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INTRODUCTION

The management of cancer pain is very challenging and, when undertreated, can affect every aspect of physical, emotional, and social function. As cancer treatments continue to advance patients are surviving longer with better outcomes. However, with increased survival time there is a higher likelihood of developing chronic pain; hence, it is important to address this sequela of increased survival.1

The American Society of Anesthesiologists (ASA) task force defines cancer pain as “pain that is attributable to cancer or its therapy,” and this definition has far-reaching implications for addressing pain.4 As with any other kind of pain management, the goals of treatment include optimizing pain control, function, psychological well-being, and quality of life.2 Treatments should be geared toward maximizing patient function while minimizing discomfort and side effects and should be discussed in detail with the patient. Palliative care, pain medicine, physical medicine, psychology, and therapy are all important players in the overall management of cancer pain.2,3 This chapter seeks to address the multifaceted nature of cancer pain and methods of evaluation, and overview some commonly used treatments.

PALLIATIVE CARE

Palliative care focuses on comfort and relief of suffering at the end of life. Cancer-related pain in terminal illness is often at its most acute. At this stage disease burden is advanced and frequently requires multiple approaches to analgesia. Palliative care medicine, an Accreditation Council for Graduate Medical Education (ACGME) recognized subspecialty that consists of physicians trained in multiple primary specialties including internal medicine and physical medicine and rehabilitation, often manages pain in these patients. Palliative care medicine addresses most acute needs related to pain, psychosocial distress, quality of life, and other services such as cancer rehabilitation. The focus of the service is to address issues at the end of life with a goal of optimizing quality of life by improving function, pain management, mobility, and other related factors.5

Despite the advantages cancer rehabilitation can provide at the end of life, their services are often underutilized.6 The reasons for this are multifactorial. There exists a poor understanding of the role of rehabilitation in advanced cancer, with the perception that rehabilitation requires a long time to accomplish and may inspire false hope to patients who otherwise should be planning for the end of life.7,8 The decision to refer patients for palliative care and rehabilitation services9 is highly dependent on preexisting physician perceptions, with oncologists who are more familiar with end-of-life care more likely to refer to rehabilitation services in the palliative setting.10

In addition to physician biases, patient attitudes contribute to the underutilization of rehabilitation services at the end of life. Cheville et al found that despite a progressive decline in function, most advanced lung cancer patients did not initially accept rehabilitation services until they were significantly debilitated.11 There are numerous possible explanations for this, ...

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