Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:160–163. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.911795

EUROPEAN PERSPECTIVES ON PAIN AND PALLIATIVE CARE

Pain and Other Symptoms in Cancer Survivors Dagmar Westerling AB STRACT Pain is common in cancer survivors. Long-term pain, often of neuropathic origin, is common after operations, radiotherapy, and chemotherapy. Pain and other concomitant symptoms and side effects should be assessed with validated and reliable scales and questionnaires. Cancer survivors with severe pain should be seen by a pain specialist. Multidisciplinary rehabilitation and individualized pain management may improve quality of life in cancer survivors. Four case reports are presented to illustrate this. This report is adapted from paineurope 2013; Issue 4, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. KEYWORDS cancer, concomitant symptoms, neuropathic, pain, survivors

Pain is a common symptom in cancer.1 About one third of patients have pain as presenting symptom.2 During cancer treatment, the proportion of patients suffering from pain increases to 50% or more.3 Operations, chemotherapy, and radiotherapy, often in combination, are usually successful, but longterm pain and other symptoms are a common consequence.4–14 The following cases focus on persistent pain and other concomitant symptoms and present options for pain relief in cancer survivors.

derwent irradiation. Five years after the operation he is seen by his primary care physician for hypertension, anxiety, and sleeping problems. He also suffers from dryness of the mouth, stiffness in his shoulder, neck, and face, burning pain on the left side of the face and skull, and poor dental health. Pain ranges between 4/10 and 8/10 on a numeric rating scale (NRS). His analgesic treatment consists of immediate-release morphine (200–300 mg/day) and diclofenac 50 mg as needed. He has nausea, gastric cramps, and he bleeds from the nose.

CASE 1: ENT CANCER

Pain Analysis

A 64-year-old retired smoker was diagnosed with cancer of the soft palate. He was operated on and un-

Nociceptive and neuropathic pain, oral complications of cancer treatment, side effects of diclofenac, possibly anxiety and depression.

Dagmar Westerling, MD, is Head of the Pain Unit at Kristianstad Central Hospital, Sweden, and Associate Professor of Clinical Sciences, Medical Faculty, Lund University. This report is adapted from paineurope 2013; Issue 4, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication. Address correspondence to: Dagmar Westerling (E-mail: dagmar.westerling@ skane.se).

Proposed Treatment Counseling and supportive cancer rehabilitation, assessment of risk addiction using, for example, the Screener and Opioid Assessment for Patients With Pain tool, and assessment of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). 160

European Perspectives on Pain and Palliative Care

Stop diclofenac. Start a controlled-release opioid, an anticonvulsant (gabapentin or pregabalin), and, subsequently, as the level of anxiety and depression is high, an antidepressant with sedative, anxiolytic, and analgesic properties. Promote oral health through dental care, improved oral moisture, and cessation of smoking.

CASE 2: BREAST CANCER A 58-year-old woman treated with sector resection, lymph node resection, irradiation therapy, and oral hormone therapy (aromatase inhibitor) for cancer of the right breast 9 years ago. The patient experienced severe postoperative pain and had a painful wound infection requiring drainage. Daily irradiation sessions as an outpatient required extensive traveling. She sees her primary care physician for depression and pain. Pain is treated with controlled-release tramadol 100 mg, taken as needed, 4–6 times daily with paracetamol. She stopped taking her antidepressants 2 years ago due to weight gain. Her pain level is 8–10/10 on a NRS. Anxiety and depression rated using the HADS are high. The impact of her pain on normal activities and enjoyment of life is rated as high on the Brief Pain Inventory (BPI-SF). Her pain drawing reveals radiating pain from the right breast, shoulder, and arm with burning, prickling, and tingling qualities. She also has nausea, tender muscles, and sore joints.

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was followed by a hemicolectomy with a temporary colostomy. At the first operation, no epidural catheter was placed, due to back problems. Instead, he was provided with an intravenous (IV) patient-controlled analgesia (PCA) morphine pump. He had severe postoperative pain, nausea, and vomiting. When the colostomy was later closed, he was anxious and anticipated nausea and pain. The patient is no longer able to work and feels utterly useless. Seven years after diagnosis, he is admitted to the hospital with pain, constipation, and sleeping problems. Pain analysis reveals burning, prickling pain of 7–9/10 on a NRS in the left, lower part of the abdomen, with allodynia in and surrounding the scar from the colostomy. He is taking a fixed combination of codeine (30 mg) and paracetamol (500 mg) as needed. When laxatives are used, he gets diarrhea, is bloated, and has problems with gas.

Pain Analysis Long-term postoperative pain with some nociceptive but predominantly neuropathic components.

Proposed Treatment Stop codeine/paracetamol as needed. Start titration of an anticonvulsant. Lidocaine patches or a highconcentration capsaicin patch may be considered for the localized neuropathic pain. If opioid treatment is beneficial, consider oxycodone/naloxone combination due to the patient’s long-term constipation.

Pain Analysis Nociceptive and neuropathic pain, anxiety, and depression.

Proposed Treatment Stop tramadol. Controlled-release preparations should not be prescribed as needed. Start a potent controlled-release opioid (morphine, oxycodone, or tapentadol) and an anticonvulsant (gabapentin or pregabalin). Suggest counseling, referral to a dietitian, and nonpharmacological analgesic treatment such as TENS (transcutaneous electrical nerve stimulation) applied to the upper body.

CASE 3: COLORECTAL CANCER A 67-year-old farmer with a history of back pain was diagnosed with rectal cancer. Preoperative irradiation

CASE 4: GYNECOLOGICAL (OVARIAN) CANCER A 67-year-old woman underwent hysterectomy, oophorectomy, radiotherapy, and chemotherapy for ovarian cancer. Prior to the operation, 17 years ago, she was borderline obese, now her body mass index (BMI) is 17. She has tingling, burning pain in her hands and feet, which are numb. She has dysuria, dyspareunia, sexual dysfunction, diarrhea, and pelvic pain, with an intensity of 6–8/10 on a NRS. Her dysuria consists of pain on micturition, urgency, and incontinence. She refrains from social activity due to urinary incontinence and is afraid that she smells. Her anxiety is rated as high and her depression rated as medium using the HADS. She takes no analgesics and has a daughter who is in addiction treatment.

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Pain Analysis She was experiencing chronic pelvic pain of nociceptive, visceral origin with a neuropathic component, chemotherapy-induced polyneuropathy, psychosocial consequences of long-term pain, and fear of addiction.

Proposed Treatment Treatment of neuropathic pain with gabapentin, pregabalin, duloxetine, and amitriptyline has been shown to be effective in the management of postherpetic neuralgia and/or diabetic polyneuropathy.16 However, there are few studies to support the shortor long-term use of anticonvulsants or antidepressants for treatment of neuropathic pain in cancer.5 Nonpharmacological and interventional treatments, indicated for nonmalignant and refractory pain syndromes, respectively, may be effective in long-term cancer pain.6,12,13 Long-term use of opioids may be advantageous in patients with opioid sensitive pain.17 However, opioids do have numerous side effects18 and serious misuse is not rare19 in long-term, nonmalignant pain. The risk of addiction to opioids in cancer survivors is not known. Pain and other symptoms caused by cancer treatment may be treated if diagnosed and assessed using validated, reliable pain scales and questionnaires. Optimal cancer rehabilitation requires multidisciplinary contribution from team members who can target the many different problem areas. Prompt identification of patients who need referral to a pain specialist decreases unnecessary suffering. In order to improve quality of life, both access to and further research in pain management are needed for the growing number of cancer survivors. Establish confidence. Multidisciplinary evaluation with contributions from urology, psychiatry, pain management, and a dietitian, and counseling with a social worker may provide an improvement. Pharmacological treatment should be introduced according to the “start low, go slow” principle. An antidepressant with analgesic properties (duloxetine) may be the first choice and a low dosage of controlledrelease opioid. A buprenorphine patch may also be considered, since uptake from an oral controlledrelease preparation may be unpredictable due to frequent diarrhea. An anticonvulsant may be added. Interventional analgesic treatment, spinal cord stimulation, or intrathecal drug administration with an implanted pump can be considered if other treatment fails.

DISCUSSION The pain induced by cancer treatments such as surgery, radiotherapy and chemotherapy is often neuropathic, that is, caused by a lesion to the peripheral or central nervous system.15 The drugs commonly used for neuropathic pain—gabapentin, pregabalin, duloxetine, and amitriptyline—have been shown to be effective in the management of postherpetic neuralgia and/or diabetic polyneuropathy.16 However, there are few studies to support the shortor long-term use of anticonvulsants or antidepressants for treatment of neuropathic pain in cancer.5 Nonpharmacological and interventional treatments, indicated for nonmalignant and refractory pain syndromes, respectively, may be effective in long-term cancer pain.6,12,13 Long-term use of opioids may be advantageous in patients with opioid sensitive pain.17 However, opioids do have numerous side effects18 and serious misuse is not rare19 in long-term, nonmalignant pain. The risk of addiction to opioids in cancer survivors is not known. Pain and other symptoms caused by cancer treatment may be treated if diagnosed and assessed using validated, reliable pain scales and questionnaires. Optimal cancer rehabilitation requires multidisciplinary contribution from team members who can target the many different problem areas (see Figure 1). Prompt identification of patients who need referral to a pain specialist decreases unnecessary suffering. In order to improve quality of life, both access to and further research in pain management are needed for the growing number of cancer survivors. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.

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[16] Dworkin RH, O’Connor AB, et al. Mayo Clin Proc. 2010;85(3 Suppl):S3–S14. [17] Turk DC, Wilson HD, et al. Lancet. 2011;377:2226–2235. [18] McNicol E. J Pain Palliat Care Pharmacother. 2008;22:270–281. [19] Von Korff M, Kolodny A, et al. Ann Intern Med. 2011;155:325–328.

Notice of correction Changes have been made to this article since its original online publication date of May 7, 2014.

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Pain and other symptoms in cancer survivors.

Pain is common in cancer survivors. Long-term pain, often of neuropathic origin, is common after operations, radiotherapy, and chemotherapy. Pain and ...
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