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    Cancer Pain

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    IndraYudhi
    1. Cancer pain is a common and debilitating symptom experienced by many patients, with up to 90% of patients with advanced cancer reporting significant pain. 2. Pain has multiple physiological mechanisms in cancer including nociceptive, neuropathic, and psychogenic pain. Total pain also incorporates physical, psychological, social, and spiritual suffering. 3. A variety of invasive pain management procedures can effectively relieve cancer pain for the 10-30% of patients with pain not adequately managed by oral medications alone, including neurolytic agents, spinal cord stimulation, and neurosurgical procedures like cordotomy.

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    Cancer Pain

    Uploaded by

    IndraYudhi
    383 views52 pages
    1. Cancer pain is a common and debilitating symptom experienced by many patients, with up to 90% of patients with advanced cancer reporting significant pain. 2. Pain has multiple physiological mechanisms in cancer including nociceptive, neuropathic, and psychogenic pain. Total pain also incorporates physical, psychological, social, and spiritual suffering. 3. A variety of invasive pain management procedures can effectively relieve cancer pain for the 10-30% of patients with pain not adequately managed by oral medications alone, including neurolytic agents, spinal cord stimulation, and neurosurgical procedures like cordotomy.

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    1. Cancer pain is a common and debilitating symptom experienced by many patients, with up to 90% of patients with advanced cancer reporting significant pain. 2. Pain has multiple physiological mechanisms in cancer including nociceptive, neuropathic, and psychogenic pain. Total pain also incorporates physical, psychological, social, and spiritual suffering. 3. A variety of invasive pain management procedures can effectively relieve cancer pain for the 10-30% of patients with pain not adequately managed by oral medications alone, including neurolytic agents, spinal cord stimulation, and neurosurgical procedures like cordotomy.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    383 views52 pages

    Cancer Pain

    Uploaded by

    IndraYudhi
    1. Cancer pain is a common and debilitating symptom experienced by many patients, with up to 90% of patients with advanced cancer reporting significant pain. 2. Pain has multiple physiological mechanisms in cancer including nociceptive, neuropathic, and psychogenic pain. Total pain also incorporates physical, psychological, social, and spiritual suffering. 3. A variety of invasive pain management procedures can effectively relieve cancer pain for the 10-30% of patients with pain not adequately managed by oral medications alone, including neurolytic agents, spinal cord stimulation, and neurosurgical procedures like cordotomy.

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    CANCER

    PAIN
    Dr. Hasanul Arifin SpAn

    Departemen Anestesiologi dan Reanimasi


    Fakultas Kedokteran USU
    Medan

    PAIN
    We must all die. But that I
    can save him from days of
    torture, that is what I feel
    as my great and ever new
    privilege. Pain is a more
    terrible lord of mankind
    Albert Schweitzer (1875 1965)
    than even
    death itself .
    On the Edge of the Primeval Forest

    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 :
    Roger Woodruff,
    Palliative Medicine
    80
    % of patients had more than

    Incidence of pain by primary site of cancer


    Patients with
    pain (mean)
    %
    > 80

    Site
    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
    dimention

    ORGANIC PAIN

    Psychologica
    l
    dimention
    Sensory
    discriminative
    Motivational

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

    TOTAL PAIN
    BIOPSYCHOSOCIOCULTUROSPIRIT

    Somatic or
    Visceral
    Nociceptio
    n

    Neuropathi
    c
    Mechanism
    s

    Pain

    Suffering

    Psychologic
    al State and
    Traits
    Loss of
    Work

    Psychologic
    al
    Disturbance
    s

    Social/
    Familial
    Functioning
    Financial
    Concerns

    Physical
    Disability

    Fear
    Of Death
    AMERICAN CANCER SOCIETY 1988

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

    Pain
    Physical
    Symptoms
    Total
    Suffering

    Cultural

    Psychological
    Social

    Unrelieved pain
    Pain
    Spiritual

    Physical
    Symptom
    s

    Cultural

    Psychologi
    cal
    Social

    Unresolved or untreated pain


    Pain
    Physical
    Sympto
    ms

    Spiritu
    al

    Psychologi
    cal

    Cultura
    l
    Social

    Diagram of pain pathways

    Classification of pain experienced


    by patients with cancer
    TEMPORAL PATHOPHYSIOLOGICAL
    acute
    chronic

    nociceptive

    AETIOLOGICAL

    due to cancer

    somatic

    due to therapy

    visceral

    due to general illness


    but no cancer

    neuropathic
    central
    peripheral
    sympathetic

    psychogenic

    un related to cancer or
    therapy

    PATHOPHYSIOLOGICAL OF
    PAIN

    NEUROPATHIC
    central
    peripheral
    sympathetic

    NOCICEPTIVE
    somatic
    visceral

    PSYCHOGENIC
    or IDIOPHATIC

    CANCER
    Can
    be divided into 2 catagories
    PAIN
    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
    projections

    MODULATION
    Thalamus

    TRANSMISSION

    TRANSDUCTION
    Spinothalamic
    tract

    Primary
    Afferent
    Nociceptor

    Noxious
    Stimulus

    PERCEPTION

    Cortex
    Epidural Opioid
    Subarachnoid Opioid

    Thalamocortical
    projections

    MODULATION

    Thalamus

    Systemic
    Opioids

    Epidural
    Local
    Subarachnoid Anesthetic
    Celiac Plexus

    TRANSMISSION

    Intravenous
    Local
    Intrapleural
    Intraperitoneal Anesthetic
    Incisional

    TRANSDUCTION
    Spinothalamic
    tract

    Primary
    Afferent
    Nociceptor

    Noxious
    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
    prostaglandins)
    produce

    VISCERAL
    PAIN

    Characteristic of
    pain:
    constant
    aching or dull
    poorly localized
    usually with nausea and
    vomit
    often referred to cuttaneous
    sites:
    Mechanism

    colicky or cramp
    occational
    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
    Baseto
    of invasion
    skull
    Due
    of bone
    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


    Surgery
    therapy
    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

    3.Pain due to general illness


    but not cancer
    Myofascial pains

    Postherpetic neuralgia
    Osteoporosis
    Debiliting (decubitus
    ulcer)
    etc

    4. Pain unrelated to cancer or the


    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
    cultural background

    previous pain
    experience
    meaning of the pain
    situational factors
    medicalization

    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
    + cultural factors
    + spiritual concerns
    - Total Suffering

    Pain
    Physical
    Symptoms

    Spiritual
    Total
    Suffering
    Cultural

    Psychological
    Social

    The distinction between Clinical Pain and Total S


    Physica
    l
    Pain

    Clinica
    l
    Pain
    Spiritual

    Total
    Suffering
    Cultural

    Physical
    Sympto
    ms

    Psychologi
    cal
    Social

    PHYSICAL
    PHYSICALPAIN
    PAIN
    Pain
    related
    to
    Pain related tocancer
    cancer
    Pain
    Painrelated
    relatedtototreatment
    treatment
    Pain
    unrelated
    to
    Pain unrelated tocancer
    cancer

    The concept of Clinical Pain


    Pain
    Other physical symptoms
    Psychological problems
    Social difficulties
    Cultural factors
    Spiritual concerns

    + or + or + or + or + or + or -

    CLINICAL
    CLINICALPAIN
    PAIN
    What
    the
    patient
    What the patientsays
    saysititisis
    What
    Whathas
    hastotobe
    betreated
    treated

    PHYSICAL
    PAIN
    Progressive pain
    Multiple or increasing
    number of pains

    Controlled pain

    Stable pain

    Significant limitation

    No limitation of activity

    of activity

    Good prior managemen

    Poor prior management

    CLINICAL
    PAIN

    PHYSICAL PAIN
    Insomnia,

    No insomnia,

    exhaustion, fatigue
    secondary to pain
    Persistent cough or
    vomiting
    Other distressing
    symptoms

    exhaustion, fatigue

    No coughing,
    vomiting
    No other distressing
    symptoms

    CLINICAL PAIN

    PHYSICAL PAIN
    Abandonment
    Boredom
    Mental isolation
    Financial problems
    Problems with
    interpersonal relation

    Social
    difficulties : none
    or resolved

    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 1030% of patientsmost often
    those with advanced diseasewho 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 evergrowing 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

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