Cancer pain management—Part I: General principles

In 2008, there were more than 2 million people in the UK with a present or past history of cancer, with the lifetime risk of developing the disease estimated at one in three (http://www. cancerresearchuk.org/cancer-info/cancerstats/). Breast cancer is the single most common form of cancer, followed by lung, prostate, and bowel. Over the last 10 yr, there has been an overall increase in incidence of 3%, with cancers strongly linked to lifestyle choices such as melanoma or oral cancers seeing the greatest increase. Fifty-three per cent of patients with cancer will experience pain, including 59% of those undergoing active treatment and increasing to 64% of patients with advanced or metastatic disease. Thirty-three per cent of those considered cured or in remission will have a chronic pain condition related to their cancer or treatment received. The three-step World Health Organization analgesic ladder (Fig. 1) was developed in 1986 to specifically address the worldwide problem of under, poorly treating cancer pain, or both. Designed in a format that can be implemented easily, with clinical and cost-effectiveness in mind, it is reported to be successful in 80–90% of patients (http://www.who.int/cancer/palliative/ painladder/en/), and emphasizes regular ‘by the clock’ administration of appropriate, effective oral analgesia. Methods of pain control in patients with cancer can be divided into pharmacological, oncological, surgical, interventional, physical therapy, psychotherapy, and complementary therapy. A holistic, multidisciplinary and multimodal approach is essential to optimize outcomes for patient benefit and this can be delivered only by established and effective communication between surgeons, oncologists, pain specialists, palliative care teams, primary care teams, and other allied healthcare professionals, thus ensuring that patients receive the best possible seamless and continuing care. Mechanisms of pain in cancer