Assessing Cancer Pain in the Adult Patient

September 1, 2006

The high prevalence of pain in the cancer population underscores why pain management is integral to comprehensive cancer care. How well pain is controlled can have a profound effect on the cancer experience for both patient and family. The goals of pain assessment are to prevent pain if possible, and to identify pain immediately should it occur. This can be facilitated by standardized screening of all cancer patients for pain, on a routine basis, across care settings. A comprehensive assessment of pain follows if a patient reports pain that is not being adequately managed. Oncology nurses play a huge role in pain assessment and management throughout the course of a patient's disease. A basic understanding of the types of pain seen in the cancer population as well as inferred neurophysiologic pain mechanisms and temporal patterns of pain can help focus the pain assessment. This in turn will lead to targeted pain management strategies

The paper by Dr. Nessa Coyle emphasizes two truths in cancer pain management: (1) We will never effectively manage pain until we accurately assess pain; and (2) the relief of pain is essential to quality cancer care.

There are two critical demands in oncology that make Dr. Coyle's comprehensive paper timely. The first is the chronic nature of cancer and the chronic pain associated with it. The article describes chronic pain as persisting for months; pain that is unrelieved contributes to greatly reduced quality of life.

A recent Institute of Medicine (IOM) report on cancer survivorship revealed that there are more than 10 million cancer survivors in the United States.[1] That number will continue to increase as treatments improve in oncology. Yet, as the IOM report emphasizes, survivorship is not without a price—that price is often living with ongoing symptoms including pain. Ongoing assessment of pain in the growing group of cancer survivors will be essential.

However, the IOM report and extensive literature in the field of cancer survivorship has demonstrated that cancer survivors are often reluctant to report pain. Cancer survivors may avoid the topic of pain as a means of denying the possibility of recurrence because they don't want to distract physicians from focusing on their cancer, or simply because they are so grateful to have survived. Applying the principles Dr. Coyle has described to the pain experience of cancer survivors serves as a form of advocacy and promotes quality of life in survivorship.

The second current imperative in cancer care is an emerging national agenda to improve nursing care for patients at the end of life.[2] As Dr. Coyle has so aptly described, assessment of pain for patients at the end of life is a dual challenge of addressing pain and suffering. There is often a tendency in the terminal phase of care to simply increase the dose of medications in response to increased pain. However, similar to the care provided earlier in illness, expert nursing care requires detailed pain assessment in order to distinguish between multiple symptoms, constantly evaluate the underlying cause of pain and be prepared for pain syndromes that may emerge, such as pathologic fractures.[3]

One of the most important principles of pain assessment is to recognize that pain is a symptom of an underlying cause. A patient report of pain is not simply a trigger for nurses to provide the next dose of medication without assessment. Rather, a patient report of pain is a trigger for nurses to determine the underlying cause through careful assessment and then work collaboratively with the physician to provide the treatment indicated by the assessment. The relief of pain remains an essential aspect of quality cancer care. Comprehensive assessment of pain is the first step.

References:

1. Institute of Medicine, from Cancer Patient to Cancer Survivor: Lost in Translation, Survivorship Report. Washington, DC, National Academy Press, 2006.

2. ELNEC website, http://www.aacn.nche.edu/elnec/

3. Paice JA, Fine PG: Pain at the end of life, in Ferrell BR, Coyle N (eds): Textbook of Palliative Nursing, 2nd ed, pp 131-153. New York, Oxford University Press, 2005.