the paper throws some light on cancer pain management

1. -PAVITHRA PRABAKARAN
THIRD BDS
DAYANANDA SAGAR COLLEGE
OF DENTAL SCIENCES
Guided by
Dr.Chaya.M.David, Head Of the Department ,
Department of oral medicine and radiology
Dayananda Sagar College of Dental Sciences, Bangalore

2. CONTENTS
•DEFINITION OF PAIN
•CLASSIFICATION OF PAIN
•PAIN PATHWAY
•CANCER PAIN MANAGEMENT
•CONCLUSION

3. “Cancer can take away all of my physical
abilities. It cannot touch my mind, it cannot
touch my heart, and it cannot touch my soul.”
-Jim Valvano

4. The International Association for the Study of Pain's widely used definition
states: "Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described in terms
of such damage."
Cancer pain is associated with malignant tumors. Tumors invade healthy
tissues and exert pressure on nerves or blood vessels, producing pain.

5. CLASSIFICATION
According to Woolf, there are three classes of pain :
• nociceptive pain,
•inflammatory pain which is associated with tissue damage and the infiltration
of immune cells, and
•pathological pain which is a disease state caused by damage to the nervous
system (neuropathic pain) or by its abnormal function (dysfunctional pain, like
in fibromyalgia, irritable bowel syndrome, tension type headache, etc.).

6. PAIN PATHWAY
•Ongoing and breakthrough pain is a primary concern for the cancer patient.
•Within the cancer microenvironment, cancer and immune cells produce and
secrete mediators that activate and sensitize primary afferent nociceptors.

7. PAIN PATHWAY
•From the site of pain generation, that
is from the periphery the pain senses
are carried by Aδ and C fibres.
•Their cell bodies are situated in the
dorsal root ganglion.
•The central process of the neuron lying
in the sensory root of the spinal nerve
enter the dorsal horn to terminate the
Substantia Gelatinosa Rolandi situated
in the tip of dorsal horn.
• From the SGR, the second order
neuron arises, crosses to the opposite
side, then finally terminates at the
cerebral cortex.

8. •The neurotransmitter at the synapse between Aδ fibres and second order neuron
at SGR is glutamate while the neurotransmitter between C fibres and second order
neuron at SGR is substance P.
•The tip of dorsal horn, particularly the SGR plays a key role in modification of pain
perception.It is called a gate. As a gate can be shut /partially opened/fully opened
to control incoming traffic, so also behaves the SGR controlling the incoming
traffic of pain.

10. CANCER PAIN MANAGEMENT
It has been shown that the key elements of diagnosis and pain management
include
• detailed assessment of pain intensity and characteristics,
• appropriate use of analgesic adjuvant medication,
• use of diagnostic and therapeutic nerve blocks and myosfacial trigger point
injections and
• high index of suspicion regarding tumour recurrence pain.
There are various medical, non medical and special treatments for
cancer pain management.

11. Cancer treatments
Cancer treatments can help to reduce pain by shrinking a tumour and
reducing pressure on nerves or surrounding tissues. When cancer
treatment is given with the main aim of reducing or getting rid of
symptoms rather than curing the cancer, it is called palliative treatment.
Treatments used in this way include
•Chemotherapy
•Radiotherapy
•Hormone therapy
•Biological therapy
•Radiofrequency ablation

12. • Special pain treatments include radiation to shrink the tumour, surgery to
remove all part of the tumour, nerve blocks in which medicine is injected into or
around a nerve or into the spine to block the pain, neurosurgery where nerves
are cut to relieve the pain.
• New techniques include intrathecal drug therapy, vertebroplasty, cordotomy,
ultra sound guided nerve blocks, neuromodulation and advances in drug
therapies.

13. Non-medical treatments for pain
Non-medical treatments are now widely used to help manage cancer pain. Many
techniques are used along with pain medicine, though they can also be used
alone for mild pain or discomfort. Some people find they can take a lower dose
of pain medicine when they also use non-medical treatments. These methods
include:
•relaxation,
•biofeedback,
•imagery,
• distraction,
•hypnosis,
•skin stimulation,
•transcutaneous electric nerve stimulation (TENS),
•acupuncture,
•exercise or physical therapy, and
•emotional support and counseling.

14. DRUGS FOR CANCER PAIN MANAGEMENT
S.NO TYPE OF THE DRUG EXAMPLES USE
1) PAIN RELIEVERS ACETOMINOPHEN
and NSAIDs such as
ASPIRIN, IBUPROFEN
Relieves mild to
moderate pain.
2) NARCOTIC PAIN
RELIEVERS
CODIENE,
MORPHINE,
HYDROMORPHONE,
OXYCODONE
Relieves mild to
moderate pain
3) ANTIDEPRESSANTS AMITRIPTYLINE and
NORTRIPTYLINE
Treat pain
4) ANTICONVULSANTS GABAPENTIN and
CARBAMAZEPINE
Control burning
and tingling pain,
painful symptoms
of nerve damage
5) OTHER DRUGS CORTICOSTEROIDS
such as PREDNISONE
Used to lessen
swelling

15. ROUTES OF ADMINISTRATION

16. Radiation Therapy for Cancer Pain
•Radiation therapy is the use of X-rays to destroy cancer cells and shrink
tumors.
•Radiation damages the genetic material of cells in the area being treated,
leaving the cells unable to continue to grow.
•Although radiation damages normal cells as well as cancer cells, the normal
cells can repair themselves. The cancer cells cannot.

17. Chemotherapy or biological therapies can shrink many types of cancer to
reduce symptoms such as pain.
Hormone treatments can shrink some types of advanced cancer such
as breast cancer, prostate cancer, womb cancer and kidney cancer.
Radiofrequency ablation (RFA) uses heat made by radio waves to kill cancer
cells. The electrical energy heats up the tumour and kills the cancer cells.
You have RFA through a probe that goes through your skin into the tumour.

18. Surgery
•In some situations surgery can be used to control pain
•A surgeon may carry out an operation to take away as much of a tumour as
possible. This is called debulking.
•It can relieve pain by relieving pressure. It may also prevent complications
developing, such as a blocked bowel.

19. Epidural /Intrathecal/Spinal Anaesthesia
•The painkiller is continuously injected through a small tube (called a
catheter) into your spine. If you are having a big operation for your
cancer this may be the best way to control your pain.
This type of pain control is not a first choice to treat non surgical cancer
pain.
•But it can help some people whose pain is not controlled by other ways of
giving painkillers, such as tablets or injections.
•Sometimes a small pump is put into the fluid around the spinal cord. It
is in your back area just below the waist. It is called an implanted
intrathecal pump.

20. Nerve blocks
•This is a way of killing or deadening a nerve to stop it causing pain. There are
not usually many side effects to nerve blocks.
•There are different types of nerve block, named after the nerves that are
treated..

21. •At times it is better to cut the nerves causing the pain, rather than just inject
them. This is a small operation and you may have it done during other surgery, such
as bypass surgery.
•Pressure on the splanchnic nerves can cause continuing pain in some types of
cancer. The splanchnic nerves send signals from the spinal cord to the organs in the
chest and abdomen. Cutting the splanchnic nerve is called splanchnicectomy. It can
reduce pain for many people.

22. •Another type of nerve block is called thoracoscopic sympathectomy. A
thoracoscope is used to reach the nerves in the chest. This is a tube with a
camera, eyepiece and light that enables the surgeon to look inside the body.
•A general anaesthetic or a sedative is given. A few small cuts (incisions) are
made between your neck and breastbone. A laser or radiofrequency probe at
the tip of the thorascope to block this chain of nerves.

23. Strengthening painful bones
Cancer in the bones can make them weak and more likely to break.
This type of break is called a pathological fracture. Doctors use
special cement to strengthen them.
•Percutaneous cementoplasty
•Vertebroplasty and kyphoplasty
•Percutaneous cementoplasty
Cementoplasty means using a special cement to strengthen and
support bone. Percutaneous means under the skin, and describes how
the cement is put into the bone. It can help to relieve pain and make
the bone more stable. It has also improved walking for some people.

24. Vertebroplasty and kyphoplasty
•These are forms of cementoplasty. In vertebroplasty, bone cement is
injected into damaged bones in the spine (vertebrae). The treatment
eases pain and helps to support the spine.
•For kyphoplasty, little balloons are put into the spine. They are slowly
inflated so that the spine goes back to as near its normal height as
possible. Then special cement is injected into the space created by the
balloon.

25. Other ways of reducing pain
Here are some things to try that can help relieve your pain
•Change your position at least every two hours to prevent stiffness and sore skin
•Hot or cold packs can help relieve pain but wrap them in a soft towel to prevent
them damaging your skin
•Watching TV, reading or chatting can help to take your mind off your aches and
pains
•Relaxation
•Professional massage,Aromatherapy, hypnotherapy, acupuncture and reflexology
may all help.

26. •Talking to someone about your pain, perhaps a counsellor, can help to relieve
stress and tension and make it easier to cope
These may help you to take some control over your pain and make it seem
better for a time.
•If you can't sleep, learning relaxation exercises can be very helpful.
Remember not to get too tired. Visitors are a wonderful distraction, but it is
often better to see people for short periods of time when you are not well.

27. CONCLUSION
•Patients with cancer have diverse symptoms, impairments in physical and
psychological functioning, and other difficulties that can undermine their
quality of life.
•If inadequately controlled, pain can have a profoundly adverse impact on
the patient and his or her family.
•The critical importance of pain management as part of routine cancer care
has been forcefully advanced by WHO, international and national
professional organisations, and governmental agencies.
•To improve the management of cancer pain, every practitioner involved in
the care of these patients must ensure that his or her medical information
is current and that patients receive appropriate education.

28. BIBLIOGRAPHY
BOOKS
•Anaesthesia, intensive care and pain management for
the cancer patient
-Paul Farquha-Smith, Tim Wigmore
•Cancer Pain Management International Edition
-Michael Fisch & Allen Burton
WEBSITES
•www.cancer.org
•www.mayoclinic.org
•www.cancer.gov

29. “We may never understand illnesses such as
cancer. In fact, we may never cure it. But an
ounce of prevention is worth more than a million
pounds of cure.”
David Agus