Surabhi Dangi-Garimella, PhD
There is no arguing that cancer survivors are growing in numbers thanks to better access to screening, development of targeted therapies, and increased awareness among providers as well as patients about precision medicine, among other reasons. Just last month, the National Cancer Institute predicted that there would be a substantial increase in the number of older cancer survivors over the next 25 years.
However, cancer survivors often face significant comorbidities and health issues that are associated with the treatment they received to control their cancer—chronic pain is one such side effect reportedly faced by as many as 40% of survivors that can have a significant bearing on their quality of life. Predictors of pain include type and invasiveness of the tumor, the treatment regimen used, the time since cancer treatment, and the efficacy of initial pain therapy.
An expert panel convened by the American Society of Clinical Oncology (ASCO) has issued a new clinical practice guideline on management of chronic pain in adult cancer survivors. These guidelines are mean to guide the exclusive management of survivors of chronic pain, as opposed to several existing recommendations for acute pain or for treating pain in patients with advanced disease.
“Many oncologists and primary care physicians are not trained to recognize or treat long-term pain associated with cancer, said Judith A. Paice, PhD, RN, a co-chair of the ASCO expert panel that developed the guideline, in an associated press release. “This guideline will help clinicians identify pain early and develop comprehensive treatment plans, using a broad range of approaches.”
The following are key recommendations by the committee:
1. Screening and Assessment
- Clinicians should screen for pain at each encounter using a quantitative or semiquantitative tool.
- Clinicians should conduct an initial comprehensive pain assessment, which should include an in-depth interview to capture the multidimensional nature of the pain, captures information about cancer treatment history and comorbid conditions, psychosocial and psychiatric history, and prior treatments for the pain.
- Physicians should be well aware of chronic pain syndromes and suitable treatment options.
- In case of new-onset pain, the patient should be evaluated for recurrent disease, second malignancy, or late-onset treatment effects.
2. Treatment and Care Options
- The patient’s comfort, functionality, and safety should be the physician’s priority.
- Patients and their caregivers should be actively engaged in pain management.
- For patients with complex needs, collaboration with other physicians for pain management is encouraged.
- Recommended systemic pharmacologic interventions:
- Nonsteroidal anti-inflammatory agents
- Adjuvant analgesics
- Topical pharmacologic interventions such as analgesics are recommended
- Corticosteroids are not preferred for long term pain management.
- Risk of adverse events with pain therapies should be monitored.
- Patients may be provided nonpharmacologic interventions, such as physical medicine and rehabilitation, integrative therapies, interventional therapies, psychological approaches, and neurostimulatory therapies.
- Physicians are advised to consider opioids as an option for pain management only in those cancer survivors who do not respond to conventional care. Additionally, risk of adverse events in those given opioids for pain management is emphasized.
3. Risk Assessment, Mitigation, and Prevention With Opioid Use
- Physicians are advised to assess risks and benefits with long-term opioid use.
- Clinicians need to monitor survivors for tolerance, dependence, abuse, and addiction as it relates to the use of opioids for pain control.
- Minimizing abuse and risk of opioid-related death should be the physician’s priority.
- Physicians should be well aware of pertinent laws and regulations, and should also educate patients and their families regarding the risk and benefits of opioids, and the safe storage of controlled substances.
“Of great importance is the attention to appropriate assessment, not only of the individual’s pain, but also of their potential for over-reliance on opioids,” Paice said. “This guideline outlines precautions that help ensure cancer survivors with persistent pain use opioids safely and effectively, while limiting access to those who are struggling with addiction.”
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 [published July 25, 2016]. J Clin Oncol. doi: 10.1200/JCO.2016.68.5206.