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Patients with cancer develop a number of devastating physical and psychosocial symptoms that may arise during different phases and stages of cancer (1). These patients need optimal control of symptoms in order to continue receiving anticancer treatment as well as to improve their quality of life in advanced stages. They need access to multidisciplinary palliative care services in order to achieve optimal symptom control. Symptoms in patients with advanced incapacitating illness include fatigue, pain, anorexia, nausea, dyspnea, constipation, anxiety, depression, and cachexia (Table 48-1).

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Table 48–1. Symptoms in Advanced Cancer
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Pain is one of the most common symptoms experienced by cancer patients. It was the most common symptom (82%) among patients referred to a palliative care service (2). Pain may be the only symptom before the diagnosis of cancer and may indicate the recurrence and spread of cancer. It can occur both during active treatment as well as in the advanced and terminal stages of cancer. Generally as many as 30 to 50% of patients in active anticancer therapy, and as many as 60 to 90% of those with advanced disease have pain (3-7).

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Most pain in cancer is caused by direct involvement of tumor with body structures, most notably neural structures. Pain associated with direct tumor involvement occurs in 65 to 85% of patients with advanced cancer (7). Cancer therapy accounts for pain in approximately 15 to 25% of patients receiving chemotherapy, surgery, or radiation therapy, and 3 to 10% of cancer patients have pain syndromes of the sort commonly observed in the general noncancer population–for example, low back pain secondary to degenerative disk disease.

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Pathophysiology

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The pathophysiologic classification of pain forms the basis for therapeutic choices. Pain states may be broadly divided into those associated with ongoing tissue damage (nociceptive) and those resulting from nervous system dysfunction (neuropathic), due either to tissue damage or in the absence of damage in some situations. Nociceptive pain can be of the somatic or visceral type. It results from the activation of nociceptors in cutaneous and deep tissues and is described as well localized aching, throbbing, and gnawing. Visceral pain is caused by activation of nociceptors resulting from distention, stretching, and inflammation of visceral organs. It is described as poorly localized, deep aching, cramping, and as a sensation of pressure. Sometimes it is referred pain, for example, pancreatic cancer pain in the abdomen with referral to back.

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Breakthrough pain is a common entity in cancer patients ...

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