Management of Chronic Pain in Survivors of Adult Cancers

Publication Date: July 25, 2016
Last Updated: December 16, 2022

Diagnosis

Clinicians should screen for pain at each encounter. Screening should be performed and documented using a quantitative or semiquantitative tool.

( IC , I , B , S )
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Clinicians should conduct an initial comprehensive pain assessment. ( IC , I , B , M )
  • This assessment should include an in-depth interview that explores the multidimensional nature of pain (pain descriptors, associated distress, functional impact, and related physical, psychological, social, and spiritual factors) and captures information about cancer treatment history and comorbid conditions, psychosocial and psychiatric history (including substance use), and prior treatments for the pain.
  • The assessment should characterize the pain, clarify its cause, and make inferences about pathophysiology. A physical examination should accompany the history, and diagnostic testing should be performed when warranted.
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Clinicians should be aware of chronic pain syndromes resulting from cancer treatments, the prevalence of these syndromes, risk factors for individual patients, and appropriate treatment options. ( IC , I , B , M )
  • A list of common cancer pain syndromes can be found in Table 1.
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Clinicians should evaluate and monitor for recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain. ( IC , I , B , M )
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Treatment

Treatment and Care Options

Clinicians should aim to enhance comfort, improve function, limit adverse events, and ensure safety in the management of pain in cancer survivors.

( IC , I , B , M )
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Clinicians should engage patient and family/caregivers in all aspects of pain assessment and management. ( IC , I , B , M )
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Clinicians should determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. ( IC , I , B , M )
  • If deemed necessary, the clinician should define who is responsible for each aspect of care and refer patients accordingly.
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Nonpharmacologic Interventions

Clinicians may prescribe directly or refer patients to other professionals to provide the interventions outlined in Table 2 to mitigate chronic pain or improve pain-related outcomes in cancer survivors.

( EB , I , B , M )
  • These interventions must take into consideration pre-existing diagnoses and comorbidities.
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Pharmacologic Interventions

Miscellaneous Analgesics

Clinicians may prescribe the following systemic nonopioid analgesics and adjuvant analgesics to relieve chronic pain and/or improve function in cancer survivors in whom no contraindications including serious drug–drug interactions exist:

( EB , I , B , M )
  • Nonsteroidal anti-inflammatory drugs
  • Acetaminophen (paracetamol)
  • Adjuvant analgesics, including selected antidepressants and selected anticonvulsants with evidence of analgesic efficacy (such as the antidepressant duloxetine and the anticonvulsants gabapentin and pregabalin) for neuropathic pain conditions or chronic widespread pain. Qualifying statement. The panel acknowledges that many other systemic nonopioids, including many other antidepressants and anticonvulsants, drugs in many other classes (such as the so-called muscle relaxants, benzodiazepines such as clonazepam, N-methyl-D-aspartate receptor blockers such as ketamine, and a-2 agonists such as tizanidine), and varied neutraceutical and botanicals marketed as complementary or alternative medicines, are taken by some cancer survivors with chronic pain and may benefit some of those who receive them. However, the efficacy of these agents and their long-term effectiveness have not been established.
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Clinicians may prescribe topical analgesics (such as commercially available nonsteroidal antiinflammatory drugs; local anesthetics; or compounded creams/gels containing baclofen, amitriptyline, and ketamine), for the management of chronic pain. ( EB , I , B , M )
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Corticosteroids are NOT recommended for long-term use in cancer survivors solely to relieve chronic pain. ( EB , I , H , M )
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Clinicians should assess the risks of adverse effects of pharmacologic therapies, including nonopioids, adjuvant analgesics, and other agents used for pain management.

( EB , I , B , M )
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Clinicians may follow specific state regulations that allow access to medical cannabis or cannabinoids for patients with chronic pain after a consideration of the potential benefits and risks of the available formulations. ( EB , I , B , M )
Qualifying statement. As of this writing, 23 states and the District of Columbia allow for medical cannabis, although it is illegal on the federal level. Currently, there is insufficient evidence to recommend medical cannabis for the first-line management of chronic pain in cancer survivors. However, evidence suggests it is worthy of consideration as an adjuvant analgesic or in the management of refractory pain conditions. There is also insufficient evidence to recommend one particular preparation of cannabis over another, and the Food and Drug Administration has not approved any drug product containing or derived from botanical marijuana.
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Opioids

Clinicians may prescribe a trial of opioids in carefully selected cancer survivors with chronic pain who do not respond to more conservative management and who continue to experience pain-related distress or functional impairment.

( EB , I , B , M )
  • Tables 3 and 4 provide guidelines intended to promote safe and effective prescribing. Nonopioid analgesics and/or adjuvants can be added as clinically necessary.
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Clinicians should assess risks of adverse effects of opioids used for pain management. Table 5 lists opioid-related long-term adverse effects. ( EB , I , B , M )
Qualifying statement. Although there is literature describing dysimmune effects and tumor proliferative effects from opioid drugs (both of which may be of particular concern in the cancer survivor population), there is insufficient evidence to determine whether there are clinically important risks. The expert panel believes that further clinical investigation is required to assess these concerns. In the absence of actionable data, physicians should be made aware of these evolving questions, and patients and their families may be informed about them as part of a discussion of the potential harms of long-term opioid therapy, as described in Table 5.
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Risk Assessment, Mitigation, and Universal Precautions With Opioid Use

Clinicians should assess the potential risks and benefits when initiating treatment that will incorporate long-term use of opioids.

( IC , I , B , M )
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Clinicians should clearly understand terminology such as tolerance, dependence, abuse, and addiction as it relates to the use of opioids for pain control. ( IC , I , B , M )
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Clinicians should incorporate a universal precautions approach to minimize abuse, addiction, and adverse consequences of opioid use such as opioid-related deaths. Clinicians should be cautious in co-prescribing other centrally acting drugs, particularly benzodiazepines (Table 5). ( EB , I , B , M )
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Clinicians should understand pertinent laws and regulations regarding the prescribing of controlled substances.

( IC , I , B , M )
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Clinicians should educate patients and family members regarding the risks and benefits of long-term opioid therapy and the safe storage, use, and disposal of controlled substances. ( IC , I , B , M )
  • Clinicians are encouraged to address possible myths and misconceptions about medication use and should educate patients about the need to be cautious when using alcohol or sedating over-the-counter medications or in receiving centrally acting medications from other physicians.
Qualifying statement. Education and information about treatment should ideally take into account the patient’s literacy level and the need for interpreters and should be provided in a culturally congruent manner.
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If opioids are no longer warranted, clinicians should taper the dose to avoid abstinence syndrome. The rate of tapering and the use of co-therapies to reduce adverse effects should be individualized for each patient.

( EB , I , B , M )
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Table 2. Disciplines and Interventions for Chronic Pain

Physical medicine and rehabilitation

  • Physical therapy
  • Occupational therapy
  • Recreational therapy
  • Individualized exercise program
  • Orthotics
  • Ultrasound
  • Heat/cold
( EB , I , B , M )
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Integrative therapies

  • Massage
  • Acupuncture
  • Music
( EB , L , B , W )
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Interventional therapies

  • Nerve blocks
  • Neuraxial infusion (epidural/intrathecal)
  • Vertebroplasty/kyphoplasty
( EB , I , B , M )
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Psychological approaches

  • Cognitive behavioral therapy
  • Distraction
  • Mindfulness
  • Relaxation
  • Guided imagery
( EB , I , B , M )
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Neurostimulatory therapies

  • Transcutaneous electrical nerve stimulation (TENS), spinal cord stimulation, peripheral nerve stimulation, transcranial stimulation
( EB , L , B , W )
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Recommendation Grading

Overview

Title

Management of Chronic Pain in Survivors of Adult Cancers

Authoring Organization

American Society of Clinical Oncology

Publication Month/Year

July 25, 2016

Last Updated Month/Year

November 11, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors.

Target Patient Population

Any adult who has been diagnosed with cancer and is experiencing pain that lasts ≥ 3 months, irrespective of cause.

Target Provider Population

Health care practitioners who provide care to cancer survivors.

PICO Questions

How should chronic pain be managed in the adult cancer survivor?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Home health, Long term care

Intended Users

Nurse, nurse practitioner, physical therapist, physician, physician assistant

Scope

Counseling, Management, Rehabilitation

Diseases/Conditions (MeSH)

D000072716 - Cancer Pain, D059350 - Chronic Pain

Keywords

chronic pain, cancer survivors

Source Citation

DOI: 10.1200/JCO.2016.68.5206 Journal of Clinical Oncology 34, no. 27 (September 20, 2016) 3325-3345.

Supplemental Methodology Resources

Data Supplement, Methodology Supplement

Methodology

Number of Source Documents
63
Literature Search Start Date
January 1, 1995
Literature Search End Date
December 31, 2015
Description of External Review Process
The ASCO Clinical Practice Guidelines Committee (CPGC) convened an Expert Panel with multidisciplinary representation in medical oncology, radiation oncology, cardiology, exercise physiology, family medicine, cancer prevention, cancer survivorship, patient/advocacy representation, and guideline implementation. The draft was submitted to two external reviewers with content expertise. It was rated as high quality, and it was agreed it would be useful in practice. Specific feedback on Table 5 suggested that oncologists would find the information, as presented, overwhelming. As such, the table was revised and broken into two separate tables in an attempt to make the presentation less complicated. Other comments, such as acknowledging the paucity of evidence in the abstract and highlighting the fact that many recommendations are based on expert consensus, and the inclusion of a strong statement on the need for research in this area, were reviewed by the expert panel and integrated into the final manuscript before approval by the Clinical Practice Guideline Committee. No dates were provided.
Specialties Involved
Family Medicine, Internal Medicine General, Oncology, Pain Medicine
Description of Systematic Review
The Protocol specifies the purpose of the guideline product, target patient population, clinical outcomes of interest, key features of the systematic literature review, and a proposed timeline for completion. ASCO staff, the Expert Panel Co‐Chairs, and possibly other panel members selected by the Co‐Chairs (the Expert Panel Steering Committee), will typically draft the protocol for full panel review. A standard protocol worksheet is used for consistency. Once the Co‐Chairs have approved a first draft of the Protocol, the Protocol will be shared with the full Expert Panel. At the discretion of the Guidelines Director, the CPGC leadership and/or the CPGC Methodology Subcommittee may review the Protocol to make suggestions for revision intended to clarify aspects of the plan for developing the guideline. These suggestions are sent to the Expert Panel Co‐Chairs. Work on the systematic literature review can proceed upon the sign‐off of the Protocol by the Expert Panel.
List of Questions
This clinical practice guideline addresses how chronic pain in survivors of adult cancers should be managed.
Description of Study Criteria
Literature search results were reviewed and deemed appropriate for full text review by two ASCO staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in the manuscript and/or in Data Supplements 1.
Description of Search Strategy
PubMed library was searched for evidence reporting on outcomes of interest. Outcomes of interest included symptom relief, pain intensity, quality of life, functional outcomes, adverse events, misuse or diversion, and risk assessment or mitigation.
Description of Study Selection
An assessment of study quality was performed for all the included evidence by one methodologist. Systematic reviews and meta-analyses were assessed for quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR). Literature search results were reviewed and deemed appropriate for full text review by two ASCO staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in the manuscript and/or in Data Supplements 1 and 2.
Description of Evidence Analysis Methods
ASCO guideline recommendations are crafted, in part, using the GuideLines Into DEcision Support (GLIDES) methodology. ASCO adopted a five‐step approach to carry out quality appraisal, strength of evidence ratings and strength of recommendations ratings. The ASCO approach was primarily adapted from those developed by the AHRQ,, USPSTF, and GRADE, however with the validation of the GRADE methodology, the sole use of GRADE is being evaluated by the Clinical Practice Guidelines Committee.
Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect. Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect. Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect. Insufficient: Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.
Description of Recommendation Grading
ASCO uses a formal consensus methodology based on the modified Delphi technique in clinically important areas where there is limited evidence or a lack of high‐quality evidence to inform clinical guidance recommendations. Evidence Based: There was sufficient evidence from published studies to inform a recommendation to guide clinical practice. Formal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the Supporting Documents" field). Informal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). No recommendation: There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.
Description of Funding Source
ASCO provides funding for Guideline Development.
Company/Author Disclosures
ASCO Conflict of Interest Policy complies with the CMSS Code for Interactions with Companies. ASCO requires disclosure by individuals involved in drafting, reviewing, and approving guideline recommendations.
Percentage of Authors Reporting COI
100