The World Health Organization (WHO)
recommends a three-step ladder to
treat cancer-related pain. For light pain,
the first stage of treatment should be a
non-opioid option. Choices range from
drugs like acetaminophen and corti-
costeroids to nondrug options such as
massage and physical therapy.
“There are a number of options for mild
pain” other than opioids, says Janette
Vardy, a medical oncologist and a clinical
researcher at the University of Sydney’s
Concord Cancer Centre in Australia. “But
patients with stronger pain and progressive
cancer are very likely to require opioids.”
The first step, says Ebtesam Ahmed, a
clinical pharmacist at St. John’s University
College of Pharmacy and Health Sciences
in New York City, is for “patients to
establish the [origin and cause] of their
pain with their provider, because there are
different treatment options specific to each
type [of pain].” Ahmed says treatment will
also be determined by whether the patient
has acute pain due to a recent treatment, or
chronic pain caused by metastases.
Pain specialists speak of two broad
categories of pain: nociceptive and neu-
ropathic. Nociceptive pain starts in the
pain receptors in tissue and results from
tissue damage. It can often be treated
with analgesics such as corticosteroids,
sometimes in combination with physical
therapy. Among cancer patients, it might
be caused by a tumor that is pushing up
against an organ or other parts of the
body. Cancer that has spread to the bones
can be another cause of nociceptive pain.
In these patients, bisphosphonates, drugs
used to prevent and treat bone loss, have
been shown to reduce both pain and the
number and size of bone metastases.
Another option for bone pain is treating
patients with corticosteroids along with
radiation at the sites of metastases.
Neuropathic pain stems from damage
to the nervous system, which could be
caused by a tumor pressing against a
nerve. It can be treated with NSAIDs,
antidepressants and anticonvulsants,
which inhibit the excessive pain signals
transmitted by damaged nerves.
The second step of treatment, according to WHO guidelines, is a mild opioid,
such as codeine. If the pain grows more
severe, the third step should be a strong
opioid, like morphine. “Many patients
have trouble accepting opioid therapy
due to the stigma of substance use disorder and associated withdrawal,” says
Ahmed. But “there is no valid or conclusive evidence that patients should be
avoiding opioids.” With “proper education,” patients should be able to receive
treatment without problems, she adds.
—BRADLE Y JONES
OPTIONS FOR MANAGING CANCER-RELATED PAIN
Pain is a common symptom and side effect of cancer and its treatments. Opioids are a known effective option for managing this pain. But with the United States in the midst of an opioid
epidemic, some patients may question whether opioids should be used to
treat their pain or whether it would be better to look for other options.
Colorectal Cancer Risk Increased in Women and Men With a BRCA1 Mutation
A meta-analysis of 14 studies that looked at cancer types and rates in patients with an inherited
BRCA1 or BRCA2 mutation found a statistically significant increased risk of colorectal cancer in
women and men born with BRCA1 mutations. Smaller studies have had conflicting results. The
researchers say their meta-analysis suggests health care providers and patients should be
aware that a BRCA1 mutation increases risk for colorectal cancer. These mutations have also
been found to be associated with increased risk for prostate, pancreatic and stomach cancer.
LEARN MORE IN THE OCT. 31, 2018, JOURNAL OF THE NATIONAL CANCER INSTITUTE.
Alternatives to Opioids
Patients With Hereditary Pancreatic Cancer
Have Better Outcomes, Study Suggests
Researchers found the most common
germline mutations in pancreatic cancer
patients were in the BRCA1, BRCA2 and
mismatch-repair genes. Patients younger
than 60 were more likely to have these
inherited mutations; they also had better
overall survival than patients without them.
The researchers say screening for these
mutations could benefit pancreatic cancer
patients and their relatives. Pancreatic
cancer is the 11th most common cancer and
the third-leading cause of cancer-related
deaths in the U.S. Most diagnoses are made
in people over the age of 65.
LEARN MORE IN THE NOVEMBER 2018 CANCER