Rafael Miguel, MD, Anesthesiology Service at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla.
Abstract and Introduction
Abstract
Background:For most patients with cancer pain, the World Health Organization's three-step analgesic ladderprovides adequate management with oral or transdermal options. However, some cancer patients are not wellpalliated with these approaches.
Methods:The author reviews interventional options that include nerve blocks, spinal administration of localanesthetics, opioids, alpha-2 agonists, spinal cord stimulation, and surgical interventions.
Results: Numerous interventional options are readily accessible and most can be performed on an outpatientbasis. They can be used as sole agents for the control of cancer pain or as useful adjuncts to supplementanalgesia provided by opioids, thus decreasing opioid dose requirements and side effects.
Conclusions: Cancer-related pain can be controlled with several interventions when oral or transdermal opioidsare inadequate. A risk:benefit ratio should be considered before implementing invasive analgesic methods.
Introduction
In 1986, the World Health Organization establisheda three-step ladder as a guideline for the treatment ofcancer pain (Fig 1A).[1] This ladder has been shown toprovide adequate analgesia to 90% of cancer patients[2] and to more than 75% of terminally ill cancer patients.[3]The ladder is an effective guide to assist physicianswith selecting medications and with determining theneed to move to the next level of intensity when previousoptions have failed. However, some problemshave been identified with use of the ladder. Amongthose are the treatment of bone pain, where somebelieve that the second step is useless and progressshould rapidly be made to the third step, as patientcondition dictates. Perhaps the most important deficiencyin the ladder is that it does not address thosepatients who have failed oral or transdermal options. Failure can include the inability to achieve adequatepain relief or the development of undesirable/intolerableside effects, such as sedation, nausea/vomiting, constipation,and confusion. In this light, serious considerationshould be given to the addition of a fourth step tothe ladder (Fig 1B). This fourth step is "interventional"and includes the use of nerve blocks, spinal (epiduraland subarachnoid) administration of local anesthetics,opioids, alpha-2 agonists, spinal cord stimulation, andsurgical interventions, as dictated by patient condition.
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Cancer Control 7(2):149-156, 2000. © 2000 H. Lee Moffitt Cancer Center and Research Institute, Inc
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