Practice Guidelines for Cancer Pain Management

Developed by the Task Force on Pain Management, Cancer Pain Section: F. Michael Ferrante, M.D., F.A.B.P.M. (Chair), Philadelphia, Pennsylvania; Marshall Bedder, M.D., F.R.C.P.(C.), Portland, Oregon; Robert A. Caplan, M.D., Seattle, Washington; Hui-Ming Chang, M.D., Houston, Texas; Richard T. Connis, Ph.D. (Methodologist), Woodinville, Washington; Patricia Harrison, M.D., Buffalo, New York; Robert N. Jamison, Ph.D, Boston, Massachusetts; Elliot J. Krane, M.D., Stanford, California; Srdjan Nedeljkovic, M.D., Boston, Massachusetts; Richard Patt, M.D., Houston, Texas; and Russell K. Portenoy, M.D., New York, New York.Submitted for publication November 28, 1995. Accepted for publication December 1, 1995. Supported by the American Society of Anesthesiologists, under the direction of James F. Arens, M.D., Chairman of the Ad-Hoc Committee on Practice Parameters. Approved by the House of Delegates, October 22, 1995. A list of the articles used to develop these guidelines is available by writing to the American Society of Anesthesiologists.Address reprint requests to the American Society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.Key words: Pain: cancer. Practice guidelines: cancer pain management. Cancer: supportive care; symptom management.Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision from time to time as warranted by the evolution of medical knowledge, technology, and practice. The guidelines provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data (Appendix 1).A. Definition of Cancer Pain. For these guidelines, cancer pain is defined as pain that is attributable to cancer or its therapy. The Task Force has not given preference to literature based on any particular system of definition or classification of cancer pain.B. Purpose of Guidelines for Cancer Pain Management. The purpose of these guidelines is to: (1) optimize pain control; (2) minimize side effects, adverse outcomes, and costs; (3) enhance functional abilities and physical and psychological well-being; and (4) enhance the quality of life for cancer patients.C. Focus. These guidelines focus on the knowledge base, skills, and range of interventions that are the essential elements of effective management of pain and pain-related problems in patients with cancer. The guidelines recognize that the management of cancer pain occurs within the broader context of supportive care, which also encompasses other quality of life concerns (e.g., functional status, psychosocial well-being).The guidelines recognize that comprehensive pain management by anesthesiologists may not be feasible in every clinical setting. However, aspects of these guidelines may be useful when comprehensive pain management cannot be offered.The Task Force recognizes that therapies used to modify the underlying cause of pain may improve analgesia and outcome. Commonly used approaches include radiotherapy, surgery, and chemotherapy. The decision to implement primary therapy should be based on a comprehensive assessment of risks and benefits and are outside the scope of these guidelines.D. Application. The guidelines are intended for use by anesthesiologists and individuals who deliver care under the direct supervision of anesthesiologists. The guidelines apply to patients of all ages and with all types of cancer.The literature suggests that a comprehensive cancer pain evaluation is associated with improved analgesia. The Task Force and panel of consultants support the conduct of a comprehensive pain evaluation. In the opinion of the Task Force and consultants, effective cancer pain management requires a clear understanding of the etiology and pathophysiology of the pain.Recommendations:1. General Constructs. The Task Force identifies four fundamental features that should guide the comprehensive evaluation of the patient with cancer pain.a. The patient's general medical condition and the extent of disease must be assessed.b. A knowledge of common pain syndromes is a prerequisite for conducting a cancer pain evaluation. Common pain syndromes include but are not limited to bone metastases, abdominal (visceral) pain, neuropathic pain (e.g., peripheral neuropathies, acute herpes zoster and postherpetic neuralgia, plexopathies), and mucositis.c. A knowledge of oncologic emergencies (e.g., hypercalcemia, spinal cord compression, cardiac tamponade, superior vena cava syndrome) is also required to conduct a comprehensive cancer pain evaluation.d. A thorough knowledge of the modalities that can be employed in the treatment of painful crisis (i.e., pain emergency) is also necessary.2. Elements. The Task Force identifies six essential features of a comprehensive evaluation and treatment plan. These features are outlined below (Table 1Template 1).a. History: A complete history includes a general medical and oncologic history with a description of the extent of disease and prognosis. A pain history should include: (1) the quality of the pain (e.g., "burning", "aching"), (2) pain intensity (i.e., numeric, categorical, or visual analog scales), (3) spatial relationships of the pain (i.e., location, areas of radiation), (4) factors that palliate or provoke pain, (5) temporal characteristics of the pain (i.e., continuous, episodic), (6) duration of the pain, (7) course of the pain (e.g., stable, progressive, "crescendo"), and (8) associated features of the pain (e.g., numbness, weakness, vasomotor changes).b. Psychosocial evaluation: A psychosocial evaluation should include: (1) the presence of psychological symptoms (e.g., anxiety, depression), (2) indicators of psychiatric disorder (e.g., delirium, major depression), (3) investigation of the "meaning" of the pain to the patient and his or her significant others, (4) changes in mood state, (5) premorbid and current coping mechanisms, (6) family function, (7) the availability of psychosocial support systems, and (8) assessment of the patient's expectations and preconceptions regarding pain management (e.g., fear of addiction surrounding opioids, psychostimulants).c. Physical examination: A physical examination should include general medical and neurologic examinations and a specific examination of the site of pain and surrounding anatomic regions.d. Impression and differential diagnosis: The findings of the history and physical examination should be used to determine the probable etiology and pathophysiology of the pain.e. Diagnostic evaluations: Additional diagnostic tests may be required to ascertain or confirm the etiology of the pain and its relationships to underlying disease processes.f. Treatment plan: Once a definitive diagnosis has been made, a treatment plan should be formulated and discussed with the patient. The treatment plan should characterize the expected outcome, define contingencies, and outline a plan for reassessment.There is insufficient literature to evaluate the efficacy of the longitudinal monitoring of pain. The Task Force and consultants support the contention that the longitudinal monitoring of pain will result in improved pain management and reduced adverse effects from therapy (Table 1template 1).Recommendations: The Task Force identifies three fundamental concepts in the longitudinal monitoring of pain.1. Patient Self-report. Reports of pain made by the patient should be the primary source of pain assessment and should take precedence, whenever possible, over inferences and observations made by others. Continuous assessment over time (e.g., pain diaries) is appropriate for outpatients. For some age groups and populations (e.g., the cognitively or developmentally impaired), external observation may be preferable. Age-appropriate instruments should be used in children.2. Rating Scale. The longitudinal monitoring of pain intensity should be based on rating scales that are easy to use and interpret. Typical examples of rating scales include discrete numeric scales (e.g., 0-10), categorical scales (none, mild, moderate, severe, worst possible), and continuous visual analog scales of pain or pain relief (Table 2Template 2).3. Frequency of Pain Ratings. Self-report should be obtained at regular intervals. Increased frequency and evaluation of self-reports may be indicated: (1) at the onset of new pain, (2) when established pain exhibits changes in pattern and/or intensity, or (3) when a major therapeutic intervention is performed.The literature supports the concept that involvement of specialists from multiple disciplines results in effective analgesia and suggests that such involvement improves other health outcomes. The panel of consultants and Task Force members endorse the importance of collaboration between anesthesiologists and other health-care providers in the management of cancer pain.Recommendations: Anesthesiologists who engage in cancer pain management should avail themselves of interdisciplinary expertise in their clinical is to note that the patient's primary must be a of the of pain management. The Task Force recognizes that interdisciplinary of cancer pain treatment is not feasible in every clinical guidelines the management of cancer pain as a from (i.e., to direct (i.e., and on of to (1) (2) of a for and continuous or (3) the of to the or in the of for the of are by the (Table These American Society of Anesthesiologists guidelines provide and recommendations for cancer pain management the and other of The literature supportive for specific elements of the (Table The literature suggests and opinion supports the that interventions according to the are associated with analgesia. The literature of adverse with the use of (Appendix and The literature suggests that and of analgesia are effective to The Task Force supports the use of these when of and The literature suggests that or of is effective for patients continuous and not the of adverse to and the risks and benefits of the continuous not been General should be used as the in patients when therapy. is not effective in all patients and may not be therapy in painful crisis (i.e., the pain the and benefits of interventions must be and must be for the and should not be on any of and/or For patients with or pain, therapy is Once and a of are the should be a occurs or when or adverse effects is of may be required of the history of the primary disease or the of pain is continuous or occurs should be with available for pain. The practitioner should be of the adverse of and their appropriate or of should be made to for in in are the result of and (Table to a particular may be at of the is The of the should be based on the of pain, the presence of adverse effects, and the medical of the patient. on clinical a to should be with a of of the should be used as (e.g., or to adverse These may be at any (Table such as or other should be employed for to pain. the use of or the use of with a is not the of is and analgesia is not pain is not or or pain is at used for pain (e.g., with a or should be with a of is the required to pain is not or is at used for pain (e.g., with a or should be of a in in pain intensity should a of the cause of analgesia with adverse effects is with the of or when is to and/or of should be The should be used in patients with and to as as effective a of a a of adverse effects by of or therapy should be and of of or should be use of is when therapy is (e.g., and to use is effective in some should be used in patients with pain who are (1) with (2) to or or (3) may from a of and The of should be used in (1) patients to or who may from a continuous of and (2) patients with pain for pain. of may be used in the setting. The recommendations for are the as for may be when the patient has is not as or therapy for cancer pain management of the and of and can be to the of the for as a to for are under to the or of is by diagnostic are to in these guidelines as (e.g., and are from is used for pain management with specific The Task Force is supportive of the efficacy of for literature is not available to the of as a or a for the treatment of cancer The literature is supportive of the efficacy of (i.e., or may be by or of a and the literature suggests that are not associated with of adverse effects, the Task Force and consultants that adverse effects may be (e.g., The literature suggests and consultants and Task Force members support the that by and or can provide of cancer pain a of adverse of include but are not limited to superior of and of include and General analgesia cannot be or side effects with of direct should be In specific or therapies should be at the of therapy or in the history of the pain and therapies should not be (1) in individuals who are or or not the to the risks and benefits and (2) when appropriate system not must access to a system that the and availability of to to patient needs on The of or with support may be For appropriate care must be available and the and should be (1) when pain cannot be with of (2) when is for neuropathic (3) or (4) patient preference its The between or is in by patient life life is should be may The presence of of efficacy and appropriate range should be by or use of a should access to for pain. may be given by any of as appropriate by the of may be in patients with and cancer and should be used of (1) the presence of pain to (e.g., pain, pain, pain of acute herpes or (2) patient when should be (1) when therapies to provide pain or when adverse side effects from therapies are (2) of (3) in the history of the cancer pain in the presence of (e.g., (e.g., cancer of the or neuropathic (e.g., pain that is to be to with limited or (4) patient preference use of for the specific and should be life is the for pain. the other of life is with of the for associated with the The must be the is over of or should not be to of should be and should be to which may in the of pain should be used to determine the efficacy of However, with under not the of a should be at the time of and should not be as a analgesia is not with or significant adverse should be should be with the of when feasible or with direct of the intended in the of open literature supports the efficacy of interventions to symptoms to primary disease and its In the literature suggests that specific interventions used to the adverse effects of pain therapy are effects from cancer pain therapies include but are not limited to and and is in the cancer patient therapy (Appendix literature not that management of symptoms or adverse effects has on Task Force and consultants are supportive of the of symptoms and adverse effects as of the comprehensive management of cancer pain.Recommendations:1. General effects should be and and appropriate should be should not be from cancer patients for fear of physical or patients with for should (Appendix or therapy should the use of (e.g., or or and/or (e.g., or A may be used with the patients should be by (1) factors such as and (2) the of by analgesia is (3) the for by the of a or (4) to (5) the use of or (6) modalities is to and is and therapy is not and should be with such as or In some or can be patients may from the use of treatment for (i.e., or a (i.e., Treatment of factors to (e.g., should be when The treatment of should the management of The of may be for by can be to in the of but should not be to is not a clinical and should be given to patients regarding its However, function, or pain, or should be A in or a to a should be in the of or is a with and should be given to of is also with and should be by of a direct such as The of should be to analgesia and (Appendix of the of a continuous may be literature suggests that psychosocial interventions are effective in analgesia and the quality of life for cancer pain The Task Force and panel of consultants Psychosocial interventions for the management of cancer pain include pain and management. is given to the effects of and for the of the patient. of the psychosocial of cancer pain includes the use of interventions (e.g., and and A psychosocial assessment should be as of the comprehensive pain evaluation. of the psychosocial assessment should be when a pain treatment plan. 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The Task Force and consultants are supportive of the of cancer pain therapies in analgesia and quality of Age-appropriate assessment includes observation (e.g., and self-reports scales (e.g., visual analog pain interventions for use include but are not limited to (1) of to specific for and (2) interventions to be or to patient or about their pain therapy (e.g., as and other interventions include for or interventions to be to The should to the assessment of pain in For to observation of patient should be the primary assessment For who can pain scales are the instruments when the efficacy of pain therapy. should be used as to of to should the of the with particular to or should be employed whenever possible, cannot be and their continuous should be made to minimize to analgesia or is a when are of therapies and direct should be used when and not or side effects their use and other of pain management should be as Task Force who to on cancer pain and to the and in tests of clinical of these guidelines in the (1) Committee to the on Practice of of Practice for a New by and (2) for Practice Guidelines of and for and publication assessment of these guidelines based on the or These about relationships between cancer pain, symptom and clinical evaluation and assessment of pain (i.e., physical improve adverse effects of pain and improve quality of monitoring of pain (e.g., patient rating and frequency of pain improves adverse effects of pain and improves quality of of specialists in multiple disciplines improves adverse effects of pain and improves quality of (i.e., by application of the pain and and improve adverse effects of pain and improve quality of (i.e., for pain and and improve adverse effects of pain and improve quality of of side effects of cancer and adverse effects from pain therapy (e.g., use of and improves adverse effects of pain and improves quality of Psychosocial interventions for pain management and interventions to psychosocial from cancer pain and pain management improve adverse effects of pain and improve quality of therapy improves adverse effects of pain and improves quality of care improves adverse effects of pain and improves quality of features of cancer pain management (i.e., and interventions to and about pain of improve adverse effects of pain and improve quality of from literature with when open and other For of literature clinical and of the The a from 1995. 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