Read an Excerpt
American Cancer Society's Guide to Pain Control
Understanding and Managing Cancer Pain
By Amy Brittain
American Cancer Society / Health PromotionsCopyright © 2004 American Cancer Society
All rights reserved.
Understanding Cancer Pain
After she was first diagnosed, Melissa was afraid that she would have pain. Actually, she thought cancer and pain went hand in hand. She had pain with her surgery, but it was well controlled and soon went away. After surgery, she feared having more pain even though her cancer had been removed. She could not block the memories of her father dying in pain from his cancer. She expected to have pain just like him. She has been without any evidence of disease for nine years. And she has no pain.
One of the first steps in managing your pain is learning about it. Having cancer does not always mean being in pain. If pain does occur, there are many ways to relieve or reduce it. Relieving pain makes you more comfortable, while untreated pain puts your body under additional stress. New studies show that improved pain control increases survival and quality of life. This chapter will discuss the nature of pain and give you the language you need to communicate with your health care team about your pain.
What Is Cancer?
Before exploring types of cancer pain and how to relieve them, we'll briefly explore cancer itself — what it is and how it forms.
Cancer is not just one disease; it's as many as 100 different diseases with one thing in common — the growth and spread of abnormal cells because of gene mutations (structural or chemical changes within genes that change the way cells function and grow).
Normal cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide more rapidly until the person becomes an adult. After that, normal cells of most tissues divide only to replace worn-out or dying cells and to repair injuries.
Some cells, however, continue to grow and divide and may also spread to other parts of the body. These abnormal cells accumulate and form a tumor. Malignant tumors are lumps that have the potential to spread and may invade and destroy normal tissue. If cells break away from a cancerous tumor, they can travel to other areas of the body. There, they may settle and form "colony" tumors, continuing to grow. The spread of a tumor to a new site is called metastasis.
What Is Pain?
Pain is a sensation that hurts. It is a warning signal that something is wrong in our bodies. A variety of factors may cause pain in people with cancer; however, not all people with cancer will experience pain. When pain does occur, the experience may range from mild discomfort to severe agony. While some people experience pain for only a short period of time, others may cope with chronic pain for months, seriously impacting their ability to do the things they enjoy.
Pain has two main components: a sensory component and a reactive component. The sensory component involves the transmission, or sending of, the pain signal from the injured part of the body to the spinal cord and brain. When the pain signal is received, the brain then sends a message to the person that he or she is having pain. The reactive component refers to how the person reacts to the pain. Each person's reaction to pain depends upon his or her pain threshold (the intensity of the stimulus a person considers painful) and pain tolerance (how intense or how long the pain stimulus can persist before the person experiences the pain). People can have differences in their pain thresholds and pain tolerances.
Types of Pain
The type of pain a person experiences depends on its source. Cancer-related pain occurs because of something related to the cancer, either the disease or the treatment of it. Most cancer pain is caused by the cancer itself, but pain can also occur because of the side effects of cancer treatment — such as radiation therapy, chemotherapy, and surgery. People with cancer may also have pain that is not related to cancer.
Pain can be acute, chronic, or breakthrough, depending on how long the pain is present and when it occurs. It can also be categorized as nociceptive or neuropathic pain, medical terms that sometimes suggest the cause of the pain. We'll explore each of these types of pain in this chapter.
Acute pain is usually severe, begins suddenly, and lasts a relatively short time. It is often a signal that body tissue is being injured in some way, and acute pain generally disappears when the injury heals.
Acute pain may be caused by surgery, a burn, a cut, or a needle stick, for example. Some cancer treatment or treatment side effects can also cause acute pain; for example, surgery to remove a tumor, sores in the mouth from chemotherapy, or inflammation of the rectal area after radiation treatment for prostate cancer. A person in acute pain may have symptoms that reflect they are in pain, such as an increase in blood pressure and a rapid heartbeat. The symptoms of acute pain can be more severe than those of other types of pain. Acute pain that lasts for more than a few weeks becomes chronic pain.
Chronic pain, which can range from mild to severe, may be ongoing and may last for several months. It can result from the cancer itself or from treatment. The most common type of pain in people with cancer is bone pain caused by cancer metastasizing to the bone. Another type of chronic pain is caused by a tumor pressing on organs or nerves. After chronic pain has been present for a while, the body adjusts to it and the physical intensity will be lessened, but a person's ability to function and continue activities can still be severely impacted. Having to cope with chronic pain on a daily basis can lead to irritability, disturbed sleep, reduced appetite, difficulty concentrating, and changes in mood, personality, lifestyle, and ability to function. Because chronic pain can make even the simplest tasks and daily activities uncomfortable or impossible, people in chronic pain may have feelings of hopelessness and depression — negative thoughts and emotions that can make pain feel worse. To reduce overall suffering, chronic pain should be treated as quickly as possible.
Many people with chronic cancer pain have two types of pain: persistent (continuous) pain and breakthrough (incident) pain. Persistent pain is present for long periods of time — in most cases, all day long. Breakthrough pain is a brief and often severe flare of pain that occurs even though a person may be taking pain medicine regularly for persistent pain. It's called breakthrough pain because it is pain that "breaks through" a regular pain medicine schedule. It is not unusual for people with persistent pain to experience episodes of breakthrough pain.
Breakthrough pain may be different for each person and is often unpredictable. It typically comes on quickly, lasts only a few minutes or as long as an hour, and feels much like persistent pain except that it is more severe. Breakthrough pain can be caused by the cancer itself or may be related to the treatment of cancer. Some people have breakthrough pain during a certain activity, like walking or dressing. For others, breakthrough pain occurs unexpectedly and has no clear cause.
In the example below, the individual has persistent pain and is regularly taking pain medication. However, this patient has two episodes of breakthrough pain, at 1 p.m. and at 7 p.m. He will need a medication for the breakthrough pain that acts quickly to relieve this pain.
Nociceptive pain involves damage to body tissue. When a person's body tissue is injured, pain receptors (thousands of nerve endings located throughout the body, called nociceptors) are activated, sending a signal to the spinal cord and brain that is interpreted as pain. When a person feels pain from cancer that has spread to muscle, bone, organs, and joints, the pain is called nociceptive pain. Nociceptive pain may be acute or chronic. The source of nociceptive pain is easier to locate than the source of neuropathic pain.
Neuropathic pain is caused by injury to, or compression of, some part of the nervous system, which includes the peripheral nerves and the central nervous system. It can result from either the cancer itself or from treatment. People often describe neuropathic pain as severe burning, sharp, tingling, or shooting pain. Neuropathic pain can also cause a loss of feeling in an area of the body or a feeling of extreme tenderness, making the lightest touch painful.
An example of neuropathic pain is post-mastectomy syndrome. Following surgery to remove a breast, a person will have some postoperative pain. After that pain subsides, the person will be able to return to normal activities. Some time later, pain may return to the original painful area without a clear cause. This pain may be described as a "strange" burning, pressure, shooting, stabbing, or knifelike sensation, or as pain or numbness. This pain is due to damage to nerves in the breast area and is referred to as post-mastectomy syndrome.
Factors that Influence Pain
Pain thresholds and pain tolerances differ from person to person, but how pain is perceived depends on how it is processed by a person through feelings, thoughts, and memories of pain. Past experiences with pain or the cause of the pain can influence a person's reaction to a new pain. For example, people who have seen the death of a friend or family member who was in pain may be terrified at the thought of pain because they associate pain with death. For a professional baseball pitcher, pain resulting from a sprained ankle may perhaps be minimized or ignored. He knows his life is not in danger from the cause of pain and he may be receiving significant reward for ignoring the pain and continuing to play.
Some people feel hopeless or helpless when in pain. Others may feel alone, embarrassed, inadequate, angry, frightened, or frantic. These strong emotions can have a significant effect on how people experience pain and how they cope with it. Rest, understanding, support, analgesics (medicines to relieve pain), and reducing anxiety can raise the pain threshold. However, other factors — such as fatigue, depression, or anxiety — can lower the pain threshold and make the pain feel worse. Dealing with these factors and their underlying causes is important in reducing pain (see chapter 2 for information about coping with feelings related to cancer and cancer pain).
Causes of Pain
Pain may be caused by various factors or combinations of factors, including diagnostic procedures, treatment, cancer itself, or other reasons. Pain is not inevitable; talk to your health care team about a pain-relief plan that's right for you and your situation. Chapters 5 through 7 provide more information about pain-relief options.
What to look for:
having no energy
not wanting to do normal activities
paying less attention to personal appearance
feeling tired even after sleeping
having trouble concentrating
What to do:
Schedule necessary activities throughout the day rather than all at once; light activity or regular exercise may be helpful.
Plan brief rest periods to conserve energy for important things.
Get enough rest and sleep.
Eat a nutritious diet and drink plenty of liquids.
Let others help you with meals, housework, or errands.
force yourself to do more than you can manage
think that you are just being "lazy"
Call your doctor or nurse if:
you are too tired to get out of bed for more than a 24-hour period
you become confused
the fatigue becomes progressively worse
you have severe or frequent dizziness
you feel out of breath
In order to make an accurate cancer diagnosis and to determine the extent of the cancer, your health care team needs to do some diagnostic procedures. Some of these procedures may cause temporary pain and discomfort, lasting only for the duration of the test or for a day or two afterwards. More invasive procedures may cause pain that lasts several days or longer. In the following sections we will outline some of the most common diagnostic procedures that may cause pain or discomfort, as well as appropriate preventive or coping measures, so you know what to expect and can better cope with potential pain. Talk to your health care team about your situation and how you might prevent or alleviate pain from diagnostic procedures.
A biopsy is the removal of a sample of tissue that is examined to determine whether cancer cells are present. A type of device is used to remove the tissue, often a sterile knife or needle. Some biopsies can be done on an outpatient basis while others may require a hospital stay. A needle biopsy may cause temporary discomfort and pain at the site of insertion. A more invasive procedure such as a surgical biopsy may involve postoperative pain and discomfort.
Bone Marrow Aspiration and Biopsy
A bone marrow aspiration involves removing a small amount of bone marrow, the soft material inside bones where blood cells are formed. During a bone marrow biopsy, a small cylindrical piece of bone and bone marrow (about 1/16 inch in diameter and ½ inch long) is removed. A local anesthetic is given before the needle is inserted into the skin. Often, a sharp jolt and a sensation of intense pressure can be felt when the marrow is withdrawn. The puncture site may also be bruised and tender for a few days.
This is a medical procedure for viewing the interior of the body through a hollow, tube-like instrument. Some endoscopes not only allow the doctor to see inside the body, they can also be used for surgery. Small instruments operated through the hollow endoscope are used to remove biopsy specimens (small pieces of tissue used for laboratory tests) or even to remove or destroy a tumor. Because there is sometimes discomfort during an endoscopy, anesthesia or sedatives may be used. The procedure can be performed on an outpatient basis, in a doctor's office, or it may require a hospital stay. The recovery time varies depending upon the method used.
An endometrial biopsy is an office procedure in which a sample of endometrial tissue is removed by a small instrument inserted into the uterus through the cervix. The degree and duration of pain vary, but the discomfort is similar to severe menstrual cramps and can be helped by taking a nonsteroidal anti-inflammatory drug such as ibuprofen an hour before the procedure.
Lumbar Puncture (Spinal Tap)
A lumbar puncture is a test in which a needle is placed in the lower back into the spinal canal, to give medicine into the central nervous system through the spinal fluid or to obtain a small sample of cerebrospinal fluid, which is examined under a microscope to determine if cancer cells are present. Patients may develop painful and severe headaches after this procedure. The pain, which feels worse when standing up, can last from a few hours to several days. The headache can usually be treated with bed rest and medication.
There are many different ways to treat cancer, but the main types of treatment are surgery, chemotherapy, and radiation. Because each treatment is different and the appropriate treatment for each person's situation depends on the person's overall health, type of cancer, and stage of disease, it is difficult to predict who will experience pain from a particular treatment.
As much fear as pain may instill in people, there is no need to suffer through pain without some kind of help. Learning to talk to your doctor, nurse, or someone on your health care team about pain and pain-relief needs can bring the relief that most people with cancer-related pain need and that all of them deserve. Living with pain does not need to be a standard aspect of undergoing cancer treatment.
Surgery is the oldest form of treatment for cancer and offers the greatest chance of cure for many types of cancer. About 60 percent of people with cancer will have some type of surgery. The pain experienced by people after surgery is generally of two types:
1. Acute, temporary pain — focused around the area of incision (surgical cutting), which is related to the healing and recovery process.
2. Chronic or long-term pain — resulting from injury to nerves, muscles, organs, or other tissue in the area where cancerous tumors and other tissue may have been removed.
After surgery, a person may feel tired, sore, and generally uncomfortable until the incision is fully healed and moving around is easier. The pain associated with surgery is common, will go away after several days, and can be controlled. However, some people may experience chronic pain resulting from damage to the body or nerves during surgery. Surgery can also result in some painful side effects such as lymphedema or phantom limb pain, both of which can occur after the removal of an appendage or body part. We will explore nerve pain, lymphedema, and phantom limb pain here.
Excerpted from American Cancer Society's Guide to Pain Control by Amy Brittain. Copyright © 2004 American Cancer Society. Excerpted by permission of American Cancer Society / Health Promotions.
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