Photo: Getty Images
Recent dramatic advances in the technology of pain treatment have expanded the armamentarium for the comprehensive management of pain in patients with cancer, says F. Michael Ferrante, MD, professor of clinical anesthesiology and perioperative medicine and director of the UCLA Pain Management Center in Santa Monica, a multidisciplinary program dedicated to the treatment of anatomically and physiologically based pain and spasticity.
Among the emerging technologies applicable to treating cancer pain is cooled radiofrequency ablation. For decades, Dr. Ferrante notes, radiofrequency ablation has been used to treat pain by applying thermal energy to cauterize the set of nerve fibers responsible for pain. The new technology circulates water through the tip of a needle, creating a larger lesion to work with in order to increase accuracy and reduce the risk of damaging adjacent tissues.
A second advance, particularly effective for patients with cancer who have lumbar spinal stenosis, involves the use of the Superion device. Through a minor surgical procedure in which a thumbnail-sized incision is made, the device can be inserted between the spinous processes — the bony ridges that run up and down the middle of the spine. “Once deployed, this device has two wings that secure it to the spinous processes above and below the affected area,” Dr. Ferrante says. “We have seen patients get substantial relief from this very simple minimally invasive procedure.”
Another technical advance noted by Dr. Ferrante is the renewed popularity of peripheral nerve stimulation, brought about by the enhanced use of ultrasound to identify the peripheral nerves. “Instead of placing a chemical agent, like a local anesthetic or a steroid, we can direct a peripheral nerve stimulator under X-ray or ultrasound guidance,” Dr. Ferrante explains. “We put it next to the nerve, and the patients can wear a wireless activating device that supplies electricity, which can bring tremendous benefit.”
Intrathecal drug delivery. Colored X-ray of a morphine pump (orange), which has been placed under the skin in the lower back. Photo: Science Photo
Opioids remain the mainstay for treating cancer pain, though given the potential downsides, including dependence, they must be applied with caution. “Opioids are the most effective painkillers we have,” Dr. Ferrante says. “On the other hand, it’s best not to use them as the sole modality, but rather as part of a plan. Using them in minimal doses, judiciously applied as part of a symphony of ways to attack the pain, still has great value.” Non-opioid treatments that can be helpful as supplements include mindful meditation, hypnosis and acupuncture, along with pharmacologic solutions such as NSAIDs and antidepressant or anticonvulsive drugs that have analgesic properties.
One underutilized approach that can be particularly helpful for treating cancer pain, Dr. Ferrante says, is intrathecal drug delivery. This involves inserting a catheter into the fluid surrounding the spinal cord, placing a pump in the soft tissue of the abdomen and then administering a drug — typically an opioid — directly into the spinal cord-surrounding fluid. “One milligram of morphine administered this way is equal to 300 milligrams of morphine given orally,” Dr. Ferrante explains. “If a patient is having side effects due to oral administration, this can greatly help.”
In general, Dr. Ferrante says, all types of pain, including pain in patients with cancer, tends to be undertreated, in part because it often has complex origins that involve both neurology and psychology. “Many physicians see pain as a sort of big, black box, but when there is an impasse, these patients should be referred,” Dr. Ferrante says. “We have so many effective ways of treating patients’ pain that it’s just a matter of making the proper assessment. At our center, we combine the perspectives of internists, orthopaedists, neurosurgeons, neurologists and anesthesiologists to determine the source of the pain and then tailor a comprehensive treatment plan.”
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F. Michael Ferrante, MD