What Are Your Options For Treating Cancer Pain? Medications, Interventions, and Integrative Solutions

In this video, I'm going to be looking at the present treatment approaches for cancer pain, including a note on integrative approaches as well. Broadly, there are two mainstream traditional approaches to managing cancer pain.

One has, of course, been medication. The other is a variety of interventions, including surgeries, where appropriate. And of course, there is this third part of a variety of other physical activity or what we used to call complementary therapy-based approaches.

Now, in my last video, I went through the various mechanisms of pain, the distinction between nociception and pain, as well as the three kinds of pain that are often seen in cancer. The nociceptive pain, which is when you have acute surgery or inflammation. The neuropathic pain, when you have an injury or damage to the nervous system due to the tumor or due to any treatment or drugs.

And finally, this entity called nociplastic pain, where the nervous system itself can get sensitized. It's very important to have treatment approaches that also look at the nociplastic component or the sensitization component, because that hasn't been done very well in traditional medicine. So broadly, what are, again, the various reasons that you can have pain due to? Now, I'm going to be looking, of course, we can understand that there are going to be surgery-related pain or the procedure-related pain.

You can have that emotional or spiritual component of pain there. But two big categories that have come through in recent times, one of them is due to the neuropathy that comes with particular groups of chemotherapy drugs, which is called chemotherapy-induced peripheral neuropathy, affecting the hands and the feet. Now, that's a big challenge for which there isn't a satisfactory set of treatments possible.

And the other thing which is becoming very, very prevalent these days are what are called aromatase-induced inhibitors related joint pain or arthralgias. Now, aromatase inhibitors are very commonly used and as breast cancer is a very common problem, these are a very often used drug for managing chemoprevention in breast cancer. These are examples you would have heard of, for example, drugs like anastrazole or eczema stain or lutrazole.

These are all drugs that are belonging to the category of aromatase inhibitors. Now, the main way that they cause pain is that they cause estrogen deprivation. By the way, the way they act is to reduce the amount of estrogen available because we know that it can provoke or maintain cancer.

So, these drugs inhibit and reduce the amount of estrogen. But unfortunately, we realize that estrogen is required for bone metabolism, is required for many functions and probably these drugs by depriving certain bones and certain structures of that estrogen modulation, that is supposed to be one of the main mechanisms for the joint pain that occurs in patients with or on aromatase inhibitors. There are many treatment approaches that have been suggested for this and in general, drugs that have been looked at in the past include testosterone.

We can use duloxetine which is a nerve pain medication and then you have got drugs that are being used like steroids or even diuretics that have been used for it there. And of course, there has also been studies done on vitamin D and even omega-3 fatty acids as ways of trying to manage this particular problem. Switching the aromatase inhibitor itself is one way to see whether that could be a way of reducing the incidence of pain, but often that's not very helpful.

But it is certainly a suggestion there. Indeed, an integrative set of approaches that has been shown to have a lot of promise with this kind of condition is actually the use of acupuncture and yoga-based techniques alongside physical activity and these drugs when you want to specifically tackle aromatase inhibitors induced muscle joint pain, which is a very very common problem there. Now, the second part is really the general cancer pain or the musculoskeletal pain that can happen either because of surgery or because of the treatments and this is accompanied often by fatigue and a variety of the symptoms which many patients suffer.

Now, for general purposes, often patients get given medications like paracetamol, codeine, tramadol, maybe even the stronger opioids like morphine or fentanyl and then you go on to the nerve pain medications like gabapentin, pregabalin, amitriptyline. So this is another group of general drug management for cancer pain. These all have side effects and we realize now that with cancer pain of this kind, which is general musculoskeletal pain, it's often difficult to get perfect reduction in pain with drugs alone.

This is because this is a mixed pain wherein there is an element of the nociceptive component and there is a huge element of the nociplastic pain and as I've mentioned before, for nociplastic pain, using any of these drugs isn't going to help. We need to bring in the integrative approaches. So in that sense, what we traditionally used to call complementary therapies are instead becoming the mainstay therapies for managing the general cancer musculoskeletal pain.

What do I mean by integrative approaches? Well, focusing on diet, nutrition, ways to calm the immune system down, other techniques that calm the mind and the nervous system can include acupuncture, would include massage, can include yoga, would include guided imagery with progressive muscle relaxation. Indeed, the Society for Integrative Oncology along with the American Society for Clinical Oncology has a guideline that was published a couple of years ago that has specifically looked at the strength of evidence for these integrative approaches and they have suggested that people should certainly consider strategies like acupuncture or yoga or massage or guided imagery, progressive muscle relaxation to be added alongside the trial of any of these drugs. So for general cancer pain, very important to have this aspect there.

The other kind of pain that comes along is this chemotherapy-induced peripheral neuropathy. Now, because there is an evidence of nerve damage in there, the drugs that can be included would certainly be looking at the nerve medication. So for example, you can look at amitriptyline or duloxetine.

These are antidepressants that have been repurposed as nerve medication and then you have the anti-epileptics like gabapentin or pregabalin which could also be trialed. Sometimes if the neuropathy is in a very specific part there, for example, the hands or the feet and it's an area of the hands and feet which is localized, then there's the option for trialing patches of capsaicin or chili plaster that could also be very useful for localized areas of neuropathy. There are sometimes trials of a local anesthetic like lidocaine which comes as a plaster that could be considered.

There has been some studies or suggestions looking at Botox as an injection in multiple areas of the feet or hands to see if that can help in calming down. Another group of drugs that's been looked at in this setup is actually medicinal cannabis to see if that might be beneficial as well. So all of these have been explored but again when you look at integrative approaches there is some suggestion that massage or probably the use of acupuncture could be added to this particular condition treatment management plan.

So specifically remember that for chemotherapy induced peripheral neuropathy it's against something that's a mixed pain. There's a neuropathic and a nociplastic component. So thinking of these approaches is very useful in this perspective.

Now there are some interventions that have been generally used for cancer pain and in certain patients where there is an invasion of the tumor into the rib or into adjacent areas or where there is a significant trapping of a bigger nerve, then there is the potential for doing interventions like a nerve block or even an epidural and certainly another common procedure that can be done is an intrathecal pump which essentially involves putting in a small tube, putting it into the spinal cord and the medicine then goes in the spinal cord at the level for example if it's a lower limb problem, legs or if it's an upper limb problem, you can guide the intrathecal pump in such a way that you deliver the morphine or the local anesthetic so that you get ongoing pain relief, continuing pain relief for that kind of cancer pain which comes from a nerve being invaded by a tumor or a inoperable tumor that is trapping a nerve. But remember again this is a form of mixed pain. So while you are using an intrathecal pump or a procedure or intervention to help with the reduction in the intensity of pain, there is always an advantage to looking at other integrative mind-body approaches as well to try alongside the intrathecal pump or the nerve block or the epidural.

Another intervention that is done in certain kinds of thoracic or chest wall cancers is chordotomy where we can do that as almost a palliative surgery and it involves actually cutting or slicing a small part of the spinal cord and this is often done in specialist centers for certain types of cancer pain which can be inoperable or where there is a very short duration of life left but you're looking at a quality of life. One other group of treatment approaches that is coming up now for which the evidence is being really looked at is psychedelics and to use psychedelic assisted therapy for some forms of cancer pain especially the emotional or the spiritual ones are quite useful and indeed there are some studies looking at the role of psychedelics in this context. So broadly we've looked at these approaches and we've seen that for certain conditions and certain forms of cancer it's very useful to combine our traditional mainstream approaches of medication or interventions alongside the integrative therapy approaches and indeed the way forward for any cancer pain management in terms of treatment is an integrative plan that blends and brings the best of both so that you can improve quality of life, reduce side effects and the earlier this is done in the cancer pain patient's journey the better it is for recovery because after all we are now finding that cancer survivorship meaning that people are getting the right treatment and surviving the cancer but then the quality of life is significantly impacted because of cancer pain, because of the side effects of the chemotherapy or the radiotherapy or the drugs and so it's important to address those side effects early on, address the drugs early on and institute integrative approaches to help with cancer pain management.

Watch the video for this post here: