3.6.1 - Sociocultural influences on experience of cancer
Sociocultural influences such as diet, life habits and environmental factors may contribute to 85-90% of cancer incidence
Lifestyles across the world emanate from cultural beliefs, values and practices
Cancer incidence is similar across the world but the different types varies widely
Cultural factors influence risk factors for cancer but also determine the meaning of cancer for different persons
Healthcare providers who learn the nuances of cultural factors are more effective in managing the pain of their patients. They are also better equipped to assist patients and families
Putting pain into words is subjective - and therefore how this is communicated is coloured by the cultural background of the patient. Even the term 'palliative care' can mean different things to different individuals and communities
For example, in some cultures discussing death may be seen as inappropriate and culturally insensitive. In some cultures families may ask that healthcare providers do not disclose a terminal diagnosis to the family member as they want to avoid emotional suffering and preserve hope.
Buddhists may refuse medications that cloud the mind close to death
Taiwanese believe that talking about impending death brings bad luck
Religion and spirituality may have a tremendous impact upon healthcare decisions made by patients but many healthcare providers do not factor this, or its functional impact, into their assessment and management.
A palliative care founder of the modern-day hospice movement, Dame Cecily Saunders, described 'spiritual pain' and said it can come from a feeling of meaninglessness.
Even the meaning of pain can be different.
Chinese cultures view pain as an imbalance of Yin and Yang.
Some cultures believe they should endure pain bravely and serve as a role model to improve their standing after death.
Some cultures are very stoic regarding pain such as American Indian and Black and may maintain a neutral face despite being in severe pain
Some religions believe they should suffer pain as this is a test of faith or a penance for past sins
Some cultures believe they should deal with pain individually whereas others believe the community should share the burden
How does this affect pain management?
Many cultures may not accept the use of opioids
Some may believe this is the same as euthanasia, and need further education
Some believe opioid use means death is imminent
They may believe that its use early means less effect later
Fear of addiction
Alternative therapies can be used where they do not cause harm
Family involvement may or may not be useful/important
Language barriers need to be considered and interpreters utilised
Pain medicine may be seen as a weakness in some cultures
"Two people, with the same faith tradition and cultural upbringing, may have different end-of-life issues that create pain, challenge, or distress. This may be because of the choices made in their lives and/or the circumstances that surround them.” (Spiritual Care in a multi-religious context. Lunn JS, Journal of Pain & Palliative Care Pharmacotherapy, 2003)
Cultural management
- Healthcare professionals may need to dispel myths and gently explore barriers
- Patients need to be taught about pain relief, its role, and how it may affect quality of life
Questions can be used like:
How important is staying mentally alert to you in the final days before death?
What pain level are you willing to endure?
What type of pain medicine or alternatives should be considered?
Rachel Naomi Remen M.D. once said: “Our power to heal is far less limited than our power to cure. Healing is not a relationship between an expert and a problem. It is a relationship between human beings.”
Barriers to appropriate cancer analgesia therapy:
Societal changes
System and regulatory barriers to prescribing
Clinician barriers such as reluctance to prescribe
Patient barriers
Health care disparities
Reference:
Givler A, Bhatt H, Maani-Fogelman PA. The Importance Of Cultural Competence in Pain and Palliative Care. [Updated 2020 Dec 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493154/
3.6.2 - Compare and contrast assessment and management of persons with cancer pain with those with chronic non-cancer pain
The term 'cancer pain' is relatively new - appearing only in the last 30 years
Arguably pain mechanisms do not support a difference between cancer and non-cancer pathophysiology.
Cancer patients are now living longer and their original pain generators may become chronic pain in and of itself, which is then little different from patients without cancer
There may also have been political motivations as relieving the suffering of cancer is seen as essential
Cancer pain:
Opioids are used more readily. Initially, because patients were suffering and the prognosis usually meant only short term use
Mechanisms may be different - for example, bone pain may be exacerbated by the local creation of RANK-L and acid-forming environment
Treatments available for cancer pain may well be different than non-cancer pain - for example radiation therapy and chemotherapy and this comes with its own problems
3.6.3 - Cancer survivors who have persistent pain
Pain after cancer is increasingly common
39% of patients after curative intent living with chronic pain
55% after receiving anticancer treatments
66% in metastatic, advanced or terminal disease
More than 40% of patients are now living longer than 10 years after a cancer diagnosis
These patients may either be cured or managing a relapsing and remitting disease process
Clearly chronic pain is debilitating and can also significantly impact activity and QOL
Causes of pain
Pain can be from:
The tumour itself
Anticancer treatments (e.g. chemotherapy, radiotherapy, surgery, stem-cell transplants)
Comorbid diseases
ICD-11 currently recognised this increasing cohort of chronic pain sufferers with a specific code/diagnosis - Chronic Cancer pain
Postsurgical pain
PSP is more common after major cancer operations than general operations
They are also more commonly associated with sensory abnormalities
Chemotherapy-induced peripheral neuropathy
Can commonly occur after chemotherapy with one report suggesting
- 68.1% in first month after chemotherapy
- 60% at 3 months
- 30% at 6 months
The pathophysiology of CIPN is not fully understood
Symptoms are often distal sensory neuropathy with sensations such as numbness, paraesthesia, tingling, and neuropathic pain.
Different chemotherapy agents have different risks for the development of CIPN
Hormone treatment-related pain
Widespread persistent joint pains and stiffness can occur in up to 50% of women taking aromatase inhibitors often leading to reduce exercise capacity and may be a factor in 20-40% of women ceasing therapy early
Radiotherapy-related pain
Radiotherapy dose is calculated using a radiation unit - Gray's (Gy)
The fractionation is how many sessions are used to provide the total Gray amount
Fractionation is done because tumour cells have less propensity to repair between treatments
It is done in three ways - Definitive (highest amount), Adjuvant (mid therapy), Palliative (to shrink a tumour)
Radiation therapy by
1. Directly by damaging DNA and regulatory proteins that repair DNA
2. Indirectly by the production of reactive oxygen species which further damage tissue DNA
Abdominal foci can cause pain, diarrhoea and rectal bleeding
Side effects can often be either acute or late (occurring 90 days+ after treatment)
GI and urological toxicity, muscular and pelvic pain are possible complications
Serious complications include:
Haemorrhagic cystitis (bladder pain and blood in urine)
Anterior urinary fistula from bladder to skin of pubic ramus (prostate cancer)
Corticosteroid induced osteonecrosis
Children with leukaemia have VERY intensive chemotherapy regimes
Bone damage can persist due to high doses of corticosteroids used in these regimes
Avascular or osteonecrosis can occur in between 2 and 4% of patients
Management of chronic pain in cancer
All the typical agents can be used as per the WHO analgesic ladder (paracetamol, NSAIDs and then upwards etc).
3.6.4 - Discuss the WHO ladder for analgesia in cancer
Written initially in 1986 for the management of cancer pain, it is widely used by doctors for the management of all types of pain.
Principle is simple - start low and go slow.
3.6.5 - Discuss end-of-life symptoms including:
Pain
The palliative care college considers pain in a slightly different way. They split it into different factors
Painful stimuli
Pain due to effects of the cancer (organ infiltration, remote effects)
Pain syndromes from cancer therapy (Radiation, surgery, chemotherapy)
Pain unrelated to cancer (Low back pain etc.)
Strategies for pain management in palliative care:
Regular analgesic as per the WHO ladder
For an opioid-naive patient at the end of their life, morphine 2.5 - 5 mg morphine given hourly is often sufficient
Breakthrough pain - occurs when pain 'breaks through' the base level of analgesia
Incident pain - Pain on movement or activity (never added to regular daily dose)
Spontaneous pain - Can occur intermittently
Rescue doses - This is the medication that can be given in breakthrough or incident pain (1/6th of daily OMED - ?short acting fentanyl)
Effects on cognition
- Often mild and will settle. Need to not drive when initiating or increasing the dose
Opioid toxicity - Pinpoint pupils, hallucinations, drowsiness, vomiting, respiratory depression, confusion, and myoclonic jerks
This is more likely to occur with: Doses increasing too rapidly, renal impairment is present, patient is poorly responsive to opioids and high doses are used to try and get a response, adjuvants have been added that give pain relief but base morphine has not been reduced
Respiratory depression can be reversed with naloxone 20 micrograms every 2 minutes until respiratory rate improves. If the naloxone is titrated to RR and consciousness then an acute pain crisis is unlikely
NB: Fentanyl patch often takes 12-24 hrs to start working. Takes 6 days to reach maximal effect
It also takes 12-24 hrs for it to stop working too!
Corticosteroids can be used as an adjunct. Their exact dosing is unclear however
When converting from oral to sub-cut morphine always go to 1/3rd the normal dose due to increased bioavailability
Nausea/Vomiting
Constipation is inevitable. They recommend movicol early
N&V - Two-thirds of patients will experience this early but often resolves
Antiemetics can be used such as:
Haloperidol 0.5-1.5 mg at night (first line)
Metoclopramide (particularly if gastric stasis) 10 mg TDS. Short term use only
Cyclizine 25-50 mg TDS - if brain tumour related
(They don't use ondansetron because of constipating effect - strong)
Respiratory distress
Simple first - sit bed upright, oxygen if hypoxia, hand-held or free-standing fan, controlled breathing techniques and the management of anxiety
Try to treat the cause e.g. anaemia - transfusion
Low doses of morphine suppress excess respiratory drive - doses are very slowly titrated e.g. 2.5 mg morphine every 4 hrs
Benzodiazepines can be used to have a calming and muscle relaxant effect. Diazepam 5 mg or lorazepam 1 mg. SL lorazepam can be used for rapid effect
Cough
Can be associated with dyspnoea or be separate
Treatable causes should always be sought first
Dry cough
Pholcodine (30 mg loading dose (because it has a long half-life) then 5-10 mg QID)
Oral morphine 2.5 mg QID
Codeine 15-30 mg TDS
Dexamethasone can be used if tumour related - 6-8 mg daily
? Bisolvon
Productive cough
Expectorant
Nebulised saline
Physiotherapy
Cough suppressants are generally avoided if wet cough
Anti-muscarinic (Hyoscine hydrobromide) may help reduce secretions
Pruritis
Can be difficult to treat
Pain and itch common share pathways
Cholestatic and uraemic itch is thought to be mediated by opioid receptors
Morphine can also contribute to itch in a similar way
Reversible causes should be sought considering endocrine disease, iron deficiency, drug allergy, and lymphoedema
Management
- Cooling agents to the skin such as menthol
- Using a soap substitute
- Oral antihistamine
- Bile sequestrant if indicated (cholestyramine 6-8 mg)
- Rifampicin for chronic cholestasis
- Anxiolytics
- H2 antagonists
- Paroxetine
Reference:
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