Misery of cancer pain

Sadaf Mushtaq1, Hamza Waheed1, Ateeq Ur Rehman Ghafoor1, Khalid Bashir1

 

Author affiliation:

1. Department of Pain Medicine, National Hospital and Medical Center, Sector L Dha Phase 1, Lahore, Pakistan.

Correspondence: Sadaf Mushtaq; E-mail: sadaf_mirza210@hotmail.com; Phone: +923009516863

 

Abstract

 

Cancer is one of the major causes of mortality and morbidity in the world. Pain is the most debilitating and exhausting symptom of the cancer. It also has deep and intense impact on patient’s quality of life. In advanced stages of cancer, the incidence of pain approaches up to 70–80%. Cancer pain can be effectively treated by expert hands. Strong opioids are the mainstay in the WHO analgesic ladder, specifically for cancer pain patients. Unfortunately, in most of the developing countries patients with cancer pain remains under-treated because of the non-availability of strong opioids. This situation is a real challenge for a pain physician. Regardless of all the knowledge and skill, provision of effective pain relief becomes an uphill task. This editorial is an attempt to highlight the plight of the cancer pain patients and the frustration of the treating physicians. We need to strengthen and upgrade our policies and protocols to provide comfort to cancer patients.

Key words: Cancer pain; Pain Management; WHO Guidelines; Opioids.

Citation: Mushtaq S, Waheed H, Ghafoor AUR, Bashir K. The misery of cancer pain. Anaesth. pain intensive care 2022;27(1):03−05; DOI: 10.35975/apic.v27i1.2130

Received: December 13, 2022; Accepted: December 24, 2022

 

Introduction

 

Cancer has considerable influence on the communities all over the world. There are more than one hundred types of cancer and it may affect almost every part of the body. It has been one of the leading causes of human morbidity and mortality globally, and was responsible for 18.1 million new cases and 9.6 million deaths in 2018.1

According to the International Agency for Research on Cancer (IARC), in Pakistan, lips, oral cavity, lungs, and the esophageal and colorectal cancers account for an approximately 34% of all cancers diagnosed in men; while in women breast, lip, oral cavity, cervical, esophageal and ovarian cancers, attributed to more than 50% of all new cases during 2020.2 It has also been estimated that by 2040, the number of new cancer cases per year may increase up to 28.9 million and the number of cancer-related deaths may rise to 16.2 million.3

By 2030, about half of the new cases are anticipated to be reported from Asia.4

Cancer pain is a crucial public health concern that significantly impairs the physical, psychological, and social well-being of the victims. According to aa revised definition of pain by International Association for Study of Pain (IASP), pain is “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”.5 Pain is particularly common in patients with advanced cancer and often requires aggressive management. Approximately 55% of the patients undertaking anti-cancer treatment and 66% of patients having advance, metastatic or terminal disease experience pain.6

Several physiological mechanisms are involved in causing cancer pain. Pain can be from the direct mechanical effect of the tumor on the adjacent organs, bones, or nerves. It can arise secondary to the cancer treatment like chemotherapy, radiotherapy and surgery. Cancer pain can broadly be categorized as nociceptive, neuropathic, or a combination of the two. It is one of the most common and distressing symptoms reported by cancer patients.7 The fear of cancer and its psychological impact in the form of anxiety and depression exacerbates pain even further. Unrelieved cancer pain eradicates patients’ comfort and greatly affects their activities, motivation, interactions with family and friends, and overall quality of life. There is mounting evidence in oncology that quality of life and survival are linked to early and effective palliative care, including adequate pain management of cancer patients.

The main aim of pain management in cancer patients is to provide them an opportunity to lead a comfortable and admissible quality to life.

 

WHO Guidelines, For Cancer Pain Management

World Health Organization (WHO) established a step-ladder approach specifically for cancer pain patients, in 1986. It emphasizes on a step-by-step approach starting with non-opioid agents and progression to stronger opioids, with adjuvant agents incorporated including nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, antidepressants, topical agents, anxiolytics, and corticosteroids. Neuro-augmentation including brain and spinal cord stimulation, injection therapy, spinal/epidural anesthesia, and neurolytic blocks are the other advance methods of treating cancer pain. Besides pharmacological treatments, psychological, physiotherapeutic, spiritual, radio-therapeutic, neurosurgical, and social interventions also play a vital role in adequate cancer pain management. Early active multidisciplinary intervention and introduction of palliative care has shown better results in terms of symptoms’ management.

 

Barriers to adequate cancer pain management

End-of-life care is a preeminent problem for public health all over the world, but there is a wide discrepancy in cancer pain management in different parts of the world, due to availability or lack of viable palliative care models and effective pain medications. In developing countries, more than 90% of cancer patients are dying with untreated pain.8

The list of barriers includes poor coordination between healthcare professionals and the patients, misconceptions about analgesics, opioid phobia,9 inadequate assessment of pain, some religious and cultural norms and strict restrictions by the governments to control the illegal use of narcotics. Pain care in a cancer patient can be required at any stage of the disease. For treating moderate to severe cancer pain, opioids are indispensable. In fact, for a primary healthcare, oral morphine is on the World Health Organization (WHO) model list of essential medicines as well as on the list of basic essential non-communicable disease (NCD) medicines.10 Morphine is either rarely or never available in many low- and lower middle-income countries.11

 

Our limitations

Cancer pain is real and alarming but its prevalence and management has been minimally studied in Pakistan. Pain relief is a basic human right. At various local forums, certain comprehensive strategies like ‘Cancer Pain Initiative’ (CPI) for effective cancer pain management have been proposed.12 Despite being an issue of human rights and despite all the individual efforts, very few people in Pakistan are receiving the pain relief they need. According to a local survey, only one-third of the patients with advanced cancer reported adequate pain management.13 This may be due to limited knowledge about pain clinics and the pain physicians, besides other factors. In Karachi, 85 per cent of general practitioners are not familiar with the modern pain relieving technologies and more than 50 per cent of general practitioners (GPs) think that a pain physician is an orthopedic surgeon or neurologist or a family physician.14 No local data is available but it can be estimated that approximately 80% of people who are loosing life because of cancer, experience moderate or severe pain lasting on average for 90 days.15 Extensive paperwork and official obstacles deter hospitals from stocking and dispensing strong opioids hence physicians are left with very limited choices.16

Pain may be universal, but misery does not have to be. Untreated cancer-related pain is an unnecessary suffering. Increased awareness, advocacy, and healthcare policies are a critical need of the hour. Healthcare system leadership and drug regulating authorities should take effective measures to ensure easy access to the opioids and other resources required to manage pain.

 

Conclusion

 

It is important to realize that we are all humans and to acknowledge what is in our control and what is not. Curing a cancer may not be completely in our hands, as it depends on multiple factors, but effective pain management services can be offered. There may be certain acceptable limitations of our national healthcare system, but still some formidable actions need to be taken to overcome the misery of the pain patients and offer them palliative and end-of-life care.

 

Conflict of interest

None declared by the authors

 

Authors’ contribution

SM: Writing and editing the manuscript
HW: Editing the manuscript
ARG: Concept, editing and final approval
KB: Editing and final approval

 

References

 

  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jema A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394-424. [PubMed] DOI: 3322/caac.21492.
  2. Cancer fact sheets [Online]. 2020 [cited 2022 Nov 22]; Available from: URL: https://gco.iarc.fr/today/data/factsheets/populations/586-pakistan-fact-sheets.pdf.
  3. Cancer tomorrow [Online]. 2020 [cited 2022 Nov 25]; Available from: URL: https://gco.iarc.fr/tomorrow/en/dataviz/isotype ?
  4. Buchman DZ, Ho A, Illes J. You present like a drug addict: patient and clinician perspectives on trust and trustworthiness in chronic pain management. Pain Med. 2016 Aug;17(8):1394-406. [PubMed] DOI: 1093/pm/pnv083. Epub 2016 Jan 11.
  5. IASP Terminology [Online]. 2021 [cited 2022 Nov 15]; Available from: URL: https://www.iasp-pain.org/resources/terminology/.
  6. Van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. J Pain Symptom Manage. 2016 Jun;51(6):1070-1090.e9. [PubMed] DOI: 1016/j.jpainsymman.2015.12.340. Epub 2016 Apr 23.
  7. Stark L, Tofthagen C, Visovsky C, McMillan SC: The Symptom Experience of Patients with Cancer. J Hosp Palliat Nurs. 2012 Jan-Feb; 14(1): 61–70. [PubMed] PMCID: PMC3358129 DOI: 1097/NJH.0b013e318236de5c.
  8. Are M, McIntyre A, Reddy R. Global disparities in cancer pain management and palliative care. J Surg Oncol. 2017 Apr;115(5):637-641. [PubMed] DOI: 1002/jso.24585. Epub 2017 Feb 23.
  9. Graczyk M, Borkowska A, Krajnik M. Pol Arch Intern Med. 2018 Feb 28;128(2):89-97. [PubMed] DOI: 20452/pamw.4167. Epub 2017 Dec 14.
  10. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. Geneva: World Health Organization; 2020 [cited 2022 Nov 13]; Available from: URL: https://www.who.int/publications/i/item/9789240009226.
  11. Saini S, Bhatnagar S. Cancer Pain Management in Developing Countries. Indian J Palliat Care. 2016 Oct-Dec;22(4):373-377. [PubMed] PMCID: PMC5072227 DOI: 4103/0973-1075.191742.
  12. Khan TH. Cancer, cancer pain and the ‘Cancer Pain Initiative’ [editorial]. Anaesth. pain intensive care 2021;25(2):126–12. [Free full text] DOI: https://doi.org/10.35975/apic.v25i2.1459
  13. Majeed MH, Nadeem R, Khokhar MA, Qaisar MN. Adequacy of Pain Control in Patients with Advanced Cancer in Pakistan. J Palliat Care. 2019 Apr;34(2):126-131. [PubMed] DOI: 1177/0825859718800490. Epub 2018 Sep 13.
  14. Afshan G, Hussain AM, Azam SI. Knowledge about Pain Clinics and Pain Physician among General Practitioners: A Cross-sectional Survey. Pain Ther 2013;2:105–111. [PubMed] PMCID: PMC4107916 DOI: 1007/s40122-013-0014-y.
  15. Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X et al. Alleviating the access abyss in palliative care and pain relief – an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018 Apr 7;391(10128):1391-1454. [PubMed] DOI: 1016/S0140-6736(17)32513-8. Epub 2017 Oct 12.
  16. Lebaron V, Beck SL, Maurer M, Black F, Palat G. An ethnographic study of barriers to cancer pain management and opioid availability in India. Oncologist. 2014 May; 19(5): 515–522. [PubMed] PMCID: PMC4012971 DOI: 1634/theoncologist.2013-0435.