From a mechanistic perspective, cancer pain can be classified as nociceptive or neuropathic in origin. Nociceptive pain results from activity in neural pathways caused by tissue damage. Examples of nociceptive pain include postoperative pain, pain from bone metastasis, or pain associated with an intestinal obstruction. In contrast, neuropathic pain results from injury to nerves in the peripheral or central nervous system. In patients with cancer, neuropathic pain can result from tumor-related compression of neural tissue or injury to the nervous system from radiation, chemotherapy, or infection (Nicholson, 2006; Miaskowski, 2004).
EPIDEMIOLOGY AND ETIOLOGY
Unrelieved pain is one of the problems that patients with cancer fear most. Both adults and children can experience acute or chronic pain associated with cancer and its treatment. Epidemiologic studies suggest that 20% to 75% of adults with cancer report pain at the time of diagnosis, that 17% to 57% of patients undergoing active treatment experience pain, and that 23% to 100% of patients with advanced disease report moderate to severe pain (Goudas et al., 2005; Miaskowski et al., 2005). In addition, 23% to 90% of patients with cancer experience episodic breakthrough pain (BTP), a transitory exacerbation of pain superimposed on a background of persistent yet tolerable and generally adequately controlled pain (Svendsen et al., 2005; Caraceni & Portenoy, 1999; Portenoy et al., 1999). Because cancer has become a chronic illness, cancer survivors may experience pain as a result of their cancer or cancer treatment or from other chronic medical conditions unrelated to their cancer.
RISK PROFILE
• Cancer:
• Nociceptive pain: Breast, gastrointestinal, kidney, lung, ovarian, and prostate cancer and multiple myeloma.
• Neuropathic pain: Myeloma; metastasis to the base of the skull; brachial plexopathy from breast cancer, lung cancer, or lymphoma; cervical plexopathy from head and neck tumors; and lumbosacral plexopathy from colorectal and renal cancer, sarcoma, and lymphoma.
• Cancer treatments
• Nociceptive pain: Surgery, administration of stomatotoxic chemotherapy (e.g., methotrexate, 5-fluorouracil, doxorubicin, bleomycin), infectious processes in soft tissues, radiation-induced desquamation, extravasation of chemotherapy (e.g., actinomycin D, doxorubicin, mitomycin C), intraperitoneal chemotherapy, intestinal obstruction, hepatic metastasis, abdominal radiation (diarrhea), and pelvic irradiation (cystitis).
• Neuropathic pain: Surgical procedures that damage peripheral nerves (e.g., limb amputation, breast cancer surgery, nephrectomy, head and neck resection, thoracotomy), herpes zoster infection, radiation damage to peripheral nerves, and neurotoxic chemotherapy (e.g., vinca alkaloids, platinum compounds, taxanes, thalidomide).
PROGNOSIS
1. Ninety percent of all cancer pain can be managed effectively through noninvasive pharmacologic and nonpharmacologic interventions (Miaskowski et al., 2005).
2. Unrelieved cancer pain has a negative impact on a patient’s mood, functional status, and quality of life (Paul et al., 2005; Rustøen et al., 2005; Miaskowski et al., 1997; Glover et al., 1995).
PROFESSIONAL ASSESSMENT CRITERIA (PAC)
1. Screen all patients for pain at every visit.
2. Perform a comprehensive pain assessment that includes:
• A detailed history to determine the presence of persistent and breakthrough pain (BTP)
• A psychosocial assessment
• A physical examination
• A diagnostic evaluation to determine whether the patient has a common cancer pain syndrome (e.g., spinal cord compression, postherpetic neuralgia)
3. Persistent pain is described as constant pain that lasts for long periods (Miaskowski et al., 2005). The assessment of persistent pain should include the following information:
• Onset and temporal pattern
• Location
• Description
• Intensity
• Aggravating and relieving factors
• Previous and current pharmacologic treatments and their effectiveness
• Effects of pain on function
4. BTP is described as sudden, severe flare-ups of pain that come and go. These flare-ups are called breakthrough pain because the pain “breaks through” the treatment for persistent pain (Miaskowski et al., 2005). The assessment of BTP should include the following information:
• Presence of BTP
• Frequency and duration of the episodes of BTP
• Intensity of the BTP
• Occurrence of BTP (e.g., spontaneous, with movement)
• Previous and current pharmacologic and nonpharmacologic treatments and their effectiveness
5. The differences between chronic nociceptive and neuropathic pain are summarized in Table 36-1.
| Characteristic | Nociceptive Pain | Neuropathic Pain |
|---|---|---|
| Mechanism | Tissue injury | Nerve injury |
| Description | Aching, throbbing, sharp, gnawing, dull, pressurelike | Burning, tingling, numbing, shooting, electrical, jolting |
| Location | Usually localized over the site of tissue injury | Usually localized to the site of neuronal injury; may radiate |
| Severity | Use a 0 (no pain) to 10 (worst pain imaginable) numeric rating scale to assess the severity of average and worst pain. | Use a 0 (no pain) to 10 (worst pain imaginable) numeric rating scale to assess the severity of average and worst pain. |
| Aggravating factors | May include movement, activity, work, increased stress. | May include clothing rubbing against the site, water or wind hitting the site, or movement. |
| Relieving factors | May include the application of heat or cold, massage, and splinting of the affected site. | May include gentle rubbing of the affected site. |
| Additional signs and symptoms | Muscle spasms, diaphoresis, distention, feeling of fullness, nausea, and vomiting | Allodynia; atrophy; hair loss; hyperalgesia; loss of reflexes; loss of normal sensations; dysesthesias; smooth, fine skin |
| Psychological symptoms | Depression, anxiety, fear | Depression, anxiety, fear |
6. The physical examination should focus on the site of the pain.
• Consider common pain problems associated with cancer and cancer treatment.
• Perform a focused neurologic examination related to the site of the pain (e.g., for back and neck pain, focus on motor and sensory function in the upper and lower extremities, as well as the function of the rectal and urinary sphincters).
7. Diagnostic tests should be done to evaluate for recurrence or progression of disease and/or tissue injury caused by cancer treatment.
• Pain should be treated to facilitate completion of the diagnostic tests.
8. Assess the patient for the most common cancer pain syndromes (i.e., bone metastasis; epidural spinal cord compression; cervical, brachial, or lumbar plexopathy; peripheral neuropathy; postherpetic neuralgia).
9. Perform ongoing reassessments of pain to evaluate the effectiveness of the pain management plan.
• Have the patient or family complete a pain management diary and have them bring it to each clinic visit. The diary recordings of pain intensity and medication intake facilitate evaluation of the effectiveness of the pain management plan, allow for evaluation of the patient’s level of adherence to the analgesic regimen, and guide revisions of the pain management plan.
NURSING CARE AND TREATMENT
2. Establish patent intravenous access if the worst pain is uncontrolled and the patient rates it as 7 or higher (based on a numeric rating scale on which 0 is no pain and 10 is the worst pain imaginable).
3. Treat a worst pain intensity score of 7 or higher as a pain emergency. The patient should be titrated on oral or intravenous opioids until the worst pain score drops to 4 (Miaskowski et al., 2005).
4. Position the patient to enhance comfort.
5. Initial treatment of cancer pain should be based on the severity of the pain that the patient reports.
6. Adjust the dosage of analgesic medications to achieve pain relief with acceptable side effects.
7. Monitor for and prophylactically treat analgesic side effects:
• Nonopioid analgesics: Gastric distress, bleeding, renal failure, central nervous system toxicity, hepatotoxicity (acetaminophen).
• Opioid analgesics: Constipation, sedation, nausea, pruritus, urinary retention, respiratory depression (rare with patients on chronic opioids).
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