Experts Call for Individualized, Evidence-Based Cancer Pain Treatment Model

The biopsychosocial approach to individualizing assessment and treatment of cancer pain should become the mainstream approach and a new model is needed to make it even more widely accessible and implemented.

That was the bottom line of a presentation by a Dutch cancer pain professor at the 7th World Congress of the World Institute of Pain (WIP), held recently in Maastricht, Netherlands; it was also the opinion of pain experts on this side of the Atlantic, who are developing guidelines to reflect the modern understanding of cancer pain management.

The three-step model for pain medicine published by the World Health Organization (WHO) in 1986 for the management of cancer pain (http://www.who.int/​cancer/​palliative/​painladder/​en/​) is still being used but does not allow for individualized diagnosis and treatment, said Kris C.P. Vissers, MD, PhD, president-elect of the WIP and research chair, Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Holland. In contrast, the biopsychosocial approach takes into account the psychological state of the patient, the patient’s social support and his or her values and sense of spirituality, he said. It also emphasizes a thorough assessment of the causes of the pain.

This holistic view of pain is able to account for the significant variations in the amount of pain, suffering and resulting coping behaviors among patients with the same anatomical abnormalities, or lack thereof, Dr. Vissers said.

He proposed that physicians use a four-pronged framework for assessing and diagnosing each patient with cancer pain. These focus on the pain source/site; how that pain is propagated and processed; and whether the pain processing is altered in some way at some point in the body (see Figure).

Figure. Proposed biopsychosocial cancer treatment model.

CBT, cognitive-behavioral therapy; TCAs, tricyclic antidepressants

Source: Vissers KP. 7th World Congress Institute of Pain. 2014.

“We have the knowledge to be able to do provide these ‘medical reasoning models’ routinely in clinical practice every day with every pain patient but we’re not implementing them. If a primary care provider refers a patient then he should provide a medical hypothesis for that patient’s pain, including the site, the nerve damage and whether there is central desensitization,” Dr. Vissers said. “This information is necessary to provide the correct therapy, rather than just providing broad, empiric therapy.”

He believes that quantitative sensory testing should be used to determine the magnitude of sensory abnormalities in pain patients. He also proposed the use of centralized databases to collect information on validation of assessment tools, patient diagnoses, treatments and long-term outcomes. This will lead to continuous improvement and standardization in use of assessment tools, increased accuracy, reduced cost of diagnosis and treatment, and improved education and training of health care professionals who treat pain patients.

Two American pain experts contacted by Pain Medicine News agreed it is important to supplant the outdated WHO pain treatment algorithm with a more nuanced, evidence-based and individualized approach, and to make sure it is implemented in a standard way.

“The biopsychosocial model Dr. Vissers described and variations of it have been implemented in various cancer institutions including ours,” said Amitabh Gulati, MD, director of ambulatory pain, Department of Anesthesia and Critical Care, Memorial Sloan-Kettering Cancer Center, New York City. “Our palliative, psychiatry, rehabilitation and anesthesiology services meet regularly to discuss patients who have complex pain symptoms and develop a comprehensive plan similar to that described by Dr. Vissers.”

Brian Bruel, MD, an assistant professor of pain medicine, University of Texas MD Anderson Cancer Center, Houston, and president-elect of the Cancer Pain Research Consortium, said his group was formed last year to develop guidelines that “fill the holes” in the care of cancer patients with pain. He added that Dr. Gulati is also a member of the consortium.

“Dr. Vissers brought up some very good points; he showed that there are some gaps in our management of cancer pain,” he said. “Our consortium is approaching this in a parallel way. In June 2014, we held a multi-institutional and multidisciplinary meeting involving neurosurgery, anesthesia, physical medicine and rehabilitation, psychology, and medical and radiation oncology, in order to come up with discipline-specific best practices. That’s an important step toward creating new evidence-based guidelines for pain management in cancer patients.”

—Rosemary Frei, MSc