DR. R. G. WISEMAN PINTO
Cancer often begins insidiously and without pain. However, in stages III and IV, many patients develop significant, sometimes excruciating pain.
It may result from a tumour growing rapidly and stretching or infiltrating surrounding tissues. It can also arise from diagnostic procedures, treatment, involvement of the skin and nerves, hormonal changes and immune responses. Inflammation, infection and chemical changes may contribute as well.
Cancer pain may be acute or chronic, mild, moderate or severe. It is commonly assessed on a scale of 0 to 10 and may be continuous or intermittent. It can be burning, shooting, sharp, visceral or severe, and may be localised, generalised or referred, depending on the cancer’s site and stage. About two-thirds of patients with advanced cancer experience pain.
It can disrupt sleep, mood, social relationships and daily activities. It may lead to anxiety, depression, fear, anger and demoralisation, significantly affecting quality of life.
Cancer can spread to the ribs and other bones, particularly from cancers of the breast, prostate and lung. Soft tissues, blood vessels and the central nervous system may also be involved. Patients can develop oedema, visceral or pelvic pain, with pain sometimes radiating to the lower back, genitals or perineum.
Treatment itself can also cause pain. This may occur following immunotherapy, radiotherapy, chemotherapy, targeted therapy, hormone therapy or surgery.
Pain must be treated to improve quality of life and maintain function. Palliative care is equally important in helping patients live and die with dignity.
Physical and psychological problems, including anxiety, depression and other mental health difficulties require attention. Counselling, spiritual care, antidepressants, family support and the involvement of friends and well-wishers can all help.
Analgesics may be administered regularly, every three to six hours where required, through oral, sublingual, subcutaneous, parenteral, rectal or spinal routes. These include paracetamol, non-steroidal anti-inflammatory drugs, COX-2 inhibitors, codeine and tramadol. When these are insufficient and severe pain persists, morphine may be necessary.
Morphine must be prescribed by a doctor and carefully monitored to prevent misuse and diversion. It should be readily available in cancer wards and hospitals, including government and private facilities, with the necessary approvals from the FDA and health authorities. The pharmaceutical industry also has a responsibility to maintain adequate stocks for cancer patients. Its use must remain restricted to patients who require it.
Palliative care centres should be established in every village and town, with adequate supplies of essential pain medicines, including morphine. The dose can be adjusted according to the patient’s needs. Important side effects include constipation and gastrointestinal symptoms such as vomiting, while respiratory depression and hypersensitivity are rare.
Other treatments include steroids and bisphosphonates. Radiotherapy may be required for bone metastases. Nerve blocks, alcohol injections, neurolysis and neurotomy can be considered in selected cases. Intrathecal pumps and epidural catheters may also have a role.
Complementary approaches such as massage, hypnosis, Reiki and acupuncture may provide additional relief in some patients. Pituitary ablation has also been used for intractable pain.
Cancer pain should be managed by specialists. Cancer pain physicians are anaesthesiologists with specialised training and fellowship experience in pain management. The National Medical Commission has made it mandatory for anaesthesia departments to have pain specialists. Recognition of this speciality is important so that the public understands that cancer pain can be treated and know where to seek help.
Patients with advanced cancer may be weak and suffer from cachexia, vomiting, pain, secondary infections and other complications. Prolonged suffering can also contribute to grief, depression and suicidal tendencies.
Care should therefore address physical, emotional, social and spiritual needs. Doctors, nurses, counsellors, physiotherapists and families all have a role to play. The goal is to relieve suffering and ensure that patients receive compassionate, dignified care throughout the course of their illness.
The writer has seen a large number of cancer patients over more than 50 years, including a time when morphine was not widely available. The pain could be so severe that
patients were shattered, unable to cope and sometimes expressed a
desire to die.
Today, with morphine, fentanyl patches, nerve blocks and other advances, cancer pain can be managed far more effectively. This progress needs to be publicised by the government, NGOs, clubs, panchayats, municipalities and the media.
Goa Medical College, Bambolim also urgently needs a Linear Accelerator and an overhaul of its Radiation Oncology facilities. These are important in cancer treatment and can be particularly useful in managing pain caused by bone metastases. Poor patients should have access to such advanced treatment on an equal footing with those who can afford private care.
Cancer is the second most common cause of death after cardiovascular disease, and the number of cases are expected to rise in the coming decades. The Joint Parliamentary
Committee of India has recommended that cancer be made
a notifiable disease.
Awareness, early detection and prevention are therefore essential.
(The writer is a professor of pathology, former head of department and former dean, Goa University, and president, South Asian Academy of Cytopathology and Histopathology)
