Controlling pain in the setting of opioid intolerance is exceedingly difficult. There are a number of interventions in addition to medication we can use, but they may not be as fast acting. Physicians need to have an interim plan for pain control.
—Candice A. Johnstone, MD, MPH
The WHO ladder is only a pharmacologic ladder. It does not mention multidisciplinary care interventions for pain. So I think as a profession, we need to develop much more rigorous standards.
—Elizabeth Rickerson, MD
Pain is now the fifth vital sign in assessing health status, and physicians should ask about the level of a patient’s pain as well as other symptoms at every visit.
—Richard Boortz-Marx, MD
The statistics are staggering. Despite the development of novel analgesics and the increasing awareness of the importance of adequately controlling pain from cancer or its treatment, up to 50% of patients undergoing treatment and between 70% and 90% of patients with advanced disease experience some degree of pain.1 What’s more, the World Health Organization (WHO) estimates that 25% of all patients with cancer die with unrelieved pain.2
Although pain from cancer can usually be sufficiently controlled for most patients, the problem remains undertreated due to several factors. They include professional-related barriers, such as poor pain management education during medical training; underutilization of opioids; unavailability of analgesics from pharmacies; inadequate pain assessment; and patient-related barriers, such as adherence to analgesic regimens and cultural differences in response to pain.
Compounding these factors is the multidimensional nature of cancer pain, which can include physical, psychosocial, emotional, and spiritual components. Thus, cancer pain requires multidisciplinary interventions from a team of experts in the diverse fields of medical oncology, radiation oncology, anesthesia, neurosurgery, palliative care, and physiatry, as well as from psychiatry, psychology, social work, nutrition, and chaplaincy.
Without a formal method in place to coordinate the number of disciplines needed to achieve cancer-related pain control, care is often haphazard, uneven, and fragmented, according to William S. Rosenberg, MD, FAANS, Medical Director of the Center for the Relief of Pain, a service of the Midwest Neuroscience Institute at Research Medical Center in Kansas City, Missouri, and President and Founder of the Cancer Pain Research Consortium (cancerpainresearchconsortium.org). Dr. Rosenberg, a neurosurgeon, launched the consortium 2 years ago to improve the management of cancer-related pain through interdisciplinary collaboration in research, best practice guidelines, and patient and physician education.
To better understand the relationship among the various disciplines involved in treating the physical aspects of cancer-related pain and the barriers that can often circumvent physicians’ efforts, The ASCO Post held a roundtable discussion with Dr. Rosenberg; Elizabeth Rickerson, MD, Instructor in Anesthesia at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston; Candice A. Johnstone, MD, MPH, Associate Professor of Radiation Oncology at the Medical College of Wisconsin and Medical Director of Froedtert and the Medical College of Wisconsin Cancer Network in Milwaukee; and Richard Boortz-Marx, MD, Chief of Interventional Pain Medicine at the Center for Neuromodulation and Associate Professor in the Department of Anesthesiology, Division of Pain Medicine at Duke University in Durham, North Carolina.
Beyond the Pain Relief Ladder
Dr. Rosenberg, please explain the multidisciplinary approach to cancer-related pain and how it works.
Dr. Rosenberg: We are still trying to figure it all out. Part of the problem is we are in the beginning of having the conversation on what is the best approach to providing multidisciplinary care to alleviate patients’ pain. Clearly, what it is not is the three-step pain relief ladder developed by WHO, which calls for prescribing nonopioids first and then mild opioids, such as codeine, followed by strong opioids, such as morphine, until the patient is free of pain.3 Although there is some clinical evidence that WHO’s recommendation manages pain, it has not been subjected to the rigors of a modern, evidence-based approach to clinical data.
At my facility, we have weekly pain conferences with physicians from all disciplines to discuss what each specialty has to offer and to determine a rational plan for coordinating care.
Strategies for Overcoming Barriers
From each of your perspectives, what are the barriers to controlling pain from cancer or its treatment, and how can they be overcome?
Dr. Rosenberg: From my perspective as a neurosurgeon, the biggest barrier is having access to patients. The staff involved in patients’ front line of care—the medical oncologists, radiation oncologists, and nurse practitioners—is usually unaware of what I do or has misconceptions of when and how neurosurgery might be incorporated into patients’ care. As a result, I often don’t see patients, except through serendipity or when it’s too late for my treatment to have a meaningful impact on their cancer journey.
Dr. Johnstone: The main barrier is that the patient’s experience of pain is unique, and not everyone responds to the same algorithm of interventions. Sometimes it’s unclear whether the problem is the type of medication being used or dosing.
Controlling pain in the setting of opioid intolerance is exceedingly difficult. Obviously, there are a number of interventions in addition to medication we can use, but they may not be as fast acting. For example, radiation therapy takes time to be effective for most people, and patients need to have adequate pain control so they can lie on the table to have their radiation planning and treatment completed. Even after radiation treatment is completed, it can take several weeks for its full effect to be realized. So physicians need to have an interim plan for pain control until the radiation has time to work.
Dr. Boortz-Marx: Overcoming the barriers to effectively treating cancer pain takes education and communication between the patient and the people who treat cancer pain. Understanding that there are effective options available to help oncologists help their patients is critical.
Dr. Rickerson: The biggest barriers are diagnosing the pain and getting patients to the specialty care they need. There is no central recording system for pain symptoms, and reporting pain is not mandatory. Also, the degree of pain patients score on a scale of 0 to 10 does not always reflect the degree of pain they are experiencing.
As Dr. Boortz-Marx said, educating both our patients and our practitioners is step one. Many times, patients think pain is just part of having cancer and they have to live with it. However, pain is now the fifth vital sign in assessing health status, and physicians should ask about the level of a patient’s pain as well as other symptoms at every visit.
Medical Oncologists: The Portal of Entry for Care
Who evaluates patients for pain and coordinates their care? Is it the medical oncologist?
Dr. Rosenberg: The medical oncologist is the primary care provider for a patient with active cancer and ultimately is the person who should be assessing pain and coordinating care. Assessing pain is complicated, however, and an oncologist only has about 15 minutes to discuss myriad issues with a patient. I think a simple triage system should be developed. For example, if a patient has a pain rating of 4 or greater, he should be prescribed an opioid like hydrocodone, and persistent pain should trigger a pain consult with the appropriate specialist.
Dr. Rickerson: I agree that the medical oncologist is the first layer in the evaluation and coordination of care. Because there is a shortage of palliative care physicians, medical oncologists and primary care physicians should have “primary palliative care skills,” which include basic symptom management skills, communication skills, and coordination of care skills. Then if patients don’t do well, they should be referred to an interventional pain physician, such as an anesthesiologist and/or a palliative care specialist.
Dr. Johnstone: Ideally, every person who interacts with patients should assess their pain and try to do something about it. Every physician should have some fundamental basic training in pain management and know who to send the patient to if interventions cannot control the pain. Some patients need the services of pain management specialists or palliative care professionals who have advanced training in pain management, but coordinating care should be a collaborative process. A physician should never say to a patient, “I don’t assess pain, you need to see someone else.” A physician may, however, determine that a single person should manage a patient’s pain medications, so there aren’t too many people making changes at the same time and a single person is in charge.
Dr. Boortz-Marx: The medical oncologist is the portal of entry for care. However, ultimately, a pain medicine specialist should evaluate a patient’s pain level.
Different Perspectives, Different Tools
From each of your perspectives, how is your specialty involved in controlling cancer pain?
Dr. Rosenberg: We have a number of procedures in neurosurgery to manage pain. For instance, cordotomy is a percutaneous outpatient procedure performed under local anesthesia in which we put a tiny electrode into the spinal cord and disrupt the pain fibers. Patients will often have immediate and total relief of pain following the procedure. For widespread metastatic bone disease, we use radiosurgical hypophysectomy to deliver high-dose radiation to the pituitary gland, which also results in immediate and total pain relief.
Dr. Johnstone: As a radiation oncologist, I can deal with both localized and widespread pain, but my primary role is in alleviating localized pain. Radiation is exceptionally good at taking care of cancer pain caused by bone metastases. According to the literature, 80% of patients will have pain relief with radiation. Radiopharmaceuticals—radiolabeled chemicals that go throughout the body and localize to bone—are another tool in our toolbox for widespread bone metastasis; however, they are more complicated to use because they can lower blood counts and make the use of chemotherapy more challenging.
Dr. Boortz-Marx: Anesthesiologists bring a unique perspective to relieving cancer-related pain. Although our lives are built around pharmacology-based therapies—it is what we use in the operating room—we also use interventional types of procedures. Peripheral nerve blocks, spinal cord stimulation, targeted drug delivery, and alcohol phenol injections are all part of our armamentarium.
Dr. Rickerson: I’m trained in anesthesia and do palliative care and interventional pain management. All of our specialties bring different perspectives to patient care and different tools. I can place needles in different parts of the body and block nerves or do small surgeries to implant intrathecal pumps in the area around the spinal cord to prevent pain signals from being perceived by the brain.
The key to working with other specialists is to know who should be first to manage the patient’s pain. Is it the surgical oncologist who removes the tumor; the radiation oncologist who radiates the lesion; or should I be first to control the pain, so the other specialists can do their jobs? There is no right answer for every single patient.
Patients in Need of Multidisciplinary Care
Multidisciplinary pain management is not necessary for every patient. What are the situations or types of patients who require this type of care the most?
Dr. Rosenberg: If we are truly going to be practicing patient-centered care, there has to be a major paradigm shift in organized medicine, and I think the work we’ve done so far in the Cancer Pain Research Consortium reflects that. We have to organize around patients’ symptoms and diseases and be agnostic to specific disciplines. Any patient who is suffering and not achieving relief is the right patient to receive our care and should get our attention.
Dr. Johnstone: Usually the patients with the most complicated health status are the ones who require multidisciplinary care. They may need to see a surgeon for part of their treatment, and if they have intractable pain, they may need to see someone else. My basic tool is radiation; I have a basic knowledge of pain medications, but if after I’ve radiated a lesion the patient is still in pain, I might transfer the patient to a palliative care specialist, a pain management physician, or an anesthesiologist for additional care.
Dr. Boortz-Marx: Any patient with physical as well as emotional distress should see an appropriate member of the multidisciplinary care team for help. This includes psychosocial care for those whose lives have been turned upside down after their cancer diagnosis or for those having a difficult time accepting their diagnosis.
Dr. Rickerson: I agree. There is a wide range of patients who fall into this category. They include patients with tumors in difficult places and patients with severe neuropathic pain, which is very difficult to control. Patients who had chronic pain before their cancer diagnosis are at higher risk for experiencing cancer-related pain, because they have already experienced a lot of pain and may be tolerant to pain medications and have a great deal of anxiety about their pain. These patients often have difficult-to-control pain and usually need specialty-level pain care.
Standards of Care
Are there standards of care for cancer-related pain?
Dr. Rosenberg: The National Comprehensive Cancer Network (NCCN) has developed guidelines for adult cancer-related pain,4 but if you read them critically from a multidisciplinary perspective, then the answer is no. In my field of neurosurgery, we have a lot to offer patients for pain, but in the NCCN guidelines, my profession is reduced to one sentence: “A neurosurgeon can cut some nerves.” Who is going to sign up for that?
Dr. Boortz-Marx: The NCCN Guidelines for pain cover two parts. One covers the assessment of cancer-related pain, and one deals with pain management. However, medical oncologists as well as other specialists need to develop a core of like-minded individuals who are interested in patient care and patient outcomes and develop standards of pain management.
Dr. Rickerson: I agree. As Dr. Rosenberg mentioned, WHO developed the three-step ladder for cancer pain relief in adults, but the evidence that it is effective is limited. There is good evidence showing that many patients who get put on the protocol in the pain ladder have much of their pain controlled. However, there are also good data showing that there are a significant number of patients who go through the three steps and don’t have good pain control. And the WHO ladder is only a pharmacologic ladder. It does not mention multidisciplinary care interventions for pain. So I think as a profession, we need to develop much more rigorous standards. ■
Disclosure: Drs. Rosenberg and Rickerson reported no potential conflicts of interest.
1. American Cancer Society: Cancer facts and figures 2007. Available at http://www.cancer.org/acs/groups/content/@nho/documents/document/caff2007pwsecuredpdf.pdf. Accessed September 4, 2015.
2. World Health Organization: Cancer Pain Relief, 1st ed. Geneva, Switzerland, World Health Organization, 1986.
3. World Health Organization: WHO’s cancer pain ladder for adults. Available at www.who.int/cancer/palliative/painladder/en/. Accessed September 4, 2015.
4. National Comprehensive Cancer Network (NCCN): NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Adult Cancer Pain, version 2.2015. Available at http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf. Accessed September 4, 2015.
Editor’s Note: The ASCO Post is planning a roundtable discussion on the psychosocial, emotional, and spiritual components of cancer-related pain, which will be published in a future Palliative Care in Oncology column.