CANCER PAIN

Cancer type Ratio of patients with pain (%)

Bone 85
Oral cavity 80< br /> Genitourinary (Male-Female) 75-78
Breast 52
Lung 45
Gastrointestinal 40
Lymphoma 20
Leukemia 5

70% of cancer pain is pain caused by the disease.

Table 2: Causes of cancer-related pain in cancer patients
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• Bone invasion,
• Compression on nerve roots and plexuses,
• Tumor infiltration into nerve tissue
• Vascular infiltration and occlusion,
• Fascia, periosteum and Infiltration of other pain sensitive structures
• Infection and inflammation of the mucous membrane and other pain sensitive structures

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25% of the pain /strong>i may occur depending on some approaches used in cancer treatment. .

Table 3: Non-cancer causes of pain in cancer patients
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• Surgery-related pain
• Acute postoperative pain
• Chronic pain (pain after mastectomy, pain after thoracotomy, phantom pain, pain due to lymphedema)
• Pain due to chemotherapy
• Acute (gastrointestinal, mucositis, myalgia, joint pain, cardiomyopathy, pancreatitis and pain resulting from extravasation)
• Chronic (peripheral neuropathy, steroid pseudorheumatism, aseptic bone necrosis and postherpetic neuralgias)
• Radiotherapy-related pain
• Acute (pains resulting from skin burns, gastrointestinal pains, proctitis, mucositis)
• Chronic (e.g. osteonecrosis, radiation fibrosis, keratitis, demyelination, pneumonia, intestinal ulceration and obstruction, pain due to myelopathies)

Various studies emphasize the inadequacy of pain-related treatment in 50-80% of patients suffering from cancer pain. However, it is possible to achieve success in 90% of patients suffering from cancer pain with simple pharmacological methods.

Cancer pain can be nociceptive or neuropathic in character. Pain of a nociceptive character is at the forefront in patients where nerve conduction is involved, and pain of a neuropathic character is at the forefront in patients where the nervous system is affected. When nociceptive pain originates from highly innervated superficial areas, it is well localized and is called somatic pain. Visceral pain, on the other hand, originates from diffusely innervated organs and cannot be well localized.

The cause of neuropathic pain may be direct pressure on the nerves, tumor invasion of the nerves, chemotherapy, viral infections or surgical trauma.

Apart from the physical characteristics of cancer pain, the psychological and social consequences are also factors that affect the patient's quality of life. Therefore, it is important to control psychological and social effects during the treatment phase. Evaluation and re-evaluation are of great importance in the treatment of cancer pain. This is useful both for monitoring the effectiveness or inadequacy of the treatment and for the progression of the disease. It is important in terms of recognizing pains of different localization and character. Pharmacological approaches, physical methods, neurolytic blocks, cognitive and behavioral approaches, and intraspinal analgesics and co-analgesics can be used in treatment.

There are also some obstacles to the appropriate approach to cancer pain. The most important of these is the patient's fear of drug addiction. This hesitation manifests itself in physicians as confusion between psychological and physical addiction, ignorance about pharmacological tolerance, and exaggerated expectation of side effects. The inadequacy of prophylactic and therapeutic approaches to an opioid side effect to which tolerance does not develop, such as constipation, also poses an obstacle to appropriate analgesic treatment approaches in cancer patients. Non-adherence to ongoing treatment protocols and lack of routine cancer pain evaluation are also factors that reduce the effectiveness of treatment.

Patient evaluation must be made with the cooperation of the patient, his family and healthcare personnel. When determining the treatment method, it is of great importance to make the decision together with the patient and his family, to ensure the active participation of the patient in the treatment, to inform the patient about the side effects, and to obtain the opinions of the relevant departments with an interdisciplinary approach regarding pain in the evaluation before the treatment plan.

Clinical In addition to detailed history and physical examination, psychosocial evaluation should also be performed in the evaluation.

Evaluation of pain is also difficult in cancer patients because it is a subjective symptom. It is necessary to determine the location of pain, its severity, its character, factors that increase and decrease it, behavioral responses and treatment targets.
In the treatment of pain, the stepwise pain treatment recommendations put forward by the World Health Organization in 1986 are accepted all over the world and vary from center to center and from country to country. can be modified according to differences in approach (Figure 1).

Figure 1: Three-step pain treatment recommendations of the World Health Organization

Agents that can be used in the first step They are nonsteroidal anti-inflammatory drugs. The dosages of the most commonly used are listed below:

• Acetaminophen
• ASA
• Ibuprofen
• Dexketoprofen
• Diclofenac
• Diclofenac (long-acting)
• Indomethacin
• Naproxen
• Ketorolac

Weak opioids and combinations that can be used in the second step:

• Codeine + Acetaminophen
• Codeine + ASA
• Tramadol
• Tramadol

The agents used in the third step are strong opioids. . The most commonly used of these is morphine. Morphine does not have a ceiling effect like nonsteroidal anti-inflammatories and there is no upper dose limit in treatment. The transdermal form of fentanyl is also a preferable opioid due to its ease of use. Opioid rotation, especially when high doses are increased, may allow the use of lower equivalent doses. Meperidine should not be used in patients with chronic cancer pain due to its short duration of action and its neurotoxic metabolite normeperidine.

Opioids can be administered in different ways. These are:

• Oral
• Rectal
• Transdermal fentanyl
• Intermittent injection
• Continuous infusion
• Patient-controlled analgesia
• Intraspinal

The most common side effects that may occur due to opioids are constipation, nausea, vomiting, drowsiness. , dry mouth and sweating. Dysphoria, delirium, bad dreams, hallucinations, itching, urticaria, urinary retention, myoclonic movements, seizure, and respiratory depression are less common side effects.

Adjuvant drugs that can be used at every stage of treatment are corticosteroids and anticonvulsants. , antidepressants, neuroleptics, local anesthetics, antihistamines and psychostimulants. In many centers, in cases where this three-step treatment is not sufficient, more invasive interventions are included as the fourth step. Among these, parenteral opioids are a method that can be used especially in the treatment of acute and severe exacerbation pain. Epidural and intrathecal opioids can be used to treat cancer pain with many different pumps and ports. Patients to whom these devices will be placed should be selected very carefully and the use of pumps or ports should be taught very well. Life expectancy plays a role in the selection of such devices. Features It is recommended to use lower cost port or catheter systems for patients with short life expectancy. Neuroablation techniques are also frequently applied in cancer patients. Peripheral and sympathetic neurolytic blocks may be preferred depending on the location of the pain. For cancer pain, splanchnic, celiac, superior hypogastric and impar ganglion blocks can be applied. Apart from these, in case of unilateral pain, cordotomy can be performed surgically or with percutaneous computed tomography guidance.

Table 4: Neurolytic Blocks

Place in the nervous systemRelevant anatomical structures

Stellar ganglion Head, meninges, arm, eye, ear, tongue, neck, larynx, pharynx

Gasser ganglion Face/mouth, typically associated with trigeminal neuralgia

Sympathetic chain

Upper Head and arms

Middle-Thorax heart, lung, esophagus, bronchi, pleura, trachea, pericardium

Lower bladder, intra-abdominal organs, uterus

Celiac plexus (splanchnic nerves) Pancreas, abdominal vessels, transverse from the esophagus

to the colon, liver, adrenals, ureters
Lumbar sympathetic chain Lower extremity vessels and skin, ureters, kidney, testicle

Hypogastric plexus Uterus, ovaries, vagina, bladder, prostate, testicle, descending and sigmoid colon, vesicle seminalis
Impar ganglion (Walther ganglion) Perineum, rectum, anus, vagina, distal urethra, vulva


Physical methods that can be applied in the treatment of cancer pain are hot-cold application, massage, pressure, vibration, exercise, changing position and immobilization. In addition to these, transcutaneous electrical stimulation method (TENS) can also be a supportive treatment approach.

Psychosocial techniques that can be used; cognitive and behavioral approaches, relaxation, hypnosis, cognitive reflection and shaping, patient education and psychotherapy.

Chemotherapy, radiotherapy and surgical methods used for the treatment of cancer also contribute to the reduction of pain with the tumor-shrinking effects they provide.

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As a result, there are many different approaches to improving the patient's quality of life in the treatment of cancer pain. In these patients, the location, severity, character of the pain, type of cancer and the psychosocial status of the patient are taken into consideration.

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