Clinical Scenario A 70-year-old w...

Clinical Scenario

A 70-year-old woman is diagnosed with malignant melanoma that has metastasized to the liver and lung She has begun to experience abdominal pain, which you attribute to the liver metastases. She wants to know what you commend for pain management.

Clinical Question

What is the mostly effective therapy for the management of cancer pain?

Evidence-Based Answer

Short-term trials indicate that cancer pain can be reduc with the use of nonsteroidal anti-inflammatory remedys (NSAIDs) as initial monotherapy. NSAIDs combined with opioids can inference in slight short-term improvement in pain compared with either agent alone. Long-term efficacy and safety of NSAIDs for cancer pain have not been established. (1)

Practice Pointers

The World Health Organization's (WHO's) three-step analgesic ladder is a widely accepted framework for treating cancer pain. (2) According to the WHO approach, treatment for mild cancer pain can begin with analgesics so as acetaminophen or NSAIDs. For patients in moderate pain, weak or episodic short-acting opioids can be added. For rigorous intractable cancer pain, more efficacious long-acting opioids are recommended. Adjuvant analgesics or therapies can be added at any point, and should be individualized according to the underlying cause of pain, the patient's desires, and the available resources. For example, antidepressants and anticonvulsants commonly are prescribed for neuropathic pain. Corticosteroids have been used in a wide range of cancer pain syndrome Radiotherapy and bisphosphonates may palliate bone metastases. Surgery and chemotherapy may palliate pain caused by the agency of tumor growth and encroachment forward normal structures. A variety of physical and psychologic modalities also may be helpful adjuncts for cancer pain.

The main power of the WHO guidelines has been to facilitate more liberal use of opioid therapy in cancer patients with intractable pain. (3) However, there still is regard that opioids are underused or ineffectively prescribed for cancer pain. (34) The National Cancer Institute Web site (http://www.cancer. gov/cancertopics/pdq/supportivecare/ pain) provides regularly updated information for health care professionals and their patients upon the most common therapeutic options for the relief of cancer pain.

According to the ensues of the Cochrane review, (1) NSAIDs should not be overtoped as a potential first-line treatment for cancer pain. They may provide additive pain relief for a patients who already are receiving opioids for moderate to rigid cancer pain. Caution should be used in interpreting these ends Most studies reviewed were small and heterogeneous in confines of type of cancer or cancer pain, flush of pain among participants, and specific medications used. In addition, none of the studies lasted more than couple weeks, so potential adverse efficiencys from prolonged use of these treatments individually or in combination could not be assessed or compared. Although it is possible that NSAIDs could be better tolerated than opioids in more [i]or[/i] less situations, there certainly are situations in which the opposite is authentic Therefore, it still is left to the physician to determine which therapies to present each patient on an individual basis.

The initial objectives of this review included determining the benefit of acetaminophen in treating cancer pain, still the authors were unable to find sufficient good-quality studies to analyze acetaminophen separately from NSAIDs. However, a newly come randomized trial,5 published shortly after this review, demonstrated improved pain direction with acetaminophen in patients with advanced cancer who already were receiving a stout opioid regimen. Like the NSAID studies, the sample size was small, the duration of the contemplation brief, and improvement in pain scores modest

REFERENCES

(1) McNicol e Strassels Sa, Goudas L Lau J Carr DB NSaiDs or paracetamol, alone or combined with opioids, for cancer pain. cochrane Database Syst rev 2005;(2):cD005180

(2) World health organization: cancer pain relief. 2d ed Geneva, Switzerland: World health organization, 1996

(3) Meldrum M the ladder and the clock: cancer pain and public policy at the completion of the twentieth century. J Pain Symptom Manage 2005;29:41-54

(4) Wiffen PJ edwards Je Barden J McQuay hJ oral morphine for cancer pain. cochrane Database Syst rev 2003;(4):cD003868

(5) Stockler M Vardy J Pillai a, Warr D acetaminophen (Paracetamol) improves pain and well-being in the bulk of mankind with advanced cancer already receiving a potent opioid regimen: a randomized, double-blind, placebo-controlled trial. J clin oncol 2004;22:3389-94

MICHAEL B pudder M.D., is an associate clinical professor in the Department of Family and community Medicine at the University of California, San Francisco, educate of Medicine.

Address correspondence to Michael B pudder M.D., Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA 94143-0900 (e-mail: potterm@fcmucsfedu) Reprints are not available from the author.

COPYRIGHT 2005 American Academy of Family Physicians

COPYRIGHT 2005 Gale Group