



Communicating About Cancer Pain

Pain can be a harsh reality of cancer. Cancer pain can be caused by a tumor or related to treatment such as radiation and chemotherapy. When surgery is indicated, postsurgical pain is also a consideration.

Studies show that anywhere from 30 to 50 percent of patients who undergo active treatment for cancer and 70 percent of those with advanced stages of the disease experience significant pain and may be reluctant to discuss their pain with their doctors.

Not all pain experienced by cancer patients is due to the cancer itself. "About 75 percent of the pain encountered in cancer patients is due to the cancer, while the balance results from treatments and procedures, such as neuropathic pain following a mastectomy," said Dr. Ann Berger, chief of the Pain and Palliative Care Service at the National Institutes of Health Clinical Center. "Cancer patients might also have migraine headaches, arthritis, or other medical conditions unrelated to their cancer that also need to be treated."

Clinicians have designed scales to help patients communicate their pain levels. If the pain is described as shooting down a leg or a tingling sensation in the hands or feet, this information can be crucial to determining the appropriate therapy. "A significant advance is that the Joint Commission on Accreditation of Healthcare Organizations now requires physicians to ask patients about pain," noted Dr. Berger. "Pain is now the fifth vital sign, like blood pressure and temperature. Physicians are required to ask patients more often about their pain."

"Patients have also stated that they don't discuss pain symptoms for fear that it will distract from talking about treating their disease," said Dr. Ann O'Mara, a program director at NCI's Division of Cancer Prevention. "Patients can be hesitant to discuss their pain due to fear that the pain is a sign that the cancer has returned."

NCI is sponsoring research that examines the barriers that prevent patients from talking about pain and their symptoms. "Patients must become empowered. When it comes to pain and symptom management, they have an important role," commented Dr. O'Mara.

In one study, researchers developed an assessment questionnaire to help patients report their symptoms. The study's goal is to determine the most effective method of enabling patients and doctors to broach the subject of pain, resulting in improved symptom management.

NCI is attempting to dispel the many myths about cancer and pain. One prevalent belief is that cancer is always associated with chronic, unrelieved pain. While many cancer patients will experience some level of pain during or after their treatment, it can be relieved in 80 to 85 percent of patients. The remaining 15 to 20 percent experience pain that can be difficult to resolve. But, even the most intractable pain can be relieved to some degree.

Another common belief - held by many cancer patients, their families, and some physicians - is that treating cancer patients for pain can lead to addiction. "Many people misunderstand the difference between addiction and physical dependence," noted Dr. O'Mara. "Addiction is a chronic, psychological state with contributing genetic and environmental factors. It is characterized by impaired control over drug use, compulsive use, craving, and continued use despite harm. Physical dependence, on the other hand, is an expected outcome with chronic use of narcotics. When the drug is abruptly withdrawn, a patient may experience specific physical reactions. However, after treatment and the cancer resolves, the dose of pain medication should be slowly decreased, enabling a patient to withdraw from the drug without side effects."

Treating pain requires constant reassessment. Clinicians should ask specific questions of their patients. It may not be sufficient to just ask, "How are you doing today?" For proper assessment, clinicians need to help patients verbalize the impact that pain is having on their daily lives. Dr. O'Mara suggested more specific questions, such as, "How have you been sleeping, what is the level of your fatigue, or how is pain affecting your work routine?"

"Just giving a pain medication is not enough. There must be continuous discussion with the patient to determine how the medication is working and how they are coping," concluded Dr. O'Mara.

By Lynette Grouse and
Dorie Hightower