Guideline sources The following summarized guidelines for the evaluation and management of cancer pain are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2022), the American Society of Pain and Neuroscience (ASPN 2021), the European Society of Medical Oncology (ESMO 2018), and the World Health Organization (WHO 2018). 1 2 3 4 5 5 5 6 Definition Cancer pain is a common symptom associated with cancer and its treatment, and is defined as an unpleasant, multidimensional, sensory, and emotional experience related to actual or potential tissue damage. 5 Epidemiology Cancer pain can be broadly divided into pain secondary to the cancer itself (spinal cord compression, bony metastases) , pain due to chemotherapy (peripheral neuropathy, mucositis, stomatitis), pain due to radiation therapy (skin burns, mucositis) and pain associated with surgical treatment. 5 Disease course https://web.pathway.md/diseases/recI6Ki5tbITdN1Hf 1/6 6/29/23, 3:24 AM Cancer pain Pathway Cancer pain is associated with anxiety, poor quality of life and performance, and increased morbidity in cancer patients. 5 Prognosis and risk of recurrence Severe pain in non-small cell lung cancer is associated with reduced survival (HR 1.39, 95% CI 1.02-1.87). 6 Guidelines 1. Diagnostic investigations Clinical assessment: monitor pain intensity regularly using the VAS or NRS, using the question: "What has been your worst pain in the last 24 hours?". B Show 2 more 2. Medical management General principles: initiate analgesic treatment with drugs indicated by the WHO analgesic ladder appropriate for the severity of pain. B Show 4 more Non-opioid analgesics: As per ESMO 2018 guidelines, insufficient evidence to support for or against the use of acetaminophen or NSAIDs, alone or in combination with opioids, in patients with mild-to- moderate cancer pain. I As per WHO 2018 guidelines, consider offering NSAIDs and acetaminophen (alone or in combination with opioids, depending on clinical assessment and pain severity) at the stage of initiation of pain management in order to achieve rapid, effective, and safe pain control in adult (including older adults) and adolescent patients with cancer pain. B Opioids: As per ASPN 2021 guidelines, consider administering opioids in patients with moderate-to- severe cancer-related pain. B Show 4 more As per ESMO 2018 guidelines, consider administering weak opioids (such as tramadol, dihydrocodeine, and codeine) in combination with non-opioid analgesics in patients with mild-to- moderate cancer pain. C Show 13 more As per WHO 2018 guidelines, consider offering opioids (alone or in combination with NSAIDs and acetaminophen, depending on clinical assessment and pain severity) at the stage of initiation of pain management in order to achieve rapid, effective, and safe pain control in adult (including older adults) and adolescent patients with cancer pain. B https://web.pathway.md/diseases/recI6Ki5tbITdN1Hf 2/6 6/29/23, 3:24 AM Cancer pain Pathway Show 3 more Ketamine: consider administering ketamine on a case-by-case basis for refractory neuropathic, bone, and mucositis-related pain. C Corticosteroids: As per ESMO 2018 guidelines, administer dexamethasone in patients with metastatic spinal cord compression. B Prescribe dexamethasone at a dose of 8-16 mg daily. B As per WHO 2018 guidelines, consider offering adjuvant corticosteroids to achieve pain control in adult (including older adults) and adolescent patients with cancer pain. B Osteoclast inhibitors: As per ASPN 2021 guidelines: Consider offering osteoclast inhibitors as adjuvant therapy on a case-by-case basis. C Insufficient evidence to support the use of osteoclast inhibitors in patients with metastatic non- small cell lung cancer. I As per ESMO 2018 guidelines, consider offering bisphosphonates as part of the therapeutic regimen for the treatment of bone metastases in patients with a good prognosis. Consider offering bisphosphonates especially when pain is not localized or radiotherapy is not readily accessible. C Show 2 more As per WHO 2018 guidelines, offer bisphosphonates to prevent and treat bone pain in adult (including older adults) and adolescent patients with bone metastases. B Radioisotope therapy: Offer radium-223 in patients with castrate-resistant prostate cancer. A Consider offering radioisotope therapy with strontium, samarium, or rhenium in selected patients, recognizing that it may cause bone marrow toxicity. C Management of cancer-related neuropathic pain: As per ASPN 2021 guidelines: Consider administering ketamine on a case-by-case basis for refractory neuropathic pain. C Consider offering spinal cord stimulation on a case-by-case basis for chemotherapy-induced peripheral neuropathy. C As per ESMO 2018 guidelines, consider administering opioid combination therapies and carefully dosed adjuvants, when opioids alone provide insufficient pain relief, for the treatment of patients with cancer-related neuropathic pain. C Show 4 more 3. Nonpharmacologic interventions Alternative and complementary therapies (acupuncture): consider offering acupuncture in patients experiencing general pain or musculoskeletal pain from cancer. C Show 3 more https://web.pathway.md/diseases/recI6Ki5tbITdN1Hf 3/6 6/29/23, 3:24 AM Cancer pain Pathway Alternative and complementary therapies (massage): Consider offering massage in patients experiencing chronic pain following breast cancer treatment. C Consider offering massage in patients experiencing pain during palliative and hospice care. C Alternative and complementary therapies (reflexology): Consider offering reflexology or acupressure in patients experiencing pain during systemic cancer therapy. C Consider offering reflexology or acupressure in patients experiencing chemotherapy-induced peripheral neuropathy. C Alternative and complementary therapies (progressive muscle relaxation): consider offering guided imagery with progressive muscle relaxation in patients experiencing general pain from cancer treatment. C Alternative and complementary therapies (yoga): Consider offering yoga in patients with breast cancer experiencing aromatase inhibitor-related joint pain. C Consider offering hatha yoga in patients experiencing pain after treatment for breast or head and neck cancers. C Alternative and complementary therapies (hypnosis): consider offering hypnosis in patients experiencing procedural pain during cancer treatment or diagnostic workup. C Alternative and complementary therapies (music therapy): consider offering music therapy in patients experiencing surgical pain from cancer surgery. C 4. Therapeutic procedures Intrathecal analgesia: As per ASPN 2021 guidelines: Consider administering intrathecal analgesia using an implantable pump in patients with cancer-related pain not responding to or developing side effects from conventional medical management. B Consider trialing before intrathecal pump implantation for cancer-related pain at the discretion of the physician and patient, recognizing that it is not a requirement. C As per ESMO 2018 guidelines, include intraspinal techniques, delivered and monitored by a skilled team, as part of cancer pain management strategies. B Neurolysis: As per ASPN 2021 guidelines, offer celiac plexus neurolysis in patients with pancreatic cancer- related moderate-to-severe abdominal pain refractory to analgesics. A Show 4 more As per ESMO 2018 guidelines, offer celiac plexus block for the reduction of pain in patients with pancreatic cancer, with a significant advantage over standard analgesic therapy at 6 months. B https://web.pathway.md/diseases/recI6Ki5tbITdN1Hf 4/6 6/29/23, 3:24 AM Cancer pain Pathway Nerve block: consider offering nerve blocks using corticosteroids or radiofrequency lesioning of a peripheral nerve for cancer pain unresponsive to medical management. C Percutaneous radiofrequency ablation: offer percutaneous radiofrequency ablation with or without cement augmentation for the treatment of severe back pain from spinal tumors and as palliative therapy for painful spinal metastases. B Radiofrequency lesioning: consider offering radiofrequency lesioning of the dorsal root ganglion in the treatment of axial thoracic back pain from vertebral malignant metastases. B Spinal cord stimulation: Consider offering spinal cord stimulation in patients with refractory cancer pain. C Consider offering spinal cord stimulation on a case-by-case basis for pain related to cancer treatment, such as chemotherapy-induced peripheral neuropathy. C External beam radiation therapy: As per ASPN 2021 guidelines, prefer external beam radiation therapy with short, fractionated regimens over conventional protracted schedules in patients with painful metastatic bone disease. Consider offering stereotactic body radiation therapy in patients with radioresistant cancers or oligometastatic disease. A As per ESMO 2018 guidelines, offer external beam radiation therapy in all patients with painful bone metastases, using a single 8 Gy single dose. A Show 4 more As per WHO 2018 guidelines, offer single-dose radiotherapy in adult (including older adults) and adolescent patients with pain related to bone metastases. A 5. Surgical interventions Cordotomy: As per ASPN 2021 guidelines, consider offering cordotomy for uncontrolled unilateral nociceptive pain after failure of more conservative options. C As per ESMO 2018 guidelines, offer cordotomy in patients with otherwise poorly controlled cancer-related pain. B Myelotomy: offer myelotomy for infradiaphragmatic visceral pain to control pain and decrease opioid consumption. B DREZ-otomy: offer DREZ-otomy for focal limb pain and in patients with Pancoast tumor. B Cingulotomy: offer cingulotomy for late-stage and uncontrolled pain refractory to other therapies. B Vertebral augmentation: consider offering vertebral augmentation in patients with symptomatic vertebral compression fractures from spinal metastases. B https://web.pathway.md/diseases/recI6Ki5tbITdN1Hf 5/6 6/29/23, 3:24 AM Cancer pain Pathway 6. Follow-up and surveillance Management of opioid side effects: prescribe laxatives routinely for the prevention and treatment of opioid-induced constipation. A Show 5 more References 1. Fallon M, Giusti R, Aielli F et al. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018 Jul 24. Open 2. Jun J Mao, Nofisat Ismaila, Ting Bao et al. Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline. J Clin Oncol. 2022 Sep 19;JCO2201357. Open 3. Mansoor M Aman, Ammar Mahmoud, Timothy Deer et al. The American Society of Pain and Neuroscience ASPN Best Practices and Guidelines for the Interventional Management of Cancer- Associated Pain. J Pain Res. 2021 Jul 16;14 2139 2164. Open 4. No authors listed. WHO Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents. Geneva: World Health Organization; 2018. Open 5. Robert A Swarm, Amy Pickar Abernethy, Doralina L Anghelescu et al. Adult cancer pain. J Natl Compr Canc Netw. 2013 Aug;11 8 992 1022.2013 Aug;11 8 992 1022. Open 6. D Zylla, M A Kuskowski, K Gupta et al. Association of opioid requirement and cancer pain with survival in advanced non-small cell lung cancer. Br J Anaesth. 2014 Jul 1;113 Suppl 1):i109-i116.2014 Jul 1;113 Suppl 1):i109-i116. Open 7. American Society for Radiation Oncology. Choosing Wisely ASRO recommendations. Choosing Wisely. 2014. Open 8. Robert A. Swarm, Amy Pickar Abernethy, Doralina L. Anghelescu et al. Adult Cancer Pain. J Natl Compr Canc Netw. 2013 Aug; 11 8 992 1022. Open 9. Laurence Leysen, David Beckw e, Jo Nijs et al. Risk factors of pain in breast cancer survivors: a systematic review and meta-analysis. Support Care Cancer. 2017 Dec;25 12 3607 3643. Open 10. D Zylla, M A Kuskowski, K Gupta et al. Association of opioid requirement and cancer pain with survival in advanced non-small cell lung cancer. Br J Anaesth. 2014 Jul 1;113 Suppl 1):i109-i116. Open 11. Judith A Paice, Kari Bohlke, Debra Barton et al. Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol. 2022 Dec 5;JCO2202198. Open 12. Judith A Paice, Russell Portenoy, Christina Lacchetti et al. Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016 Sep 20;34 27 3325 45. Open https://web.pathway.md/diseases/recI6Ki5tbITdN1Hf 6/6