Cancer Pain or Non-Cancer Pain – Does It Really Matter ?

Last week Mrs D came to the clinic complaining of pain in her right breast. One morning 20 months ago she discovered a tumour in the breast while showering. I saw her the same day, referred her to mammography, and the cancer was diagnosed. She went through operation followed by radiation and chemo therapy. Since then she has followed the program of controls, and since then she has had pain in the right breast radiating to her armpit. Mrs D has chronic cancer pain, and we agreed that the goals for the treatment was reducing pain and improving her quality of life.

Today I saw Mrs F in the clinic. She was involved in a traffic accident five years ago on a snowy day, where she lost control of her car and crashed into a tree. She fractured of her left clavicle, several ribs and two vertebrae in her upper spine. She came today to discuss the treatment of the pain she had had since that accident, a pain going from her right shoulder blade under her right arm to her right breast. Follow up x-rays and scans have shown that all has healed in the best imaginable way, but nevertheless she has had the pain ever since the accident.  We adjusted the treatment in accordance to the goal reducing pain and improving quality of life that we had agreed to. Mrs F has chronic non-cancer pain.

Two cases of two women at approximately the same age, experiencing pain in the same area, describing them more or less in the same way, and having the same goal for the treatment. Both women have a long life expectancy, their pain condition is chronic , but one classified as chronic cancer pain, the other chronic non cancer pain.

Why then this distinction between cancer and non cancer pain?  This distinction has a long history and has become a tradition, but today it is not meaningful and bears some potential risks for patients.

Click on picture to visit WHO cancer pain site

WHO’s pain ladder was introduced in 1986 as a way to describe guidelines for the use of drugs when treating cancer pain. Starting with non-opioids, adding (weak) opioids for moderate pain and turning towards strong opioids for moderate to severe pain, and adding “adjuvant” when needed at all levels. It is noteworthy, that WHO still calls it “pain relief ladder” for cancer pain relief, and that the ultimate goal on top of the ladder is “freedom for cancer pain”. It draws attention since chronic pain is chronic. and as such cannot disappear. The WHO ladder vas made when cancer most often was a condition including a short life expectancy form time of diagnosis, it was most often a terminal disease. Since then diagnosing and treatment of cancer has made huge improvements turning many cancer diseases into chronic conditions a person can live with for many years. However that longer life is often not pain free, as a result of the cancer, following operation or following other treatments like some form of chemo therapy, chronic pain is often an inevitable part of the continued life, but still the pain is classified as cancer pain.

On the other side the WHO ladder is often referred to when treating chronic non-cancer pain, but chronic non-cancr pain is persistent and the goal  “freedom from pain” is rarely an option, as well as it rarely is for persons living many years with pain as a result for a cancer condition. The term cancer pain implies that the pain is more “real” and that treatment with opioids is more justified, since we can objectify the reason for the pain – or at least we think we can, but the mechanisms can be the same as for non-cancer pain. Chronic cancer pain might therefor lead to ever increasing doses of opioids, with more focus on the pain than on the long term quality of life.

Use of opioids in non-cancer pain has been accompanied by increasing death due to use of prescribed opioids, especially in US. The reason for this is of course many, some of which has been discussed previously here on Picture of Pain, but focusing solely on the symptom pain bears the risk of following the WHO ladder and increasing opioids instead of taking care of the accompanying depression, anxiety, sleep problems, reduced function and what ever follows a chronic pain condition, by other form of medication and indeed by non medical treatments.

A more contemporary classification would be “terminal” and “non terminal” pain.

Mrs D and Mrs F both have chronic non-terminal pain, and that is how we deal with their conditions and will do for many years to come.

Kim Kristiansen, M.D. (2012). Cancer Pain or Non-Cancer Pain – Does It Really Matter ? Picture of Pain blog