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clinical recommendations

Annals of Oncology 20 (Supplement 4): iv170–iv173, 2009 doi:10.1093/annonc/mdp164

Management of cancer pain: ESMO Clinical Recommendations
L. Jost1 & F. Roila2 On behalf of the ESMO Guidelines Working Group*
1

Department of Oncology, Kantonsspital, Bruderholz, Switzerland; 2Department of Medical Oncology, S. Maria Hospital, Terni, Italy

incidence of painOver 80% of cancer patients with advanced metastatic disease suffer pain caused mostly by direct tumor infiltration. Pain undermines quality of life considerably and is a clinically important indicator of tumor progression. Cancer pain may be acute or chronic and should be addressed accordingly. Approximately 20% of pain in cancer patients may be attributed to the effects of surgery, radiotherapyor chemotherapy.

assessment and management
All patients should be evaluated for the presence of pain at every visit. Pain severity is best assessed by patient self-report and may be aided by visual analogue scales (VAS), numerical rated scales (NRS) and/or verbal rated scales (VRS). The extent of diagnostic investigation must be appropriate to the patient’s general status and the goals ofcare. Pain should already be managed during the diagnostic evaluation. Most cancer patients can attain satisfactory relief of pain through an approach that incorporates primary anti-tumor treatments, systemic analgesic therapy and other non-invasive techniques such as psychological or rehabilitative interventions. Step-wise escalation of analgesic therapy should usually follow the ‘pain ladder’ asdescribed by the World Health Organization (WHO).

treatment of moderate pain (WHO step II analgesics) Traditionally, patients with moderate pain (NRS: 5–7) have been treated with a combination product containing acetaminophen, aspirin or an NSAID plus a weak immediate release opioid such as codeine, dihydrocodeine, tramadol or propoxyphene or a strong opioid at low doses such as morphine oroxycodone (Table 2). The doses of these combination products can be increased until their maximum dose is attained (e.g. 4000 mg of acetaminophen and 240 mg of codeine). Recent years have witnessed the proliferation of new opioid formulations that may improve the convenience of drug administration for patients with moderate pain. These include controlled release formulations of codeine,dihydrocodeine, tramadol, morphine and oxycodone in dosages appropriate for moderate pain. Additional options include low-dose formulations of transdermal fentanyl and of transdermal buprenorphine. treatment of severe pain (WHO step III analgesics) Morphine is most commonly used in severe pain (NRS: 8–10). Oral administration is the preferred route. If given parenterally, the equivalent dose is one-third ofthe oral medication. Hydromorphone or oxycodone, in both immediate release and modified release formulations for oral administration are effective alternatives to oral morphine. Transdermal fentanyl and transdermal buprenorphine are best reserved for patients whose opioid requirements are stable. They are usually the treatment of choice for patients who are unable to swallow, patients with poortolerance to morphine and patients with poor compliance. Earlier worries regarding an inferior equipotency ratio of buprenorphine to oral morphine or of a ceiling effect and partial antagonistic effects of buprenorphine as compared with fentanyl have not been substantiated by newer publications. Methadone is a valid alternative but may be more complicated to use because of marked inter-individualdifferences in its plasma half-life and duration of action. Methadone use should be initiated by physicians with experience and expertise in its use. Strong opioids may be combined with ongoing use of a nonopioid analgesic (step 1). Patients presenting with severe pain that needs urgent relief should be treated with parenteral

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