About14 million people in the United States have a history of cancer, and their long-term survival following a diagnosis of the disease continues to improve. Despite these advances, cancer survival often comes with a physical, psychosocial, and financial toll from treatment of the disease as well as other comorbidities. “One of the comorbidities that can be a negative consequence of surviving cancer is chronic pain,” says Judith A. Paice, PhD, RN. Some studies have reported that the prevalence of pain among cancer survivors is as high as 40%.
Few evidence-based cancer pain guidelines address the intricacy of caring for pain when it persists for months or years. “As more people survive cancer, it’s imperative that all clinicians who interact with these patients are knowledgeable and have the skills to implement best practices in the management of chronic pain,” adds Dr. Paice.
The American Society of Clinical Oncology (ASCO) has released a clinical practice guideline in the Journal of Clinical Oncology that addresses the management of chronic pain in survivors of adult cancers. ASCO convened an expert panel that systematically reviewed 63 studies that investigated various aspects of chronic pain management in cancer survivors. “Recommendations are provided on symptom relief, pain intensity, quality of life, functional outcomes, adverse events, misuse or diversion, and risk assessment or mitigation,” says Dr. Paice, who was chair of the group that developed the guideline.
According to ASCO, clinicians should screen for pain at each patient encounter and evaluate, treat, and monitor recurrent disease, second malignancies, or late-onset treatment effects in those who report new-onset pain. “Clinicians should also consider involving other health professionals in order to provide comprehensive pain management care in patients with complex needs,” Dr. Paice says. “Because this is such a challenging group to manage, screening and diagnosis of pain is imperative to appropriately care for these individuals.”
Opioid-based pharmacotherapy is widely accepted as the foundation of care for acute pain or pain associated with advanced cancer. However, the management of patients who are free of cancer after treatment or who are living with cancer as a chronic illness is not grounded in broad consensus. “When managing chronic pain in adult cancer survivors, we need to use a multimodality plan of care that balances pharmacologic and non-pharmacologic techniques,” says Dr. Paice. “When considering analgesics, it’s critical to think about the possible adverse effects of prescribing these drugs, especially opioids.”
The ASCO clinical practice guideline notes that systemic non-opioid analgesics and adjuvant analgesics may be prescribed to relieve chronic pain and/or to improve function. Clinicians can prescribe a trial of opioids in carefully selected patients with cancer who do not respond to more conservative management and continue to experience distress or functional impairment. “A key recommendation is to assess patients who may be at risk for adverse effects of opioids,” Dr. Paice says (Table). If long-term opioid therapy is being considered because patients are having pain that is severe and disabling, clinicians are urged to evaluate their potential for opioid-related harm over time.
The guideline also notes that clinicians should use universal precautions to minimize abuse, addiction, and adverse consequences. “Many clinicians may feel inadequately trained or prepared to assess and treat pain in this patient population,” says Dr. Paice. “Accordingly, it’s important to educate all clinicians who care for these survivors on pain management.” Such educational resources are available through ASCO and other expert organizations.
“It is great news that patients with cancer are living longer, but chronic pain from treatment-related adverse effects can significantly affect the quality of life of many cancer survivors for years after their initial treatment is stopped,” Dr. Paice says. She notes that clinicians should frequently talk to patients to see how they are coping with pain and to suggest collaborative approaches to improve the management of symptoms. Survivors who understand all aspects of their pain treatment plan—and their role in this plan—may have better overall outcomes.
The understanding of chronic pain syndromes in adults who survive cancer is evolving. “We still have needs and opportunities to advance the pace and quality of pain research,” Dr. Paice says. “We need more data on the impact of pain on function and quality of life for survivors as well as studies on pharmacologic and non-pharmacologic pain interventions. In addition, data are needed to determine which cancer survivors will respond optimally to opioids and establish who is at greatest risk of adverse effects. This information will better inform patients and clinicians about how to optimize the care of chronic pain in cancer survivors.”
Readings & Resources (click to view)
Paice JA, Portenoy R, Lacchetti C, et al. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Onc. 2016 Jul 25 [Epub ahead of print]. Available at: http://jco.ascopubs.org/content/early/2016/07/19/JCO.2016.68.5206.full.pdf+html.
van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, et al. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. J Pain Symptom Manage. 2016;51:1070-1090.
Green CR, Hart-Johnson T, Loeffler DR. Cancer-related chronic pain: examining quality of life in diverse cancer survivors. Cancer. 2011;117:1994-2003.
Portenoy RK, Ahmed E. Principles of opioid use in cancer pain. J Clin Oncol. 2014;32:1662-1670.