CANCER

PAIN
Prof. Dr. Achsanuddin Hanafie, Sp.An, KIC KAO

Departemen Anestesiologi dan Reanimasi

Fakultas Kedokteran USU
Medan
PREVALENCE of CANCER PAIN
Bonica 1985
50 % of patient of all stage reported pain
> 70 % with advanced cancer

Faley 1985
50 % of patient with non metastatic cancer
had significant pain
60-90 % of patient with advanced cancer
reported debiliting pain

WHO 1986
70 % of patient with advanced cancer pain
3,5 million people suffering from cancer
pain with or without satisfacttory treatment
every day
 INCIDENCE
 moderate or severe pain occurs in about
one-third
( 30 - 40 % ) of patients at the time of
diagnosis

 more than two-thirds ( 60 - 100 % ) of

patients
with advanced or terminal cancer

 most cancer patients have more than

one pain :
 80
Roger Woodruff, % ofMedicine
Palliative patients had more than
one pain
 Incidence of pain by primary site of cancer
Patients with
pain (mean) Site
%
> 80 bone, pancreas, oesophagus

71 - 80 lung, stomach, hepatobilliary, prostate,

breast, cervix, ovary
61 - 70 oropharynx, colon, brain, kidney/bladder

51 - 60 lymphoma,leukemia, soft tissue

Source : Bonica J J. The management of Pain. Philadelphia, Lea and Febiger, 1990
In General PAIN is defined (by IASP
1979)
“ anasunpleasant
: sensory and
emotional experience associated
with actual or potential tissue
damage or described in term of
such damage”
• unpleasant sensory
• emotional
experienced
PAIN
Physical Psychologica
dimention l
dimention

• Sensory
ORGANIC PAIN discriminative
• Motivational
THE PHENOMENON of
CANCER PAIN IS VERY
COMPLEX and
COMPLICATED is the
cumulative
• ORGANIC among
PAIN :
• PSYCHOLOGICAL
PAIN
• SUFFERING

TOTAL PAIN

BIOPSYCHOSOCIOCULTUROSPIRIT
 Neuropathic
Somatic or Mechanisms
Psychological
Visceral Disturbances
Nociception
Pain

Psychological Suffering Social/

State and Familial
Traits Functioning

Loss of
Work Financial
Concerns

Physical Fear
Disability Of Death

AMERICAN CANCER SOCIETY 1988

 TOTAL SUFFERING
Pain
+ physical symptoms
+ psychological problems
+ social difficulties Pain
+ cultural factors
Physical
+ spiritual concerns Spiritual
Symptoms
- Total Suffering
Total
Suffering

Cultural Psychological

Social
Unrelieved pain

Pain

Spiritual Physical
Symptom
s

Cultural Psychologi
cal

Social
Unresolved or untreated pain

Pain

Spiritu Physical
al Sympto
ms

Cultura Psychologi
l cal

Social
Diagram of pain pathways
Classification of pain experienced
by patients with cancer
TEMPORAL PATHOPHYSIOLOGICAL AETIOLOGICAL

 acute  nociceptive  due to cancer

 chronic – somatic  due to therapy
– visceral  due to general illness
 neuropathic but no cancer

– central
 un related to cancer or
therapy
– peripheral
– sympathetic

 psychogenic
PATHOPHYSIOLOGICAL OF
PAIN

NOCICEPTIVE NEUROPATHIC
• somatic • central
• visceral • peripheral
• sympathetic

PSYCHOGENIC
or IDIOPHATIC
CANCER
PAIN
Can be divided into 2 catagories
1. ORGANIC PAIN
2. PSYCHOLOGICAL
PAIN
ORGANIC PAIN
1. Nociceptive pain
 Somatic pain
(skin, muscle, connective tissue)
 Visceral pain
(thoracic and abdominal viscera)
2. Non nociceptive pain
 Neuropathic pain (deafferentiation
pain) damage of peripheral or
MECHANISME of NOCICEPTIVE
PAIN
Nociceptive pain means pain with
nociception
Nociceptive means activity of afferent
neurons induced by a noxious stimulus
 TRANSDUCTION

 TRANSMISSION
 MODULATION
 PERCEPTION
 PERCEPTION

Cortex

Thalamocortical MODULATION
projections
Thalamus
TRANSMISSION

TRANSDUCTION

Spinothalamic
tract Primary
Afferent Noxious
Nociceptor Stimulus
 PERCEPTION

Cortex Epidural Local

Epidural Opioid Subarachnoid Anesthetic
Subarachnoid Opioid Celiac Plexus

Thalamocortical MODULATION
projections
Thalamus
Intravenous
TRANSMISSION Intrapleural Local
Systemic
Intraperitoneal Anesthetic
Opioids Incisional

TRANSDUCTION

Spinothalamic
tract Primary
Afferent Noxious
Nociceptor Stimulus
 SOMATIC PAIN
 Characteristic of pain:
 constant
 aching, quawing
 well localized

 Example 
: bone metastasis.
 tumor of the soft
tissue
 activation of
 Mechanisms nociceptors
:
 release algesic
substances may(specially
 Continuous activation
produce prostaglandins)
 VISCERAL
•
PAIN
Characteristic of
pain:  constant
 aching or dull
 poorly localized
 usually with nausea and
vomit
 often referred to cuttaneous
sites
• Mechanism :
 occational colicky or cramp
activation of
nociceptors
• Example : pancreatic cancer
 liver/lung metastasis with
shoulder
 NEUROPHATIC PAIN
(DEAFFERENTIATION
PAIN)
• Characteristic of
pain:  burning pain
 paroxysmal shooting
or electrical shock-like
pain
 spontaneous discharges
• Mechanismsof : peripheral or central
n.s.
 loss of central inhibition
 metastasis brachial or
• Example : lumbosacral
plexopathies
 post herpetic neuralgia
 AETIOLOGICAL OF PAIN

1. due to cancer

2. due to therapy

3. due to general illness but

not cancer

4. unrelated to cancer or
1. Pain associated with direct tumor involvement
 Due to invasion of bone
Base of skull
Orbital syndrome
Parasellar sinus syndrome
Sphenoid sinus syndrome
Clivus syndrome
Jugular foramen syndrome
Occipital condyle syndrome

Vertebral body
Atlantoaxial syndrome
C7-T1 syndrome
L1 syndrome
Sacral syndrome
Generalized bone pain
Multiple metastase
Intramedullary neoplasm
 Due to invasion of nerves
Peripheral nerve syndrome
Paraspinal mass
Chest wall mass
Retroperitoneal mass
Painful polynueropathy
Brachial, lumbal, sacral plexopathies
Leptomeningeal metastase
Epidural spinal cord compression

 Due to invasion of visceral

 Due to invasion of blood vessels
 Due to invasion of mucous membranes
2. Pain associated with cancer therapy
 Surgery
Postthoracotomy syndrome
Postmastectomy syndrome
Postradical neck dissection syndrome
Postamputation syndromes
 Chemotherapy
Painful polyneuropathy
Aseptic necrosis of bone
Steroid pseudorheumatism
Mucositis
 Radiation
Radiation fibrosis of brachial or lumbosacral plexus
Radiation myelophaty
Radiation-induced peripheral nerve tumors
Mucositis
Radiation necrosis of bone
3.Pain due to general illness
but not cancer
 Myofascial pains

 Postherpetic neuralgia

 Osteoporosis

 Debiliting (decubitus

ulcer)

 etc
Pain unrelated to cancer or therapy
 about one-fifth of pain reported by
patients
with advanced cancer are unrelated
to cancer
or therapy

 arthritis

 ischaemic heart disease

 peripheral vascular disease

FACTORS INFLUENCING
PAIN
• cultural
background
• previous pain
experience
• meaning of the
pain
The cancer itself causes pain
through:
 Extension into soft
tissues
 Visceral involvement

 Bone involvement

 Nerve compression

 Nerve injury


 TOTAL SUFFERING
Pain
+ physical symptoms
+ psychological problems
+ social difficulties Pain
+ cultural factors Physical
+ spiritual concerns Spiritual
Symptoms
- Total Suffering
Total
Suffering

Cultural Psychological

Social
e distinction between Clinical Pain and Total Sufferin

Physica
l
Pain

Clinica
l
Pain Physical
Spiritual Sympto
ms
Total
Suffering
Cultural Psychologi
cal

Social
 PHYSICAL
PHYSICALPAIN
The concept of Clinical Pain Pain
PAIN
Pain related tocancer
related to cancer
Pain
Painrelated
relatedtototreatment
treatment
Pain
Pain unrelated tocancer
unrelated to cancer
+ or -
Pain
+ or -
Other physical symptoms
+ or -
Psychological problems
+ or -
Social difficulties

Cultural factors + or -

+ or -
Spiritual concerns

CLINICAL
CLINICALPAIN
PAIN
What
What the patientsays
the patient saysititisis
What
Whathas
hastotobe
betreated
treated
 PHYSICAL
PAIN
Progressive pain
Multiple or increasing Controlled pain
number of pains  – Stable pain
Significant limitation No limitation of activity
of activity Good prior management
Poor prior management

CLINICAL
PAIN
 PHYSICAL PAIN

Insomnia,
No insomnia,
exhaustion, fatigue
exhaustion, fatigue
secondary to pain  –
No coughing,
Persistent cough or
vomiting
vomiting
No other distressing
Other distressing
symptoms
symptoms

CLINICAL PAIN
 PHYSICAL PAIN

• Abandonment
• Boredom
• Mental isolation
– Social
• Financial problems 
difficulties : none
• Problems with
or resolved
interpersonal relation
ships

CLINICAL PAIN
 Invasive Procedures for Cancer Pain

Between 70% and 90% of all cancer pain can be

controlled with oral medication, but for those
patients with unrelieved pain invasive procedures
have an important role. Appropriate use of invasive
measures in the 10–30% of patients—most often
those with advanced disease—who fail oral
therapy can relieve nearly all cancer pain.
 Neurolytic Agents
Ethanol (alcohol).

Ethanol has been used extensively for

neurolytic procedures in concentrations
from 3% to 100%. It acts by destroying
nerves and producing Wallerian
degeneration without disruption of the
Schwann cell sheath.
 Phenol.
Studies by Mandl in 19507 reported that 6% phenol applied
to cervical ganglia in animals produced local necrosis in 24
hours, complete degeneration by 45 days, and regeneration
in 75 days. Thus, sensory recovery after phenol is faster
than after alcohol. Phenol, like alcohol, has been
administered for subarachnoid, peripheral nerve, and
ganglion neurolysis.
 Neurosurgical Procedures
With the development of the multidisciplinary
approach to pain management and an ever-
growing range of available pharmacologic agents,
few patients require surgical intervention to
interrupt central or peripheral nociceptive
pathways.
The most commonly performed surgical
procedure for cancer pain relief is anterolateral
cordotomy, which ablates the spinothalamic tract
1. Pain is common problem and a major
symptom of cancer patient.
2. Pain is one at most feared aspect and can
cause to suicide
3. Cancer pain can be organic or psychological
pain
4. Organic pain may be somatic, visceral or
neuropathic pain or combined.
5. Total pain is a
BIOPSYCHOSOCIOCULTUROSPIRITUAL
problem.
THANK YOU FOR