Interventional Management of Cancer-Associated Pain
Publication Date: July 15, 2021
Last Updated: March 14, 2022
Recommendations
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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 |
Overview
Title
Interventional Management of Cancer-Associated Pain
Authoring Organization
American Society of Pain and Neuroscience