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Treatment of Chronic Pain in Oncology: Cooperation Between the Oncologist and Psychooncologist

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Treatment of Chronic Pain in Oncology: Cooperation Between the Oncologist and Psychooncologist REVIEW ARTICLE Dariusz Pysz-Waberski1, Weronika Bulska-Będkowska2, Ewa Wachuła3 1Clinical Oncology Department, University Clinical Centre in Katowice, Poland 2Department and Clinic of Internal Diseases and Oncology Chemotherapy, Faculty of Medicine in Katowice, Medical University of Silesia in Katowice, Poland 3Oncology Clinic, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland Treatment of chronic pain in oncology: cooperation between the oncologist and psychooncologist Address for correspondence: ABSTRACT Lek. Ewa Wachuła The aim of this work is to present the problem of chronic pain in neoplastic disease as a situation requiring dia­ Klinika Onkologii, Wydział Lekarski gnosis and interdisciplinary treatment. The phenomenon of chronic pain, its types, and causes are discussed. z Oddziałem Lekarsko-Dentystycznym A discussion was held on appropriate scales for measuring pain intensity. Pharmacotherapy and psychotherapy w Zabrzu were primarily presented among the discussed treatment methods, and issues related to other methods of inter­ Śląski Uniwersytet Medyczny w Katowicach actions related to the treatment of patients with chronic pain in the course of neoplastic disease were discussed. e-mail: [email protected] The key aspect of the article is to draw attention to the implementation of multi­specialist treatment of chronic pain, including personalised solutions and the accommodation of the most favourable form of therapy and the Oncology in Clinical Practice 2019, Vol. 15, No. 4, 208–216 methods of its implementation. DOI: 10.5603/OCP.2019.0027 Key words: chronic pain, pain treatment, pharmacotherapy, psychotherapy, oncology, psychooncology Translation: dr n. med. Dariusz Stencel Copyright © 2019 Via Medica Oncol Clin Pract 2019; 15, 4: 208–216 ISSN 2450–1654 Introduction of Pain (IAPS) and the World Health Organisation (WHO), pain is “an unpleasant sensory and emotional The incidence of cancer is constantly growing both sensation caused by actual or potential tissue dam- in the world and in Poland. Malignant neoplasms are age”. This definition includes sensory (related to pain the second cause of death in Poland after cardiovascular perception) as well as emotional components (related disease. It is estimated that one in four people will die to mental reactions to a given painful stimulus). The from cancer [1]. In more than half of patients cancer is emotional component is subjective and, as mentioned in an advanced stage at the time of diagnosis and is as- earlier, it has an individual dimension for a given sociated with the presence of clinical symptoms. patient [3, 4]. In addition to anti-cancer therapy the proper diag- The following factors characterise pain as a holis- nostics and treatment of pain is one of the key aspects tic experience: of oncological care. — physiological symptoms of pain (physical dimen- Literature data show that during radical treatment, sion); as many as 30–50% of patients experience pain, and — the impact of pain on the patient’s functioning and in advanced stages this problem affects over 80% of self-care activities (functional dimension); patients [2]. — the impact of pain on emotions as well as the quantity Pain should be considered as a psychosomatic phe- and quality of social relations (the psychosocial di- nomenon, which is defined as a subjective, multi-area mension); experience that is individually felt by the person. Ac- — understanding the meaning of suffering, purpose of cording to the International Association for the Study life, worldview, life attitudes (spiritual dimension); 208 Dariusz Pysz-Waberski et al., Treatment of chronic pain in oncology: cooperation between the oncologist and psychooncologist — history of pain experiences, current experience of Pain caused by the presence pain, anxiety problems, adaptation to cancer (be- of a tumour havioural dimension) [4]. Pain is a manifestation of cancer, occurring at various The pain caused by the presence of the tumour is stages of disease, starting from being the first symptom usually mixed and consists of several types of pain with of the developing disease (primary tumour or metas- different pathomechanisms (i.e. neuropathic, somatic, tases), pain occurring during anti-cancer treatment and visceral). (oncological surgery, chemotherapy, radiotherapy, and Somatic pain affects 70–80% of patients with exist- others), up to pain at the end-stage of the disease. Pain ing tumour mass and it may be the result of irritation can also occur during remission or in cured patients as of nerve endings (nociceptors) or lowering their excit- a consequence of previous causal treatment [5, 6]. The ability threshold in the case of inflammation around results of a meta-analysis conducted in 2016 and based on tumour tissues and consequent release of inflammatory the data from over 66,000 people showed that 39.3% of mediators (e.g. prostaglandins, histamine, bradykinin) people experienced pain associated with the treatment, [11, 12]. Somatic pain derives from bones, joints, mus- 55% suffered from pain during cancer treatment, and cles, skin, or connective tissue. Pain from soft tissues is 66.4% suffered from pain in the advanced, metastatic, the result of occlusion of blood and/or lymph vessels by or terminal phase of the disease [7]. Scientific analyses the tumour and infiltration of soft tissues and serous performed in the last two decades suggest an improve- membranes. On the other hand, bone pain arises from ment in the pharmacological adequacy of analgesic the invasion of the bone marrow by the tumour, which therapy. However, almost 30% of patients still do not leads to an increase in intraosseous pressure, periosteal receive analgesics adequately to the intensity of pain [8]. distension, and proliferation of nerve fibres in the bone In the current, 11th version of the International Clas- marrow and periosteum as a consequence of nerve sification of Diseases (ICD), chronic pain is defined as growth factor (NGF) activity. Metastases in the bones persistent (continuous) or recurrent (intermittent, epi- can cause local or root pain [9]. Somatic pain is acute sodic) for more than three to six months. It does not play pain, strictly located, which increases in direct propor- the role of warning physiological nociception in acute tion to the deterioration of the local condition [13]. conditions. It is estimated that chronic pain affects about Visceral pain caused by the presence of a tumour 20% of people worldwide [6]. In response to this issue, occurs in 30% of patients [11]. It is described by patients new categories of chronic have pain emerged, including: as aching, colic, and diffuse pain. Visceral pain arises — chronic primary pain; in the organs of the digestive system due to stretching — chronic cancer pain; of the organ’s capsule, compression or pulling through — chronic post-traumatic and post-operative pain; the tumour tissue of ligaments, blood vessels, mesentery, — chronic neuropathic pain; pleura, or peritoneum. Inflammatory mediators, as in — chronic headache and mouth and facial pain; the pathomechanism of somatic pain, can stimulate vis- — chronic visceral pain; ceral nociceptors. In addition, infiltration of nerve fibres — chronic musculoskeletal pain [6]. and vessels that supply visceral organs is responsible for the development of diffuse pain [9, 11]. Neuropathic pain due to tumour expansion occurs in Types and causes of cancer pain 30–40% of patients and shows paroxysmal and stabbing features [11]. It is accompanied by breakthrough pain, The Polish Society for the Study of Pain (PTBB) that is short and very strong. It can also be characterised classifies pain in cancer according to the cause and by generalised dysaesthesia, hyperalgesia, and allodynia. distinguishes the following types of pain: Depending on primary tumour or metastases location — pain caused by the presence of primary tumour/metastases; neuropathic pain is divided into peripheral or central. — pain caused by the diagnosis and treatment of cancer; Neuropathic pain is the result of pressure or damage of — pain syndromes indirectly related to cancer or not peripheral nerves or nerve plexuses. Peripheral nerve related to oncological disease; injury is a signal for the parent’s neuron body in the — breakthrough pain [9]. spinal ganglia to activate gene expression and produc- In turn, the European Society for Clinical Oncology tion of protein particles transported to the site of injury. (ESMO), among the causes of non-tumour-related pain, ad- As a result of biochemical changes, new receptors are ditionally distinguished pain occurring in convalescents [10]. formed, which are the source of stimuli responsible for Cancer pain can also be categorised by the type of the formation of paroxysmal pain. In addition, nerve ailments: neuropathic pain (non-receptor, pathologi- damage leads to pathological synaptic connections be- cal) and nociceptive pain (receptor), which consists of tween different types of nerve fibres, contributing to the somatic and/or visceral pain [10]. incorrect sensation of stimuli (analogous to allodynia, hy- 209 ONCOLOGY IN CLINICAL PRACTICE 2019, Vol. 15, No. 4 peralgesia, dysaesthesia) [12]. In addition, neuropathic An example of a group of patients particularly exposed pain occurs in paraneoplastic syndromes (e.g. peripheral to persistent iatrogenic pain are women after radical sensory polyneuropathy, Lambert-Eaton myasthenic surgical treatment due to breast cancer and supplemen- syndrome
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