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Robert A. Swarm

More than 30% of patients with cancer report chronic pain, which is an indication of both the frequency of cancer-related pain and the failure to optimally manage it. Although access to opioid analgesics has greatly improved over the past 25 years, much remains to be done for patients experiencing severe pain. Opioids are far from ideal analgesics, noted Dr. Robert A. Swarm at the recent NCCN 18th Annual Conference. Universal screening for cancer pain is part of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain. This is not a one-time effort but should be part of management throughout the cancer care continuum.

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Robert A. Swarm and Maria Dans

The NCCN Framework aims to provide adapted guidelines for low- and middle-resource countries to improve the experience of patients with cancer. In particular, the NCCN Frameworks for Adult Cancer Pain and Palliative Care and were designed to help expand access to pain management and palliative care for patients in low-resource countries. The NCCN Framework is one of several tools that can improve cancer care in the developing world. The NCCN Harmonized Guidelines for Sub-Saharan Africa, a collaborative effort between NCCN, American Cancer Society, Clinton Health Access Initiative, and African Cancer Coalition, was developed to harmonize NCCN recommendations with local guidelines across Africa and to make best use of available services and resources.

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Anthony Eidelman, Traci White and Robert A. Swarm

Optimized use of systemic analgesics fails to adequately control pain in some patients with cancer. Commonly used analgesics, including opioids, nonopioids (acetaminophen and non-steroidal anti-inflammatory drugs), and adjuvant analgesics (anticonvulsants and antidepressants), have limited analgesic efficacy, and their use is often associated with adverse effects. Without adequate pain control, patients with cancer not only experience the anguish of poorly controlled pain but also have greatly diminished quality of life and may even have reduced life expectancy. Interventional pain therapies are a diverse set of procedural techniques for controlling pain that may be useful when systemic analgesics fail to provide adequate control of cancer pain or when the adverse effects of systemic analgesics cannot be managed reasonably. Commonly used interventional therapies for cancer pain include neurolytic neural blockade, spinal administration of analgesics, and vertebroplasty. Compared with systemic analgesics, which generally have broad indications for control of pain, individual interventional therapies generally have specific, narrow indications. When appropriately selected and implemented, interventional pain therapies are important components of broad, multimodal cancer pain management that significantly increases the proportion of patients able to experience adequate pain control.

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Rahul Rastogi, Trusharth Patel and Robert A. Swarm

Vertebral compression fractures are common in malignant disease and frequently cause severe back pain. However, management of that pain with conventional medical, radiotherapy, or surgical modalities is often inadequate. Vertebral augmentation techniques, such as vertebroplasty and kyphoplasty, are minimally invasive techniques in which methylmethacrylate bone cement is percutaneously injected into compressed vertebral bodies. Vertebral augmentation often improves mechanical stability of compressed vertebrae, provides pain relief, and may prevent progression of vertebral collapse. Kyphoplasty may provide increased chance for vertebral body height restoration, but the clinical importance of slight change in vertebral body height is unclear. Vertebral augmentation can be used in conjunction with other treatment modalities, and associated pain relief may improve patient tolerance of needed antitumor therapies, such as radiation therapy. Vertebral augmentation is generally very well tolerated, and complications associated with bone cement extravasation beyond the vertebral body have rarely been reported. Because it often provides good to excellent relief of otherwise intractable pain and is generally well tolerated, vertebral augmentation is becoming a first-line agent for management of painful vertebral compression fractures, especially in the setting of malignant disease.

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Robert Swarm, Amy Pickar Abernethy, Doralina L. Anghelescu, Costantino Benedetti, Craig D. Blinderman, Barry Boston, Charles Cleeland, Nessa Coyle, Oscar A. deLeon-Casasola, June G. Eilers, Betty Ferrell, Nora A. Janjan, Sloan Beth Karver, Michael H. Levy, Maureen Lynch, Natalie Moryl, Barbara A. Murphy, Suzanne A. Nesbit, Linda Oakes, Eugenie A. Obbens, Judith A. Paice, Michael W. Rabow, Karen L. Syrjala, Susan Urba and Sharon M. Weinstein

Overview Pain, defined as “a sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage,”1 is one of the most common symptoms associated with cancer. Cancer pain or cancer-related pain is distinct from pain experienced by patients without malignancies. Pain occurs in approximately one quarter of patients with newly diagnosed malignancies, one third of patients undergoing treatment, and three quarters of patients with advanced disease,2–4 and is one of the symptoms patients fear most. Unrelieved pain denies patients comfort and greatly affects their activities, motivation, interactions with family and friends, and overall quality of life. The importance of relieving pain and availability of effective therapies make it imperative that physicians and nurses caring for these patients be adept at the assessment and treatment of cancer pain.5–7 This requires familiarity with the pathogenesis of cancer pain; pain assessment techniques; common barriers to the delivery of appropriate analgesia; and pertinent pharmacologic, anesthetic, neurosurgical, and behavioral approaches to the treatment of cancer pain. The most widely accepted algorithm for the treatment of cancer pain was developed by the WHO.8,9 It suggests that patients with pain be started on acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). If this is not sufficient, patients should be escalated to a weak opioid, such as codeine, and then to a strong opioid, such as morphine. Although this algorithm has served as an excellent teaching tool, the management of cancer pain is considerably more complex than this 3-tiered “cancer pain ladder”...
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Robert A. Swarm, Amy Pickar Abernethy, Doralina L. Anghelescu, Costantino Benedetti, Sorin Buga, Charles Cleeland, Oscar A. deLeon-Casasola, June G. Eilers, Betty Ferrell, Mark Green, Nora A. Janjan, Mihir M. Kamdar, Michael H. Levy, Maureen Lynch, Rachel M. McDowell, Natalie Moryl, Suzanne A. Nesbit, Judith A. Paice, Michael W. Rabow, Karen L. Syrjala, Susan G. Urba, Sharon M. Weinstein, Mary Dwyer and Rashmi Kumar

Pain is a common symptom associated with cancer and its treatment. Pain management is an important aspect of oncologic care, and unrelieved pain significantly comprises overall quality of life. These NCCN Guidelines list the principles of management and acknowledge the range of complex decisions faced in the management oncologic pain. In addition to pain assessment techniques, these guidelines provide principles of use, dosing, management of adverse effects, and safe handling procedures of pharmacologic therapies and discuss a multidisciplinary approach for the management of cancer pain.

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Robert A. Swarm, Judith A. Paice, Doralina L. Anghelescu, Madhuri Are, Justine Yang Bruce, Sorin Buga, Marcin Chwistek, Charles Cleeland, David Craig, Ellin Gafford, Heather Greenlee, Eric Hansen, Arif H. Kamal, Mihir M. Kamdar, Susan LeGrand, Sean Mackey, M. Rachel McDowell, Natalie Moryl, Lisle M. Nabell, Suzanne Nesbit, BCPS, Nina O’Connor, Michael W. Rabow, Elizabeth Rickerson, Rebecca Shatsky, Jill Sindt, Susan G. Urba, Jeanie M. Youngwerth, Lydia J. Hammond and Lisa A. Gurski

In recent years, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Adult Cancer Pain have undergone substantial revisions focusing on the appropriate and safe prescription of opioid analgesics, optimization of nonopioid analgesics and adjuvant medications, and integration of nonpharmacologic methods of cancer pain management. This selection highlights some of these changes, covering topics on management of adult cancer pain including pharmacologic interventions, nonpharmacologic interventions, and treatment of specific cancer pain syndromes. The complete version of the NCCN Guidelines for Adult Cancer Pain addresses additional aspects of this topic, including pathophysiologic classification of cancer pain syndromes, comprehensive pain assessment, management of pain crisis, ongoing care for cancer pain, pain in cancer survivors, and specialty consultations.