Case Study: Managing pain for metastatic cancer patients

Associate Professor Gregory Crawford

By Associate Professor Gregory Crawford for Australian Doctor
23 February 2016

Jean is 78 years old and has recently moved close to her daughter. In her first consultation with her new GP, Jean explains she is widowed, and has recently been diagnosed with carcinoma of the lung.

She was a smoker, and has brought a bone scan result and CT scans of her chest, abdomen and pelvis. She has spine and pelvis metastases, and is under the care of a medical and radiation oncologist.

Jean appears to be fairly anxious. She has arranged for her clinical notes to be sent from her previous GP, and says she has come "just to introduce herself".

How do you approach pain in cancer?
Jean denies that the lung cancer is causing her any problems, but does admit to some "aches and discomfort", particularly on waking. The GP is aware that pain is a symptom greatly feared by people in Jean's position. Early assessment and management of pain is likely to result in overall better pain control, and subsequently less analgesic requirements in the longer term.

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Meeting a new patient, particularly with malignant disease, is certainly a challenge. It is also an opportunity to take a history that includes not only her symptoms, but also her understanding of the extent of her cancer, how her treatment is unfolding and what her hopes, goals and even fears might be.

Assessment and management
It is also an opportunity to identify and record who is in her ‘family' (interpreted in the widest context), and who else is currently providing her with support — physical, social and emotional.

The GP knows how to take a careful, comprehensive history, and is glad to have recently participated in a refresher course about assessing and managing pain, with and without opioids.

There are common barriers to good pain management, however.

One is having a practice where there are many drug-seeking patients, and sometimes losing focus when faced with a patient with cancer in pain needing increasing opioids. Another is lack of experience of the GP in this field — not all GPs see patients with metastatic cancer.

For people requiring opioids for chronic non-cancer pain, it is usual not to prescribe immediate-release opioids such as Ordine (morphine mixture), Endone, or OxyNorm.

Related:

For palliative care patients, this is generally quite different, and they need some control over analgesia. Sometimes their need for activity (for example, playing with active grandchildren) results in increased pain, and hence the patient may need a ‘top up' or breakthrough dose of analgesia. As their life is limited, allowing patients some freedom to choose is the ideal.

Patient barriers to good pain management are more challenging. Patients do not always give a logical, concise history. Their anxiety or depression or personality may make developing rapport and gaining a clear history more difficult.

Many people are fearful of becoming addicted to opioids, or fearful that "nothing will be left if there is severe pain at the end". These are myths.

Patients are not always good at understanding or adhering to the planned regimen of administration, despite their pain. Sometimes it is a challenge for us to make this as simple as possible to follow.

Discussion
Pain is a very personal experience and, for someone with advanced cancer, it is rarely the sole issue. There are multiple physical symptoms, as well as issues associated with the anticipation of the end of one's life. Insomnia, persisting nausea and a sense of demoralisation, or depression, all influence their perception of pain.

Financial pressures and relationship crises are also common at such times. It is important to listen to the patient's experience, and to understand the meaning that they ascribe to their symptoms. The doctor's role is to listen and to understand the likely pathophysiology or mechanism that might explain the particular symptoms. This will give some direction to what interventions are recommended.

Outcome
The GP reviews Jean's experience of cancer so far, and she has agreed on management and follow-up plans. She agrees to take paracetamol regularly, and has a prescription for morphine mixture to take if breakthrough pain occurs, particularly on waking. She is going to keep a record of her pain and morphine use, and return in two weeks' time.

Resources for GPs

  1. Palliative Care Knowledge
  2. Palliative Care Expert Group. Therapeutic Guidelines Palliative Care. Therapeutic Guidelines Limited, Melbourne, 2010.

Associate Professor Gregory Crawford is a senior consultant in palliative medicine, director of research and education, Northern Adelaide Palliative Service, and associate professor of palliative medicine, University of Adelaide, SA.  

This article was originally published in Australian Doctor on 23 February 2016. It was independently written, produced, edited and fact-checked by the Australian Doctor editorial team for our print and digital products.

By Associate Professor Gregory Crawford for Australian Doctor 23 February 2016 Jean is...

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