Iceu Dimas Kulsum, dr.

, SpPD, SpP

Tempat/Tanggal Lahir : Kuningan, 26 Februari 1976

Email : iceu_dk@yahoo.com
Pekerjaan : Divisi Respirologi dan Respirasi Kritis, Departemen Ilmu
Penyakit Dalam, RSHS
Jabatan : Staff Departemen Ilmu Penyakit Dalam RSHS
Riwayat Pendidikan :
2006-2011 Program Pendidikan Dokter Spesialis Penyakit Dalam
Universitas Padjadjaran
2013-2016 Program Pendidikan Dokter Spesialis Paru Universitas
Indonesia
MANAGEMENT OF CANCER PAIN

Iceu Dimas Kulsum

Department of Internal Medicine
Pulmonary and Respiratory Critical Division
Padjadjaran University / RSHS
 +

The 5th vital sign

Pain is "an unpleasant sensory and emotional experience associated with actual
or potential tissue damage, or described in terms of such damage“ (IASP)
2001 initiative in USA Pain: the
5th vital
sign

 Patients should be assessed for pain every

time pulse, blood pressure,
core temperature, and respiration
are measured
 Mandatory for hospital accreditation ($)

American Pain Society Quality Improvement Committee. JAMA. 1995;1847–1880.

Pain is the most common presenting
symptom leading to cancer diagnosis
31%

n=4947

Base: all who has specified cancer (n=4947)

S3. What symptoms lead you to see the doctor prior to your diagnosis of cancer?
Cancer pain
 Pain may be a problem for people with cancer during
any stage
 Often a mixed pattern:
 Nociceptive
Somatic
Visceral
 Neuropathic

All AC, Huyce LI, Pain Cancer and older adults 199
Ahmedzi S. New approaches to pain control in patients with cancer Eur Journal of Cancer 1997
 Cancer Pain Prevalence
For many patients pain is the first sign of cancer.
• 30 – 50 % of all cancer patients will
experience moderate to severe
pain.
• 75 – 95 % of patients with advanced stages
will experience severe pain.
• 45 % of cancer patients have
inadequate pain control.
• 25 % Will die in pain.
Nature Reviews Cancer March 2002
Pain in patients with cancer may be:

 Due to cancer
- 85-93%
 Due to cancer diagnosis and treatment
- 17-21%
 Unrelated to cancer or its treatment
- 2-9%

Zech DF, et al. Pain. 1995, 63:65-78

Caraceni A, Portenoy RK. Pain. 1998;82:263-74
The cancer itself causes pain through:

 Extension into soft tissues

 Visceral involvement
 Bone involvement
 Nerve compression
 Nerve injury
 Raising intracranial pressure
The A-B-C of pain management
American Pain Society, 1999
Ask about pain regularly;
Assess systematically
Believe the patient and family

Choose treatment options appropriate to

patient and setting
Deliver medications on an "around-the-
clock" basis with adequate
"breakthrough" doses
Evaluate results frequently; Empower
patients and families to control pain
 Pain Assesment
• Is pain present?
• Where is the pain?
• What are descriptions of the pain? (Quality)
• What is pain intensity rating (0-10)? (Quantity)
• What make your pain worst or better?
• What is the current pain regimen?
• What is the meaning of the pain?
 Pain Assessment
Two things must be determined before treating
cancer pain.
1. Type of pain ( quality of pain)
 Somatic pain
 Visceral pain
 Neurophatic pain
In most cancers pain, mostly combined form
2. Intensity of pain (quantity of pain)
 Mild pain 1–3
 Moderate pain 4–7
 Severe pain 8 – 10
 Measurement tools

 Verbal descriptions None

 Visual analog scale
Mild
 Numerical rating
scale Moderate
 Happy face-sad face
scale Severe

Verbal rating scales

Visual Analog Scale (VAS)
Simple descriptive pain intensity scale

Pain score
Happy face – sad face scale
Three-Step ladder of WHO
Step III
Severe pain,
Severe pain Strong Opioid analgesics
Step II Moderate Pain ± Non-opioid analgesics
For mild to moderate pain, ± adjuvant analgesics
Pain level

Mild Opioid analgesics

± Non-opioid analgesics
± adjuvant analgesics
Step I Mild Pain
Non-opioid analgesics
± adjuvant analgesics
Pain
Strong opioids
Morphine (MST Continus)
Pain
Mild Opioid
Codeine or Tramadol
Paracetamol+Codeine
paracetamol+Tramadol
APAP/NSAIDs ± adjuvants
APAP /NSAIDs ± adjuvants
Successive change

WHO. Cancer Pain Relief. 2nd ed. 1996

19

By the mouth
With attention Per Oral By the clock
to detail Sesuai jadwal
Perhatian khusus

For the individual By the ladder

Dosis obat per individu Sesuai tahap2 penggunaan
sesuai derajat nyeri analgetik (WHO)
 Opioid tolerant

Oncologic emergency

NCCN 2016
Rapid titrating short-acting opioid

Titrate short-acting opioid

NCCN 2016
Opioid dose 10-20% total opioid taken in previous 24h
FDA recommendations for transdermal fentanyl

 TDF (transdermal fentanyl) should always be prescribed at

the lowest dose needed for pain relief. TDF patches are
potent opioid analgesics that may cause death from overdose.

 TDF should not be used to treat short-term pain, pain that is

not constant, or pain after an operation. TDF should only be
used by opioid tolerant patients who are already taking
other narcotic analgesics, and who have chronic pain that is
not well controlled with shorter-acting analgesics.
 Recommended dose conversion from other
opioid to transdermal Fentanyl

Trans- Morphine Codeine Oxycodone* Hydromorphone*

dermal (mg/d) (mg/d) (mg/d) (mg/d)
Fentanyl
(mcg/h)
IV/SC Oral IV/SC Oral Oral IV/SC Oral

25 20 60 130 200 30 1.5 7.5

50 40 120 260 400 60 3 15
75 60 180 390 600 90 4.5 22.5
100 80 240 520 500 120 6 30
IV = intravenous
SC = subcutaneous
*not yet available in Indonesia O = oral
Cessation of therapy

When the patient no longer requires

therapy with any opioids, doses
should be tapered gradually to prevent
signs and symptoms of withdrawal in
the physically dependent patient.
WHO. Cancer Pain Relief. 2nd ed. 1996
WHO. Cancer Pain Relief. 2nd ed. 1996
Respiratory depression due to opioid side effect

Respiratory depression is rare in cancer patients

because the dose of the opioid is balanced by
the underlying pain

Can be reversed immediately by the intravenous

administration of 0,2-0,4 mg of naloxone
(opioid antagonist)

WHO. Cancer Pain Relief. 2nd ed. 1996

Breakthrough pain
• Defined as transitory exacerbation of pain in a patient
who has relatively stable and adequately controlled
baseline pain (rapid onset, brief flare of severe pain
despite regular analgesia).
 Common in cancer patients
 Despite around the clock treatment regimen, patients
have approximately 4 episodes/day

Portenoy RK, Hagan NA : Breakthrough pain: definition, prevalance & characteristics.

Pain 1990;41:273–281.
Time Pattern of Cancer Pain

Over Medication

Around-the-Clock Breakthrough pain

Medication
Breakthrough pain

 In 43% patients, pain reached peak intensity within 3

min
 Mean duration was about 30-40 min
 Immediate released, short-acting analgesic is an ideal
option for breakthrough pain (IV/IM, IR-Oral,
suppositoria, buccal*)

*not yet available in Indonesia

Portenoy RK, Hagan NA : Breakthrough pain: definition, prevalance &

characteristics. Pain 1990;41:273–281.
INTEGRATION OF OTHER INTERVENTIONS TO
THE WHO LADDER

Anaesthetic
physiotherapy
interventions

Occupational
Cancer 1 therapy
therapies

2 psychology
surgery

3 Spiritual care

WHO. Cancer Pain Relief. 2nd ed. 1996

Take Home Message
 Pain free and quality of life are the goal of
treatment
 For moderate and severe pain, opioid is the first
choice
 Opioid therapy is the mainstay treatment in
cancer pain with 90% effectiveness
 Integration of multimodalities interventions for
cancer pain

1. VielhaberA, Portenoy RK. Advances in cancer pain management

Hematology/oncology Clinics of North America Vol 16, No 3, 2002
2. Fallon M. Palliation of breathlessness. Clinical Medicine Vol 6 No 2
March/April 2006
FDA recommendations for transdermal fentanyl

 Patients who are using TDF and their caregivers

must be fully informed about:
 the directions for safe use of the patch
 safe methods for storage and disposal of used, unneeded
or defective patches.
 Health care professionals who prescribe TDF and
patients who use TDF and their caregivers should
be aware of the signs of fentanyl overdose:
 troubled or shallow breathing; tiredness, extreme
sleepiness or sedation; inability to think, talk or walk
normally; and feeling faint, dizzy or confused
FDA recommendations for transdermal fentanyl

 A patient using TDF may have a sudden and

possible dangerous rise in their body level of
fentanyl or have a more potent fentanyl effect if
 They use other sedating medicines;
 They drink alcohol (beer, wine or distilled spirits);
 They have an increase in body temperature or are
exposed to heat;
 or they use other medicines that increase the elimination
half-life of fentanyl
(such as CYP450 3A4 inhibitors).
This N-methyl-D-aspartate (NMDA) receptor antagonist binds to receptor sites in
the spinal cord and central nervous system, thereby blocking the generation of
central acute and chronic pain sensations