Introduction, Assessment & Analgesia

General notes

Assessment of the new patient

Pain relief for cancer patients

Common causes of pain

Management of cancer related pain

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General Notes

• All cancer patients must have a thorough examination at diagnosis & follow up
• The diagnosis of cancer comes as a great shock to most. Handle the matter with sensitivity & sympathy.  Avoid terms like “huge”, “biggest I’ve seen” in front of the patient
• Await biopsy results before making definitive statements
• Some patients have a surprisingly good prognosis. Knowing survival figures can help to encourage patients
• Remember that HIV positive patients have two diagnoses to contend with
• Social organization is vital to all people. Engage relatives, with patient consent, wherever possible. Be sensitive to requests to arrange domestic affairs but encourage patients to return
• Terminally ill patients must have good analgesia. Ask about pain. Involve the palliative care team, social workers, relatives, & hospices

ASSESSMENT OF THE NEW PATIENT

All new patients must be thoroughly assessed.

• A patient may come referred as a known cancer patient or may be newly suspected by yourself, in either case….
• ‘Top & Tail’ ALL patients – i.e.
  •  A  thorough history detailing
    • Symptoms
    • Past Gynae/Medical/Surgical History
    • HIV status
    • Any/All investigations – if taken
    • Social including financial support/relatives
  • Full examination
    • General well-being, vital signs, anaemia, jaundice
    • All regional lymph nodes
    • Breast examination
    • Chest & Abdomen (full examination)
• What you notice, somebody else may have missed

PAIN RELIEF FOR CANCER PATIENTS 

Cancer patients vary from well patients to those in extreme pain or terminally ill. It is important to ask patients regularly about pain. Consult the Palliative Care Team if there are difficulties with pain relief. Beware that not all pain relates directly to the cancer. Patients awaiting treatment, undergoing treatment, & under review imagine that all pain is cancer related. If it is not, after investigation, say so.

Also a pain may relate to a specific pattern of spread of the cancer as below:-

Common causes of pain 

Abdominal pain

• Urinary tract infection – history & urine examination: antibiotics
• Constipation – history, tenderness & loaded bowel in left iliac fossa: laxatives
• Bowel obstruction – examination, abdominal X-ray: drip & suction
• Referred root pain (metastases) – examination, X-ray, bone scan: radiotherapy

Back pain

• Nonspecific backache – history, examination, exclude metastasis: simple analgesia, advice
• Pyelonephritis – history, examination, urine examination: antibiotics
• Lumbosacral metastases – examination, lumbar x-ray, bone scan: radiotherapy
• Refer patients with bone metastases for urgent radiotherapy

Management of cancer related pain

Use the WHO stepwise approach (below, Steps 1 to 4). Gradually increase doses, then change the type of analgesia according to the effectiveness. Communicate regularly with the patient

Use laxatives with opiates of any strength (i.e. Liquid Paraffin or Lactulose 10ml bd, or another).

Also exclude non-malignancy causes as mentioned above, and involve the Palliative Care Team if help is needed.

Step 1: Simple analgesics

• Paracetamol, Aspirin, Ibuprofen, Naproxen etc.

Step 2: Mild opiate containing agents

• Add dihydrocodeine (DF118) 30 mg orally 4 times daily, increasing to 60 mg (rarely 120 mg) orally 4 times daily if necessary
• Prescribe laxatives with all opiate preparations – e.g. liquid paraffin 10mL orally twice daily with sennosides (Senokot) 7.5 mg orally at bedtime
• Continue with anti-inflammatories as above

Step 3: Strong opiates

• Morphine sulphate tablets 30 mg orally twice daily, increasing to 60 mg orally twice daily or more if necessary
• Supplement with morphine oral solution 10-20 mL 4 times daily when necessary, for breakthrough pain
• Continue with anti-inflammatories & prescribe laxatives as above

Step 4: Alternative methods

• These include radiotherapy to bony metastases, epidural analgesia, & nerve ablation