require more than pharmacologic interventions. Radiation therapy is an exceedingly effective intervention for pain related to bone metastases, celiac plexus blocks have demonstrated benefit for patients with abdominal pain from pancreatic cancer, and a radiosurgical hypophysectomy may be an effective option for patients with pain due to advanced widespread bone metastases. But, these interventions are generally a step after optimization of pharmacologic management for treatment of the physical domain of cancer pain.
More Than Just Physical
The experience of pain, however, is more than physical. Dame Cicely Saunders, who established the discipline and principles of palliative care, articulated the concept of “total pain” to emphasize the multidimensional nature of pain. The experience of pain, the suffering that is pain, arises from all of the domains of distress—physical, psychological, social, emotional, and spiritual. So, absolutely, as the roundtable discussion noted, we need multidisciplinary care in the broadest sense to manage cancer pain effectively. ■
Disclosure: Dr. Von Roenn reported no potential conflicts of interest.
References
1. Ripamonti CI, Bandieri E, Roila F: Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol 22(suppl 6):vi69-vi77, 2011.
2. Swarm R, Abernethy AP, Anghelescu DL, et al: Adult cancer pain. J Natl Compr Canc Netw 8:1046-1086, 2010.
3. World Health Organization: World Health Organization’s Cancer Pain Ladder for Adults. Available at who.int/cancer/palliative/painladder/en/. Accessed September 22, 2015.
4. Greco MT, Roberto A, Corli O, et al: Quality of cancer pain management: An update of a systematic review of undertreatment of patients with cancer. J Clin Oncol 32:4149-4154, 2014.
5. Mearis M, Shega JW, Knoebel RW: Does adherence to National Comprehensive Cancer Network guidelines improve pain-related outcomes? An evaluation of inpatient cancer pain management at an academic medical center. J Pain Symptom Manage 48:451-
458, 2014.
Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD. Dr. Von Roenn is ASCO’s Senior Director of Education, Science and Professional Development Department.
