Having a cancer is one of the most unfortunate experiences in life. Pain is an integral part of cancer. More than 3.5 million suffer with cancer pain the world over. However, it does not mean that all patients with cancer develop pain. Some are painless. Bone pain is the commonest type of pain in cancers. The ordeal of going through a cancer is a miserable experience for those affected and their loved ones. Pain can result from the direct result of cancer, treatment or as an indirect result of treatment.
Classification of cancer pain
1. As a result of direct tumour or secondary:
Bone - Base of skull, Vertebrae, Generalised bone pain
Nerve Pain - Neuralgias, Plexopathies
Organs - liver, Intestines, etc
Blood vessels
Mucous membranes – oral cancer
2. As a result of therapy:
Post Operative, Post chemotherapy, Post radiotherapy
3. Unrelated:
Post herpetic neuralgia, Osteoporosis
In the UK there is hospice care to manage patients with end stage carcinoma which gives end of life care with TLC (tender loving care). The pain is controlled well and delivers psychological support to cope with the stress.
Hospice care
This is a type of health care that focuses on the palliation of a terminally ill patient’s pain and symptoms and attending to their emotional and spiritual needs at the end of life. Hospice care prioritises comfort and quality of life by reducing pain and suffering.
Therefore, reducing pain is a key factor in managing cancer patients. As a Pain Consultant I used to visit hospices in the U.K. in my area of Kent to provide pain relief to its patients.
A patient was once brought to me in Sri Lanka who suffered with pancreatic carcinoma with excruciating abdominal pain. But he was only on Paracetamol. This is not sufficient to manage his pain. At that time prescribing Morphine was an issue in Sri Lanka. I was able to get Fentanyl patches dispensed at Osu Sala on a specialist prescription. This is a win win situation for patients and the doctors. I had to request the National Medicines Regulatory Authority (NMRA) to facilitate this and am grateful to the committee on therapeutics for authorising Fentanyl to be used in the private market at least at the Osu Sala. Fentanyl (Fentouch) is an opiate and is available as a transdermal patch which delivers a particular dose every hour. The patch is kept for 72 hours (three days). The dosage varies from 12.5 mcg – 100 mcg per hour. The advantage of a transdermal patch is, less incidence of overdose, easy to administer and no chance of misuse like the other opiates.
Cancers can take place anywhere in the body, from the skin outside to the organs in the inner body. From the brain upwards down to the genitalia.
I will discuss the management of pain in cancer patients in general. Pain killers can be given according to the World Health Organization (WHO) ladder which classifies three steps as in a step ladder.
1.Simple Analgesics
Paracetamol, NSAIDS such as Diclofenac, Ibuprofen, Naproxen,
COX 2 inhibitors such as Celecoxib (Celebrex)
2.Moderate Analgesics
Codeine Phosphate, Co codamol
3.Strong Analgesics
Oral Morhine, Morphine SR (MST)
OxyContin, Oxycodone
Pethidine
Fetanyl Transdermal patches
Bupronorphine Transdermal
PCA - Patient control analgesia intravenously with Morphine.
Patient Control Analgesia pump
This particular pump is a disposable PCA pump available in Sri Lanka.
Fill the bag with a morphine solution and deliver the drug intermittently through the Intrathecal venous route.
The side effects of oral morphine and intravenous morphine are high compared to the transdermal patches. The common side effects are:
Nausea and vomitting
Urticaria and itching
Constipation
Breathing problems
Drowsiness
Addiction is an issue with Morphine but in cancer patients this is
less of a problem.
There are some interventional procedures that can be done for
particular cancers.
Neurolytics
Intrathecal and Epidural Alcohol and Phenol
Sympathetic blocks such as:
Coeliac plexus block for cancer of the Pancreas
Hypogastric block for lower abdominal cancers
Sympathetic ganglion blocks
Peripheral nerve blocks - Therapeutic
Nerve blocks
Pain should be localised and unilateral. Visceral or somatic pain is
more appropriately treated with nerve blocks.
Intrathecal and epidural morphine pumps.
These are carried out in extreme cases of pain. These pumps are programmed
and deliver a fixed dose to the Intrathecal or epidural space.
Pain management of the cancer patient depends on the interaction between the patient and the pain specialist. Options should be discussed with the patient and the immediate family and a cost effective and an appropriate method of pain relief should be determined.
I hope to play a key role in the future in regard to cancer pain management in Sri Lanka.
Dr Namal Senasinghe MBBS, Dip in Pain Med, FFARCS, FFPMCA, CCST(U.K) Consultant in Pain medicine at the ‘London Pain Management Centre,’ 31, Horton Place, Colombo 7, Sri Lanka. Hotline 0767155716