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