Cancer Pain Expert Eduardo Bruera Explains Why Patients Need to Be Honest About Their Pain

Eduardo Bruera, MD, chair of the Department of Palliative Care and Rehabilitation Medicine at the University of Texas M.D. Anderson Cancer Center in Houston, answers critical questions about cancer pain.

Q: What can go wrong when patients don't tell doctors about their cancer pain?

A: The main problem with not reporting cancer pain is that it might be a serious problem that goes untreated. They might have a new cancer site that needs a change in the cancer treatment. A lump may be starting to pinch on nerves or the spinal cord and might need immediate treatment. By not talking about it, the patient might not take advantage of changes in treatment that might be extremely useful.

Q: What about the impact on them emotionally?

A: The other big problem is quality of life. People are suffering unnecessarily, which leads to less activity, being very depressed, and being more uncomfortable with cancer.

Q: How often do people keep silent about it?

A: Most of the data suggest it's frequent that patients and their families will not mention that they have pain. There are reasons why patients might not. They might think that it may not be related to cancer. They might think it could be some other condition like arthritis or a cold. The patient may not want to distract or confuse their doctor, whose time is limited, and want them to focus on the treatment. In other cases, patients might be a little bit worried and not willing to accept the fact that it might be a sign cancer is there.

Q: What are the main causes of cancer pain?

A: The main cause is actually the presence of the tumor in a particular area of the body. Either the primary cancer grows and starts pinching on the nerves or the primary cancer gives a little seed that travels with the blood to another part of the body and leads to another lump, or metastasis, and that starts growing and pinching on the nerves. That's about 75% of the cases. About 15% of patients have pain that is due to some of the treatments, some of the chemotherapy or surgery treatments hurt little nerves and patients get peripheral neuropathy (pain in the hands and the feet). Another 5% to 10% of patients have pain that has nothing to do with the cancer, such as rheumatic issues, or issues with the bowel or the heart.

Q: When a patient comes to you for pain treatment what is the most helpful way for them to communicate it to you?

A: First we ask them, "Where is it hurting?" Then we usually ask them, "If zero is no pain at all and 10 is the worst possible, how bad does it hurt on average?" The other thing it would be nice for them to notice is what makes it better—a certain position, rubbing it? What makes it worse—walking, coughing, a certain position? That might help us figure out why the pain is there. Then it is very useful to know how it responds to painkillers. What did they take, how long did it take to work, and how long did the pain improvement last? Those are very useful pieces of information to then decide the next step.

Q: What are the first-line drugs for cancer pain?

A: If people have a pain that is just starting and is not really very high, it can be treated initially with nonsteroidal anti-inflammatory drugs (NSAIDs), or even plain acetaminophen. If the pain is a little bit more problematic, we usually start what are called opioid analgesics (derived from the opium poppy plant or made synthetically), which act on a receptor that we have in the spinal cord and the brain. They act on the intensity of the pain. There are mild opioids, such as codeine or hydrocodone products that are usually given in combination with acetaminophen or aspirin, or strong opioids like morphine, methadone, and fentanyl. Those are the most powerful treatments we have. The main opioid we use, morphine, has been around for some 200 years. Most of the opioids we use have been effective for 60 to 80 years, which means we know them well and they are usually quite safe when used appropriately.

More about cancer pain

Q: How do other medications factor into cancer pain treatment?

A: The number one treatment for patients with cancer who develop pain are the so-called analgesics, the nonsteroidals or the opioids. We always start with those first. The addition of other drugs, like antidepressants, anticonvulsants, or corticosteroids happens mostly when the painkiller alone is not able to control the pain. In most cases, the painkiller alone is effective. In general, the studies have not shown that one painkiller is better than another. We, as patients, have different responses to one painkiller or another, but as a group, you do not find differences between one painkiller and another.

Q: What role does stress play in cancer pain?

A: Stress is a major factor because it causes suffering, but it also decreases our ability to block the pain message. When we are suffering, our ability to tolerate a pain that we would otherwise be able to tolerate decreases and so the management of stress needs to accompany the management of pain for it to be successful.

Q: How can a patient be sure that all the medications they are on they don't interact badly with other treatments?

A: The best thing is to make a list and bring it to the hospital or their doctor. Or bring a bag of medications so the doctor, nurses, or pharmacist can review them and figure out if the list is OK or if there are any interactions. Another source of error is when people go to the medication cabinet and take the wrong bottle. Discard the medicines you are not taking anymore so that you and your family are not confused. If you are not feeling well and a relative is helping you take medication, this will make sure they only give you the ones you are currently taking.

Q: What role does the family play in helping a patient handle cancer pain?

A: The family is also affected dramatically by the presence of cancer and pain. They are the unit of care when cancer patients develop pain, and we need to acknowledge that they are all suffering—emotionally, financially, and physically—by having a family member be really ill. They can have a positive role and sometimes a little bit of a negative role depending on how they approach the patient. The family is the first line of coping. As health professionals, we need to keep an open line of communication with the family so they feel free to contact us and work with us to plan the best care.

Q: What do you recommend that patients ask of their caregivers? In what areas can they help out?

A: The most important thing as patients is to have frank and open communication with our families about our needs to give them the opportunity to become involved in our care. Many of us have relatives or friends who would like to become involved, but they truly don't know how. Sometimes they might spend a lot of time with us when it might be more useful for them to drive us to the doctor, do grocery shopping, distract us, or listen to us. For most patients, when we are sick, our relatives do not know how to be useful. We need to articulate to them what helps us the most. We are all different, so we need to be upfront about what we need from our friends and families.

Q: What would you say to a patient who is worried about becoming addicted to opioid painkillers?

A: These medications can occasionally cause people to become addicted to them. With an adult who has never had a problem with dependence on alcohol or drugs, the chance of that happening is low. By all means, we should take advantage of these medications, because of the problems with untreated pain. If the patient has a history of dependence, we will carefully monitor their use of the medication and limit the escalation of medicine. But even if the patient has a history of alcohol or drug dependence, these medications continue to be the best we have, so we have to work together to minimize problems.

Q: What are the most effective complementary therapies for cancer pain?

A: It varies very much from individual to individual. Some of us respond very well to relaxation, music, distraction, walking, or exercise. There is not a single intervention that would have an overarching effect on decreasing pain. By talking to the patient and the family, sometimes it is possible to figure out added interventions that might help. By keeping a dialogue with their physician and nurse, patients can be guided to some interventions that can be good adjuvants. It's most useful to keep an open dialogue so the patient can prevent these therapies from having a bad interaction with their cancer treatment.

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