פרופסור עפר מרימסקי

 

Cancer Pain כאב סרטני

Shulamith Kreitler, Ph.D. and Ofer Merimsky, M.D.

 

Introduction

     Cancer is a ubiquitous disease: an estimated 6.35 million new cases are diagnosed worldwide annually, and the number of surviving cancer patients increases steadily due to improved detection and treatment (Bonica & Ekstrom, 1990). Pain is among the most common symptoms associated with cancer. About 70% of cancer patients suffer from severe pain at some time in the course of their disease; 25% have pain when they are first diagnosed, 30-60% during active therapy, 75% if their disease is advanced, and 25% when they die (Bonica, 1990; Twycross & Lack, 1983). The incidence of cancer pain is so high that it has justifiably been identified as a world-wide health problem of the highest priority (World Health Organization, 1986).

     Pain seems to be related to stage of disease: persistent severe disease-related pain occurs in 5-10% of patients with nonmetastatic disease (Daut & Cleeland, 1982) but the rates increase to 20-40% in patients with metastatic disease (Cleeland, 1984).

     Pain varies with type of cancer. The lowest rates are reported for patients with leukemia (5%) or lymphoma (20%), higher rates (50-75%) for patients with lung, gastrointestinal or genitourinary tumors, and the highest rates (85%) for patients with cervix or primary bone tumors (Foley, 1975). It is generally estimated that about 20% of the pain is cancer-induced, about 75% is treatment-dependent, and about 5% is unrelated to the cancer or treatment (e.g., cervical or lumbar osteoarthritis, thoracic and abdominal aneurysms, and diabetic neuropathy).

Pain syndromes in cancer  

     The major mechanisms involved in causing cancer pain are invasion of pain-sensitive sites or organs by tumor mass, obstruction of vascular and lymphatic channels, compression or infiltration of nerves, necrosis, distention of a hollow viscus, tissue inflammation and edema. An important distinction usually drawn in regard to cancer pain is between primary nociceptive pain (cased by stimulation of pain receptors) and neuropathic pain (painful sensations caused by injury to peripheral or central nervous system structures) (Patt & Burton, 1999).

      Cancer pain syndromes are often defined in terms of distinct etiologies and pathophysiologies. They are associated with particular pain characteristics and have important implications in regard to prognosis and treatment (Cherny & Portnoy, 1999). The two major types are acute and chronic pain syndromes. The acute pain syndromes are mostly related to diagnostic or therapeutic procedures and include the following: 1. Pain due to diagnostic interventions (e.g., bone marrow biopsy, lumbar puncture, myelography); 2. Postoperative pain; 3. Pain due to analgesic procedures (e.g., epidural injection, strontium-induced pain); 4. Pain due to therapeutic interventions (e.g., pleurodesis, nephrostomy insertion, intercostal catheter, porth-a-cath insertion); 5. Pain due to chemotherapy infusion techniques (e.g., intravenous infusion pain, hepathic artery infusion pain, intraperitoneal chemotherapy abdominal pain); 6. Pain due to chemotherapy toxicity (e.g., pain along the vein in association with dacarbazine infusion, extravasation of drugs, mucositis, taxol-induced, corticosteroid-induced, diffuse bone pain, pain due to acute tumor reaction to chemotherapy as seen in soft tissue sarcoma); 7. Pain due to radiotherapy (e.g., burns, subacute myelopathy, early-onset brachial plexopathy); 8. Pain due to immunotherapy (e.g., interferon-induced); 9. Pain due to hormonal therapy (e.g., flare phenomena in breast or prostate cancer); 10. Pain due to a variety of other causes, mainly infection (e.g., herpetic neuralgia), vascular events (e.g., superior vena cava obstruction) or supportive care (Granulocyte Colony Stimulating Factor cases low back pain, ondansetrone causes headache). 

     The chronic pain syndromes are mostly tumor-related and include the following: 1. Headache and facial pain (e.g., due to intracerebral tumor, leptomeningeal metastases, cranial neuralgias); 2. Somatic pain (e.g., multifocal or generalized bone pain, pelvis and hip pain, muscle pain); 3. Visceral pain (e.g., chronic intestinal obstruction, hepatic distension syndrome, adrenal pain syndrome); and 4. Neuropathic pain (e.g., cervical or brachial plexopathy, paraneoplastic peripheral neuropathy, nerve tumors).  

     However, some chronic pain syndromes are associated with cancer treatments, due mainly to: 1. Radiation (e.g., plexopathies, burning perineum syndrome, soft tissue fibrosis); 2. Surgery (e.g., phantom pain syndromes, postradical neck dissection pain); 3. Chemotherapy (e.g., chronic peripheral neuropathy, plexopathy due to intra-arterial infusion); and 4. Hormonal therapy (e.g., gynecomastia in prostate cancer). 

Effects of cancer pain

     Following Cecily Saunders (1967), the pain of cancer patients is often referred to as “total pain” because of its all-encompassing nature and multi-dimensional effects, especially if it is not totally relieved by analgesics (Hanks, 1991). Pain has physical, emotional, cognitive and behavioral effects.  It interferes with the ability to eat, to sleep, to think, to function physically, or to interact with others (Cleeland et al., 1996; Ferrel, 1995; Feuz & Rapin, 1994). Further, it is correlated with fatigue (Burrows et al., 1998), intensifies psychological distress and mood disturbance, and enhances the sense of vulnerability and loss of control and increases thinking about catastrophic outcomes (Ferrel, 1995). Hence, pain may seriously reduce the patient’s quality of life (Padilla et al., 1990).

     The effects of cancer pain may be detected in many domains of the patient’s life, primarily the physical, emotional, cognitive, interpersonal and behavioral. By reducing the sense of physical strength and limiting the number, nature and duration of motor or motor-dependent activities, the pain may appreciably lower physical well-being. In the cognitive domain it affects adversely functions, such as attention, memory, concentration, learning, interest and curiosity, decision making and problem solving, involved in a broad array of activities. In the emotional sphere, there are two major trends of effects. On the one hand, pain may promote negative emotions, mainly anxiety, fear, depression, and anger, which may be manifested in different degrees (e.g., the range for anger runs from slight irritability to explosive attacks of rage). On the other hand, pain may depress positive emotions, mainly affection, joy, pleasure and hope. In the interpersonal domain, major adverse effects of the pain were detected in regard to keeping up social relations, communicating with others, and being interested in others. Social interactions may become gradually focused on getting and maintaining social support and other needed help from others. In the general behavioral field, pain may reduce or practically eliminate motivation for a great number of activities, with a resultant narrowing down of the behavioral range. The effects of pain in the different domains may interact and enhance one another. For example, limiting the range of physical activities may increase frustration, which could be manifested in more frequent manifestations of anger of depression, which in turn may cause problems in the interpersonal field, and so on (Rummans et al., 1998; Ward et al., 1998).

     However, it is important to emphasize that the effects of pain are not necessarily all negative. The need to reduce activities may bring about focusing on a particularly creative or satisfying activity that the individual has long desired to do or a newly discovered one; it may deepen relations with beloved ones; it may enhance joy and love; it may lead to the promotion or discovery of spiritual needs and to the discovery of new meanings of life and existence. This does not mean in any way that efforts to control pain are to be limited, but that in case these efforts are not completely successful at least some patients may still find ways to maintain a certain level of quality of life.

 

Basic principles of the pharmacologic treatment of pain in cancer patients

     WHO Analgesic Ladder. Drug therapy is the cornerstone of the treatment of cancer pain. Pharmacologic therapy follows basically the World Health Organization guidelines which define a three-step ladder for analgesic pain management (Ventafridda, Caraceni & Gamba, 1990). Three main principles inspire this approach. First, the goal is freedom from pain. Second, the selection of analgesics is to proceed in line with the severity of pain. Third, pain management is to be tailored to the needs of the patient, selecting on each step of the ladder the drug which best fits the individual’s characteristics. Accordingly, on each level the simplest dosage schedules and least invasive pain control modalities are used first. If pain persists, substitution of drugs within the same category is attempted or dose and potency of the drug are increased before proceeding to the next step. The dosage is scheduled on a regular basis in order to maintain continuously the level of drug that helps prevent recurrence of pain. On each level, drugs of the preceding level may be added, as well as adjuvant drugs.  

     Step 1: Mild to moderate pain: For pain at this intensity level nonopioid analgesics (NSAIDs e.g., cox-2 inhibitors, naproxene, aspirin, ibuprofen) and paracetamol, dypirone, propoxyphene and acetaminophen (it resembles NSAIDs in analgesic potency but lacks peripheral anti-inflammatory activity) are recommended. The major underlying mechanism consists in bringing about a reduction of prostaglandins in the tissues. Their main characteristics are that they have a ceiling effect for analgesia, do not produce tolerance or dependence, are administered through oral tablets, capsules or liquid, have antipyretic effects and their major side effects include gastrointestinal reactions (from mild discomfort to gastric ulceration),  hepatic dysfunction, renal failure and bleeding.  

     Step 2: Mild to moderate pain (which has not been or could not be controlled by NSAIDs): The recommendation focuses on so-called weak opioids (e.g., oxycodone, hydrocodone, codeine) or opioid-like agents (tramadol)  which may be combined with NSAIDs. Tramadol  is a pain reliever which affects chemicals and receptors in the body that are associated with pain. Tramadol is used to relieve moderate to moderately severe pain. It differs from other opioids by combining a weak opioid and a monoaminergic mode of action. It is effective in different types of moderate-to-severe pain, including neuropathic pain. Moreover, as the mode of action of tramadol does not overlap with that of NSAIDs, it is a useful agent to be combined with these drugs. Tramadol induces fewer opioid adverse reactions for a given level of analgesia compared with traditional opioids. Common adverse reactions of tramadol such as nausea and dizziness, which usually occur only at the beginning of therapy and attenuate over time, can be further minimized by up-titrating the drug over several days.

     Step 3: Moderate to severe pain: For pain at this intensity level opioids, usually of the “strong” type are recommended.

     Opioids analgesics: Types. Opioids  are classified, on the basis of their affinity to opioid receptors, into three classes: (a) full morphine-like agonists, whose effectiveness with increasing doses is not limited by a “ceiling”, and they do not antagonize the effect of other full agonists ingested simultaneously (e.g., morphine, methadone, levorphanol, fentanyl); (b) partial agonists, which are less effective at the opioid receptor and are subject to a “ceiling” effect (e.g., buprenorphine), and (c) mixed agonist-antagonists, which are neutral or block at one type of opioid receptor while activating another opioid receptor (e.g., pentazocine, butorphanol, nalbuphine). Their analgesic effectiveness is limited by a dose-dependent “ceiling” effect. They can reverse opioid effects and precipitate withdrawal symptoms in patients who are opioid dependent or tolerant).    

     Opioids: Tolerance, dependence and addiction: The three mentioned phenomena are relevant in regard to opioids and are often confused with one another. Tolerance indicates a markedly diminished analgesic effect with continued use of a drug or the need for greatly increased amounts of the drug in order to maintain a given or desired effect of analgesia over time. Physical dependence is characterized by the onset of withdrawal symptoms if the opioid is suddenly stopped or an opioid antagonist is administered. Addiction (or psychological dependence) denotes a compulsive behavior of drug abuse, manifested in a craving for the drug, in undertaking extraordinary efforts to get and use it for goals other than pain relief, and in failure to cut down or control its use despite awareness that its continued use causes physical or psychological problems. Tolerance and physical dependence often occur together but are not necessarily accompanied by addiction. The former two are rather frequent in cancer patients, whereas addiction is rare and almost never occurs in patients without a previous history of drug abuse (Kanner & Foley, 1981).      

     Opioids: Half-life, onset and duration of analgesia. The opioids vary in their plasma half life, and analgesic onset and duration. Opioid analgesics with long half-lives (15-30 hours, e.g. methadone, levorphanol) require about 5 days to attain a steady state, but tend to accumulate with early initial dosing, so that they bring about delayed toxicity effects. Morphine and oxycodone have a much shorter half-life (2-3 hours). Further, Opioids vary greatly in duration of analgesia they provide. For example, immediate-release preparations of morphine or oxycodone often provide only 3 hours of analgesia so that they need to be administered on a round-the-clock basis, in contrast to levorphanol or methadone which may provide up to 6 hours of relief, or longer-lasting sustained release oral preparations (of morphine, e.g., Oramorph SR or of oxycontin) which provide relief for 8-12 hours, or transdermal fentanyl patches which may act for 48 to 72 hours. However, the longer-lasting preparations may have a delayed analgesic onset (e.g., fentanyl patch 12-18 hours) and may need to be complemented by other drugs for acute or breakthrough pain. Facts of this kind may significantly affect the patients’ quality of life. In selecting drugs for pain-control, it is advisable to take into account psychological effects in addition to medical and pain-dependent considerations. Thus, longer-lasting drugs may be more adequate for patients who want to be freed from thoughts about pain control, whereas drugs that need to be administered round-the-clock may be more adequate for patients whose well-being depends on being constantly “in control”. 

     Opioid: Routes of administration. There are various routes of administering opioid analgesics that vary also in their quality of life effects. Oral administration is usually preferred because of its convenience and low cost. The rectal route is safe and inexpensive, suitable for patients who have nausea or vomiting, but inappropriate for those with diarrhea, rectal lesions, mucositis, trombocytopenia or neutropenia. The transdermal route is appropriate for stable pain when no rapid dose titration is necessary. Intravenous administration provides the most rapid onset of analgesia but it is of shorter duration than with other routes. Hence, when continuous pain-control is required, continuous intravenous access or subcutaneous infusion may be used. Patient-controlled analgesia (PCA) helps the patient maintain control by matching drug delivery to analgesic needs, orally or by a portable pump. Intraspinal drug administration is an invasive route with several disadvantages (e.g., mechanical problems, infection potential) but provides profound analgesia without motor, sensory or sympathetic blockade in cases of intractable pain especially in the lower body part. 

     Opioids: Side effects: Side effects are a major disadvantage of opioids. Common side-effects include constipation, nausea and vomiting, respiratory depression or a subacute overdose manifested as slowly progressive somnolence and respiratory depression, as well as dry mouth, urinary retention, pruritis, myoclonus and sleep disturbances. Also psychological side-effects are frequent, mainly sedation, mental clouding, and delirium, often accompanied by attentional deficits, disorientation, and perceptual disturbances, such as illusions and visual hallucinations. Some of the side effects become weaker or disappear with continued use of the drug, and some can be controlled by the use of adjuvant agents and other drugs.

     Adjuvant drugs. The need to supplement the opioid treatment of pain by other drugs may arise because of unpleasant or dangerous side-effects and increased tolerance, or because the pain is only semi-responsive to opioids (e.g., bone metastasis, nerve compression), not responsive to opioids (e.g., muscle spasm), or can be treated more specifically (e.g., functional gastrointestinal pains). Thus, in the treatment of cancer pain adjuvant drugs are often used, during all stages of the analgesic ladder, in order to enhance the analgesic effect of opioids, treat concurrent symptoms that may exacerbate pain, or provide independent analgesia for particular kinds of pain. The major kinds of adjuvant drugs are (Breitbart & Payne, 2000):

(a) Corticosteroids: They may contribute to controlling pain directly or indirectly, by affecting neuropathic pain or pain resulting from inflammatory processes, or elevated intracranial pressure and epidural spinal cord compression; by reducing cerebral and spinal cord edema; by improving appetite and combating nausea; and by elevating mood. The major side effects are psychiatric, gastrointestinal and immunosuppressive.

(b) Anticonvulsants: They are used mainly for neuropathic pain characterized by continuous or lancinating dystenias.

(c) Oral local anesthetics: They are used mainly for neuropathic pain with dystenias, especially when antidepressants are not well tolerated or anticonvulsants are ineffective.

(d) Neuroleptics: They are used mainly for treating chronic pain syndromes, especially in cases suffering from dose-limiting side effects of other drugs.

(e) Bisphosphonates: They are used mainly for preventing pathologic fractures and for treating bone pain.

(f) Antidepressants: They were found to have an analgesic effect in different types of pain, chronic neuropathic and nonneuropathic pain syndromes, probably through both their serotonergic and noradrenergic properties, as well as their antihistaminic and direct neuronal effects. They are used as adjuvant analgesics most often for potentiating the analgesic effects of opioids, and thus enabling even a reduction in their use. The tricyclic antidepressants (e.g., amitriptyline) are the most widely studied and used antidepressants for analgesia, but the use of heterocyclic and noncyclic antidepressants a well as of fluoxetine is increasing. The effect is often biphasic with peaks after a few days or hours and after 2-4 weeks.

(g) Psychostimulants: One main use of psychostimulants (e.g., dextroamphetamine, modafinil) is as potent adjuvant analgesics alone but mainly in combination with opioids. A second important effect they have is to diminish sedation side-effects of narcotic analgesics, thereby improving, for example, cognitive functioning of patients getting continuous infusion of opioids. In addition, they stimulate appetite, decrease fatigue and elevate the patient’s overall sense of well-being. Modafinil has been used in patients with non-malignant pain syndromes, and reported to improve opioid-induced sedation.  There have been reports on the use of modafinil for the treatment of fatigue in various neurological syndromes (Webster 2003). Its role in cancer patients treated by narcotics needs to be elucidated.

 

Chemotherapy: chemotherapeutic agents are widely and commonly used in patients with metastatic cancer in order to palliate cancer-related symptoms. Cancer related pain might result from the primary tumor (eg: lung cancer involving the pleura and chest wall) or from organ involvement by metastases (bone and liver metastases from lung cancer). The decision of which chemotherapy should be used for this purpose in a particular patient is based primarily on the chemosensitivity of the tumor and on the tolerability of the patient to possible side effects. Chemotherapy may be combined with radiation therapy, with analgesic therapy or with any modality used for pain control.

 

Non-pharmacologic treatment of pain in cancer patients

     Non-pharmacologic therapies include a variety of more and less invasive approaches, which may be used, each in line with its potentials and risks, for different reasons, such as psychological resistance of the patient to opioids, patients’ desire to apply all available means or specific therapies, failure to attain adequate pain control by means of drugs, and inability to stabilize a satisfactory balance between analgesia and side effects of opioids. The more aggressive or destructive procedures (see d. and e. below), such as coeliac plexus blocks or percutaneous cordotomy, have been promoted by some clinicians because despite their destructiveness, their effect is localized, in contrast to opioids which affect the whole body and the whole person with much more adverse impact on quality of life (Lipton 1989). The major non-pharmacologic approaches are the following:    

(a) Radiation therapy: Local or hemi-body radiation may enhance the effectiveness of analgesic drugs and other noninvasive therapies by affecting directly the cause of pain (viz. by reducing tumor bulk), while minimizing adverse effects on normal cells and repair of damaged tissue. An example for palliative radiation therapy is spinal cord compression unamenable by surgery or chemotherapy (Kovner 1999, Merimsky 2004a)

(b) Surgery: Curative excision or palliative debulking of a tumor may reduce pain directly or relieve symptoms of compression or obstruction. It is especially true in cases of spinal cord compression, in which laminectomy, vertebrectomy, tumor debulking, and spine stabilization are used for pain alleviation together with relief of cord compression and restoration of neurological functions. A second example of palliative surgery is major amputations such as forequarter amputation or hemipelvectomy applied in cases of soft tissue and bone sarcomas that are uncontrolled by any other treatment modality. (Merimsky 1997, Merimsky 2001, Merimsky 2004b) . Less  extensive surgery, viz. surgical internal fixation of fractures and impending fractures of long bones with lytic lesions is applied in cases with metastatic renal cell carcinoma (Kollender 2000, Bickels 2002).

(c) Local anesthetic: Intractable localized or regional pain may be handled by the relatively brief application of an intra-axial infusion with opioids and/or local anesthetics. Pain relief is temporary but sympathetic sensation and function are preserved while supraspinal side-effects are prevented.

(d) Sympathetic blocks: Nerve blocks of a permanent nature are attained by using neurolytic agents in regard to leading neural pathways or ganglions, for example, ganglion impar, superior hypogastric, or celiac plexus block. A study with pancreatic cancer patients showed that celiac plexus block prevented a marked decrease in the patients’ quality of life by providing a long-lasting analgesic effect, reducing morphine consumption and its side-effects (Kawamata, Ishitani & Ishikawa, 1996). 

(e) Nerve blocks by surgical means: Surgical neurolysis is possible at every level of the neuraxis (e.g., face-unilateral, chest wall, upper or lower abdomen), and is mostly attended by neurologic complications. The most frequent procedure is cordotomy that consists in blocking the spino-thalamic pathway for pain relief on the opposite body side.

(f) Physical interventions: Physical therapies are used primarily for the generalized weakness and pains associated with cancer diagnosis and therapy. They include the following techniques: 1. cutaneous stimulation, for example, by applying heat (e.g., hot pack, heating pad, diathermy), cold (e.g., flexible ice pack), massage, pressure or vibration to the aching body area (counterindicated on irradiated skin); 2. Exercise, useful for subacute and chronic pain due to its beneficial effects on weak muscles, stiff joints, impaired coordination and balance (counterindicated when bone fractures are likely); 3. Repositioning, designed to prevent or alleviate pain in the immobilized patient; 4. Immobilizing, by means of adjustable  elastic or thermoplastic braces, designed  to reduce breakthrough pain induced by movement of the spine or a limb or to stabilize fractures and otherwise compromised limbs or joints; 5. Counterstimulation, by means of transcutaneous electrical nerve stimulation (TENS), applied to large myelinated peripheral nerve fibers in order to inhibit pain transmission, or by means of acupuncture.          

Psychologically-based treatments of pain in cancer patients

     There is an important role for psychological treatments of pain in regard to cancer pain, both because of their potential effect on the physical pain and because of the psychological effects and connotations of suffering that accompany cancer pain.

     The psychological treatments of pain in general apply also in the case of this population of patients, but they need to be selected and adapted for the special needs and characteristics of cancer patients. First, because the pain is often of at least moderate intensity and continuous, it is recommended that the treatments do not require a too long period of preparation before they start having a real effect on pain alleviation. Second, in view of the reduction in the sense of control of many patients, it is desirable to select treatments that enable the patients to feel that they have some kind of control over the pain and themselves. Third, because of the tendency of pain in cancer to affect a variety of domains, the selected treatments should address different components of pain and of its impact.

     Psychological treatments of pain may be grouped into four groups, in line with the component of pain which they primarily target: sensory, affective, cognitive or behavioral (see chapter by Kreitler and Kreitler, Psychological Approaches to Treatment of Pain, this book). In view of the above considerations, the most highly recommended treatments for cancer pain are the following: (a) Treatments focused on the sensory component: guided imagery, suggestion and autosuggestion, relaxation and meditation, distraction and displacement, music therapy and hypnosis; (b) Treatments focused on the affective component: Supportive therapies, meaning-based control of negative emotions, a modified version of dynamic psychotherapy, and art therapy; (c) Treatments focused on the cognitive component: educational-didactive information based therapy, cognitive-attitudes based therapy, and cognitive coping; and (d) Treatments focused on the behavioral component: family therapy and cognitive-orientation therapy. The less recommended treatments are biofeedback (because of limitations in generalizing the technique beyond the training period, Fotopoulos, Graham & Cook, 1979), dynamic psychotherapy (because of the length of time before it takes effect), and conditioning, environmental and behavioral therapies (because of the length of preparatory training they require, and their reduced reliance on the patient’s active control).

     In this context we will review briefly the major components of the recommended techniques (more extended descriptions are provided in the chapters on Hypnosis and on the Psychological Approaches to Treatment of Pain). The major elements in the sensory-focused therapies are the active use of fantasy and of distraction in order to control pain. Thus, the patient may be taught and encouraged to construct fantasy images transforming the nature, intensity, location, duration and context of the sensation of pain, relying mainly on suggestion or imagery in a relaxed state or deeper hypnotic state (Fishman, 1990; Levitan, 1992). Relaxation techniques aim at reducing physiological and psychological arousal by images, muscular acts or positions or meditative means. They help to alleviate pain intensity directly or by serving as context for further imagery-based techniques. Conjointedly, distraction by means of fantasy, cognitions or actions may be practiced (e.g., by focusing on some pleasant image, a thought, a problem, or engaging in doing something, such as counting, praying). A technique like music therapy which focuses on listening to music may be used primarily as an aid to constructing pain-controlling images or for distraction or both.   

     The major elements in the affective-focused therapies are cathartic relief and reduction of negative emotions, mainly anxiety, fear, depression, despair, frustration, anger and distress accompanying the cancer pain. The supportive, psychotherapeutic and art therapies all provide frameworks for relief through expressing one’s distress and sharing it, as well as getting encouragement from others. Learning specific means for overcoming negative emotions is served in particular by the meaning-based technique, psychotherapy and art therapy. The meaning-based therapy consists in learning to process inputs in terms of processes enabling anxiety control (e.g., action) and unlearning to process them in terms of processes enhancing anxiety (e.g., metaphors, emotional connotations). Psychotherapy and art therapy, when adequately structured, enable the patient to get insight into psychological tendencies, partly nonconscious, that enhance pain and suffering (e.g., considering the pain as punishment for one’s “sins”) and acquire approaches that enable controlling pain (e.g., focusing on fulfilling one’s long-standing wishes).     

     The cognitive-focused therapies provide the patient with an array of cognitions that may help in pain control. These include informations about the cause and functioning of pain and medical means for controlling it (e.g., drugs), attitudes and beliefs in regard to pain that enable reducing its harmful effects (e.g., enhanced pain does not necessarily indicate disease progression; it is possible to function and enjoy life despite the pain), a variety of cognitive coping means that promote pain control (e.g., self-statements emphasizing pain as a challenge) and the avoidance of coping mechanisms that maintain or increase pain (e.g., catastrophizing, over-dramatizing the pain, self-pity).

     The behavior-focused therapies target reducing or preventing the development of behaviors that maintain the pain and broaden its impact. The most useful means in this context are control by means of family therapy, and by increasing cognitive support for cognitions that combat pain (viz. cognitive-orientation therapy).

     In sum, best effects of psychological therapies are enabling each patient to use a variety of means. The advantages of this approach are first, each patient will be able to find out which means are best suited to his or her tendencies and goals; second, the chances are increased that the different components of pain – sensory, affective, cognitive and behavioral – will be addressed; and third, the broad range of alternative therapies will insure that when one or another loses its effectiveness temporarily or indefinitely other techniques may be applied for pain control.

General conclusions 

     Cancer pain is one of the more complex and negative facets of malignancy. Its prevalence, intensity, duration and connotations are complicating factors that have led many to doubt whether its management can be handled by the same means as other kinds of pain. In contrast to these views, the approach that has come to dominate the field in recent years is based on the assumption that the principles of general pain management apply in this case too with certain adjustments and adaptations.

     First, pain should be identified and recognized as an important and basic aspect of the disease. Awareness of this fact on the part of health professionals and of patients would facilitate communication about pain, consulting about treatments, and readiness of physicians to treat pain as well as readiness of patients to cooperate in pain treatments even if these treatments are merely “palliative” rather than curative.

     Second, an attempt is to be made to consider cancer pain in a matter-of-fact manner, dissociated as much as possible from connotations of suffering and death that tend to be evoked in the case of malignancies. Weeding out the extra baggage of significations that serve to enhance the patient’s load of distress may promote circumscribing the problem and rendering it more manageable and treatable.

     Third, psychological approaches to the treatment of pain are to be considered as an integral component of the treatment of cancer pain on all levels rather than one among several available approaches designed to be applied when one or another of the applied treatments has failed or not functioned up to the expected level. Hence, psychological pain treatments do not constitute one level in the WHO ladder but are to be considered as part of each step on the ladder, possibly as a support railing for climbing up or down the ladder. The message beyond the metaphor is that psychological pain treatments should accompany all other pain treatments in cancer pain, enhancing their effect and thus in the very least slowing down progression up the ladder.