Seminars in Oncology Nursing 38 (2022) 151248

Contents lists available at ScienceDirect

Seminars in Oncology Nursing

journal homepage: https://www.journals.elsevier.com/seminars-in-oncology-nursing

The Assessment and Management of Acute and Chronic Cancer Pain

Syndromes
Jeannine M. Brant*
Executive Director of Clinical Science & Innovation, City of Hope, Duarte, California

A R T I C L E I N F O A B S T R A C T

Key Words: Objectives: To provide an overview of the most common acute and chronic cancer-related pain syndromes
Pain along with their assessment and management.
Acute Data Sources: Data sources include peer-reviewed articles, textbooks, and the internet.
Chronic Conclusion: Various pain syndromes occur throughout the cancer trajectory. Assessing and managing these
Opioids
syndromes, up to years’ after treatment, can assure that comfort is provided from diagnosis throughout
Complementary
survivorship.
Cancer
Implications for Nursing Practice: Oncology nurses are essential in assessing and managing acute and chronic
cancer-related pain syndromes. Nurses have both a professional and an ethical responsibility to understand
these syndromes and to provide optimal pain management.
© 2022 Elsevier Inc. All rights reserved.

Introduction
Pain is a significant and highly prevalent problem in patients with
cancer. Approximately 53% of patients experience pain at some point
during their cancer illness, and 59% to 64% in patients with metastatic
disease experience pain. Patients going through cancer treatment are
also at risk with 59% experiencing pain. Once treatment is complete,
pain can persist in disease-free patients, and studies report that as
many as 33% of patients following curative treatment experience
pain.1
Pain in patients with cancer can be acute or chronic. Pain related
to surgery, procedures, and treatment is often acute. Acute pain lasts
6 months or less and then resolves.2 Some pain syndromes can per-
sist and become chronic and relentless. Chronic pain can be related
to the cancer itself, cancer treatment, or could be due to another con-
dition unrelated to the cancer.3
Significant gaps continue to exist in the management of pain.
Studies reveal approximately 43% patients with cancer pain rated
pain as moderate, and up to 26% rated the pain as severe.1 Those in
the hospital may be at greatest risk. One study reporting pain on 114
US oncology inpatient units (n = 810 patients) found the mean pain
intensity score was 5.9 on a 0-10 scale with “0” being “no pain” and
“10” being “worst possible pain.” One quarter of those hospitalized
patients reported being in frequent (>50% of the time) or constant
severe pain.4
* Address correspondence to Jeannine Brant, Billings Clinic, 801 N 29th St, PO Box
35100, Billings, MT, 59101.
E-mail address: JBrant@BillingsClinic.org
Nurses play a significant role in both the assessment and manage-
ment of pain. In the hospital, nurses are with the patient around the
clock and conduct ongoing assessment and management of pain. In
the ambulatory setting, nurses assess pain during ambulatory and
infusion visits, and many advanced practice nurses provide follow-up
care to patients who may commonly experience pain. Equipping
nurses with essential assessment and management skills can help
narrow the gap in patients with uncontrolled pain.
This article will provide an overview of acute and chronic pain
syndromes experienced by patients with cancer and will highlight
assessment and management strategies that will help to identify and
alleviate these syndromes throughout the cancer trajectory.
Acute Cancer-Related Pain
Pain is defined as an unpleasant sensory and emotional experi-
ence associated with actual or potential tissue damage or described
in terms of such damage.5 Acute pain is one type of pain character-
ized by a sudden onset, lasts weeks to a few months, and most impor-
tantly, is self-limiting. Uncontrolled acute pain can be devastating
and can lead to prolonged hospitalizations, loss of hope, poor quality
of life, and increased costs. If left untreated, it can even lead to neuro-
nal remodeling and the development of chronic pain.6
Acute cancer-related pain can be attributed to a plethora of cancer
and treatment-related factors. Diagnostic and therapeutic procedures
(e.g., lumbar puncture, thoracentesis) are commonly employed
throughout the cancer trajectory and can lead to pain. Surgical proce-
dures to remove and debulk tumors cause acute pain. Cancer treat-
ment including chemotherapy, radiation therapy, and even hormonal

https://doi.org/10.1016/j.soncn.2022.151248
0749-2081/© 2022 Elsevier Inc. All rights reserved.
2 J.M. Brant / Seminars in Oncology Nursing 38 (2022) 151248

TABLE 1 TABLE 2
Cancer-Related Acute Pain Syndromes Cancer-Related Chronic Pain Syndromes

Etiology of the Pain Syndrome Types or Causes of Pain Pain Syndrome Etiology Characteristics Cancer Types

Diagnostic Procedures-Related  Intravenous catheter insertion Brachial RT to the bra- Pain often affects Breast
 Blood draws plexopathy chial region the shoulder and Lymphoma
 Bone marrow biopsy radiates down the
 Lumbar puncture affected arm
 Paracentesis or thoracentesis Lumbosacral RT delivered to Radiating pain from Anus
Therapeutic Procedures-Related  Intraspinal injection or infusion plexopathy the pelvic the pelvis down Gynecologic
 Pleurodesis region the associated
 Tumor embolization lower extremity
 Nephrostomy tube placement Phantom pain Surgical Phantom limb pain Breast
Chemotherapy-Related  Access device placement removal of a decreases over Sarcoma
 Mucositis body part the course of a
 Intraperitoneal therapy year; pain present
 Intra-arterial therapy at 1 year is likely
 Chemotherapy-induced peripheral neu- to persist
ropathy (CIPN) chronically
 Bone or muscle pain from growth factors Stump pain Amputation Stump pain can be Sarcoma
or other agents (pain flare) related to a poorly
Radiation Therapy-Related  Bone pain from Strontium-89 fitting prosthesis.
administration Intercostal Mastectomy Sensations include Breast
 Mucositis neuralgia Thoracotomy paresthesias, dys- Lung
 Proctitis and enteritis esthesias, hyper-
 Brachial and lumbosacral plexopathy algesia, and
Hormone Therapy-Related  Gynecomastia allodynia
 Hormone flare in breast cancer Lymphedema Surgery that Sense of fullness, Breast cancer
 Luteinizing hormone releasing factor impacts lym- achiness Gynecologic
tumor flare (prostate cancer) phatic and pelvic
 Arthralgias related to aromatase inhibitors drainage malignancies
Immunotherapy-Related  Pain flare with interleukin or interferon Neck and shoul- Head and neck Can involve neck, Head and neck
therapy der pain Surgery shoulder, and Breast
Acute Tumor-Related  Vertebral collapse or spinal cord RT to the head myofascial pain
compression and neck Can lead to a frozen
 Intracranial hypertension Breast Cancer shoulder
 Tumor hemorrhage surgery Pain includes loss of
Infection-Related  Myalgias and arthralgias sensation and
 Wound or abscess pain neuropathic pain
syndromes.
Facial, mouth, Head and neck Dry mouth, tight- Head and neck
Data from Sundaramurthi et al.2 and Garg et al. .7
dental, or Surgery, RT, ness, achiness
mandibular CT
pain
therapy can cause acute pain.2,7 Table 1 includes some of the most Chronic pelvic Pelvic RT Pain is usually only Prostate
pain CT present during Gastrointestinal
common acute pain syndromes, including diagnostic procedure-, urination or is malignancies
therapeutic procedure-, chemotherapy-, radiation therapy-, hormone exacerbated dur-
therapy-, immunotherapy, acute tumor-and infection-related ing urination.
syndromes.2,7 Peripheral CT Extremity numb- Multiple
neuropathy ness, tingling, and cancers
aching sensations
Chronic Cancer Pain Syndromes CT, chemotherapy; RT, radiation therapy.
Data from Brant et al. ,3 Karri et al. ,8 and Portenoy and Ahmed.9
Chronic cancer pain can also develop and often presents unique
challenges. Chronic pain is the result of three distinct mechanisms:
peripheral sensitization, central sensitization, and descending modu-
lation. Peripheral sensitization occurs when noxious stimulators con- examples such as brachial plexopathy, phantom pain, lymphedema,
tinue and contribute to inflammation and peripheral and peripheral neuropathy-related pain.3,8,9
hyperexcitability. Persistent hyperexcitability then extends to the Breakthrough pain (BTP) deserves its own discussion. It is defined
dorsal horn of the spinal cord or into higher levels within the central as an acute exacerbation of pain that occurs in the background of
nervous system, thereby leading to central sensitization. The dorsal well-controlled pain. Defining it another way, it is acute on top of
horn then modulates peripheral and central sensitization, creating chronic pain.10 BTP occurs in approximately 23% 90% of patients
supraspinal modulation. As this occurs, windup of the nervous sys- with a cancer experience. The wide range of prevalence is due to the
tem occurs, leading to hyperalgesia and allodynia, or pain that occurs way in which it is defined. Of those who experienced BTP, 44%
in situations that are not normally painful. In essence, the nervous reported it as incident pain, 41.5% as spontaneous pain, and 14.5%
system is remodeled and rewired and leads to chronic pain.6 experienced a combination of both.11,12
Chronic cancer pain is most often due to the cancer itself but may
also be attributed to postsurgical pain (e.g., postmastectomy, post- Assessment
thoracotomy), cancer treatment (e.g., chemotherapy-induced periph-
eral neuropathy [CIPN]), and radiation therapy. Radiation pain syn- Patients with a diagnosis of cancer should be screened for the
dromes can occur weeks, months, or even years after the delivery of presence of pain. If present, a comprehensive pain assessment should
radiation and should therefore be monitored for in post-treatment be conducted.13,14 Assessment of acute pain that is self-limiting and
survivors receiving radiation therapy.8 Some of the most common that is anticipated to resolve is succinct with a focus on the physio-
chronic cancer pain syndromes are included in Table 2 and include logical aspects of the pain. However, risk factors for the exacerbation
 J.M. Brant / Seminars in Oncology Nursing 38 (2022) 151248
TABLE 3
Assessment of Cancer Pain Syndromes
Assessment Parameter Rationale
Cancer History  Type - Can identify the pain syndrome risks
 Stage - Later stage cancers are associated with
more pain
Type of Treatment  Surgery type and extent of surgery
 Chemotherapy specific agents
 Radiation therapy location fields, dosages
Comorbid Conditions  May impact cancer-related pain, especially
conditions such as diabetes, arthritis, and
fibromyalgia
Pain Assessment  Location(s) where the pain is located or
referred to
 Intensity “0” to “10” scale preferred
 Quality
description of how the pain feels,
which can help to identify the pain syndrome
 Temporality how the pain changes over
time; includes background and breakthrough
pain experiences
○ Is pain constant or intermittent?
○ What makes the pain worse?
○ What makes the pain better?
 Pain behaviors such as splinting or impaired
gait
Diagnostic Evaluation  Computed tomography or magnetic resonance
imaging scans to detect structural problems
 Electromyogram to detect weakness, most
often related to neuropathy
 Laboratory analysis (e.g., lactate dehydroge-
nase)
Past Strategies  What has been tried to alleviate the pain
 What worked and what did not work, degree
of relief
○ Exercise, physical or occupational therapy
○ Invasive procedures (e.g., blocks, steroid
injections)
○ Pharmacologic modalities
○ Complementary modalities (e.g., acupunc-
ture, cannabis)
Functional Assessment  Determine how the pain interferes with activi-
ties of daily living, other desired activity
 Ability to work
 Ability to recreate
Psychological Assessment  History of depression and anxiety
 Adverse childhood events that may impact
symptoms and symptom expression (e.g.,
physical abuse, emotional abuse, neglect)
 Coping abilities
Social History  Presence of family or a caregiver for support
 History of substance use disorder personally or
in the family
Spiritual History  Spiritual beliefs that may link pain (e.g., pain is
a punishment from God)
 Spiritual support as a source of coping
Data from Fink and Brant,13 Gallagher et al. ,15 Fink and Gallagher,17 and Brant and
Stringer.19
of pain such as anxiety, fear, and other emotional, social, and cultural
factors, should occur to ensure that pain has been holistically
addressed.13 Assessment of pain prior to and following interventions
is paramount to determine success of acute pain interventions and
progress toward resolution.15
Chronic pain, on the other hand, requires a more comprehensive
and detailed assessment. History of the pain, onset, duration, past
cancer treatment, and tried interventions should be reviewed. This
holistic assessment also recognizes the impact that pain can have on
the body, mind, and spirit.16 Therefore, assessment of the psychologi-
cal, social, and spiritual domains is essential, which can provide infor-
mation about the total suffering experienced by the patient and the
multiple factors that may be contributing to the pain.13,17 Patients
with chronic pain commonly experience a cluster of symptoms that
include fatigue, depression, and sleep disturbance. Pain assessment
3
should include all these symptoms within that known cluster. At
times, one symptom can be managed and result in the resolution of
the other symptoms within that cluster.18 An assessment guide for
patients experiencing chronic pain is included in Table 3.15,17,19
Management
Management of both acute and chronic cancer pain requires a mul-
timodal approach. The approach should include pharmacologic, non-
pharmacologic, and complementary therapies that work together to
provide comfort. Although some strategies are used for both acute and
chronic-related cancer pain, chronic pain has its own set of approaches
that need to be trialed when pain is uncontrolled or refractory.20
The Oncology Nursing Society provides a tiered system for Putting
Evidence into Practice (PEP) strategies, based on the amount of evi-
dence available for the various multimodal interventions. Interven-
tions that are Recommended for Practice are ones in which
randomized-controlled trials have demonstrated ongoing success of
the intervention. The second tier, Likely to Be Effective, applies to
interventions in which some studies exist, but there is an overall lack
of randomized-controlled trials with clear evidence to support the
intervention. The third tier, Effectiveness not Established, refers to
interventions in which studies have been conducted, but a lack of evi-
dence is available, indicating a need for further research to be con-
ducted. Two additional tiers within the Putting Evidence into Practice
tier system are Not Recommended for Practice or those in which Bene-
fits are Balanced with Harm.21 Acute and chronic interventions for the
first three tiers are included in Table 4.2,3,9
Pharmacologic Management
Nonopioids
Nonopioids are used for both acute and chronic cancer pain. For
acute pain, oral naproxen is likely to be effective in alleviating bone
pain in patients receiving growth factors for chemotherapy. Some
evidence also exists that nefopam, given intravenously in the intrao-
perative period, can decrease postoperative pain in women undergo-
ing breast cancer surgery.2 Nonsteroidal anti-inflammatory drugs are
recommended for practice in patients with chronic cancer pain, usu-
ally as an adjunct to opioids.3,22 Clinicians should be on the alert for
possible side effects that can occur with the most common being gas-
trointestinal (GI) disturbance, renal compromise, and inhibition of
platelet aggregation that can lead to gastrointestinal bleeding.20
Opioids
Opioids are the mainstay of both acute and chronic cancer pain
management. Pure mu opioids such as morphine, oxycodone, hydro-
morphone, fentanyl, and methadone are the most common ones
used in the US to manage pain.20 Plentiful evidence exists that they
are effective in managing pain. Doses can be titrated without a ceiling
affect; however, when side effects occur, the opioid may need to be
rotated to an alternative opioid.
Each opioid is unique and has individual characteristics to consider.
For example, morphine and hydromorphone contain metabolites that
can accumulate and contribute to oversedation and neurotoxicity. Older
patients and those with compromised renal function are at greatest risk
for metabolite accumulation.20 Fentanyl is an opioid that is highly lipo-
philic, and its onset of action is highly dependent on the route in which
it is given. When given via the transmucosal route for BTP, it has a
rapid absorption with an onset in as little as 5 minutes.23 The transder-
mal (TD) route, on the other hand, has a slow onset of approximately
12 hours. It can last up to 72 hours and then a new patch should be
applied.24 Important to note is that TD fentanyl should not be used to
manage acute pain because patients should be able to tolerate opioids
4 J.M. Brant / Seminars in Oncology Nursing 38 (2022) 151248

TABLE 4
Evidence-Based Interventions to Manage Acute and Chronic Cancer-Related Pain

Acute Pain
Recommended Likely to Be Effective More Research Needed

 Opioids  Gabapentin for postoperative pain  Systemic anesthetics

 Epidural analgesia for postoperative pain  Parecoxib for postoperative pain (not approved in  Antihistamines
 Local anesthetic injected or infused into the surgi- the US)  Anxiolytics
cal site  Intraspinal analgesia given intraoperatively  Dexamethasone for pain related to IV
 Oral tramadol chemotherapy
 Naproxen for bone pain related to growth factor  Dexmedetomidine for bladder spasm
administration  IV fentanyl for procedural pain
 Nefopam for breast cancer surgery  Preoperative administration of ketamine
 Music and music therapy  Morphine mouthwash for mucositis
 Hypnosis and hypnotherapy  Paravertebral block for postoperative pain
 Perioperative drug combinations
 Pregabalin
 Preoperative dexamethasone
 Remifentanil via patient-controlled analgesia
 Steroids for bone flare
 Topical anesthetics for procedure-related pain
 Transmucosal opioids
 Acupressure
 Acupuncture
 Foot massage
 Guided imagery
 Honey for mucositis pain
 Massage
 Meditation
 Progressive muscle relaxation
 Reflexology
 Therapeutic touch
 Patient education
Chronic Pain
Recommended Likely to Be Effective More Research Needed

 Extended and Sustained-Release Opioids  Using opioids early in the disease process  Acetaminophen
 TD Fentanyl  Abiraterone for pain from metastatic prostate  Corticosteroids
 TD Buprenorphine cancer  Herbal medicines
 Methadone  Antidepressant combinations  Numerous other assorted trials
 Oxycodone and naloxone combination  Cannabis/Cannabinoids  Dance movement therapy
 Tapentadol  Duloxetine  Exercise
 Tramadol  Radiopharmaceuticals for metastatic bone pain  Expressive writing
 Bone-modifying agents  Ketamine (but balance with side effects)  Hypnosis
 Gabapentin combined with other analgesics (imip-  Educational interventions  Relaxation
ramine, amitriptyline, tramadol, antidepressants,  Yoga
antiepileptics, corticosteroids, other opioids)  Acupressure
 Anesthetics  Acupuncture
 Nonsteroidal anti-inflammatory drugs  Massage
 Intraspinal analgesia  Reiki
 Radiation therapy  Therapeutic touch
 Celiac plexus block  Organizational initiatives
 Celiac ganglion irradiation
 Cranial stimulation
 Cryoablation
 Scrambler therapy
 Transcutaneous Electrical Nerve Stimulation
(TENS)
 Neural block for postmastectomy chronic pain
 Radiosurgery
 Ultrasound

IV, intravenous; TD, transdermal.

Data from Sundaramurthi et al. 2 Brant et al.,3 and Portenoy.9

when TD fentanyl is initiated. Methadone deserves careful attention,
and only skilled clinicians should prescribe methadone. It is highly
bound to protein, which creates a long and variable half-life between 1
and 2 days. A multitude of drug-drug interactions also exist as metha-
done is metabolized via the cytochrome P450 system.20 Methadone
also has N-methyl-D-aspartame (NMDA) antagonism, and a handful of
studies suggest that a low dose of methadone in conjunction with other
opioids can improve chronic cancer pain management and prevent
hyperalgesia.25,26
Opioids can be delivered via various routes including oral, rectal,
TD, transmucosal, subcutaneous, intravenous, and intraspinal. The
simplest route of administration should be used if possible. When the
oral route is unavailable, TD, parenteral, or intraspinal routes should
be considered. Additionally, if pain is uncontrolled despite aggressive
titration of oral opioids, then rotation to the parenteral route is war-
ranted. Regarding the transmucosal route, only lipophilic opioids
such as fentanyl are absorbed. Hydrophilic opioids such as morphine
and hydromorphone must be swallowed to achieve effectiveness.27
Understanding how to effectively titrate opioids is an important
skill for nurses. Although some nurses prescribe and can order opioid
titration independently, others can assess pain and recommend opi-
oid titration to prescribers to ensure rapid change that is sometimes
 J.M. Brant / Seminars in Oncology Nursing 38 (2022) 151248
needed to optimally manage pain. For pain that is moderately con-
trolled, the 24-hour dose should be increased by 25%-50%. For severe,
uncontrolled pain, the 24-hour dose can be titrated by 50%-100%.22
Adequate time should be given between titrations to allow a steady
state to be established, especially with long-acting opioids. While the
long-acting dose is titrated, it is also important to titrate the BTP
dose. This BTP dose should be kept at 10%-20% of the 24-hour dose.22
For example, if the patient is receiving 200 mg of long-acting mor-
phine per day, then the BTP dose is 20-40 mg, every 3-4 hours as
needed for pain. The BTP dose for patients taking methadone for both
long-acting and BTP is 10% of the 24-hour dose.23,27
Analgesic Adjuvants
Adjuvants are combined with other analgesics to improve pain
management or control symptoms that may exacerbate pain. Some of
the most used adjuvants include the anticonvulsants such as gabapen-
tin and pregabalin, which are first line for chronic neuropathic pain.28-
30
The tricyclic (e.g., desipramine and nortriptyline) and serotonin nor-
epinephrine reuptake inhibitors (e.g., duloxetine and venlafaxine) and
are also used for neuropathic pain and help with sleep.28,29 Local anes-
thetics such as lidocaine can be used topically for postherpetic neural-
gia or systemically for refractory neuropathic pain.31 Corticosteroids are
helpful for cerebral edema, pain related to inflammation, and neuro-
pathic and visceral pain syndromes. N-methyl-D-aspartame antagonists
such as ketamine are unique in that they reset the nervous system
when pain is refractory or if allodynia or hyperalgesia develops.32,33
Bone modifying agents, while initially approved for the control of
osteolytic bone metastases, have also helped in the management of
bone pain.34 Adjuvants should be maximized and tailored to specific
pain syndromes to minimize opioid requirements.
Procedures
Pain-relieving procedures play an important role in the manage-
ment of both acute and chronic cancer-related pain. Some pain blocks
can help relieve procedural pain. Other blocks such as a celiac plexus
block can help relieve pain related to pancreatic and other gastroin-
testinal cancers. Radiation therapy is a mainstay to relieve bone pain.
External beam radiation is used to relieve localized bone pain
whereas radioisotopes are used for systemic bone metastases.35
These procedures should be routinely employed to prevent pain and
to reduce opioid requirements for more optimal pain control.36
Complementary Management
A variety of complementary approaches can be used to help alle-
viate pain. These include educational interventions, exercise, and
mind, body, and energy-based interventions. Although evidence is
mixed regarding the overall results of these interventions, it is impor-
tant to trial them as they may assist in the overall management plan.
Some interventions are more evidence-based than others in terms of
effectiveness, but limitations of these studies include small sample
sizes and lack of rigor in trial design. Overall, more studies are needed
that explore the overall efficacy of many of these complementary
therapies.39
Chronic Pain Syndromes in Post-Treatment Survivors
Managing chronic pain syndromes in disease-free post-treatment
survivors deserves special attention. It is important to maximize
analgesic adjuvants appropriate to the specific pain syndrome and
minimize opioids as much as possible. Risks of misuse, abuse, and
diversion are important to consider in lieu of the long-term therapy
needed for this patient population. This discussion is beyond the
scope of this review.
5
Nursing Implications
Pain is a nurse-sensitive indicator because nurses have a direct
impact on the assessment and management of pain. Pain can be a
symptom in which “nobody owns”; therefore, nurses have a pri-
mary role in assuming responsibility. And this responsibility
involves care that goes beyond the assessment and management
but also includes advocating for appropriate pain management,
ensuring availability of opioids throughout the world to effec-
tively manage pain, and for pain care quality to ensure that pain
care is delivered in a way that promotes patient and family well-
being and overall quality of life. One tool, the pain care quality
tool (PainCQ), can assist in gathering patient-reported outcomes
for pain to ensure that the nurse and interdisciplinary team are
delivering quality pain care.37,38
Future Directions
A plethora of evidence exists in the management of both acute
and chronic cancer-related pain syndromes. And yet, the alarming
fact exists that cancer pain, especially chronic cancer pain remains
uncontrolled. Significant barriers exist that are beyond the scope of
this review. And yet this review provides a foundation of knowledge
in the assessment, management, and quality monitoring for pain con-
trol. More work, however, is desperately needed. Clinicians need to
be equipped with tools to effectively manage pain. More research is
needed to discover methods to effectively manage pain, especially in
terms of complementary interventions. Continuing to strive for better
pain control around the world is not only a nursing responsibility but
also an ethical mandate.
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