Palliative Care in Lung Cancer: Management of Chronic Pain

Many patients with advanced cancer suffer from chronic pain. Palliative pain management is a crucial component of the care provided to individuals with lung cancer. It helps to alleviate any pain or discomfort experienced from the adverse effects of chronic pain.

“When pain is managed effectively, people can enjoy time with family and friends, rest better and continue many of their daily activities, like work, school and play. No one should live or die in pain.”

- Dr Etienne Krug, Director of WHO’s Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention.

In palliative care, lung cancer patients may be referred to pain specialists when the pain is too difficult to control. Pain specialists may vary in training background and may not have experience in palliative care. When referred, it is best to find a pain specialist experienced in cancer pain.

Besides the primary cancer site, lung cancer patients often experience chronic pain at other sites where the cancer has spread to:

• Rib and intercostal pain - When the tumor invades the ribs and intercostal spaces (spaces between adjacent ribs in the ribcage), patients may suffer from persistent chest discomfort. This discomfort intensifies when coughing or taking deep breaths.
• Pleural pain - Experienced when the tumor invades the thin membrane that surrounds the lungs and lines the chest cavity. The pain associated with pleural involvement in lung cancer is often described as sharp, stabbing, or aching and is typically felt in the chest or upper back. It can be exacerbated by deep breathing, coughing, or movement.
• Spinal pain - If metastases occur in the spinal cord, individuals may endure enduring pain along their spine. This pain can be constant and challenging to manage.
• Shoulder, arm or hand pain - Lung cancer can lead to chronic pain that radiates down the shoulder, arm, or even into the hand. This discomfort can hinder daily activities and reduce overall quality of life.
• Abdominal pain - Abdominal pain can occur if the tumor invades the liver and/or adrenal gland (small glands located on top of each kidney). Both structures do not have nerve endings that sense pain. The pain associated with these metastases often arises from the pressure on surrounding structures and the compression of nearby nerves by the tumor. Inflammation triggered by the presence of a tumor can also contribute to pain.
• Bone pain - Bone metastases is a frequent result of metastatic lung cancer. It often causes bone pain. Patients experience this pain deep within their bones, which can be quite distressing.
• Skull/brain pain - In cases of skull or brain metastases, patients may encounter persistent headaches or discomfort in the skull area. This type of pain can be debilitating and difficult to alleviate.

Mild cancer pain is often treated with non-steroidal anti-inflammatory agents (NSAIDs). This class of analgesic is sometimes combined with another type of analgesic (adjuvant analgesic) to treat

• Specific pain (e.g., pain due to damaged nerves)
• Side effects of cancer treatments
• Or both

There are certain contraindications associated with the use of NSAIDs so they should be prescribed with caution:

• NSAIDs can cause irritation and damage to the gastrointestinal (GI) tract, leading to conditions like gastritis, ulcers and GI bleeding
• NSAIDs can have adverse effects on renal function and may cause or worsen renal impairment
• Some NSAIDs have been associated with an increased risk of cardiovascular events, such as heart attack and stroke

Please inform your cancer care team If you have a high risk or a history of the conditions mentioned above.

Opioid therapy is the standard approach for moderate to severe cancer pain. However, administration of opioids must be closely monitored for any severe side effects and misuse or overuse. Adverse effects associated with opioid-derived drugs include nausea, dizziness, sedation and neurotoxicity. These side effects can be concerning for some patients, but it’s important to know that your cancer care team will only prescribe what is best for your treatment and care. They will closely monitor your condition and make any necessary adjustments as needed to ensure that you are comfortable and safe.

Apart from pain relief, opioids are also used to manage chronic cough. End-stage cancer patients often suffer from a combination of pain, like pain in the chest and metastatic areas. To control different types of pain effectively, adjuvant analgesics is combined with opioid:

• Glucocorticoids
• Antidepressants
• Antiepileptic or antiseizure, alpha-2 adrenergic agonists
• Cannabis and cannabinoids
• Topical therapies
• Botulinum toxin
• Osteoclast inhibitors

External beam radiation therapy (EBRT) is used to relieve painful bone metastases and other metastatic sites. EBRT is effective in providing significant pain relief, either partially or completely, for most patients with bone metastases.

Besides pharmacological methods, integrative therapies may also help in reducing cancer pain. The National Institute of Health (NIH) and the US Food and Drug Administration (FDA) declared acupuncture to be a sound medical technique for managing cancer pain and nausea.

In instances of extreme pain or if the patients have difficulties taking the medicine, doctors may

• change the prescription and incorporate other types of pain relief drugs
• modify the dose or dosing regimen
• change the drug delivery methods

Depending on where the patient receives the care, the cancer care team will work with the caregivers to provide comfort based on the patient’s needs and specific conditions.

Related: Approaching the End of Life With Lung Cancer: What to Expect and What to Do