Cancer Pain

By
Humaira Ulfa Herman 1210313060
Izzatul Azmi 1310311044
Rahmi Aldila Putri 1310311083

Preseptor : dr. Beni Indra, Sp.An

Definition
• Cancer pain is remains a significant clinical problem
worldwide. Causes of cancer pain are multifactorial and
complex and are likely to vary with an array of tumor-related
and host-related factors and processes.

• Pain is an important concern in patients with cancer who are

receiving active treatment and in long-term cancer survivors. It
is one of the most feared aspects of cancer, and it can have a
major adverse impact on quality of life. It has long been
recognized that untreated or undertreated pain is common in
patients with cancer, with little evidence of recent improvement.
•WHO – World Cancer Report :10 juta
penderita baru per tahun

• Nyeri kanker : 50% pada pasien yang pertama

kali berobat dan 90% pasien stadium lanjut
Characteristics of Cancer Pain :

• Cancer can invades surrounding structures

(nerve compression, bone or visceral invasion)
• Side effects of cancer treatment (eg
chemotherapy-induced peripheral neuropathy)
• Other effects of cancer (weakness, decubitus, and
constipation)
• Other additional diagnosis (osteoarthritis)
Mechanism of Cancer pain

Consist of 2 :
(1)Noseeptive pain
results from direct stimulation of nociceptors or increased
sensitivity due to inflammatory processes, this may be
described as 'sick', or 'pulsed‘
(2) Neuropathic pain
caused by a lesion or disease of the somatosensory system

Cancer pain is a combination between nociceptive and

neuropathic pain.

For example, spinal metastasis causes localized nociceptive

bone pain and neuropathic radicular pain by compression of
nerve roots
The Principle Of Cancer Pain Management
 The principle underlying this approach is the treatment with
medication is the main management of cancer pain and will be
discussed in detailed below, but the nonpharmacologic treatment
option is also taken into consideration in management plans.
 One of the three patients would experience at least 50% pain
relief after one month after treatment.
 Via oral (by the mouth) is better than parenteral route.
It allows the patient and his family to handle simple analgesia on
their own, and can be done at home.
 Rectal or transdermal route can be done when the patient is
experiencing dysphagia, intestinal obstruction, uncontrolled vomitin
g, dizziness or because of his own choices.
 The awarding of the transdermal (with patch)
primarily effective on cancer pain that is chronic
and stable.This is preferred because the
patient feel comfortable so that it can improve
the quality of life. However, this cant be
applied on unstable pain conditions because it
requires a long time to reach steady state.
 Continuous subcutaneous infusion is another
alternative in this situation and at the terminal
phase of life, when the patient cannot swallow
anymore.
 Nonpharmacology Therapy
Psychologic Cognitive Behavioural Therapy (CBT)
Management Counselling
Supportive and Emotional Care
Music
Relaxation/hypnosis
Immobilization Splint
Slings
Radioteherapy External Beam XRT for bone metastases
Radionucleotide for metastatic bone pain (e.g., samarium)

Surgery Orthopedic pin of pathologic fracture

Colostomy for malignant bowel obstruction
Physical Therapy Physiotherapy
Lymphedema management
Massage
TENS
Mobility and home aid
Adjuvant Therapy Accupunture
 Analgesia for cancer pain should be prescribed on a regular
basis, not when needed (per requested need) . The aim is to
prevent the onset of pain, by prescribing "on the clock", with
some different pharmacokinetic agents.
 Methods developed by WHO describes a 3 step "pain
ladder“;
 step 1 providing a non opioid analgesia for mild cancer pain;
 step 2, weak opioid for moderate pain;
 step 3 strong opioid for severe pain.
 Additional-are also given for specific indications. If cancer
pain becomes more severe, takes stronger analgesics that can
still be tolerated.
 The dose may vary widely between individuals and overall is
based on how much is needed for the relief of pain.
Pharmacological management on cancer pain

1. Handling of mild cancer pain (step 1)

 Mild cancer pain is treated with non opioid analgesia, such
as paracetamol/acetaminophen, and or NSAIDS.
 Paracetamol dosage may need to be reduced, or avoided, in
those with significant hepar dysfunction due
to chemotherapy or metastases, especially if there is a
history of alcohol abuse
 Gaster toxicity due to NSAIDS can be reduced by using in
the short-effect, or the selective cyclooxygenase-2 (COX-2)
or accompanied by proton pump inhibitor or misoprostol.
 Thrombocytopenia or platelet dysfunction, usually caused
by cancer and its treatment, is contraindication of NSAIDS
usage, but not with the Selective COX-2 agents
2. Handling of Moderate cancer pain (step 2)

 Weak opioids is recommended if pain can't

be controlled with step 1. In practice,
this refers to a number
of potential low opioids (e.g. codeine, dihydr
ocodein, and dextropropooxifen)
or mixed with drugs such as tramadol.
 Tramadol is central analgesic containing
opioid and monoaminergic.
 Tramadol has a good bioavailability,
with proven effectiveness on severe
pain and especially effective in
neuropathic pain.
 Standard dose of tramadol is 50-400 mg
per day divided doses.
 When step 2 is not enough, it is
recommended to change in step
3 than combining medication on the
same step.
3. Handling of Severe cancer pain (step 3)
 The powerful opioids frequently used in step 3
are morphine, oxycodon, hydromorphin, methadon, fenta
nyl and buprenorphin.
 Pethidin (meperidin) is not recommended for long term
use because it can make accumulation
of toxic metabolites, which causes restlessness, tremors,
seizures, and mioklonus.
 There are a number of fears about a
strong opioid dependence about
the excessive sedation, respiratory depression and all of
this not found.
 Strong Opioid can be initiated at any time in cancer
patients, followed by the secure, can be increased
if required, reduced or terminated if the pain gets better.
 Morphine has been the standard opioid,
first choice for moderate to severe
cancer pain.
 Morphine is available in a number of oral
formula and can also be provided in
parenteral and rectal.
 Active metabolites may accumulate on
the State of kidney failure and can lead
to toxicity.
Start Strong Opioid
 Titration of the dose required
for initial new patients using opioids.
 The simplest method is to give a dose
of oral opioids work fast
(morphine 5 mg/5 mg/oksikodon hidromorfin 1 mg) every 8
hours, with the same doses for breakthrough pain.
 A dose of ' rescue ' may be granted per hour when needed,
so that the total daily dose needed to control pain can be
calculated.
 If pain control not adequat, the dose every 4 hours should be
increased (eg. up to 50%). Dose doubled when bedtime
usually allows a good nights sleep.
 When the 24-hour requirement is already stable, a dose of
the drug can be converted to oral formulations off slowly
(given every 12 to 24 hours depending on the formulation)
or strong opioid patch equivalent.
Tabel 3. Side effect of opioid

Often Sometimes Rarely

Nausea Hallucinations Respiratory depression

Vomiting Mood changes Delirium
Constipation Anxietas Seizures
Sedation Pruritus Hiperalgesia
Sleepy Mioklonus Allodinia
Cognitive disorder Rigiditas Spasme biliaris
Miosis Dry mouth Pulmonal non cardioge
Cough depression Stasis gaster nic edema
Rentention urine Bronchoconstriction Tolerance
Physical dependence
Addiction
Opioid Rotation
 Opioid rotation is the replacement of one opioid to
another with equivalent doses due to pain therapy do
not adequat and or unacceptable toxicity despite having
been titrated and has gained attention in controlling side
effects.
 The theoretical foundations of this practice include the
difference of individual receptors, inkomplit cross tolerance,
active metabolite pharmacokinetics and variations of
different opioid.
 The reported success of rotation varies from 40% to 80%.
table 4 lists the data equipoten of oral opioid analgesics are
common, although it is recommended that a new opioid
dose starts at 25% lower than that calculated to have
some Table.
Opioid Subcutaneous
 If the patient requires parenteral opioid, a
better path is
through continuous subcutaneous
infusion using syringe portable.
Tabel 4. Equianalgesik Dose
Opioid Dosis ekuianalgesik oral dibandingkan
dengan morfin oral 10 mg
Morfin 10 mg
Kodein 90 mg
Dihidrokodein 60 mg
Tramadol 50 mg
Pethidin 100 mg
Nalbuphin 10 mg
Oksikodon 7,5 mg
Levorphanol 2 mg
Hidromorfon 2 mg
Butorphanol 2 mg
Oksimorfon 1,5 mg
Metadon 1 mg
Corticosteroids
 The main steroid used on severe cancer
pain syndrome include pain because of
tumor induced, visceral distension, increased
of intracranial pressure, compression of the
medulla spinalis, maligna colon obstruction,
pain of bone and pinch nerve.
 Dexamethasone has the
standard dose varies from 4 to
16 mg given once per day, it's good early in
the morning.
The use of systemic anticancer on
palliative
 Systemic anticancer that use on palliative
therapy is chemotherapy, hormonal
therapy and biological agents can also be
used to control cancer pain.