Twenty years ago, the main barriers to successful
cancer pain management were poor assessment by physicians, and patients' reluctance to report
pain and take
opioids. Those barriers are almost exactly the same today.
Cancer pain remains under-treated; in Europe, almost three-quarters of
cancer patients experience
pain, and almost a quarter of those with moderate to severe
pain do not receive any
analgesic medication. Yet it has been suggested that
pain management could be improved simply by ensuring that every consultation includes the patient's rating of
pain, that the physician pays attention to this rating, and a plan is agreed to increase
analgesia when it is inadequate. After outlining current concepts of
carcinogenesis in some detail, this paper describes different methods of classifying and diagnosing
cancer pain and the extent of current under-treatment. Key points are made regarding
cancer pain management. Firstly, the
pain may be caused by multiple different mechanisms and
therapy should reflect those underlying mechanisms - rather than being simply based on
pain intensity as recommended by the WHO three-step ladder. Secondly, a multidisciplinary approach is required which combines both pharmacological and non-pharmacological treatment, such as psychotherapy,
exercise therapy and electrostimulation. The choice of
analgesic agent and its route of administration are considered, along with various interventional procedures and the requirements of
palliative care. Special attention is paid to the treatment of
breakthrough pain (particularly with fast-acting
fentanyl formulations, which have pharmacokinetic profiles that closely match those of
breakthrough pain episodes) and
chemotherapy-induced
neuropathic pain, which affects around one third of patients who receive
chemotherapy. Finally, the point is made that medical education should place a greater emphasis on
pain therapy, both at undergraduate and postgraduate level.