Cancer vs Noncancer Pain: Time to Shed the Distinction? – Charles E. Argoff, MD – July 23, 2013
What exactly is the difference between chronic cancer-related pain and chronic non-cancer-related pain?
are we helping ourselves by making a clear dichotomy when the dichotomy may not exist in a chronic setting? Let’s talk about acute pain related to cancer.
If someone has a cancer-related surgery, direct tumor involvement, or a procedure related to a cancer-related matter and develops pain for several weeks, that can be attributed to various processes associated with cancer, depending upon the type of pain.
Similarly, if someone sprains his or her ankle and has several weeks of acute pain not related to a cancer-related process (a sports injury, for example), that ankle sprain is clearly not cancer-related.
But let’s think about the patients whom we are seeing on a regular basis in our practices and who are seeking help. Do we help those people by thinking that we can put them into neat boxes and make a dichotomy between cancer-related and non-cancer-related pain?
Let’s think about a woman with breast cancer who has persistent pain after being cured of her cancer with radiation following surgery and chemotherapy. Those therapies led to her being cured, and she has been in remission for more than 10 years.
She has been told that she is cured, and she nevertheless continues to experience very severe pain, especially in her distal lower extremities, compromising her quality of life. Would this be chronic cancer-related pain?
Is Chronic Pain Just Chronic Pain?
What about the next scenario? Another woman with breast cancer has persistent pain associated with radiation and chemotherapy-related treatment 20 years after her treatment. Over the past few years, she has developed diabetes apparently unrelated to her breast cancer history, and now has diabetic neuropathy-related symptoms. Would we approach her as having a mixture of cancer- and non-cancer-related pain?
How would that influence our ability to help her? Would we choose different treatments because of her history of cancer?
Is it still cancer-related 15 or 20 minutes after the cancer has been cured?
This is exactly the question I have been asking: what exactly is the difference between
- cancer-related pain before the cancer is cured
- cancer-related pain after the cancer has been cured?
How would we treat a patient who is in the same situation of persistent pain from breast cancer radiation therapy and chemotherapy who now has developed significant osteoarthritis, perhaps unrelated to her history of breast cancer?
Contrast that with an individual without cancer-related issues who also develops, over time, chronic pain due to diabetic neuropathy or who may develop chronic pain associated with osteoarthritis or a motor vehicle accident
the US Food and Drug Administration (FDA) has approved analgesics specifically for the treatment of cancer-related pain, and particularly for breakthrough pain, and these medicines are now available for these indications.
in at least several of those studies leading to FDA approval, there was no requirement to prove that the individual who was enrolled in that study had active cancer.
It’s time to consider not focusing on a dichotomy between cancer- and non-cancer-related pain, but realize that there are ways to approach each category of pain and that in fact, the categories of pain are often not distinct categories.
Many people may have lingering effects of cancer-related treatments that are not clearly related to active cancer.
A Universal Approach
There are many permutations that have to be considered, and so it’s extremely important to take a universal approach to the safest and most effective ways of helping people and recognize that some of the guidance we receive, and some of the medicines that are available for so-called cancer-related pain, may not have been studied in individuals who had active cancer.
People may have pain related to an effect of their cancer, although they don’t have active cancer.
We aren’t dealing with the kind of specificity and sensitivity that might be possible when treating patients with specific diseases, when we can target and pick treatments for a specific process. By using strict categories, such as “cancer-related” and “non-cancer related,” we suggest that we can do the same with pain, when in fact our understanding of those processes may be very blurred.
We should evaluate our patient’s past, including cancer and non-cancer-related history; review the best available literature and information about what is best for those groups; and keep in mind that some of the studies of “cancer-related pain” may have been in individuals who don’t have active cancer.
We need to realize that we still have significant barriers to pain management, and that this dichotomy is not helping at all; it’s only increasing those barriers. We need to address healthcare professional-related concerns about managing people with pain.
Approaching somebody with cancer-related pain as if they are somehow “above” the concerns that we would have for a patient with non-cancer-related pain with respect to opioid or other analgesic prescribing (concerns about misuse, abuse, not adhering to the regimen appropriately, seeing multiple practitioners, receiving duplications of therapy, etc.) is not appropriate
It is not appropriate to think that because a patient has a diagnosis of active cancer or a history of cancer, that we shouldn’t have the same concerns about making sure that we are prescribing as safely as possible from our point of view.
We should address these concerns in a universal way, so that we are treating individuals and not categories, such as “cancer” or “noncancer,” that have no solid foundation or evidence base for being separate categories.
End the Dichotomy
We need to be concerned about side effects, both short- and long-term, regardless of whether a patient has cancer or not.
Whether a person has cancer or not, the history we receive is often only about the pain, but we need to probe the psychosocial background as well, as completely as possible, for maximum benefit and safety for the patient.
There are many healthcare system issues as well, including lack of access to the most appropriate care for a patient (whether that person has cancer or noncancer pain), such as a particular medicine or category of medicine.
Some patients lack access to other therapies (invasive, noninvasive, complementary and alternative), preventing us from using our skills as providers to identify and personalize care, to determine what is best for a patient with chronic pain.
In summary, let’s go beyond a simple dichotomy that has been around for too many years.
Let’s start to treat the people as they are — incredibly complex, wonderful people who need our help in such a way that addresses their true needs, and not a false dichotomy that it is time to end.
Author: Dr. Charles Argoff, Professor of Neurology at Albany Medical College and director of the Comprehensive Pain Management Center at Albany Medical Center in Albany, New York.