The American Society of Clinical Oncology (ASCO) is taking new steps to help clinicians better manage chronic pain in adult cancer survivors. On July 25, 2016, ASCO issued a new clinical practice guideline that deals comprehensively with the pain patients experience after cancer treatment.1 In this article, authors propose recommendations based on clinical evidence for safe and effective treatment of persistent pain.
“This new guideline is the first to address the growing population of cancer survivors with chronic pain. More than 15 million people are living with cancer in the United States and studies suggest the prevalence of pain in cancer survivors is close to 40%. This guideline is also unique in describing the wide range of pain syndromes associated with cancer treatment. As this field is quickly evolving, it is anticipated that future updates will be warranted,” said Judith Paice, PhD, RN, a Research Professor at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois and co-chair of the ASCO Expert Panel that developed the guideline.
ASCO’s recommendations include routine screening for chronic pain, a multi-disciplinary approach to pain management, with inclusion of practices such as hypnosis and meditation, and the use of medical cannabis in states where it is legal. Dr Paice said training of many oncologists and primary care physicians did not include guidance regarding detection and management of long-term pain associated with cancer.
“Pain is a serious medical and public health problem, as are addiction and misuse of opioids. All of these negatively affect the quality of life of those individuals experiencing these disorders. These guidelines provide recommendations for screening people to determine if they are at risk for misuse, as well as strategies to limit misuse, addiction and adverse consequences of opioid use. The goal is to ensure safe and effective pain control. Much of this information about addressing opioid misuse risk is new to the oncology community,” Dr Paice told Clinical Pain Advisor.
The recommendations outlined in this article were formulated by a panel of experts in the fields of medical oncology, hematology/oncology, pain medicine, palliative care, hospice, radiation oncology, social work, symptom management research, rehabilitation, psychology, and anesthesiology. The panel also included a patient representative. A systematic review of medical literature published from 1996 to 2015 was conducted by the panel.
Although other guidelines address advanced cancer-associated pain relief, those published by Dr Paice and colleagues address for the first time chronic pain experienced by cancer survivors.The guideline is also unique in describing the wide range of pain syndromes associated with cancer treatments.
The guideline recommends clinicians screen for pain at each patient visit, and evaluate, monitor and treat cancer re-occurrence as well as delayed treatment-associated effects. In addition, it is suggested that clinicians prescribe non-pharmacologic interventions including integrative therapies such as acupuncture and massage, interventional therapies, and psychological approaches. The psychological approaches include guided imagery, hypnosis, and meditation. The guideline also recommends prescribing systemic non-opioid analgesics, such as NSAIDS and acetaminophen and prescribing adjuvant analgesics, which may include selected antidepressants and anticonvulsants to relieve chronic pain and/or improve physical function.
“Assessment must include a comprehensive pain evaluation along with determination of the patient’s risk of misuse of opioids. This includes current or past use of tobacco, alcohol, and recreational drug use, as well as family history of addiction and a past history of sexual abuse. Universal precautions can be implemented to minimize the risk of addiction or diversion, ultimately to ensure safe and effective pain control,” said Dr Paice.
The guideline addresses the use of cannabis, which is expanding significantly in the US. It suggests clinicians follow specific state regulations on access to medical cannabis for chronic pain patients. Formulation of such regulations should assess benefits and risks of available treatment options. It is recommended clinicians prescribe a trial of opioids in carefully selected cancer patients who do not respond to more conservative treatments to manage their pain, and who experience distress or impairment of physical function as a result.
Thomas Froehlich, MD, a Professor of Internal Medicine and the Medical Director of the Simmons Comprehensive Cancer Center at UT Southwestern, Dallas, Texas, said the new guideline is very thorough and addresses an education deficit in many younger oncologists. “I have been doing this for 36 years,” Dr. Froehlich said in an interview with Clinical Pain Advisor. “Many younger physicians have pain management specialists and they don’t have a lot of experience. They have resources to refer to but the guidelines help formulate an approach.”
Barbara Murphy, MD, a Professor of Medicine (Hematology/Oncology) and the Director of the Head & Neck Oncology and the Program Director for Pain & Symptom Management Program at Vanderbilt University, Nashville, Tennessee, said the biggest challenge for the average clinician who is out in the community is taking on the task of pain management and symptom management. “Most of us are good with straightforward pain syndromes and identifying the causes of pain and treating pain, but many find challenges in patients with pain who are not responsive to first-line and second-line treatments,” Dr. Murphy said in an interview with Clinical Pain Advisor.
She noted that patients with multiple symptoms in multiple sites and patients with substance abuse issues in their past require special attention. Dr. Murphy said there is a need for better guidance in managing these types of patients. “However, there is a lack of data on how best to do just that,” she added.
“We really need to explore models of care for the complex patient, who has refractory pain, and patients with multiple pain generators requiring complex pharmacologic agents. You also have patients with prior substance abuse history,” said Dr. Murphy. “Some patients come in not wanting to take pain medication because they know what it was like to be dependent and how hard it was to get off of it. We get a lot of those referrals. This is a real challenge. You don’t want them to suffer but it is a slippery slope.”
She said some patients create an ethical quandary because they have a terminal disease but it is clear they are misusing the pain medications or diverting those medications. “We need a next step and the next step needs to be identifying the patients who are the most difficult and how we are going to deal with them. We should develop a database that will allow us to understand chronic pain in the long-term survivors so we know what we are dealing with,” said Dr Murphy.
- Hershman DL, Lacchetti C, Dworkin RH, et al. Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2014;32(18):1941-67.