This summary of well-informed and thoroughly documented management strategies for pain in adult cancer survivors is sorely needed in health care, because multiple coalescing factors place cancer pain survivors at significant risk for poor pain control.

— Rajiv Shah, MD, and Robert A. Swarm, MD

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With impeccable timing, as well as considerable forethought and planning, Dr. Paice and colleagues have produced a superb evidence-based guideline on “Management of Chronic Pain in Survivors of Adult Cancers.”¹ (See this issue of The ASCO Post.) This summary of well-informed and thoroughly documented management strategies for pain in adult cancer survivors is sorely needed in health care, because multiple coalescing factors (such as those below) place cancer pain survivors at significant risk for poor pain control:

• Markedly improved, appropriately aggressive cancer therapies have dramatically increased cancer survival rates, but survivors often bear the consequent burden of chronic pain—attributable to the cancer itself or cancer treatments.
• Opioids remain the principal analgesic for management of severe pain, yet there is increasing concern for the physiologic consequence of chronic opioid therapy: tolerance, hyperalgesia, hormonal abnormality, immune dysfunction, etc.
• Nonopioid, broadly based pain therapies appear preferable to overreliance on opioids for chronic pain control, but multidisciplinary pain management places greater demands on provider time and health-care resources.
• There is increased expectation that health-care providers will broadly work to consistently improve pain management and symptom control, especially in cancer-related settings; however, the health complexity of many cancer survivors may strain resource availability in efficient, care path–focused delivery systems.

In response to the U.S. epidemic of opioid abuse, the Centers for Disease Control and Prevention (CDC) has published extensive guidelines² to improve the safety and reduce the abuse of prescribed opioid analgesics; however, these guidelines come with their own significant burdens on health-care provider time and effort.

The CDC guidelines² specifically apply to the prescription of opioid medication for chronic pain management, not including “active cancer treatment, palliative care, and end-of-life care”—but including pain management in survivors of adult cancers. The CDC’s distinction between “active cancer treatment” and other areas of broad cancer care, including care of cancer survivors, may serve to promote the trend of oncology practice, choosing to focus care on those receiving active cancer treatments. Other health-care providers may be unwilling or unable to take on complex health-maintenance issues of adult cancer survivors including pain management.

Routine Screening Required

This evidence-based ASCO guideline for “Management of Chronic Pain in Survivors of Adult Cancer” can improve the availability of appropriate pain care from screening to multimodal pain therapy, with appropriate inclusion of patient and family members and/or other care providers. Because pain is a subjective experience, optimized pain care requires screening for pain as a routine part of all scheduled and nonscheduled evaluations. Cancer survivors are at risk for recurrent disease or secondary malignancy; therefore, new or worsening pain should be carefully reevaluated. As with all pain management, the goal of cancer survivor pain care is to limit adverse effects and improve function and quality of life. Patients should be referred to other providers as necessary to provide multidisciplinary approaches.

Guideline Components

The ASCO guideline reviews the use of analgesics as part of multimodal therapy, including nonopioid, opioid, and adjuvant analgesics, in treating patients’ overall chronic non-cancer pain. At any stage of treatment, it remains important to identify the etiology of the pain to optimize treatment. Clinicians should use analgesics with evidence of efficacy for specific cancer pain syndromes where applicable.

Despite the lack of a solid evidence base, marijuana has gained attention as a consideration for management of many disease symptoms. Although the legal availability of marijuana depends on individual state regulations, under U.S. federal law, the possession of marijuana remains illegal, and it is not approved by the U.S. Food and Drug Administration for the treatment of any cancer-related symptom or side effect of cancer therapy.

Considerations regarding prescribing opioids for cancer survivors are reviewed; they include potential opioid risks and benefits, incorporating universal precautions to minimize abuse and addiction, educating patients and families regarding the use of long-term opioid therapy, and weaning the dose if opioids are no longer warranted.¹ After the patient completes active cancer treatment, the use of opioids shifts from “routine prescribing” to more “measured and thoughtful approaches” for long-term therapy.³ Prior to a trial of opioids, using an opioid risk-assessment tool, such as the Screener and Opioid Assessment for Patients with Pain, to assess how much monitoring a patient may require is useful. These patients should have frequent return visits to assess the response to chronic opioid therapy.

The initiation of opioids in select patients with chronic pain may be necessary. Ultimately, if pain improves or opioid treatment goals are not attained, a gradual taper to prevent opioid withdrawal symptoms is recommended.

As for nonpharmacologic management, carefully selected patients should be offered interventional treatments to ease pain and improve quality of life. They should also be evaluated for concurrent diseases, which may be better treated with interventional approaches.

Closing Thoughts

The authors have created an insightful and comprehensive guideline for pain management for cancer survivors. As cancer survival has improved, managing chronic pain in cancer survivors has become more complex and a greater health-care burden for both patients and providers. The ideal treatment for survivors of adult cancer is evidence-based, multimodal therapy maximizing patient comfort and function—as outlined in this new ASCO guideline. ■

Disclosure: Drs. Shah and Swarm reported no potential conflicts of interest.

References

1. Paice JA, Portenoy R, Lacchetti C, et al: Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 34:3325-3345, 2016.

2. Centers for Disease Control and Prevention (CDC): CDC Guideline for Prescribing Opioids for Chronic Pain (March 16, 2016). Retrieved from http://www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed September 22, 2016.

3. Glare PA, Davies PS, Finlay E, et al: Pain in cancer survivors. J Clin Oncol 32:1739-1747, 2014.