I read with pleasure this article from the staff of the Harry R. Horvitz Center for Palliative Medicine, an institution with expertise and experience to draw upon. All multidisciplinary cancer centers should have an expertise in palliative medicine if not a formalized program, as one of the most important jobs of oncologists is to relieve pain and suffering for patients and their families. When pain is effectively addressed, the patient's aggregate quality of life is optimized and time spent with family and friends is more enjoyable.
To accomplish this goal requires not only knowledge but a sense of collegial connectedness and the willingness to refer to those interested in pain management-ie, to escape the hubris that one oncologist can know all. If we have oncology subspecialization in disease treatment and research, pain management deserves a role as prominent as that of the lymphoma expert.
Tailored Approach Needed
The relief of pain requires a timeintense individualized approach that is often contrary to the requirements of clinical studies, translational research, and managed care time restraints. Despite the existence of validated World Health Organization (WHO) guidelines, their application is spotty, and an understanding of WHO guidelines is often assumed rather than carefully taught.
The clear identification of pain as either (1) constant, (2) incidental, or (3) breakthrough gives an excellent stratification with which to address the concepts of (1) strategy, (2) titration, and (3) conversion. The authors' clearly discussed 11 errors offer a succinct approach to addressing these items.
The number 1 job in oncologic pain management is to avoid rescue or prn dosing, as this is the surest way to create dependence, decrease quality of life, and promote drug-seeking behavior. All too often we approach the management of pain in cancer patients in the same way we approach pain in the patient with a broken ankle. Cancer pain is not going away anytime soon, is unlikely to be relieved by positioning, and, in a terminal condition, is likely to be exacerbated by emotional components.
To start a patient on immediaterelease medicine around the clock is acceptable, but in a cancer patient we need to address the persistent nature of pain and focus on sustained-release medications, with immediate-release agents reserved for breakthrough episodes. Another issue that is often overlooked in this setting is incident pain. If we wish the highest quality of life for our patients, then we need to find unique ways for them to perform their activities of daily living and have pain-free periods in which to interact with their families. Taking a bath/ shower, shaving, dressing, defecating, or riding in a car should not be negative experiences with good clinical practice.
Adjuvant medications are discussed briefly and appropriately, but I would add that a panoply of nonpharmacologic adjuvant analgesic options are available that physicians do not think about. These include modalities such as massage, triggerpoint release, gentle relaxation yoga, and acupuncture. Such options should be explored so that the medication load and its potential side effects are kept to a minimum. We do not need polypharmacy and its attendant complications and side effects to lessen the quality of the patient's remaining time.
A Physician's Touch
The effort to provide appropriate dosing time intervals, utilize equianalgesic medications, and pay attention to the pain stratification of constant, incident, and breakthrough pain requires a physician's touch. This most important part of patient care cannot be delegated or relegated to health-care extenders. Physician involvement is paramount in an effective palliative and analgesic program.
The physician and patient must create a therapeutic relationship that is effective in pain management and complementary to conventional pain management approaches as well as nonpharmacologic analgesic activities. This takes time, and the cognitive and empathetic interaction should be rewarded appropriately and without distasteful health-care management interference.
Finally, I think directors of oncology fellowships, and directors of internal medicine residencies should compile the excellent 20 references identified by Kochhar et al along with this article and local favorites to be read by all their students. A champion for pain management or palliative medicine should be identified and supported by each institution, whether an academic or community facility. No patient's pain should be ignored.