Advances in diagnosis and treatment of cancer have led to better survival. It is estimated that by 2030 the number of people living with a diagnosis of cancer will be over four million in England.1 It is increasingly recognised that many cancer survivors live with the cumulative burden of toxicity from treatment and the cancer itself. A systematic review reported that the prevalence of pain in patients with cancer after curative treatment was 33%, and in patients currently undergoing anticancer treatment was 59%, with over 30% reporting moderate or severe pain.2 Pain in cancer survivors can have multiple aetiologies (Box 1).
Inflammatory and neuropathic mechanisms both have a role in cancer pain and these can lead to hypersensitivity of spinal cord sensory neurons. In turn, this can cause unique neuronal function reorganisation within the spinal cord and change central modulation leading to emotional and affective responses to pain.3 A cross-sectional study of chronic, stable, multiple myeloma patients showed positive correlations between pain, insomnia and appetite loss, and circulating levels of the cytokine interleukin-6 which has a role in the pathophysiology of multiple myeloma and is related to disease activity.4
Cancer survivors may have a range of under-diagnosed and poorly-managed symptoms, including pain. These symptoms can persist for years after treatment, reducing quality of life and, for some, preventing return to work or hobbies.
Assessing pain in cancer survivors
Early identification and assessment are vital for optimal, individualised pain management in cancer survivors. A detailed history to determine the aetiology and impact of pain, including previous analgesic regimens (efficacy, toxicity and adherence), together with a review of the general medical records will help clinicians manage pain. Cancer survivors are at risk of recurrent disease or second primary cancers, so if new pain develops these possibilities must be carefully assessed.
A neuropathic pain grading system has been developed to help characterise pain that has a suspected neuropathic element and this can be applied to cancer pain.5
Pain can have a negative impact on physical, mental, emotional, spiritual and social wellbeing, which influences quality of life. A holistic model of care is needed, centred on treating the person (and possibly the family) as a whole. Conducting structured holistic needs assessments at key stages – cancer diagnosis, during anticancer treatments, in survivorship – will help healthcare professionals understand and manage patients’ concerns, and educate where appropriate.6
Managing pain in cancer survivors
Although many cancer survivors will be discharged from hospital follow-up and are mainly under the care of general practitioners, a multidisciplinary approach is needed to tackle all aspects of chronic pain. Regular follow-up is required to titrate analgesic doses, monitor side effects and signpost patients to other agencies such as chronic pain clinics, cancer survivorship teams and palliative care services, where appropriate.
The National Comprehensive Cancer Network released guidelines for survivorship in 2013, and one aspect covered was pain; however, there is limited research on pain management in cancer survivors.7 The management of pain in cancer survivors follows the same principles as for those in earlier stages of cancer, including the consideration of further radiotherapy or antineoplastic treatment if recurrent disease is the cause. In some patients, it might be appropriate to continue or commence opioid analgesics. However, a recent systematic review of opioid use in adult patients with cancer showed that opioids were likely to be associated with shorter survival.8 Moreover, opioids have side effects including sedation, constipation and possible physical dependence and tolerance.
The suitability of other pharmacological therapies depends on the cause of pain. For example, there is evidence for the use of duloxetine in chemotherapy-induced peripheral neuropathy.9 Non-pharmacological treatments such as acupuncture and manual therapy might be helpful alongside pharmacological agents in alleviating pain.
Chronic pain is a common problem in cancer survivors. Comprehensive pain assessments are necessary to evaluate the pain, identify other psychosocial and emotional aspects and tailor treatment to the individual’s needs. Managing pain holistically can reduce the impact on patients’ quality of life and improve their recovery. Cancer survivors should be involved in their personalised management plan, educated about treatment options and included in discussions about their concerns.
Date of preparation: November 2015; MINT/PAEU-15022