prof nusirwan acang pembicara ii

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CANCER PAIN(Pathophysiology and Etiology)

Nuzirwan Acan 

Bagian Ilmu Penyakit Dalam Fakultas Kedokteran

Universitas Andalas Padang

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Pain as “an unpleasant sensory andemotional experience which we primarilyassociate with tissue damage or describe in

erms o suc amage, or o .(The International Association for the Studyof Pain = IASP)

This definition recognizes that pain is aperception and not a sensation.

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An estimated 6.6 million people from around

the world die from cancer each year. Pain can occur at any point during the course

of the illness 

The prevalence of pain- At the time of cancer diagnosis : 50 %

- At advanced stages : 75%

- In cancer survivors to be : 33%

- Approximately 25% of those in nursing

homes

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After curative treatment : 33% Under anticancer treatment : 59%

Advanced/metastatic/terminal disease : 64%

  Highest prevalence in head/neck cancer patients

: 51% to 88%).

(Annals of Oncology. 2007;18(9):1437-1449.)

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Type of cancer and prevalence of pain:Thoracic 52 %

Lung 45 %

Bone 85 %

Gastrointestinal 40 %

Genitourinary tract (male) 75 %

Genitourinary tract (woman) 70 %Lymphoma 20 %

Leukemia 5 %

Oxford Textbook of Palliative Care, 2005

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Unrelieved severe pain may associated with:Unrelieved severe pain may associated with:Unrelieved severe pain may associated with:Unrelieved severe pain may associated with:

◙ Disturbed sleep◙ Reduced appetite

◙ Un-concentration

 rr ta ty an epress on

69% of severe cancer pain patient to cause69% of severe cancer pain patient to cause69% of severe cancer pain patient to cause69% of severe cancer pain patient to cause

consideration of suicide.consideration of suicide.consideration of suicide.consideration of suicide.(Wisconsin 1985)(Wisconsin 1985)(Wisconsin 1985)(Wisconsin 1985)

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Nociceptive pain: Ongoing tissue injury insomatic structures

Neuropathic pain: Aberrant somatosensoryprocessing

Visceral pain: Damage of visceral structures

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NociousNociousNociousNocious StimuliStimuliStimuliStimuli

mechanical thermal chemicalelectrical

Tissue damageTissue damageTissue damageTissue damage

Release of mediatorsRelease of mediatorsRelease of mediatorsRelease of mediators

Hydrogen and potassium ions,neurotransmitters, kinins,

prostaglandins

Stimulation of nociceptorsStimulation of nociceptorsStimulation of nociceptorsStimulation of nociceptors

Transmission to CNSTransmission to CNSTransmission to CNSTransmission to CNS

vvvvia afferent pathways

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Disease itself :

- localized- Metastese

Cancer Treatment-- Radiotherapy- Khemotherapy- Hormonal therapy

Noncancer pain condition- Low back pain- Arthritis

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Tumor expansion can cause pressure on

surrounding organs. Proteolytic enzymes produced by tumor cells candamage sensory and sympathetic nerve fibers

Tumors secrete inflammatory andpro ypera ges c me a ors.

Tumor infiltration in nerve plexuses and damageto nerve tissue can cause neuropathic pain.

Metastatic spread of cancer to bone

Stretching of hollow viscera, distortion of thecapsule of solid organs, inflammation of themucosa, and ischemia or necrosis activatevisceral nociceptors, resulting in visceral pain.

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Adverse effects of treatment :- Joint pain following chemotherapy and hormonal

therapy- Painful mucositis due to radiotherapy and

chemotherapy with certain agents.- europa c pa n : pos ra a on p exopa es,

peripheral polyneuropathy after chemotherapy- Opioid-induced hyperalgesia

Surgical interventions nerve damage and chronicpostoperative pain.

Procedures related to cancer pain ; biopsies, blooddraws, lumbar punctures, laser treatments

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Painful peripheral neuropathy fromchemotherapeutic agents :

vincristine, platinum, taxanes, thalidomide,bortezomib, and other agents; radiation-induced

Damage of tissue :- Radiation-induced brachial plexopathy

- Postradiation pelvic pain syndrome

- Postsurgical pain syndromes frommastectomy, amputation, and thoracotomy.

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Acute PainAcute PainAcute PainAcute PainA. Due to procedures and therapies

- Acute pain associated with diagnosticprocedures 

Lumbar puncture headache

 Bone marrow biopsyLumbar puncture, VenepunctureParacentesis, Thoracentes

- Acute pain associated with analgesic techniques 

Spinal opioid hyperalgesia syndromeAcute pain after Strontium-89 therapy of

metastatic bone pain

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- Acute pain associated with othertherapeutic procedures 

Pleurodesis

 Tumour embolisationNephrostomy insertion

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B. Acute pain associated with chemotherapy 

Pain from intravenous or intra-arterialinfusion

Intraperitoneal chemotherapy

ea ac e ue o n ra eca c emo erapy Painful oropharyngeal mucositis

Painful peripheral neuropathy

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C. Acute pain associated with hormonal

therapy  Painful gynaecomastia Luteinising hormone-releasing factor tumour

flare in prostate cancer Hormone-induced acute pain flare in breast

cancer

 . cute pa n assoc ate w t mmunot erapy  Arthralgia and myalgia from interferon and

interleukinE. Acute pain associated with radiation therapy  Painful oropharyngeal mucositis Acute radiation enteritis and protocolitis

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Multifocal or generalised pain (focal metastases 

or marrow expansion) 

Base of skull metastases

Pain syndromes of the bony pelvis and hip

umour nvas on o o nt, or so t t ssue, orboth

Paraneoplastic pain syndromes 

Hypertrophic osteoarthropathy Tumour-related gynaecomastia

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Neoplastic involvement of viscera  Hepatic distension syndrome

Chronic intestinal obstruction and peritonealcarcinomatosis

Chronic ureteral obstruction

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Process of the pain disease

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Acute pain + insufficient pain therapyAcute pain + insufficient pain therapyAcute pain + insufficient pain therapyAcute pain + insufficient pain therapy

Central sensitizationCentral sensitizationCentral sensitizationCentral sensitization

Pain memoryPain memoryPain memoryPain memory

Pain diseasePain diseasePain diseasePain disease

Collapse of the body's pain defensesCollapse of the body's pain defensesCollapse of the body's pain defensesCollapse of the body's pain defenses

Sandkühler, J.: Preventing Pain Memory. MMW 2002; Special

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Adapted from Mundy G. Nature reviews cancer 2. 584-593. 2002

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Other somatic symptoms (chronic cough,nausea, hiccup)

Knowledge and understanding of the patient

Feelings of frustrations, angry anddepression

Social factors (financial, partner, children)

Existential problems Cultural factors

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Pain is a common symptom of cancer, consist of

acute and chronic Delineate type of cancer: nociceptive,

neuropathic, visceral

  Local tumors cause spinal and supraspinalhyperreactivity

Metastatic/spread of cancer produced Nociceptive

and visceral pain

Different tumors cause different pain reactivity

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 ANDALAS

UNIVERSITYHOSPITAL