jueves, 14 de julio de 2016

Cancer Pain (PDQ®)—Patient Version - National Cancer Institute

Cancer Pain (PDQ®)—Patient Version - National Cancer Institute

National Cancer Institute



National Cancer Institute

Cancer Pain (PDQ®)–Patient Version





SECTIONS



General Information About Cancer Pain

KEY POINTS

  • Cancer, treatment for cancer, or diagnostic tests may cause you to feel pain.
  • Pain control can improve your quality of life.
  • Pain can be managed before, during, and after diagnostic and treatment procedures.
  • Different cancer treatments may cause specific types of pain.
  • Cancer pain may affect quality of life and ability to function even after treatment ends.
  • Each patient needs a personal plan to control cancer pain.

Cancer, treatment for cancer, or diagnostic tests may cause you to feel pain.

Pain is one of the most common symptoms in cancer patients. Pain can be caused by cancer, treatment for cancer, or a combination of factors. Tumors, surgery, intravenous chemotherapy, radiation therapy, targeted therapy, supportive care therapies such asbisphosphonates, and/or diagnostic procedures may cause you pain.
Younger patients are more likely to have cancer pain and pain flares than older patients. Patients with advanced cancer have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends.

Pain control can improve your quality of life.

Pain can be controlled in most patients with cancer. Although cancer pain cannot always be relieved completely, there are ways to lessen pain in most patients. Pain control can improve your quality of life all through your cancer treatment and after it ends.

Pain can be managed before, during, and after diagnostic and treatment procedures.

Many diagnostic and treatment procedures are painful. It helps to start pain control before the procedure begins. Some drugs may be used to help you feel calm or fall asleep. Treatments such as imagery or relaxation can also help control pain and anxiety related to treatment. Knowing what will happen during the procedure and having a relative or friend stay with you may also help lower anxiety.

Different cancer treatments may cause specific types of pain.

Patients may have different types of pain depending on the treatments they receive, including:

Cancer pain may affect quality of life and ability to function even after treatment ends.

Pain that is severe or continues after cancer treatment ends increases the risk of anxietyand depression. Patients may be disabled by their pain, unable to work, or feel that they are losing support once their care moves from their oncology team back to their primary care team. Feelings of anxiety and depression can worsen cancer pain and make it harder to control.

Each patient needs a personal plan to control cancer pain.

Each person's diagnosis, cancer stage, response to pain, and personal likes and dislikes are different. For this reason, each patient needs a personal plan to control cancer pain. You, your family, and your healthcare team can work together to manage your pain. As part of your pain control plan, your healthcare provider can give you and your family members written instructions to control your pain at home. Find out who you should call if you have questions.
This summary is about ways to control cancer pain in adults.

Assessment of Cancer Pain

KEY POINTS

  • You and your healthcare team work together to assess cancer pain.
  • Physical and neurological exams will be done to help plan pain control.

You and your healthcare team work together to assess cancer pain.

It's important that the cause of the pain is found early and treated quickly. Your healthcare team will help you measure pain levels often, including at the following times:
  • After starting cancer treatment.
  • When there is new pain.
  • After starting any type of pain treatment.
To learn about your pain, the healthcare team will ask you to describe the pain with the following questions:
  • When did the pain start?
  • How long does the pain last?
  • Where is the pain? You will be asked to show exactly where the pain is on your body or on a drawing of a body.
  • How strong is the pain?
  • Have there been changes in where or when the pain occurs?
  • What makes the pain better or worse?
  • Is the pain worse during certain times of the day or night?
  • Is there breakthrough pain (intense pain that flares up rapidly even when pain-controlmedicine is being used)?
  • Do you have symptoms, such as trouble sleeping, fatigue, depression, or anxiety?
  • Does pain get in the way of activities of daily life, such as eating, bathing, or moving around?
Your healthcare team will also take into account:
This information will be used to decide how to help relieve your pain. This may includedrugs or other treatments. In some cases, patients are referred to pain specialists orpalliative care specialists. Your healthcare team will work with you to decide whether the benefits of treatment outweigh any risks and how much improvement you should expect. After pain control is started, the doctor will continue to assess how well it is working for you and make changes if needed.
A family member or caregiver may be asked to give answers for a patient who has a problem with speech, language, or understanding.

Physical and neurological exams will be done to help plan pain control.

The following exams will be done:
  • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of your health habits and past illnesses and treatments will also be taken.
  • Neurological exam : A series of questions and tests to check the brain, spinal cord, and nerve function. The exam checks your mental status, coordination, and ability to walk normally, and how well the muscles, senses, and reflexes work. This may also be called a neuro exam or a neurologic exam.
Your healthcare team will also assess your psychological, social, and spiritual needs.

Using Drugs to Control Cancer Pain

KEY POINTS

  • The doctor will prescribe drugs based on whether the pain is mild, moderate, or severe.
  • Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to relieve mild pain.
  • Opioids are used to relieve moderate to severe pain.
    • Most patients with cancer pain will need to receive opioids on a regular schedule.
    • Opioids may be given in different ways.
    • Common side effects are constipation, nausea, and drowsiness.
  • Other drugs may be added to help treat your pain.

The doctor will prescribe drugs based on whether the pain is mild, moderate, or severe.

Your doctor will prescribe drugs to help relieve your pain. These drugs need to be taken at scheduled times to keep a constant level of the drug in the body to help keep the pain from coming back. Drugs may be taken by mouth or given in other ways, such as by infusion orinjection.
Your doctor may prescribe extra doses of a drug that can be taken as needed for pain that occurs between scheduled doses of the drug. The doctor will adjust the drug dose for your needs.
A scale from 0 to 10 is used to measure how severe the pain is and decide which painmedicine to use. On this scale:
  • 0 means no pain.
  • 1 to 3 means mild pain.
  • 4 to 6 means moderate pain.
  • 7 to 10 means severe pain.

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to relieve mild pain.

Acetaminophen and NSAIDs help relieve mild pain. They may be given with opioids for moderate to severe pain.
Pain relievers of this type include:
Patients, especially older patients, who are taking acetaminophen or NSAIDs need to be closely watched for side effects. See Treating Cancer Pain in Older Patients for more information.

Opioids are used to relieve moderate to severe pain.

Opioids work very well to relieve moderate to severe pain. Some patients with cancer pain stop getting pain relief from opioids if they take them for a long time. This is calledtolerance. Larger doses or a different opioid may be needed if your body stops respondingto the same dose. Tolerance of an opioid is a physical dependence on it. This is not the same as addiction (psychological dependence).
Since 1999, there have been four times the number of prescriptions written for opioids and four times the number of deaths caused by drug overdose in the United States. Although most patients who are prescribed opioids for cancer pain use them safely, a small percentage of patients may become addicted to opioids. Your doctor will carefully prescribe and monitor your opioid doses so that you are treated for pain safely.
There are several types of opioids:
The doctor will prescribe drugs and the times they should be taken in order to best control your pain. Also, it is important that patients and family caregivers know how to safely use, store, and dispose of opioids.

Most patients with cancer pain will need to receive opioids on a regular schedule.

Receiving opioids on a regular schedule helps control the pain and keeps it from getting worse. The amount of time between doses depends on which opioid is being used. The correct dose is the amount of opioid that controls your pain with the fewest side effects. The dose will be slowly adjusted until there is a good balance between pain relief and side effects. If opioid tolerance does occur, the dose may be increased or a different opioid may be needed.

Opioids may be given in different ways.

Opioids may be given by the following ways:
  • Mouth: If your stomach and intestines work normally, medicine is usually given by mouth. Opioids given orally are easy to use and usually low-cost. Oral opioids are sometimes placed under the tongue (sublingual route) or on the inside of the cheek (buccal route) to be absorbed.
  • Rectum: If you cannot take opioids by mouth, they may be given as rectalsuppositories.
  • Skin patches: Opioid patches are placed on the skin (transdermal route).
  • Nose spray: Opioids may be given in the form of a nasal spray.
  • Intravenous (IV) line: Opioids are given into a vein only when simpler and less costly methods cannot be used, don't work, or are not wanted by the patient. Patient-controlled analgesia (PCA) pumps are one way to control pain through your IV line. A PCA pump allows you to control the amount of drug that is used. With a PCA pump, you can receive a preset opioid dose by pressing a button on a computerized pump that is connected to a small tube. Once the pain is controlled, the doctor may prescribe regular opioid doses based on the amount you used with the PCA pump.
  • Subcutaneous injection: Opioids are given by injection into the fatty layer of tissuejust under the skin.
  • Intraspinal injection: Intraspinal opioids are injected into the fluid around the spinal cord. These may be combined with a local anesthetic to help some patients who have pain that is very hard to control.

Common side effects are constipation, nausea, and drowsiness.

Your doctor will discuss the side effects with you before opioid treatment begins and will watch you for side effects. The following are the most common side effects:
Drowsiness and nausea most often occur when opioid treatment is first started and usually get better within a few days.
Opioids slow down the muscle contractions and movement in the stomach and intestines, which can cause hard stools. To keep the stool soft and prevent constipation, it's important to drink plenty of fluids. Unless there are problems such as a blocked bowel or diarrhea, you will be given a treatment plan to follow to prevent constipation and information on how to avoid problems with your intestines while taking opioids.
Other side effects of opioid treatment include the following:
Talk with your doctor about side effects that bother you or become severe. Your doctor may decrease the dose of the opioid, change to a different opioid, or change the way the opioid is given to help decrease the side effects. See the following PDQ summaries for more information about coping with these side effects:

Other drugs may be added to help treat your pain.

Other drugs may be given while you are taking opioids for pain relief. These are drugs that help the opioids work better, treat symptoms, and relieve certain types of pain. The following types of drugs may be used:
There are big differences in how patients respond to these drugs. Side effects are common and should be reported to your doctor.
Bisphosphonates (pamidronate and zoledronic acid) are drugs that are sometimes used when cancer has spread to the bones. They are given as an intravenous infusion and combined with other treatments to decrease pain and reduce risk of broken bones. However, bisphosphonates sometime cause severe side effects. Talk to your doctor if you have severe muscle or bone pain. Bisphosphonate therapy may need to be stopped.
The use of bisphosphonates is also linked to the risk of bisphosphonate-associated osteonecrosis (BON). See the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information.
Denosumab is another type of drug therapy that may be used when cancer has spread to the bones. It is given as a subcutaneous injection and may help prevent and relieve pain. It is not used in certain patients, such as patients with myeloma.

Other Treatments for Cancer Pain

KEY POINTS

  • Nerve blocks
  • Neurological treatments
  • Cordotomy
  • Palliative care
  • Radiation therapy
    • External radiation therapy
    • Radiopharmaceuticals
  • Physical medicine and rehabilitation
  • Complementary therapies
    • Acupuncture
    • Hypnosis
    • Support groups
Most cancer pain can be controlled with drug treatments, but some patients have too many side effects from drugs or have pain in a certain part of the body that needs to be treated in a different way. You can talk to your doctor to help decide which methods work best to relieve your pain. These other treatments include:

Nerve blocks

A nerve block is the injection of either a local anesthetic or a drug into or around a nerve to block pain. Nerve blocks help control pain that can't be controlled in other ways. Nerve blocks may also be used to find where the pain is coming from, to predict how the pain willrespond to long-term treatments, and to prevent pain after certain procedures.

Neurological treatments

Surgery can be done to insert a device that delivers drugs or stimulates the nerves with mild electric current. In rare cases, surgery may be done to destroy a nerve or nerves that are part of the pain pathway.

Cordotomy

Cordotomy is a less common surgical procedure that is used to relieve pain by cutting certain nerves in the spinal cord. This blocks pain and also hot/cold feelings. This procedure may be chosen for patients who are near the end of life and have severe pain that cannot be relieved in other ways.

Palliative care

Certain patients are helped by palliative care services. Palliative care providers may also be called supportive care providers. They work in teams that include doctors, nurses, mental health specialists, social workers, chaplains, pharmacists, and dietitians. Some of the goals of palliative care are to:
See the PDQ summary on Planning the Transition to End-of-Life Care in Advanced Cancerfor more information.

Radiation therapy

Radiation therapy is used to relieve pain in patients with skin lesions, other tumors, or cancer that has spread to the bone. This is called palliative radiation therapy. It may be given as local therapy directly to the tumor or to larger areas of the body. Radiation therapy helps drugs and other treatments work better by shrinking tumors that are causing pain. Radiation therapy may help patients with bone pain move more freely and with less pain.
The following types of radiation therapy may be used:

External radiation therapy

External radiation therapy uses a machine outside the body to send high-energy x-rays or other types of radiation aimed toward the cancer. External radiation therapy relieves pain from cancer that has spread to the bone. Radiation therapy may be given in a single dose or divided into several smaller doses given over a period of time. The decision whether to have single or divided dose may depend on how easy it is to get the treatments and how much they cost.

Radiopharmaceuticals

Radiopharmaceuticals are drugs that have a radioactive substance that may be used todiagnose or treat disease, including cancer. Radiopharmaceuticals may also be used to relieve pain from cancer that has spread to the bone. A single dose of a radioactive agent injected into a vein may relieve pain when cancer has spread to several areas of bone and/or when there are too many areas to treat with external radiation therapy.

Physical medicine and rehabilitation

Patients with cancer and pain may lose their strength, freedom of movement, and ability to manage their daily activities. Physical therapy or occupational therapy may help these patients.
Physical medicine uses physical methods, such as exercise and machines to prevent and treat disease or injury.
Physical methods to treat weakness, muscle wasting, and muscle and bone pain include the following:
  • Exercise to strengthen and stretch weak muscles, loosen stiff joints, help coordination and balance, and strengthen the heart.
  • Changing position (for patients who are not able to move on their own).
  • Limiting the movement of painful areas or broken bones.
Some patients may be referred to a physiatrist (a doctor who specializes in physical medicine) who can develop a personal plan for them. Some physiatrists are also trained in procedures to treat and manage pain.

Complementary therapies

Complementary and alternative therapies combined with standard treatment may be used to treat pain. They may also be called integrative therapies. Acupuncture, support groups, and hypnosis are a few integrative therapies that have been used to relieve pain.

Acupuncture

Acupuncture is an integrative therapy that applies needles, heat, pressure, and other treatments to one or more places on the skin called acupuncture points. Acupuncture may be used to control pain, including pain related to cancer. See the PDQ summary onAcupuncture for more information.

Hypnosis

Hypnosis may help you relax and may be combined with other thinking and behavior methods. Hypnosis to relieve pain works best in people who are able to concentrate and use imagery and who are willing to practice the technique.

Support groups

Support groups help many patients. Religious counseling may also help by offering spiritualcare and social support.
For more information, see a list of PDQ summaries about Integrative, Alternative, and Complementary Therapies.

Treating Cancer Pain in Older Patients

KEY POINTS

  • Older patients with cancer pain may have special needs.
    • Lower doses
    • More than one chronic disease and source of pain
    • Side effects of nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Effects of opioids
    • Patient-controlled pain relief
    • Changes in living arrangements

Older patients with cancer pain may have special needs.

Some problems are more likely in older patients. For caregivers of older patients, the following should be kept in mind:

Lower doses

Pain medicine should be started at lower doses in older patients and adjusted slowly to allow for differences in their pain threshold and the ways they respond and function.
Older patients may need simpler and more frequent tests to find out how much pain they are having.

More than one chronic disease and source of pain

Older patients may have more than one chronic disease and take several drugs for different conditions. This can increase the risk of drug interactions. Drugs taken together can change how they work in the body and can affect the patient's chronic diseases.

Side effects of nonsteroidal anti-inflammatory drugs (NSAIDs)

Side effects of NSAIDs, such as stomach and kidney damage, memory problems,constipation, and headaches, are more likely in older patients.
NSAIDS and tricyclic antidepressants are not to be given to certain older patients.

Effects of opioids

Older patients may need lower doses of opioids since they are more sensitive to their effects. Lower doses of opioids may give older patients better pain relief that lasts longer than in younger patients.
Opioid doses may need to be adjusted lower when treating older patients for either acuteor chronic pain and when given by mouth, injection, or other ways.

Patient-controlled pain relief

Patient-controlled pain relief must be used carefully in older patients, since drugs are slower to leave the body and older patients are more sensitive to the side effects.

Changes in living arrangements

When older patients move (for example, from hospital to home or nursing home), their needs for pain control may change. These needs should be checked so that pain control methods can be adjusted if needed.

About This PDQ Summary

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute's (NCI's) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.
PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about the causes and treatment of pain. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change.
The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Clinical trials are listed in PDQ and can be found online at NCI's website. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”
The best way to cite this PDQ summary is:
PDQ® Supportive and Palliative Care Editorial Board. PDQ Cancer Pain. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at:http://www.cancer.gov/about-cancer/treatment/side-effects/pain/pain-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389322]
Images in this summary are used with permission of the author(s), artist, and/or publisher for use in the PDQ summaries only. If you want to use an image from a PDQ summary and you are not using the whole summary, you must get permission from the owner. It cannot be given by the National Cancer Institute. Information about using the images in this summary, along with many other images related to cancer can be found in Visuals Online. Visuals Online is a collection of more than 2,000 scientific images.

Disclaimer

The information in these summaries should not be used to make decisions about insurance reimbursement. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s E-mail Us.
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