Cancer pain is a complex phenomenon that is still not well understood or classified. People with cancer may experience pain that is either related to the cancer itself, or to cancer treatment. Pain can occur for several reasons and is different for every person. The way a person feels and describes pain can vary significantly and this can make it challenging to define and treat pain successfully. Post-treatment pain can start or get worse months or even years after treatment has finished. This may be due to the nervous system rewiring itself after damage to the nerves and pain relating to cancer can last for years, or even decades, after diagnosis and treatment.
Classification of pain is complicated and there are many different types of pain, each arising through unique mechanisms, e.g. sharp pain, prickling pain, thermal pain, aching pain. Pain can arise from a physical cause, a psychological cause, or a combination of both. Physical causes are both due to the underlying disease and/or the various cancer treatments and pain has been known to exacerbate other symptoms, such as stress and anxiety.
Cancer treatments can cause pain for a range of reasons, for example, chemotherapy can cause painful chemotherapy-induced peripheral neuropathy (CIPN), radiotherapy can produce late effect radiation toxicity causing pain linked to the areas and surrounding tissues treated (pelvic, brachial plexus etc.) and surgery may lead to the development of persistent post-surgical pain syndromes. Some people may experience phantom limb pain after an amputation (e.g. for sarcoma). In addition, the emotional and psychological aspects of the person and their wellbeing can have a profound impact on the ability to tolerate pain, and for example, feelings of anxiety or depression may make pain worse.
Multi-disciplinary management of pain by clinical nurse specialists, pharmacists, occupational therapists, physiotherapists and speech and language therapists at registered, enhanced and advanced level includes:
- Undertake holistic/biopsychosocial assessment
- Consider both pharmacological and non-pharmacological approaches to pain management
- Be guided by the nature and cause of the pain and the context in which it is present
Refer to physiotherapy or occupational therapy if pain results in any of the following (NB this is not an exhaustive list):
- loss of general mobility
- difficulty performing activities of daily living/low levels of performance status
- maladaptive pain behaviours e.g., fear, avoidance
- muscle weakness or joint stiffness
- loss of social/family/productivity (including paid work) role
- distress due to any of the above
Refer to dietitian if pain results in poor nutritional status.
In addition to pharmacological/medical management of pain, rehabilitation professionals can add:
- Holistic assessment using biopsychosocial model incorporating the impact of beliefs, thoughts and emotional responses towards the pain experienced by the person
- Identification of pain impact on functional performance: self-care, leisure, productivity and maintenance of roles
- Teach therapeutic exercise, set graded and purposeful activity, provide postural re-education (physiotherapists)
- Massage and mobilise soft tissue (e.g. from physiotherapists)
- Provide Transcutaneous Electrical Nerve Stimulation (TENS), heat and cold therapies to help ease pain
- Assess for and provide orthoses
- Occupational therapists can ensure graded engagement in meaningful activity using goal setting and activity scheduling techniques, manage anxiety, help with relaxation and provide guided imagery training, help with lifestyle adjustment to include task adaptation, work simplification, compensatory techniques, time management, ergonomic principles and energy conservation, provide equipment and adaptations and advise on posture, seating, positioning and pressure care
- Cognitive behavioural approaches including third wave cognitive therapies with an evidence base
- Offer complementary and alternative medicine (if appropriately trained) e.g. acupuncture