Symptom Management

Pain Management

Symptom management, particularly pain management, is an integral part of treatment for patients with cancer and has been linked to improved quality of life and survival. Although management differs depending on the patient, the following principles and guidelines apply to all patients:

• Pain should be assessed and quantified at every visit.

• Other causes of pain should be ruled out and addressed, and new pain or worsening pain should prompt repeat workup.

• Mild pain should be treated with nonopioids first and then mild opioids as necessary. More-severe pain usually requires stronger opioids.

• Severe, uncontrollable pain is a medical emergency and requires hospitalization and intravenous (IV) pain management. Nonopioids alone will be insufficient for inpatients hospitalized for pain crisis.

• To maintain freedom from pain, drugs should be given on a schedule rather than on an as-needed basis.

• A history of prior opioid use should be taken into account when treating pain with opioids.

• Adjunctive therapy (e.g., anxiolytics) may be beneficial.

• Pain management often requires a multidisciplinary approach including pain specialists, palliative care medicine, and psychosocial support.
  
  

The World Health Organization (WHO) has developed the following three-step ladder for cancer pain relief in adults.

(Source: WHO’s Cancer Pain Ladder for Adults, reprinted with permission from the World Health Organization. Originally published in Cancer Pain Relief: With a Guide to Opioid Availability, 2nd ed., WHO 1996, page 15.)

Treatment

(Source: Nonnarcotic Methods of Pain Management. N Engl J Med 2019.)

Other resources for pain management:

• Use an opioid conversion calculator

• See the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Adult Cancer Pain algorithms on initiating short-acting opioids in opioid-naive patients (page 10) and management of pain in opioid-tolerant patients (page 11).

Nausea and Vomiting

Nausea and vomiting are significant side effects from both cancer and chemotherapy and can be very distressing to the patient. Care should be taken to elicit a detailed history to rule out treatable causes (e.g., obstruction, constipation, hypercalcemia, etc.). Women and younger patients have higher risks for chemotherapy-induced nausea and vomiting. The National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) can be used to categorize the severity of chemotherapy-induced nausea and vomiting (CINV) and other chemotherapy-related adverse events.

(Source: Antiemetic Prophylaxis for Chemotherapy-Induced Nausea and Vomiting. N Engl J Med 2016.)

Mechanism of CINV

The mechanism of CINV involves the serotonin pathway (5-hydroxytryptamine), which is mediated by the brain and parts of the small intestine (see figure below). This peripheral mechanism is predominant in acute emesis. The central mechanism of emesis is mediated by the NK1 receptor and is particularly important in delayed emesis.

(Source: Chemotherapy-Induced Nausea and Vomiting. N Engl J Med 2008.)

Prophylactic Antiemetics

Many chemotherapy regimens cause nausea and vomiting and some patients require prophylactic antiemetics. The agents listed below are classified according to risk of emesis. Patients who receive drugs associated with high-risk for emesis might present to the emergency department with nausea and vomiting despite prophylaxis. It is important to counsel patients about management of symptoms and review all medication on discharge.

(Source: Antiemetic Prophylaxis for Chemotherapy-Induced Nausea and Vomiting. N Engl J Med 2016.)

Management of Non-Chemotherapy Induced Nausea and Vomiting

Management of non-CINV is dependent on the underlying cause. The following diagram depicts the Cleveland Clinic approach to managing nausea and vomiting in a palliative inpatient unit:

(Source: Nausea and Vomiting in Advanced Cancer: The Cleveland Clinic Protocol, J Support Oncol 2013. Copyrighted 2016. IMNG. 122784:0416BN. Reproduced with permission.)