Interventional Management of Cancer-Associated Pain

Publication Date: July 16, 2021
Last Updated: March 14, 2022


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Therapy Statement Evidence Level Grade
Opioids for cancer pain Opioids should be considered for moderate to severe cancer-related pain. I A
Opioid agent selection should be individualized to account for the variance in pain presentations and co-existing medical comorbidities. III B
Methadone Methadone should be considered when other opioids are ineffective, or additional NMDA or serotonin receptor modulation is desired. II-3 C
Dosing initiation is dependent on opioid tolerance with low introductory doses for naïve patients. II-3 B
For opioid tolerant patients a conservative approach is recommended starting at 75–90% less than the calculated equianalgesic dose using 1:15 to 1:20 conversion factor. II-3 A
Ketamine Ketamine therapy for cancer pain should be considered on a case-by-case basis for refractory neuropathic, bone, and mucositis-related pain. II-1 B
Radiotherapy, radioisotopes, and bone-modifying agents for metastasis      External beam radiation therapy with short, fractionated regimens are favored over conventional protracted schedules for painful metastatic bone disease. Stereotactic body radiation therapy may be preferred for radio-resistant cancers or oligometastatic disease. I A
There is evidence for the use of osteoclast inhibitors, though it has not been found to be effective for some cancers, such as metastatic non-small cell lung cancer. Therefore, these agents should be used as an adjuvant treatment and considered on a case-by-case basis II-1 B
Blocks and neurolysis Celiac plexus neurolysis should be performed for pancreatic cancer-related abdominal pain. I A
Splanchnic nerves neurolysis should be considered in patients with intractable abdominal cancer-related pain due to advanced body and tail located pancreatic CA. I B
Early neurolysis is associated with better outcomes II-3 B
Superior hypogastric plexus neurolysis should be considered in patients with intractable pelvic cancer-related pain. II B
Ganglion impar neurolysis should be considered in patients with intractable perineal cancer-related pain. III B
Targeted drug delivery Intrathecal drug delivery using an implantable pump should be strongly considered in patients with cancer-related pain that is not responding to conventional medical management I A
Trialing before intrathecal pump implantation for cancer-related pain should be optional and at the discretion of the physician and patient. III C
Spinal cord stimulation Spinal cord stimulation may be considered in patients with refractory cancer pain. II-3 C
Spinal cord stimulation may be considered on a case-by-case basis for pain that is related to cancer treatment such as chemotherapy induced neuropathy. III C
Vertebral augmentation and radiofrequency ablation Vertebral augmentation should be strongly considered for patients with symptomatic vertebral compression fractures from spinal metastases. I A
Percutaneous radiofrequency ablation with or without cement augmentation is indicated for treatment of severe back pain from spinal tumors and has proven to be a safe and effective palliative therapy for painful spinal metastasis. II-2 B
Radiofrequency lesioning and nerve blocks Consider radiofrequency lesioning of the dorsal root ganglion in the treatment of axial thoracic back pain from vertebral malignant metastases. I C
For cancer pain unresponsive to medical management, application of nerve blocks using corticosteroid or radiofrequency lesioning to a peripheral nerve, brachial plexus can be considered. II-2 C
Surgical options Cordotomy should be considered for uncontrolled unilateral nociceptive pain after failure of more conservative options. II B
Myelotomy is used for infra-diaphragmatic visceral pain for pain control and decrease opioid consumption. III C
DREZ-otomy is indicated for focal limb pain and in Pancoast tumors. III I
Cingulotomy is indicated for late-stage and uncontrolled pain refractory to other therapies III C

Recommendation Grading

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Degree of Recommendation Meaning
A Extremely recommendable (good evidence that the measure is effective, and benefits outweigh the harms)
B Recommendable (at least, moderate evidence that the measure is effective, and benefits exceed harms)
C Neither recommendable nor inadvisable (at least moderate evidence that the measure is effective, but benefits are similar to harms and a general recommendation cannot be justified)
D Inadvisable (at least moderate evidence that the measure is ineffective or that the harms exceed the benefits)
I Insufficient, low quality or contradictory evidence; the balance between benefit and harms cannot be determined
Evidence Level Study Type
I At least one controlled and randomized clinical trial, properly designed
II-1 Well-designed, controlled, nonrandomized clinical trials
II-2 Cohort or case studies and well-designed controls, preferably multicenter
II-3 Multiple series compared over time, with or without intervention, and surprising results in noncontrolled experiences
III Clinical experiences-based opinions, descriptive studies, clinical observations, or reports of expert committees



Interventional Management of Cancer-Associated Pain

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