Cancer Pain Management Part 1: Assessment

Clinical Practice Guideline

Siti Shazwani binti Zulkaflee Ba. Health Sc. (Honor) Nursing, USMKK

Introduction
Pain is among the commonest symptoms experienced by cancer patients Pain occurs in over 50% of cancer patients and at least 1/3 of these patients experience moderate to severe pain. Management of cancer pain should follow the WHO Analgesic Ladder.

15,000 patients with moderate to severe cancer pain

Have you seen this man?

Unrelieved pain DESTROYS quality of life for both the cancer patient & the family
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Pain is a highly complex & subjective phenomenon

Its components are not only physiological, but also include behavioural, cognitive, emotional, spiritual & social aspects

Assessment should be comprehensive

1SIGN,

Control of pain in adults with cancer, 2008 2Breitbart W, et al., Psycho-oncology., 1998
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PAIN is what the patient says SAKIT

Types of Pain
Nociceptive Pain1

-1

Pain that is due to tissue damage associated with an identifiable somatic or visceral lesion

1de

Leon-Casasola OA. Cancer Pain Pharmacologic, Interventional, & Palliative Approaches, 2006
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Types of Pain
Somatic Pain1

-2

Damage of somatic tissue such as bones & soft tissue

Character is aching, stabbing or throbbing & usually well-localised

1de

Leon-Casasola OA. Cancer Pain Pharmacologic, Interventional, & Palliative Approaches, 2006
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Types of Pain
Visceral Pain1

-3

Damage to viscera such as liver, intestines, bladder, etc. Character is cramping or gnawing when there is obstruction of hollow viscus Aching, sharp or throbbing due to organ involvement Usually diffuse and difficult to localize

1de

Leon-Casasola OA. Cancer Pain Pharmacologic, Interventional, & Palliative Approaches, 2006
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Types of Pain
Neuropathic Pain1, level III

-4

Pain is due to abnormal somato-sensory processing in the peripheral or central nervous system Character is burning, pricking, electric-like, shooting or stabbing

Pain is often associated with loss of sensation in the painful region.

De Leon-Casasola (2006) Cancer Pain Pharmacologic, Interventional and Palliative approaches

1Portenoy

RK, Lancet Oncol,1992

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Knowledge about pain characteristics provide a useful background to understand cancer pain & help to determine appropriate interventions1
1Caraceni

& Portenoy, Pain, 1999

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Sources of Pain1
92.5% of cancer patients with pain experienced pain due to the cancer itself 20.8% experienced it due to its treatment e.g. chemotherapy, radiotherapy, surgery-related 2.3% pain was not related to cancer or its treatment e.g. osteoarthritis, migraine, osteoporosis, chronic back pain, etc.
1Caraceni

& Portenoy, Pain, 1999

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25% of patients had more than one type of pain1

1Caraceni

& Portenoy, Pain, 1999

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How to Assess Pain?

P : Place or site of pain
Where does it hurt? (a body chart might help describe their pain) What makes the pain worse? How bad is the pain?

A : Aggravating factors

I : Intensity N : Nature & neutralising factors

What does it feel like What makes the pain better?

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Factors Affecting Patients Perception of Pain

Psychological pain Physical pain
Other symptoms Adverse side effects of treatment
Anger at delay in diagnosis, etc. Disfigurement Fear of death/pain Feeling of helplessness

Total pain
Social pain
Family Finances Role Isolation

Spiritual pain
Why me? Meaning? Purpose in life

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Pain Assessment

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Most Commonly Used Unidimensional Assessment Tools1

i. Visual Analogue Score
Patient is asked to slide a small bead along a scale to indicate the severity of pain Total length of scale is 100 mm (10 cm)

1Caraceni

A, et al., J Pain Symptom Manage, 2005

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ii. Combination Rating Scale (NRS & VAS)

On a scale of 0 I0 (show the pain scale), if 0 = no

pain & 10 = worst pain you can imagine, what is your pain score now?

1Caraceni

A, et al., J Pain Symptom Manage, 2005

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Wong-Baker FACES Pain Rating Scale

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FLACC Score
(By Observation), for
Paediatric patient of <4 yrs old Elderly patient Cognitively impaired patient
i. Observe behaviour ii. Select score according to behaviour iii. Add the scores for the total

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FLACC SCORE

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Relief of pain allows the person to live the rest of his/her life constructively & productively. PALLIATIVE CARE USING MORPHINE RELIEVES CANCER PAIN IN 90% OF PATIENTS.
WHO Cancer & Palliative Care Unit, Geneva

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