1046 NCCN Overview Pain, defined as “a sensory and emotional experience Adult Cancer Pain associated with actual or potential tissue damage or described in terms of such damage,”1 is one of the Clinical Practice Guidelines in Oncology most common symptoms associated with cancer. Robert Swarm, MD; Amy Pickar Abernethy, MD; Cancer pain or cancer-related pain is distinct from Doralina L. Anghelescu, MD; Costantino Benedetti, MD; pain experienced by patients without malignancies. Craig D. Blinderman, MD, MA; Barry Boston, MD; Pain occurs in approximately one quarter of patients Charles Cleeland, PhD; Nessa Coyle, PhD, NP; with newly diagnosed malignancies, one third of pa- Oscar A. deLeon-Casasola, MD; June G. Eilers, PhD, APRN; Betty Ferrell, RN, PhD; Nora A. Janjan, MD, MPSA, MBA; tients undergoing treatment, and three quarters of 2–4 Sloan Beth Karver, MD; Michael H. Levy, MD, PhD; patients with advanced disease, and is one of the Maureen Lynch, MS, APRN; Natalie Moryl, MD; symptoms patients fear most. Unrelieved pain denies Barbara A. Murphy, MD; Suzanne A. Nesbit, PharmD, BCPS; patients comfort and greatly affects their activities, Linda Oakes, RN, MSN; Eugenie A. Obbens, MD, PhD; motivation, interactions with family and friends, and Judith A. Paice, PhD, RN; Michael W. Rabow, MD; Karen L. Syrjala, PhD; Susan Urba, MD; and overall quality of life. Sharon M. Weinstein, MD The importance of relieving pain and availabili- NCCN Clinical Practice Guidelines in Please Note Oncology on Adult Cancer Pain The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) are a statement of consensus of the authors regarding their views of currently accepted approach- Key Words es to treatment. Any clinician seeking to apply or consult the NCCN Clinical Practice Guidelines, NCCN Guidelines, cancer, NCCN Guidelines™ is expected to use independent medical pain, malignancy, pain assessment, pain intensity rating (JNCCN 2010;8:1046–1086) judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National NCCN Categories of Evidence and Consensus Comprehensive Cancer Network® (NCCN®) makes no Category 1: The recommendation is based on high-level representation or warranties of any kind regarding their con- evidence (e.g., randomized controlled trials) and there is tent, use, or application and disclaims any responsibility for uniform NCCN consensus. their applications or use in any way. Category 2A: The recommendation is based on lower- © National Comprehensive Cancer Network, Inc. level evidence and there is uniform NCCN consensus. 2010, All rights reserved. The NCCN Guidelines and the Category 2B: The recommendation is based on lower- level evidence and there is nonuniform NCCN consensus illustrations herein may not be reproduced in any form (but no major disagreement). without the express written permission of NCCN. Category 3: The recommendation is based on any level of Disclosures for the NCCN Guidelines evidence but reflects major disagreement. Panel for Adult Cancer Pain All recommendations are category 2A unless otherwise At the beginning of each NCCN Guidelines panel meeting, panel noted. members disclosed any financial support they have received from industry. Through 2008, this information was published in an Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical aggregate statement in JNCCN and online. Furthering NCCN’s trials is especially encouraged. commitment to public transparency, this disclosure process has now been expanded by listing all potential conflicts of interest respective to each individual expert panel member. Individual disclosures for the NCCN Guidelines on Adult Cancer Pain panel members can be found on page 1086. (The most recent version of these guidelines and accompanying disclosures, including levels of compensation, are available on the NCCN Web site at www.NCCN.org.) These guidelines are also available on the Internet. For the latest update, please visit www.NCCN.org. © JNCCN–Journal of the National Comprehensive Cancer Network | Volume 8 Number 9 | September 2010 1047 NCCN Guidelines™ Journal of the National Comprehensive Cancer Network Adult Cancer Pain ty of effective therapies make it imperative that phy- algorithm has served as an excellent teaching tool, the sicians and nurses caring for these patients be adept management of cancer pain is considerably more com- at the assessment and treatment of cancer pain.5–7 plex than this 3-tiered “cancer pain ladder” suggests. This requires familiarity with the pathogenesis of This guideline is unique in several important cancer pain; pain assessment techniques; common ways. First, it contains several required components: barriers to the delivery of appropriate analgesia; and • Pain intensity must be quantified by the patient (whenever possible), because the algorithm bas- pertinent pharmacologic, anesthetic, neurosurgical, es therapeutic decisions on a numerical value as- and behavioral approaches to the treatment of can- signed to the severity of the pain. cer pain. • A formal comprehensive pain assessment must The most widely accepted algorithm for the treat- be performed. 8,9 ment of cancer pain was developed by the WHO. • Reassessment of pain intensity must be per- It suggests that patients with pain be started on acet- formed at specified intervals to ensure that the aminophen or a nonsteroidal anti-inflammatory drug therapy selected is having the desired effect. (NSAID). If this is not sufficient, patients should be • Psychosocial support must be available. escalated to a weak opioid, such as codeine, and then • Specific educational material must be provided to a strong opioid, such as morphine. Although this to the patient. Text continues on p. 1077 NCCN Adult Cancer Pain Panel Members Natalie Moryl, MDÞ£ Memorial Sloan-Kettering Cancer Center *Robert Swarm, MD/Chairϕ£ Barbara A. Murphy, MD£† Siteman Cancer Center at Barnes-Jewish Hospital and Vanderbilt-Ingram Cancer Center Washington University School of Medicine Amy Pickar Abernethy, MD†£ Suzanne A. Nesbit, PharmD, BCPS∑ Duke Comprehensive Cancer Center The Sidney Kimmel Comprehensive Cancer Center at Doralina L. Anghelescu, MDϕ Johns Hopkins St. Jude Children’s Research Hospital/ Linda Oakes, RN, MSN# University of Tennessee Cancer Institute St. Jude Children’s Research Hospital/ Costantino Benedetti, MDϕ£ University of Tennessee Cancer Institute The Ohio State University Comprehensive Cancer Center - Eugenie A. Obbens, MD, PhD£Ψ James Cancer Hospital and Solove Research Institute Memorial Sloan-Kettering Cancer Center Craig D. Blinderman, MD, MAÞ£ Judith A. Paice, PhD, RN£# Massachusetts General Hospital Cancer Center Robert H. Lurie Comprehensive Cancer Center of Barry Boston, MD£† Northwestern University St. Jude Children’s Research Hospital/ Michael W. Rabow, MD£ University of Tennessee Cancer Institute UCSF Helen Diller Family Comprehensive Cancer Center Charles Cleeland, PhDθ Karen L. Syrjala, PhDθ The University of Texas MD Anderson Cancer Center Fred Hutchinson Cancer Research Center/ Nessa Coyle, PhD, NP£# Seattle Cancer Care Alliance Memorial Sloan-Kettering Cancer Center Susan Urba, MD£† Oscar A. deLeon-Casasola, MDϕ£ University of Michigan Comprehensive Cancer Center Roswell Park Cancer Institute Sharon M. Weinstein, MD£Ψ June G. Eilers, PhD, APRN# Huntsman Cancer Institute at the University of Utah UNMC Eppley Cancer Center at The Nebraska Medical Center KEY: Betty Ferrell, RN, PhD£# City of Hope Comprehensive Cancer Center Nora A. Janjan, MD, MPSA, MBA§ *Writing Committee Member The University of Texas MD Anderson Cancer Center Sloan Beth Karver, MD£ Specialties: ϕAnesthesiology; £Supportive Care, Including H. Lee Moffitt Cancer Center & Research Institute Palliative, Pain Management, Pastoral Care, and Oncology Michael H. Levy, MD, PhD£† Social Work; †Medical Oncology; ÞInternal Medicine; Fox Chase Cancer Center θPsychiatry, Psychology, Including Health Behavior; #Nursing; Maureen Lynch, MS, APRN£# §Radiotherapy/Radiation Oncology; ∑Pharmacology; Dana-Farber/Brigham and Women’s Cancer Center ΨNeurology/Neuro-Oncology © JNCCN–Journal of the National Comprehensive Cancer Network | Volume 8 Number 9 | September 2010 1048 Adult Cancer Pain Version 1:2010 UNIVERSAL SCREENING ASSESSMENT MANAGEMENT OF PAIN Opioid-naïve See Management of Pain in patientsa Opioid-Naïve Patients (page 1050) See Management of Pain in Opioid-Tolerant Patients, pain Pain not related to an Opioid- rating 4 (page 1052) tolerant Quantify pain intensity and Comprehensive pain assessment oncologic emergency or patientsb characterize quality (see pages 1058 and 1059) in order Pain rating 0-3 (see page 1053) ➤ See Pain Intensity Rating (pages to identify pain 1055 and 1056) ➤ Etiology If pain Ask patient to describe characteristics ➤ Pathophysiology present of pain (i.e., aching, burning, etc.) ➤ Specific cancer pain syndrome Severe uncontrolled pain is a medical (see page 1060) ➤ Determine patient goals for emergency and should be responded Anticipated comfort, function to promptly painful events See Procedure-Related Pain and Anxiety (page 1057) and procedures Screen for pain Pain related to an oncologic emergency: Rescreen at each If no pain Bone fracture or impending fracture of weight-bearing bone subsequent visit Analgesics as specified by above Brain metastases pathway in addition to specific treatment Epidural metastases for oncologic emergency (e.g., surgery, Leptomeningeal