8 Jan 2020

Anesthetic Management of Cancer Pain

Cancer progression is often associated with pain,1 whether it arises from the disease itself or from therapeutic approaches such as surgery, chemotherapy or radiotherapy.2 Cancer pain can be difficult to treat, particularly in emergency settings where the treating physician and full history of the condition may be unavailable.1 Anesthesia providers can reduce pain for cancer patients in various ways depending on disease pathogenesis and presentation.3 In order to provide proper care to patients with cancer, anesthesiology practitioners must select appropriate analgesic agents and consider anesthesia-related complications that may arise in these patients.

Anesthesia providers must know the extent and etiology of cancer-related pain in order to select the best analgesic solution. Fifty-three percent of patients with cancer will experience pain, and 33 percent of those in remission will have a chronic pain condition related to their cancer or treatment they received.3 It is the anesthesia provider’s role to assess the level of cancer-related pain and choose treatments that fit the patient’s needs. In 1986, the World Health Organization developed an analgesic “ladder” that has been successful in 80 to 90 percent of cancer patients, consisting of non-opioids (acetaminophen, NSAIDs, etc.), weak opioids (codeine, tramadol and dihydrocodeine) and finally strong opioids (morphine, oxycodone and fentanyl).4 Other pharmacological strategies include long- and short-acting opioids, ketamine, cannabinoids, steroids, bisphosphonates and antispasmodics,3 which may be delivered intravenously, orally or topically.1 A study by Klepstad et al. found that—despite limited evidence—peripheral nerve blocks are generally effective in relieving cancer patients’ pain.5 For optimized pain management, the anesthesia provider may combine these medications with other techniques, including physical therapy, chemotherapy, surgery or psychotherapy.3 For example, a review by Hochberg et al. on lung cancer pain states that interventional approaches such as joint injections, nerve blocks and/or neurolysis, neuromodulation and cement augmentation techniques may provide better analgesia than opioid medications alone.2 The best pain treatment can also depend on the cause of cancer pain. Patients with cancer often suffer from pre-existing conditions such as chronic low back pain, and their pain may be exacerbated by inflammation, surgical stress, infection, prolonged immobility, osteoporosis or immune dysfunction.3 Because patients with cancer experience many types of pain, which can be caused by disease and/or treatment, anesthesia providers must tailor analgesic strategies to each individual’s condition.

Patients with cancer also require special attention of anesthesia providers because of their susceptibility to cancer-related complications. Anesthesiologists who provide analgesia and anesthesia to patients with cancer should be aware of their patients’ treatment history and vulnerabilities specific to cancer.6 For one, chemotherapy drugs have various deleterious effects on patients’ organ systems. Bleomycin causes pulmonary damage, anthracyclines cause heart damage and platinum-based agents cause kidney damage, while many other chemotherapy drugs lead to abnormal liver function, vomiting and diarrhea.6 Damage to any of these body systems can make anesthetic drugs more harmful to the patient. Additionally, anesthetic drugs can cause immunosuppression in already immunocompromised cancer patients.6 According to several studies, immunosuppression during the perioperative period may actually lead to cancer recurrence or metastasis.6-9 Thus, the anesthesia provider should aim to prevent perioperative immune system stress and reduce infection risk by maintaining a steady temperature and providing supplemental oxygen.9 Anesthesiology professionals may also consider epidural or local anesthetics to reduce perioperative morbidity risk.10,11 Evidently, the selection of anesthesia drugs depends not only on the patients’ pain levels and types, but also on their medical histories and immune systems.

Pain associated with cancer is common, and it may arise from disease or treatment techniques. Anesthesia professionals are responsible not only for provision of analgesia, but also for minimizing the potential harms of anesthetic drugs on patients with cancer. Given the complexity of cancer origins and progression, future studies should assess the best types of analgesia for various types and stages of cancer. Also, researchers should clarify the potential long-term effects of anesthesia on cancer recurrence.

1.         Money S, Garber B. Management of Cancer Pain. Current Emergency and Hospital Medicine Reports. 2018;6(4):141–146.

2.         Hochberg U, Elgueta MF, Perez J. Interventional Analgesic Management of Lung Cancer Pain. Frontiers in Oncology. 2017;7(17).

3.         Scott-Warren J, Bhaskar A. Cancer pain management—Part I: General principles. Continuing Education in Anaesthesia Critical Care & Pain. 2014;14(6):278–284.

4.         World Health Organization. WHO’s cancer pain ladder for adults. Cancer 2019; https://www.who.int/cancer/palliative/painladder/en/.

5.         Klepstad P, Kurita GP, Mercadante S, Sjogren P. Evidence of peripheral nerve blocks for cancer-related pain: A systematic review. Minerva Anestesiologica. 2015;81(7):789–793.

6.         Gudaitytė J, Dvylys D, Šimeliūnaitė I. Anaesthetic challenges in cancer patients: Current therapies and pain management. Acta Medica Lituanica. 2017;24(2):121–127.

7.         Tavare AN, Perry NJS, Benzonana LL, Takata M, Ma D. Cancer recurrence after surgery: Direct and indirect effects of anesthetic agents. International Journal of Cancer. 2012;130(6):1237–1250.

8.         Byrne K, Levins KJ, Buggy DJ. Can anesthetic-analgesic technique during primary cancer surgery affect recurrence or metastasis? Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2016;63(2):184–192.

9.         Exadaktylos Aristomenis K, Buggy Donal J, Moriarty Denis C, Mascha E, Sessler Daniel I. Can Anesthetic Technique for Primary Breast Cancer Surgery Affect Recurrence or Metastasis? Anesthesiology: The Journal of the American Society of Anesthesiologists. 2006;105(4):660–664.

10.       Singh AP, Tewari M, Singh DK, Shukla HS. Cervical Epidural Anesthesia: A Safe Alternative to General Anesthesia for Patients Undergoing Cancer Breast Surgery. World Journal of Surgery. 2006;30(11):2043–2047.

11.       Horlocker TT, Wedel DJ. Regional anesthesia in the immunocompromised patient. Regional Anesthesia & Pain Medicine. 2006;31(4):334–345.