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Cancer Pain

Assessment, Diagnosis, and Management—Cancer Pain

From Molecules to Suffering

Carr, Daniel B., MD, DABPM, FFPMANZCA (Hon)

doi: 10.1213/ANE.0b013e31821a582f
Book, Multimedia, and Meeting Reviews: Media Reviews

Saltonstall Professor of Pain Research Department of Anesthesiology Tufts Medical Center and Tufts University School of Medicine Boston, Massachusetts (Carr)

Dramatic advances have occurred in the last 25 years in our understanding of the diagnosis and treatment of cancer-related pain. However, routine pharmacotherapy for cancer pain still begins with step 1 of a 3-step ladder developed and promulgated by the World Health Organization in the 1980s. This step involves the use of aspirin or other nonsteroidal antiinflammatory drugs whose origin lies in natural products of antiquity (e.g., tree bark). Steps 2 and 3 involve the addition of progressively stronger opioid analgesics whose lineage may be traced to the medicinal use of opium extracts thousands of years ago. At any step, one may use “adjuvant” medications to augment or control the side effects of opioids or alleviate distress. Barriers to effective implementation of this simple World Health Organization ladder include scarce resources in developing economies or, in developed countries, regulatory constraints as a result of opioid abuse.

A small number of trend-setting institutions worldwide have been successful at translating emerging knowledge of the mechanisms of cancer pain into effective therapies that draw not only on the basic 3-step approach, but integrate this with other resources such as nonpharmacologic modalities and anesthetic, surgical, and radiotherapy interventions. Concurrently, self-organizing networks and collaborations within the global “pain community” have brought together scientists, clinicians, patients, and their families to study, advance, and advocate for improved control of cancer pain. A quick search in early 2011 on the website of a major online bookseller using the words “cancer pain” yielded 985 book titles. For the most part, these books are either the products of individuals or groups of academicians or formal committees convened by professional or governmental organizations concerned with the management of cancer pain.

Published last year, these 2 very different volumes have already reached the “top 10” books on cancer pain management. They represent, respectively, the product of 2 clinicians distilling decades of practice at one leading medical center, and a worldwide interdisciplinary organization summarizing a multilevel research agenda. Fitzgibbon and Loeser are both from the University of Washington, whose founding Chair of Anesthesiology, John Bonica, had a dominant role in creating the specialty of pain medicine and the founding of the International Association for the Study of Pain (IASP). IASP's mission statement is to “bring together scientists, clinicians, health care providers, and policy makers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.” On behalf of the very same IASP, Paice et al. convened a symposium in 2009 to discuss and analyze basic and clinical research surrounding the problem of cancer pain. This international group of experts assembled a volume whose rapid production is impressive given the sophistication of the individual contributions to its 20 chapters.

Although the purposes of these 2 cancer pain books differ, there is more overlap than one might expect. The textbook by Fitzgibbon and Loeser provides an up-to-date accounting of current science and technology related to cancer pain, and the illustrations include a functional magnetic resonance image of brain activation in relation to pain and suffering, thoracic positron emission topography computed tomographic scans showing tumor growth, and a 3-dimensional reconstructed color computed tomography of the pelvis showing a tumor-related pathological fracture. The basic science descriptions of mechanisms that produce bone pain related to metastases are state of the art, as are other descriptions such as the genetic basis for variability in opioid responsiveness, and the application of nanotechnology to cancer treatment. These explanations are well integrated in this comprehensive guide to the diagnosis and treatment of cancer-related pain. In keeping with this broad goal, these authors offer in-depth descriptions of important therapies that many specialists in cancer pain control might describe only superficially (e.g., radiotherapy, neurolytic blocks, spinal analgesia, stenting and drainage procedures, prophylactic antibiotic therapy in patients with ascites, and palliative neurosurgery). These topics, as well as more fundamental ones such as pharmacotherapy of pain and psychological comorbidities, are presented with abundant citations from both the classic and current literature. Given Loeser's background in the neurosurgical treatment of pain, it is no surprise that the color plates of spinal instrumentation and kyphoplasty are selected from classic publications in the neurosurgical literature. Everyday concerns for those practicing in today's complex environment are also covered, such as the detection and management of substance abuse and home care of cancer patients. Appendices A through N provide practitioners with every necessary questionnaire, template, and guidance to satisfy the needs of a comprehensive cancer center or an individual practitioner. Not limited to just pain assessment questionnaires, they also include opioid-abuse screening questionnaires, driving instructions for patients taking opioids, medical marijuana authorization, and quality of sleep assessment. One has the sense after reading through this volume that there is very little in the management of patients with cancer pain about which these 2 authors could not say, “been there, done that.” For a basic textbook authored by 2 clinicians, its combination of clinical acumen and erudite scholarship is awe-inspiring.

The IASP research volume by Paice et al. is by no means divorced from clinical practice. It is coedited by 4 accomplished clinical researchers (1 nurse and 3 physicians) each with extensive hands-on experience in the management of cancer pain. Although the expressed purpose in writing the volume was to bring together current research related to cancer pain, it contains much information with everyday clinical applicability. In contrast to the Fitzgibbon-Loeser text, this book makes no mention of anesthetic or surgical interventions. However, the chapters on opioid rotation, management of opioid tolerance, radiotherapy, and the importance of patient attention to pain as a basis for nondrug management, all provide useful pearls for busy clinicians involved in the management of acute and chronic cancer-related pain syndromes. Other chapters may not at first glance seem relevant to clinical practice, for example, those on education of healthcare providers, the design of clinical trials of analgesic medications, or reducing regulatory barriers to adequate pain control particularly in developing countries, but these topics are extremely important in caring for patients with cancer-related pain.

Inevitably, both books have some minor flaws. Neither book devotes appreciable space to the management of acute procedure-related pain even though this can be a major management problem for patients with cancer. The Fitzgibbon-Loeser book discusses the serotonin syndrome within its chapter on opioid analgesics when it would seem better placed within the chapter on adjuvant therapies (e.g., antidepressants). The authors' statement of the superior efficacy of palliative cordotomy over neuraxial opioids (p. 278) concludes with the cryptic statement that “health care is largely a social convention … and neuraxial opioids are the standard.” The implication is that patients would be better served if cordotomies were performed more frequently, yet one is left to wonder why the authors stopped short of stating that. The chapter on specialized pain management that this reader assumed would present criteria for when to refer a patient to a cancer pain specialist devotes minimal space to that topic. Instead, most of its content concerns late sequelae of cancer treatment and the gap in certification processes for expertise in cancer pain control, both topics that could be distributed among the other chapters in this monograph. As the proceedings of an international symposium, the IASP volume inevitably, deliberately even, makes no attempt to speak with a single voice, but instead presents a wide assortment of topics without achieving the clinical comprehensiveness and unifying narrative of the Fitzgibbon-Loeser book. Both volumes devote valuable space to nonessential photographs of external beam radiotherapy machines.

The strengths and the shortcomings of both volumes are well recognized by the editors. In his erudite foreword to the Fitzgibbon-Loeser text, Cahana states that “This book is not a theoretical journey … it is a story of the authors' constant desire to comfort the uncomfortable and care for those whom, sometimes, we have difficulty caring.” Sir Michael Bond, a past President of IASP, writes in his foreword to the IASP volume that “the breadth of the field [of cancer pain management] is revealed by the wide ranging topics … and the volume itself [that] are at the cutting edge of knowledge.”

In summary, the Fitzgibbon-Loeser text is a must have for anyone treating cancer pain who wants a coherent, time-tested, yet up-to-date account of exceptional clinicians' practice. The IASP text is a must have for anyone who wishes to gain an international perspective on where key research in this area is headed, including in developing countries, and who might wish to join this global effort to alleviate cancer-related pain.

Daniel B. Carr, MD, DABPM, FFPMANZCA (Hon)

Saltonstall Professor of Pain Research

Department of Anesthesiology

Tufts Medical Center and Tufts University School of


Boston, Massachusetts

© 2011 International Anesthesia Research Society