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Interventional options for the management of refractory cancer pain—what is the evidence?

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Abstract

Purpose

Pain is the most common symptom in cancer patients. Standard pain treatment according to the WHO three-step analgesic ladder provides effective pain management in approximately 70–90 % of cancer patients. Refractory pain is defined as not responding to “standard” treatments. Interventional analgesic techniques can be used in an attempt to control refractory pain in patients in whom conventional analgesic strategies fail to provide effective pain relief or are intolerable due to severe adverse effects. This systematic review aims to provide the latest evidence on interventional refractory pain management in cancer patients.

Methods

Systematic literature search in Cochrane, EMBASE and PubMed including reviews and randomised controlled trials (RCTs) and non-randomised controlled trials in the absence of reviews.

Results

Neuraxial analgesia may play a role in refractory cancer pain management. Paravertebral blocks decrease the incidence of persistent post-surgical pain after breast cancer. Coeliac plexus blocks improve pain scores in refractory pancreatic cancer pain for up to 4 weeks after the intervention with fewer burdensome side effects as compared to opioids. Cordotomy has mainly been studied in mesothelioma, and the case series suggest possible benefit for pain at the expense of a relatively high risk of side effects.

Conclusions

Overall, very few RCTs have been conducted on interventional pain techniques. In reality, it is very difficult to undertake large controlled trials for a number of reasons. Therefore, today’s best evidence for practice may be from large case series of comparable patients with careful response and toxicity evaluation and follow-up.

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Authors and Affiliations

  1. Readaptation and Palliative Care, University Hospital of Geneva, Geneva, Switzerland

    Petra Vayne-Bossert

  2. Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia

    Petra Vayne-Bossert, Banafsheh Afsharimani, Phillip Good & Janet Hardy

  3. Palliative Care Services, St Vincent’s Private Hospital Brisbane, Kangaroo Point, Australia

    Phillip Good

  4. School of Medicine, University of Queensland, St Lucia, Australia

    Paul Gray & Janet Hardy

  5. Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Australia

    Paul Gray

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  1. Petra Vayne-Bossert
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  3. Phillip Good
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Correspondence to Janet Hardy.

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The authors declare that they have no competing interests.

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PVB travel expenses and living costs are supported by the “Commission de la relève et des stages de perfectionnement à l’étranger” of the University Hospitals of Geneva.

Disclosures

JH sits on the medical advisory boards of Mundipharma Pty Ltd and Menarini Australia Pty Ltd. She has contributed to the opioid educational modules of Mundipharma Pty Ltd.

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Vayne-Bossert, P., Afsharimani, B., Good, P. et al. Interventional options for the management of refractory cancer pain—what is the evidence?. Support Care Cancer 24, 1429–1438 (2016). https://doi.org/10.1007/s00520-015-3047-4

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