Patient Selection Criteria
When to Use Neurostimulation or Intrathecal Drug Delivery
Cancer Pain
Introduction to Cancer Pain
Managing Breast Cancer Pain
Managing Colorectal Cancer Pain
Managing Pelvic Cancer Pain
Managing Prostate Cancer Pain
Nonmalignant Pain

Cancer Pain Treatment Continuum

Figure 1 represents the treatment continuum for cancer pain adapted by T. Lamer from the World Health Organization Analgesic ladder.

Figure 1: Cancer Pain Treatment Continuum
(Adapted from Lamer, Mayo Clin Proc, May 1994)

Lamer, T., Treatment of Cancer-Related Pain: When Orally Administered Medications Fail, Mayo Clinic Proceedings, 64: 473-480, May 1994.

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Physiological Factors

Chronic pain is experienced by 30-50% of patients with cancer and 75-90% with advanced disease.¹ Several physiological factors are responsible for cancer pain, which is most often somatic and nociceptive in nature. However, cancer pain can also cause visceral nociceptive, neuropathic, or mixed pain. Physiological causes of cancer pain are:

• Bone, muscle, body wall, connective tissue or soft tissue destruction, invasion, and irritation, resulting in somatic/nociceptive pain.
• Obstruction of lumina of tubular organs or distension, compression, and inflammation of solid organs, resulting in visceral nociceptive pain.
• Damage or irritation of peripheral nerves or nerve plexi resulting in neuropathic pain.
• Combinations (i.e., breast or lung cancer) with body wall (somatic nociceptive) and brachial plexus invasion (neuropathic); or pelvic or colon cancer with obstruction (visceral nociceptive) and lumbosacral plexus invasion (neuropathic).

• Direct invasion of the malignant tumor into nerves, bones, soft tissue, ligaments, and fascia. This is responsible for 62% to 78% of cancer pain.³ Metastasis is also a significant factor in cancer pain.
• Anticancer therapies or diagnostic procedures can injure, irritate, or inflame body tissues. For example, surgical removal of lympth tissue or breast, lung, or neck tumors may cause chronic postoperative pain. Chemotherapy can cause peripheral neuropathy or tissue necrosis (tissue death). Radiation therapy may cause acute pain (e.g., from skin burns or itching), or chronic pain from tissue necrosis, fibrosis, bowel ulceration or obstruction, or infection. Diagnostic procedures, such as a lumbar puncture, biopsy, or endoscopy, can also cause pain. Treatment-related factors cause 19% to 25% of cancer pain.³
• Painful conditions unrelated to cancer such as headache, arthritis, and chronic low back pain. These conditions affect 3% to 10% of patients.³

Cancer pain can be effectively treated in 85 to 95 percent of patients with an integrated program of systemic, pharmacologic, and anticancer therapy. Many of the remaining patients can be helped by the appropriate use of invasive procedures.²

¹Portenoy, R.K. Managing Pain in patients with advanced cancer: the role of neuraxial infusion. Oncology, May 1999;13(Supp 2):7-8.

²Levy, M.H., Pharmacologic Treatment of Cancer Pain, NEJM Oct 10 1996, 335 (15): 1124-1132

• Strong opioids have been prescribed in adequate doses and the patient is on around-the-clock dosing, not as-needed dosing
• The patient experiences inadequate pain relief or intolerable side effects from systemic opioids
• The patient has a life expectancy greater than 3 months
• Rule out tumor encroachment of the thecal sac

Krames, E., Intraspinal Opioid Therapy for Chronic Nonmalignant Pain: Current Practice and Clinical Guidelines, JPSM (6): 333-352, June 1996.

To see Citations regarding Patient Selection. . .

To see Case Studies. . .

Patient Selection Criteria
When to Use Neurostimulation or Intrathecal Drug Delivery
Cancer Pain
Introduction to Cancer Pain
Managing Breast Cancer Pain
Managing Colorectal Cancer Pain
Managing Pelvic Cancer Pain
Managing Prostate Cancer Pain
Nonmalignant Pain