The word CANCER carries much heavier weight than the 6 letters in the spelling. To some, it is the very pronouncement of doom. Whilst all cancers are not painful or life threatening, the diagnosis itself generates significant emotional turmoil and a constant sense of insecurity. One can understandably be enveloped by multiple worries of pain, treatment outcomes and side effects, loss of life, financial concerns, career, concerns about loved ones etc.
When cancer patients are asked about their greatest fear, pain is a common response. In the Maslow’s hierarchy pyramid, both survival and absence of pain would be competing for the bottom spot. Whilst survival is being rightly addressed with high-tech medical innovations, not as much attention is focussed on pain and quality of life; after all, the aim is not just to survive into bare existence. As the survival rates improve, cancer pain is transforming into more of a chronic problem and despite decades of efforts it still remains prevalent, poorly managed, and one of the most fearsome aspects of the disease. Appropriate timely treatment including active pain control is an essential component of cancer treatment with direct relationship to one’s quality of life.

Importance of Pain Control
Pain though highly individual and variable is a common problem affecting as many as 28 percent of newly diagnosed cancer patients. Poorly controlled pain not only causes physical suffering, disability, psychological and social issues, it also interferes with one’s ability to tolerate anticancer treatments.
Whilst there are plenty of words to describe the character or severity of pain, they often fail to capture the full impact on one’s life. Not being able to communicate what one is going through, loss of control and the feeling of helplessness one experiences with uncontrolled pain can have a devastating impact on the psyche. Besides this, uncontrolled pain is frequently accompanied by reduced strength and mobility, anxiety, fear and depression and these can have a devastating long-lasting impact on patients as well as caregivers, causing stress in their relationships.
As the disease progresses, the pain incidence generally increases with as many as 50 to 70 percent of patients affected during treatment stages and 64 to 80 percent of those with advanced disease.

Pain Control in Cancer
Pain in cancer is a result of various combinations of multiple factors including the cancer itself, pressure on neighbouring organs or nerves, spread to distant body parts, or associated issues such as constipation and swelling of body parts. It can equally be the side effect of treatments (such as surgery, chemotherapy, etc) or a totally unrelated coincidental problem such as arthritis of spine. Accurate comprehensive assessment is the key for identifying the source of pain and to control the success of pain reducing interventions. This is one of the reasons why specialist pain management input is of prime importance.
The good news is that a significant proportion of cancer patients can achieve satisfactory pain relief with a treatment plan that incorporates primary therapy aimed at the tumour along with other pain reliving modalities such as medications, interventions including nerve blocks, physiotherapy and psychological techniques. Pain specialists can help device an individualised, multimodal pain management plan and a backup plan for dealing with periods of increased pain. This becomes more relevant as the complexity of the disease or the severity of pain increases.
Pain control in cancer is not just about medications or injections. Satisfactory control requires addressing concomitant factors such as mood, anxiety, spiritual and social needs, as these can amplify the perceived pain. Relaxation therapies including meditation, mindfulness can help in producing a calming effect and in coping with feelings.

Pain Reliving Interventions
Pain impulses travel to the brain as electrical signals via the nerves. These signals are processed in brain and interpreted as pain. This pathway is influenced by multiple factors providing an opportunity to control the pain one experiences. From example the pain signals from upper abdomen pass through a collection of nerves known as the Coeliac Ganglion and an injection targeting this structure is often used to reduce pain from cancers such as the pancreatic cancer. Other similar procedures use special needles and radiofrequency machine to generate heat lesions around the nerves, thereby interrupting the transmission of pain signals. There are multiple other commonly preformed interventions such as nerve blocks, epidurals, sympathetic blocks, injections directly into spinal fluid (intrathecal), pump implants, spinal cord stimulators, etc, which can help provide prolonged relief.

Opioids and Cancer
Morphine and Morphine like drugs (addressed as Opioids) are one of the strongest pain killers. Like it or not, a large majority of cancer patients with moderate to severe pain are likely to require these painkillers. Sometimes use of morphine like drugs is wrongly synonymised to impending death and it is not uncommon to see patients with extreme pain refusing to use these. Patients and caregivers do a disservice to themselves by putting up barriers, often secondary to preconceived notions.
Over the years, I have heard multiple reasons from refusal to use painkillers including the “be brave and leave it for as long as possible” approach, “invest in future and leave it for later” or else “they may stop working” concerns about addiction and failure to pick up disease progression by masking the pain.
Multiple fears, social, cultural, individual factors lie at the root of such beliefs and these need to be explored and addressed as there is no benefit in suffering. Whilst respecting one’s wishes is important, it is the responsibility of the treating clinician to empower patients with right knowledge. With correct supervised usage, opioids are often helpful in improving pain control and quality of life. Patient and family education is important in understanding the problem and in fostering realistic expectations. Family support is an important pillar of treatment during this difficult period.

The writer is Senior Consultant & Head, Pain Management Services, Max Super Speciality Hospital, Saket, New Delhi.

Dr Amod Manocha