CANCER DIAGNOSIS AND MANAGEMENT RAGHAVA R. INDURU, MD RUTH L. LAGMAN, MD, MPH, FACP Taussig Cancer Center, Cleveland Clinic Taussig Cancer Center, Cleveland Clinic

Managing cancer : Frequently asked questions

■■ABSTRACT ome 90% of patients with cancer ex- S perience pain during their illness.1 The For a variety of reasons, cancer pain is often undertreat- pain usually worsens as the disease progresses, ed, adversely affecting the quality of life for patients and and patients may experience different types of caregivers. To manage cancer pain effectively, physicians pain. need to understand its pathogenesis, how to assess it, Persistent pain decreases function, appe- how to treat it, and, in particular, how to optimize tite, and sleep, induces fear, causes depression, and generally lowers the quality of life.2 Persis- treatment. We discuss common questions faced by physi- tent pain is demoralizing and debilitating for cians in everyday practice. patients and their caregivers.3 ■■KEY POINTS Adequate pain control is important to en- sure that patients can function productively, can be used effectively for the management of maintain social relationships, and improve 2 cancer pain, provided the physician has sufficient knowl- their quality of life. Yet 86% of practicing edge, education, and training. physicians surveyed believed that most can- cer patients with pain were undermedicated,2 and most felt that pain management is unsuc- Adjuvants, if properly used, can help manage cancer pain cessful in more than half of patients who seek more effectively. help.3 The critical importance of pain manage- Complementary and alternative therapies look promising, ment has been emphasized by the World but too little is known about them, so caution is advised Health Organization (WHO), by interna- when recommending them. tional and national professional organizations, and by government agencies. All practitioners who care for cancer patients need to be well Patients should be referred to a pain clinic if they have educated in managing cancer pain, a key part intractable pain or if they have severe side effects from of which is to educate patients about the pro- opioid therapy. cess and what to expect. This results in better pain control.4 Overall improvement in patient satisfaction and quality of Although much has been written on the life can be noted when pain is effectively managed. management of cancer pain in a referral set- ting, little has been published on how to man- age it in primary care. In this article, we discuss common questions faced by generalists. We emphasize the use of opioids, perhaps the most challenging aspect of cancer pain manage- ment. We also discuss when consultation with a specialist in pain management or a palliative

doi:10.3949/ccjm.78a.10054 medicine specialist is especially helpful.

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 78 • NUMBER 7 JULY 2011 449 CANCER PAIN

Table 1 unrelated to cancer or its treatment (eg, osteo- arthritis or diabetic neuropathy).2 Common barriers to the effective use of opioids Familiarity with the causes and the types of pain, including pain related to cancer, is im- Patient-related barriers portant, as this influences treatment decisions. Reluctance to report pain Poor communication between patients and their physicians ■■ HOW IS PAIN ASSESSED? Lack of adherence to treatment recommendations Concerns about analgesic use (fear of addiction, tolerance, side effects) The assessment of pain is vital in managing it. Maladaptive beliefs (eg, that pain related to cancer is inevitable) Since pain is inherently subjective, the pa- Lack of trust in the health care system tient’s self-report is the gold standard.4 Char- Affective barriers such as anxiety, depression, mood disorders acteristics of the pain along with a physical History of side effects from opioids examination, laboratory testing, and imaging Cost