Interventional Pain Procedures in the Treatment of Refractory Cancer Pain

“We don’t beat the Reaper by living longer. We beat the Reaper by living well.” Professor Randy Pausch declared this statement during his famous last lecture at Carnagie Mellon University prior to his death from pancreatic cancer in 2008. (1) As opposed to the widely utilized WHO approach of utilizing opioids first, many now advocate a mechanism based approach to cancer pain treatment. Old dogma treated cancer pain as a problem mainly toward the end of life situation in the context of metastatic, progressive disease, whereas new data shows pain to be problematic throughout the cancer care cycle. (2) The effective management of these acutely painful surgeries and related treatments may limit the development of chronic pain states in long-term survivors.(3) Effective treatment strategies include multidisciplinary, multimodal care utilizing: (i) combinations of long acting opioids for constant pain with short acting opioids for incidental pain; (ii) ‘adjuvant’ co-analgesics including nonsteroidal anti-inflammatories, anticonvulsants, antidepressants, and topical agents to optimize analgesia and minimize opioid doses thereby reducing concomitant opioid related side effects; (iii) prophylactic treatment of constipation, nausea, and other common troublesome symptoms; (iv) interventional options for pain control including: nerve blocks, spinal infusions, vertebral augmentation, and other procedures. Lastly (v), psychological evaluation and support must not be overlooked. This monograph will focus on the role of procedures in context of the overall cancer treatment and in the overall context of palliative care. Traditional analgesic procedures will be discussed in addition to briefly highlighting neurodestructive procedures, vertebro and kyphoplasty, fracture stabilization, tumor ablation, and others. Finally, the decision making relating to the role, timing, and special risks of procedures in the cancer patient will be highlighted. This monograph is devoted to the science and decision making aspects of interventional cancer pain techniques; for a “how” to do it approach, the interested reader is directed to either Rathmell or Brown’s excellent atlas’of interventional pain procedures. (4,5)