(ĐTĐ) – Patients with advanced cancer may suffer from a number of pain states that show a typical pattern and require specific treatments.
Most patients with advanced cancer will develop bone metastases, but this does not mean that they will develop pain in the affected area:
The patient may have:
- a number of large lesions on x-ray and no pain.
- a number of lesions but pain only in only one or two
- severe pain in an area where no lesions can be seen (but these willbecome obvious later)
The pain is:
- dull, aching
- worse on movement (or there may only be pain on movement)
- severe pain on weight-bearing.
If a patient with bone metastases develops a sudden severe pain in an affected area, the risk of a pathological fracture should be considered. Painfull bone metastases can be treated with radiotherapy or biphosphonates.
Pain in the spine
Pain in the spine and especially back-pain is a very common symptom in cancer patients.
It may be due to a number of factors:
- metastasis to the spine
- pain due to degenerative changes (made worse by muscular weakness)
- muscular pain
- epidural cord compression
It is important to establish the cause of the pain as the treatments can be very different.
- pain from metastasis in the spine can be relieved by radiotherapy.
Epidural cord compression
Is one of the few emergencies in palliative care.
The pain is:
- Progessive pain in the back
- Radicular band-like pain around the thorax or abdomen (may be unilateral)
- Pain worse on recombency
Progressive pain radiating from the back is the first and sometimes the only sign of epidural cord compression. A fully developed epidural cord compression has a devastating effect on the life of the patient, therefore it is important to diagnose the condition as qickly as possible.
ALL PATIENTS WITH ADVANCED CANCER AND A PROGESSIVE PAIN IN THE BACK SHOULD BE CLOSELY OBSERVED AND INFORMED ABOUT WHEN TO REACT. ALL PATIENTS WHO HAVE A BAND-LIKE PAIN OR ANY SIGNS OF MUSCULAR WEAKNESS SHOULD BE INVESTIGATED FOR EPIDURAL CORD COMPRESSION.
Epidural cord compression should always be treated with high dose steroids, this may relieve a number of the symptoms. If possible the patient should undergo acute spinal surgery or radiotherapy.
Nerve plexus involvement
Cancer patients with pelvic tumours may develop cancer-infiltration of the pelvic nerve plexus.
Cancer patients with tumours in the apex of the lung or in the axilla may develop infiltration of the brachial plexus.
The symptoms are:
- severe pain in the affected area
- neuropathic pain radiating down the limb on the affected side
- sensory deficits in the limb on the affected side
- muscular weakness in the limb on the affected side
The treatment of nerve plexus involvement is often very complex and may include the use of radiotherapy to shrink the tumor.
Headaches in cancer patients may be due to cerebral metastasis, but in the majority of cases these headaches occur in combination with one or more of the following symptoms:
- neurological deficits (often paresis/paralysis)dizziness
- vomiting without nausea
- nausea on the movement of the head
Brain metastasis are treated with steriods and/or radiotherapy.
Pain in the liver.
Many cancer patients develop liver metastases; the liver itself does not have any pain receptors, so these lesions do not cause pain.
The most common cause of pain in the liver is liver capsule pain caused by the stretching and irritation of the liver capsule.
The pain is:
- located in the right upper abdomen
- dull and aching
- worse on bending or deep inspiration
- may be referred to the right side of neck, shoulder or scapula.
The treatment of liver capsule pain is moderate doses of steriods.
Bleeding in liver metastasis: Will cause acute pain in the right upper abdomen, which may be referred to the right side of thorax.
Pain due to retroperitoneal tumours.
Many patients with pelvic or abdominal tumours will develop a spread of the cancer to the retroperitoneal lymph nodes.
The pain is:
- dull and boring
- reffered to the posterior abdominal wall and bilateral flank regions
- may be referred to the epigastrium
- worse when lying down
- better on sitting up
Pain due to retroperitoneal tumours should be differentiated from the pain due to epidural cord compression.