Commentary - Journal of Cancer Immunology (2022) Volume 4, Issue 1
Cancer-Related Pain: Inside a New Dynamic Personalized Approach. A Narrative Review
Mariateresa Giglio1, Giustino Varrassi2, Filomena Puntillo1,3*
Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
Paolo Procacci Foundation, Italy
Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy
- *Corresponding Author:
- Filomena Puntillo
E-mail: firstname.lastname@example.org; email@example.com
Received date: February 01, 2022; Accepted date: February 18, 2022
Citation: Giglio M, Varrassi G, Puntillo F. Cancer-Related Pain: Inside a New Dynamic Personalized Approach. A Narrative Review. J Cancer Immunol. 2022;4(1):17-21.
Copyright: © 2022 Giglio M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Chronic cancer-related pain, according to the latest International Classification of Diseases (ICD-11), is defined as “chronic pain caused by the primary cancer itself or metastases (chronic cancer pain) or its treatment (chronic post-cancer treatment pain)” .
It is a world-wide problem with a prevalence ranging from 40% after curative treatment to 66% in advanced, metastatic, or terminal disease. In 38% of cases, it was described as moderate to severe .
Fatigue, insomnia, anxiety, and depression are all concomitant and pain-related symptoms in patients with cancer, so they are called symptom clusters  which dramatically impact on the patient’s overall quality of life and significantly affect perceived sense of well-being as well as physical and social functions . These symptom clusters can also be more debilitating for the patients than the single symptom, potentiating each other and making their clinical management complex and challenging. Almost 50% of cancer patients nowadays report their pain as inadequately controlled [5,6]. In addition, several barriers still exist in pain management, related to the lack of an adequate knowledge and education by all the figures involved (i.e., physician, patients, nurses, and pharmacists), and the adequate drugs prescription, the fear of aberrant drugseeking behaviors, the presence of regulatory constraints, the socio-economic and cultural disparities: all these factors can further contribute to suboptimal pain identification and treatment .
To overcome this problem, several expert panels have recently published guidelines and recommendations to improve diagnosis and treatment in cancer pain patients, based on the best scientific available evidence [8-10]. All these documents underline the importance of an adequate and comprehensive pain assessment that should never forget that pain is a complex multidimensional experience, involving sensory-discriminative, cognitive, emotional, and behavioral dimensions. Therefore, not only intensity of pain must be assessed, but also its duration (i.e., continuous, intermittent, or transient pain) and location (diffuse, localized, overall pain), its etiology and pathogenesis (neuropathic, nociceptive, mixed pain). Cancer related pain can arise from the mechanical or chemical activation and sensitization of nociceptors (i.e., nociceptive pain), caused by tissue compression or cancer cells mediators release which can also be amplified by immune cells recruitment (i.e., inflammatory pain).
It can also be caused by a damage or a disease affecting the nervous system (i.e., neuropathic pain), such as root compression or chemotherapy-induced neuropathy, but can also recognize, as chronic non cancer pain, a mixed phenotype, in which different pathogenetic mechanisms can overlap each other (such as bone metastasis) [11,12]. However, differently from chronic non cancer pain, cancer pain is more frequently associated with affective, motivational and cognitive component [11)]. Other aspects such as sex, age, co-morbidities, anxiety and depression, the impact on quality of life, sociocultural influence and coping strategies, should be addressed to better understand the effect of “total pain” to the whole person (Figure 1) .
Inside the New Approach for Cancer-Related Pain
Cancer-related pain can have a multimorphic behavior, since its etiology, pathophysiology, temporality, and location may vary during its natural course. Comorbidities, mood, and adaptive strategies but also cancer treatments and their related adverse effects can amplify this dynamic behavior . Pain assessment and treatment should dynamically match the multimorphic cancer related pain and should be multimodal to offer a targeted patient-centered approach. In this personalized strategy, several tools can be used simultaneously to better describe pain. Global self-rating scales such as the numerical or verbal rating scale and multidimensional questionnaires, like the McGill Pain (MPQ) and Brief Pain Inventory (BPI), can be adopted according to patient cognitive status . Moreover, neuropathic component must be documented, as well as the impact on quality of life. The Edmonton Symptom Assessment System (ESAS), that provides comprehensive and rapid assessment symptom clusters, can be useful for a comprehensive assessment of cancer patients .
In addition, physicians should investigate for basal and breakthrough cancer pain (BTcP)  in order to plan an adequate basal pain control as well as rescue doses for transient exacerbations of pain. An accurate characterization of BTcP is crucial, therefore the Breakthrough Pain Assessment Tool has been proposed to improve its diagnosis and treatment. The right formulation (i.e., rapid onset opioids), the right route (buccal vs nasal), the preemptive use in case of predictable episodes, and the correct titration strategy  are pivotal for
a tailored treatment of BTcP episodes.
Every therapeutic strategy, starting from the definition of a personalized pain goal, should be shared with the patients and their caregiver  and should be reassessed in terms of
analgesia, side effects, function and quality of life.
The WHO Ladder and Its Limits
The main accepted algorithm for cancer pain management still remains the WHO three-step analgesic ladder, which suggests non-opioids, weak opioids, and strong opioids according to pain intensity, associated or not with adjuvants . This strategy, however, raised some criticisms by several pain therapists  since its “static” nature does not combine with the real-world experience and the multifaceted and evolving nature of cancer pain. Therefore, a multimodal approach that considers pharmacological and non-pharmacological strategies (such as psychological support and physiotherapy)  but also combined interventional techniques (such as infiltrative therapy and neuromodulation) has been proposed . In addition, several different approaches to opioid prescribing, not in accordance with the historical WHO ladder, have been proposed: strong opioids at low doses can be used as first-line treatment, assuring an adequate pain control with similar incidence of adverse events in comparison to weak opioids . The implementation of the “opioid science” is still needed, as a recent Delphi survey underlined . A deep knowledge of opioids’ pharmacology is crucial. The oral route with long-acting opioids remains the first choice, while the transdermal one should be considered in those patients who cannot swallow or have an impaired gastrointestinal function or ileostomy. Short acting opioids can be useful for a rapid daily dose titration, while after titration, the combination of a long and a short acting formulation of opioid is essential to obtain a more flexible and effective treatment plan [7,10].
Also, opioid rotation or route rotation, in case of poor pain control despite appropriate dose escalations or unsafe drugdrug interactions, are suggested  and well accepted in real world pain practice . In patients not responding to the best combined available therapy or who develop untreatable side effects from conventional medical management, an intrathecal drug infusion should be considered, since this approach can allow a safe and rapid control of refractory cancer pain, with high levels of patient satisfaction [26-30]. Very recent guidelines confirmed this figure, with a level of recommendation IA, but also recommend the adoption of other techniques such as celiac plexus neurolysis in pancreatic cancer, radiation therapy in painful metastatic bone disease or vertebral augmentation in symptomatic vertebral compression from spinal metastases .
Two other points should be remembered when prescribing an opioid: the risk of abuse and the management of adverse events. Although the risk of abuse and misuse is low in oncological patients, screening tools are recommended, not to limit opioid prescription, but to identify patients at highest risk for misuse (i.e., younger patients with a prior history of abuse or with aberrant behaviors) and to tailor the pharmacologic and non-pharmacologic options in this special population .
Adjuvants and Complementary Pain Therapy
A dynamic treatment of cancer related pain in a multimodal way cannot ignore other approaches, both pharmacological and non-pharmacological.
As previously stated, the neuropathic component, related
both to cancer invasion or secondary to chemotherapy, radiotherapy or surgery, should always be considered and
treated accordingly. The prevalence of neuropathic pain is
around 40% among cancer patients , and, in the case of
chemotherapy-induced neuropathy, it involves almost 70%
of patients receiving anticancer drugs . The mechanisms
proposed are alteration of axonal transport, changes in
ion channel and receptor activities, neuronal injury and
inflammation, oxidative stress, and each chemotherapeutic
shows its specific target. However, no specific drug is
recommended for chemotherapy-induced neuropathy
prevention, therefore the mainstay of treatment still remain
anticonvulsants (gabapentinoids) or antidepressant (selective
serotonin reuptake inhibitors, serotonin-norepinephrine
reuptake inhibitors, tricyclic antidepressant) local anesthetics
or corticosteroids [10,15]. A personalized pain control strategy
passes through a combined therapy, considering synergistic
effects of these drugs on pain but also possible, preventable
adverse events, such as sedation, dizziness, or drug to drug
interaction (i.e., cytochrome inhibition).
In recent years, other integrative therapies, such as cognitive therapy  and acupuncture  are emerging as an add-on useful option in cancer patients, while data on cannabis are still conflicting. Preclinical data showed promising evidence, but human studies did not confirm that the addition of cannabis or cannabinoids is effective to treat cancer pain . Even if direct cannabinoids effect on cancer pain is not clear, their usefulness in treating some symptom cluster like anorexia or depression can make them an adjuvant option that needs to be further investigated .
Suggestions and Conclusions
The multimorphic presentation of cancer pain and its strict link with other symptom clusters such as anxiety, depression and insomnia dramatically impact on patients’ quality of life. Therefore, a holistic biopsychosocial approach is essential to pain assessment and management. This requires an interdisciplinary team management, composed by physicians, nurses, medical social workers, physiotherapists, pharmacists, and psychologists, who all together work out the best pain treatment plan for every patient. The challenge for the future will be the real-life application of this integrated care model to proactively improve the management of chronic cancerrelated pain.
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