What is the recommended approach for managing tumor-related pain?

From the Guidelines

The recommended approach for managing tumor-related pain involves a stepwise strategy following the World Health Organization's analgesic ladder, as outlined in the most recent guidelines from 2019 1.

Key Principles

The management of cancer pain is complex and requires a comprehensive approach.

• Pain intensity must be quantified by the patient, and a formal comprehensive pain assessment must be performed.
• Reassessment of pain intensity must be performed at specified intervals to ensure that the therapy selected is having the desired effect.
• Psychosocial support must be available, and specific educational material must be provided to the patient.

Stepwise Approach

Begin with non-opioid medications like acetaminophen (500-1000mg every 6 hours) or NSAIDs such as ibuprofen (400-800mg every 6-8 hours) for mild pain.

• For moderate pain, add weak opioids like codeine (30-60mg every 4-6 hours) or tramadol (50-100mg every 4-6 hours).
• Severe pain requires strong opioids such as morphine (starting at 5-15mg every 4 hours, titrated as needed), oxycodone, or hydromorphone.

Adjuvant Medications

Adjuvant medications are essential for specific pain types:

• Gabapentin (300-1200mg three times daily) or pregabalin (75-300mg twice daily) for neuropathic pain.
• Corticosteroids like dexamethasone (4-16mg daily) for inflammatory pain or when tumors cause pressure.
• Bisphosphonates for bone pain.

Ongoing Management

Regular pain assessments using standardized scales help guide treatment adjustments, while managing opioid side effects (constipation, nausea) proactively improves adherence and quality of life, as supported by recent guidelines 1. This multimodal approach targets different pain mechanisms simultaneously, providing more effective relief with fewer side effects.

From the FDA Drug Label

Fentanyl transdermal system is indicated for management of persistent, moderate to severe chronic pain that: requires continuous, around-the-clock opioid administration for an extended period of time cannot be managed by other means such as non-steroidal analgesics, opioid combination products, or immediate-release opioids The recommended approach for managing tumor-related pain is to use fentanyl transdermal system for patients who are already receiving opioid therapy, have demonstrated opioid tolerance, and require a total daily dose at least equivalent to fentanyl transdermal system 25 mcg/hr.

• Patients should be opioid-tolerant, meaning they have been taking at least 60 mg of morphine daily, or at least 30 mg of oral oxycodone daily, or at least 8 mg oral hydromorphone daily, or an equianalgesic dose of another opioid.
• The dose of fentanyl transdermal system should be individualized based on the patient's previous opioid use and titrated to achieve adequate analgesia.
• Fentanyl transdermal system should be used with caution in elderly, cachectic, or debilitated patients due to altered pharmacokinetics. 2 2

From the Research

Tumor-Related Pain Management

• Tumor-related pain is a common symptom experienced by 30% to 50% of all people with cancer, with moderate to severe pain having a major negative impact on their quality of life 3.
• The World Health Organization (WHO) cancer pain treatment ladder recommends non-opioid drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), for cancer pain management, either alone or in combination with opioids 3, 4.

Pharmacological Management

• NSAIDs are commonly used to treat cancer pain, with studies suggesting that they can reduce pain intensity in some patients with moderate or severe cancer pain 3, 5.
• However, the evidence for the use of NSAIDs in cancer pain management is of very low quality, and there is no high-quality evidence to support or refute their use alone or in combination with opioids 3.
• Opioids are also used to manage cancer-related pain, with the WHO guidelines recommending their use based on pain intensity and opioid responsiveness 4.

Non-Pharmacological Management

• Non-pharmacological therapies, such as radiation therapy and interventional procedures, can also be used to manage cancer-related pain 6.
• Adjuvant analgesics and interventional pain techniques can be integrated into the management of cancer-related pain to improve patient outcomes 4.

Key Considerations

• Assessment of pain requires measurement of pain intensity, delineation of opioid responsiveness, and clarification of the impact of pain on a patient's psychological, social, spiritual, and existential domains 4.
• Healthcare professionals should follow the WHO guidelines to manage cancer-related pain, paying attention to detail and identifying potential adverse events 4.
• The role of NSAIDs in cancer prevention and promotion is complex, with some studies suggesting that they may decrease the risk of certain types of cancer, while others suggest that they may have negative effects 5, 7.