Background:
Large-scale studies suggest the overall up to 35% of cancer survivors experience pain, with up to 30% experiencing moderate to severe pain restricting major activity (1). Treatment strategies advocate for multimodal and multidisciplinary management, with a growing interest in opioid-sparing strategies. The introduction of the 4th step to the World Health Organization analgesic ladder (2)that includes invasive and minimally invasive techniques, providing a bidirectional relationship between escalation and de-escalation. There has been also increasing visibility (3) of the extent and need for better supportive therapies for cancer pain with the new ICD-11 cancer pain taxonomy (4) with reporting from January 2022, that may lead to more funding for cancer-pain interventional treatment.
Teaching points:
Cancer pain interventions are one of many approaches to managing pain associated with cancer and its treatment. These interventions include treatment-directed approaches as well as pain-modifying treatments. Several types of minimally invasive to invasive interventions are used to manage cancer pain (5), including 1) neurolytic blocks, 2) neuraxial analgesia, 3) vertebral procedures, 4) neurosurgical techniques (such as cordotomy/myelotomy), 5) neuromodulation (peripheral nerve or Spinal cord stimulation). The most recognised and thoroughly studied approach is the celiac plexus neurolysis for epigastric or back pain arising from exocrine pancreatic cancer (6). A Pain specialist or interventional radiologist commonly approach this via image intensification. Phenol is usually preferred over alcohol as it is painless to inject for the purposes of neurolysis. It can also be done endoscopically to target the celiac ganglion. There is level 1 evidence for decreasing opioid dose, pain and constipation at 4 weeks and also before death (7). Neuraxial analgesia has level 2 evidence of treatment effectiveness, and while has a high initial cost, in well selected patients it lowers systemic side effects and can offer superior improvement in analgesia over systemic conventional medication management (8) (9). Vertebral procedures have limited studies evaluating use in cancer pain, with a 2015 systematic review (5) finding only five studies meeting inclusion criteria, and kyphoplasty alone receiving a recommendation in favour in the setting of vertebral bone pain/compression fracture without neurological sequalae, particularly if patient has limited life expectancy where complex surgery or radiofrequency are not effective (10). Percutaneous cordotomy exploits the decussation of the spinothalamic tract and is used predominantly for unilateral pain originating below C4 dermatome level, by disrupting the tract between C1 and C2 vertebrae either via open approach or percutaneous radiofrequency. There is level 4 evidence, and often used in malignant mesothelioma (11). Neuromodulation remains limited but promising, with many barriers including cost, invasiveness, and lack of high-quality evidence (12).
Summary:
Interventions for cancer pain face many barriers, including clinician knowledge and available technology. Even in resource-rich settings, treatment barriers persist, and the evidence base continues to evolve.
References
1. Prevalence of Chronic Pain and High-Impact Chronic Pain in Cancer Survivors in the United States. Jiang, Changchuan, et al. 8, 2019, JAMA Oncology, Vol. 5, pp. 1224-1226.
2. Interventional treatment of cancer pain: the fourth step in the World Health Organization analgesic ladder? Miguel, R. 2, March 2023, Cancer control: journal of the Moffitt Cancer Center, Vol. 7.
3. Should cancer pain still be considered a separate category alongside acute pain and chronic non-cancer pain? Reflections on ICD-11. Backryd, Emmanuel. May 2024, Frontiers in Pain Research, Vol. 5.
4. The IASP classification of chronic pain for ICD-11: chronic cancer-related pain. Bennett, M I, et al. 1, 2019, Journal of Pain, Vol. 160, pp. 38-44.
5. Interventional Techniques for the Management of Cancer-Related Pain: Clinical and Critical Aspects. Kurita, G P, et al. 4, 2019, Cancers (Basel), Vol. 11, p. 443.
6. Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage. Porta, M, Fabregat, X and Malats, N. 2005, Clinical Translation Oncology, p. 7:189.
7. Celiac plexus block for pancreatic cancer pain in adults. Arcidiacono, Paolo Giorgio, et al. 2011, Cochrane Database Systemic Review, Vol. 3, p. CD007519.
8. Pain Management, Including Intrathecal Pumps. Smith, thomas, Swainey, Craig and Coyne, Patrick. 6, 2004, Current Oncology Reports, pp. 291-296.
9. Intrathecal Drug Delivery Systems for Cancer Pain: An Analysis of a Prospective, Multicenter Product Surveillance Registry. Stearns, Lisa, et al. 2, 2020, Anesthesia & Analgesia, Vol. 130, pp. 289-297.
10. Interventional pain management in cancer patients—a scoping review. Habib, Muhammad Hamza, et al. 6, 30 November 2023, Annals of Palliative Medicine, Vol. 12, pp. 423-433.
11. Destructive procedures for control of cancer pain: the case for cordotomy. Raslan, Ahmed, et al. 1, 2011, Journal of Neurosurgery, Vol. 114, pp. 155-170.
12. Current Perspectives on Spinal Cord Stimulation for the Treatment of Cancer Pain. Hagedorn, Jonathan, et al. 13, 2020, Journal of Pain Research, pp. 3295-3305.