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Pain can be a harsh reality of cancer, whether the pain is related to a tumor or caused by treatment of the disease. Some studies show that 30 percent to 50 percent of patients undergoing active treatment for cancer and 70 percent of those with advanced stages of the disease experience significant levels of pain and may be reluctant to discuss their pain with their doctors.

"Patients don't discuss pain symptoms for fear that it will distract from talking about their disease. They want to stay focused because they are there to be cured," stated Ann O'Mara, Ph.D., program director in the Division of Cancer Prevention, National Cancer Institute (NCI). During an appointment with an oncologist, discussions often focus on surgery and treatment; there may not be time to explore how the patient is coping. "Cancer patients can also feel that discussing their symptoms makes them appear as complainers and this will displease their physician," continued O'Mara. "All of these factors create an environment where effective pain management can fall through the cracks."

Scales have been designed to help patients describe their levels of pain. If the pain is described as shooting down a leg, or a tingling sensation in the hands or feet, this information can be crucial to identifying the source of the pain and appropriate therapy. For example, pain caused by nerve damage is treated differently than pain from an invasive tumor or bone metastasis. In addition, not all pain may be related to cancer; it may be caused by an unrelated medical condition, such as arthritis.

NCI is sponsoring research that examines the barriers that prevent patients from talking about pain and their symptoms. "Patients must become empowered. When it comes to pain and symptom management, they are in charge," said O'Mara. In one study, researchers developed an assessment questionnaire that would teach patients how to report their symptoms. The study has three test parameters: in one case, patients are asked to complete the assessment prior to meeting with their physician; in another only the physician completes the assessment prior to a patient's visit; and in the final case, both the patient and physician complete the assessment before each visit. This is an ongoing study that aims to identify if there are differences in symptom management strategies in any of these groups. The study's goal is to determine the most effective method that enables patients and doctors to broach the discussion of pain, resulting in improved symptom management.

Another NCI-supported study found that side effects, such as lack of mental clarity and constipation, could discourage patients from adhering to their pain management regimen. These symptoms often can be easily and effectively managed. "The hand that writes the narcotic analgesic prescription also writes the laxative prescription, resulting in improved patient compliance," said O'Mara.

NCI also is working to dispel myths about cancer and pain. One prevalent belief is that cancer is always associated with chronic, unrelieved pain. While many cancer patients will experience some level of pain during or after their treatment, it can be relieved in 80 percent to 85 percent of patients. The remaining 15 percent to 20 percent experience pain that can be difficult to resolve. However, even the most unretractable pain can be relieved to some degree.

Another common myth is that treating cancer patients for pain can lead to addiction. This belief is held among many cancer patients, their families, and some physicians. Many people misunderstand the difference between addiction and physical dependence. Addiction is a chronic, psychological state with genetic and environmental factors influencing its development and manifestations. It is characterized by impaired control over drug use, compulsive use, craving, and continued use despite harm. Physical dependence, on the other hand, is an expected outcome with chronic use of narcotics. When the drug is abruptly withdrawn, a patient may experience specific physical reactions. However, when the source of the pain is eliminated (e.g., tumor shrinkage), the dose of pain medication should be slowly decreased, enabling a patient to withdraw from the drug without side effects.

Treating pain requires constant reassessment. Clinicians should ask specific questions of their patients. It may not be sufficient to just ask, "How are you doing today?" For proper assessment, clinicians need to help patients verbalize the impact that pain is having on their daily lives. O'Mara suggested more specific questions, such as, "How have they been sleeping, what is the level of their fatigue, or what is their work routine?"

"Just giving a pain medication is not enough. There must be continuous discussion with the patient to determine how the medication is working and how they are coping," concluded O'Mara.

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For definitions related to the use of opioids for the treatment of pain, go to http://www.asam.org/pain/definitions2.pdf .