Physical treatments
Cancer patients may benefit from formal rehabilitation, evaluation, and treatment. Physical modalities, such as massage, ultrasonography, hydrotherapy, transcutaneous electrical nerve stimulation, electroacupuncture, and trigger-point manipulation, are indicated for musculoskeletal pain. Also, any of these techniques may enhance exercise tolerance in a patient undergoing rehabilitation. Skillful soft-tissue manipulation probably is underused. Electrical stimulation may also be applied to the peripheral nerves, spinal cord, and even deep brain structures.

Management of psychological, sociocultural, and spiritual factors
The appropriate treatment of cancer pain must extend beyond the physical complaint. Psychological, sociocultural, and spiritual factors significantly affect the patient’s quality of life. Thus, the clinician must always care for the whole person. A multimodal approach to pain management recognizes the complexity of the human being, especially one with a terminal illness.

Although the physician’s initial therapeutic goal is to cure the disease, cancer is often incurable. Caring entails recognizing the whole person as a physical, intellectual, social, emotional, and spiritual being. Empathic caring helps the patient perceive the value in life despite the gravity of the situation.

Psychiatric diagnoses
Psychiatric conditions, such as anxiety and depression, and psychological factors must be thoroughly addressed, as revealed by emerging evidence from the disciplines of psycho-oncology and psychoneuroimmunology. Attitude and state of mind affect the individual’s perception of pain and response to it in myriad ways and may affect the duration of survival.

A detailed discussion of pharmacologic and nonpharmacologic approaches to anxiety and depression in cancer patients may be found in chapter 36. In addition, patients may regain a much needed sense of control by using psychological techniques, such as imagery, hypnosis, relaxation, biofeedback, and other cognitive or behavioral methods.

Sociocultural influences
These factors affect the patient’s experience and expression of pain. This is especially true for the patient whose cancer does not respond to therapy and progresses to end-stage disease.

Pain may be an unwelcome reminder of the presence and progression of cancer. Concomitant fear, anger, frustration, disappointment, and other negative emotions may hold the patient hostage to physical pain.

Existential distress
This may bridge an undesirable transition from hopeful coping with pain to hopeless suffering from it. As patients are confronted with personal mortality, the limits of their life spans move from an abstract concept to a real issue. Self-image changes, and patients may develop emotional and psychic turmoil, which may compromise their medical condition and treatment.

Achieving relief of psychic suffering may enable the patient to transcend physical pain, enhancing the effects of pain medications and other treatments. Prayer, meditation, counseling, clergy visits, and support groups may all be beneficial. Relieving suffering means allowing the patient and family to realize improved quality of life and even find contentment or peace in the face of failing health and imminent death. Palliative care of the family includes bereavement counseling in anticipation of and after the loss of a loved one.

Ongoing care
The goals of pain management must be frequently reviewed and integrated into the overall management plan. Communication among the professional staff, patient, and family is essential. A sensitive, frank discussion with the patient regarding his or her wishes should guide medical decision-making during all phases of the illness.