Nathan I. Cherny, MBBS, FRACP, FRCP

This article addresses some of the most common major challenges in oncologist-patient communication with a nuanced approach to the concepts of autonomy, paternalism, and culture.

Approximately 60% of cancer patients experience pain, and 25% to 30% have severe pain. With some cancers, opioids will be needed before chemotherapy begins and may be more frequently prescribed than chemotherapy. Given the frequency with which pain management is necessary in cancer patients, all oncologists should be familiar with opioid prescribing principles. This article reviews the World Health Organization recommendations for analgesic therapy in this setting, as well as guidelines for opioid therapy in patients with renal failure or hepatic failure, assessment of pain, dosing strategies in both acute and chronic pain, management of opioid overdose, pain associated with dose-limiting side effects, and pain in the actively dying.

The management of cancer pain requires familiarity with a rangeof therapeutic strategies, including antineoplastic therapies, analgesicpharmacotherapy, and anesthetic, neurosurgical, psychological, andrehabilitation techniques. Successful pain management is characterizedby implementation of the techniques with the most favorable therapeuticindex for the prevailing circumstances, along with provision forrepeated evaluations, so that a favorable balance between pain reliefand adverse effects is maintained. For most patients, pain managementinvolves the administration of specific analgesic approaches. In all cases,these analgesic treatments must be skillfully integrated with the managementof other symptoms.

The problem of pain among cancer patients is endemic. Appropriate and effective clinical responses to this problem require that the physician appreciate the cause of the pain, its underlying mechanism, its natural history, and its significance.