Cancer or treatment for cancer may cause you to feel pain.

Tumors, surgery, chemotherapy, or radiation therapy may cause you pain. Patients with advanced cancer have more severe pain, and many cancer survivors have pain that continues after cancer treatment ends.

Pain control can improve your quality of life.

Pain can be controlled in most patients with cancer. Although cancer pain cannot always be relieved completely, there are ways to lessen pain in most patients. Pain control can improve your quality of life all through your cancer treatment and after it ends.

Pain can be managed before, during, and after diagnostic and treatment procedures.

Many diagnostic and treatment procedures are painful. It helps to start pain control before the procedure begins. Some drugs may be used to help you feel calm or fall asleep. Treatments such as imagery or relaxation can also help control pain and anxiety related to treatment. Knowing what will happen during the procedure and having a relative or friend stay with you may also help lower anxiety.

Each patient needs a personal plan to control cancer pain.

Each person's diagnosis, cancer stage, response to pain, and personal likes and dislikes are different. For this reason, each patient needs a personal plan to control cancer pain. You, your family, and your healthcare team can work together to manage your pain. As part of your pain control plan, your healthcare provider can give you and your family members written instructions to control your pain at home. Find out who you should call if you have questions.

This summary is about ways to control cancer pain in adults, including the following:

• Medicine.
• Physical therapies.
• Psychological support.

You and your healthcare team work together to assess cancer pain.

It's important that the cause of the pain is found and treated quickly. The first step in controlling pain is to assess and measure it. Your healthcare team will help you measure pain levels often, including at the following times:

• After starting cancer treatment.
• When there is any new pain.
• After starting any type of pain treatment.
• During pain treatment.

To learn about your pain, the healthcare team will ask you to describe the pain with the following questions:

• When did the pain start?
• How long does the pain last?
• Where is the pain? You will be asked to show exactly where the pain is on your body or on a drawing of a body.
• How strong is the pain?
• Have there been changes in where or when the pain occurs?
• What makes the pain better or worse?
• Is the pain worse during certain times of the day or night?

This information will be used to decide how to help relieve your pain. This may include drugs or other treatments. Your healthcare team will work with you to decide how much pain you can stand and how much improvement you should expect. After pain control is begun, the doctor will continue to assess how well it is working for you and make changes if needed.

The family or caregiver may be asked to give answers for a patient who has a problem with speech, language, or understanding.

A physical exam and tests will be done to help plan pain control.

The assessment will include the following:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of your health habits and past illnesses and treatments will also be taken.
• Neurological exam: A series of questions and tests to check the brain, spinal cord, and nerve function. The exam checks your mental status, coordination, and ability to walk normally, and how well the muscles, senses, and reflexes work. This may also be called a neuro exam or a neurologic exam.

Your healthcare team will also assess your mental and spiritual needs.

The doctor will prescribe drugs based on whether the pain is mild, moderate, or severe.

Your doctor will prescribe drugs to help relieve your pain. These drugs need to be taken at scheduled times to keep a constant level of the drug in the body to help keep the pain from coming back. Drugs may be taken by mouth or in other ways, such as by infusion or injection.

Your doctor may prescribe extra doses of a drug that can be taken as needed for pain that occurs between scheduled doses of drug. The doctor will adjust the drug dose for your needs.

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to relieve mild pain.

NSAIDs help relieve mild pain. They may be given with opioids for moderate to severe pain. Acetaminophen also relieves pain, although it does not have the anti-inflammatory effect that aspirin and other NSAIDs do.

Patients, especially older patients, who are taking acetaminophen or NSAIDs need to be closely watched for side effects. See Treating Pain in Older Patients for more information. Most NSAIDs affect the blood platelets so that it takes longer for blood to clot and stop any bleeding. Aspirin should not be given to children to treat pain.

Opioids may be used to relieve moderate to severe pain.

Opioids work very well for the relief of moderate to severe pain. Some patients with cancer pain stop getting pain relief from opioids during long-term therapy. This is called tolerance. Larger doses or a different opioid may be needed if your body stops responding to the same dose. Tolerance of an opioid is a physical dependence on it. This is not the same as addiction (psychological dependence). Opioid doses can be safely increased by your doctor as needed for your pain, without causing addiction.

There are several types of opioids:

• Morphine (the most commonly used opioid for cancer pain).
• Hydromorphone.
• Oxycodone.
• Oxymorphone.
• Methadone.
• Fentanyl.
• Meperidine.
• Tapentadol.
• Tramadol.

The doctor will prescribe drugs and the times they should be taken in order to best control your pain.

Other drugs may be added to help treat your pain.

Other drugs may be given while you are taking opioids for pain relief. These are drugs that help the opioids work better, treat symptoms, and relieve certain types of pain. The following types of drugs may be used:

• Antidepressants.
• Anticonvulsants.
• Local anesthetics.
• Corticosteroids.
• Stimulants.
• Bisphosphonates.

There are big differences in how patients respond to these drugs. Side effects are common and should be reported to your doctor.

Bisphosphonates are drugs that are sometimes used when cancer has spread to the bones. They are used to decrease pain and reduce risk of broken bones. However, bisphosphonates sometime cause severe side effects. Talk to your doctor if you have severe muscle or bone pain. Bisphosphonate therapy may need to be stopped.

The use of bisphosphonates is also linked to the risk of bisphosphonate-associated osteonecrosis (BON). See the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation for more information.

The use of cannabinoids given with pain medicine is being studied for cancer-related pain.

Radiation therapy may be used to relieve bone pain.

Radiation therapy is used to relieve pain in patients with cancer that has spread to the bone. This is called palliative radiation therapy. It may be given as local therapy directly to the tumor or to larger areas of the body. Radiation therapy helps drugs and other treatments work better by shrinking tumors that are causing pain. Radiation therapy may help patients with bone pain move more freely and with less pain.

The following types of radiation therapy may be used:

When radiation therapy does not relieve pain, other treatments may be used.

Other therapies can be used along with drugs and radiation therapy to manage pain. You can help decide which methods work best to relieve your pain.

Nerve blocks

A nerve block is the injection of either a local anesthetic or a drug into or around a nerve to block pain. Nerve blocks help control pain that can't be controlled in other ways. Nerve blocks may also be used to find where the pain is coming from, to predict how the pain will respond to long-term treatments, and to prevent pain after certain procedures.

Neurological treatments

Surgery can be done to implant a device that delivers drugs or stimulates the nerves with mild electric current. In rare cases, surgery may be done to destroy a nerve or nerves that are part of the pain pathway.

Physical treatments, such as heat, cold, and exercise, can help relieve pain.

Physical methods to treat weakness, muscle wasting, and muscle and bone pain include the following:

• Applying heat (a hot pack or heating pad).
• Applying cold (ice packs).
• Exercise to strengthen weak muscles, loosen stiff joints, help coordination and balance, and strengthen the heart.
• Changing position (for patients who are not able to move on their own).
• Limiting the movement of painful areas or broken bones.
• Transcutaneous electrical nerve stimulation (TENS), a procedure in which mild electric currents are applied to some areas of the skin to control pain.

Integrative treatments include massage therapy, acupuncture, and music.

Integrative therapy combines conventional (standard) medical treatment with complementary and alternative (CAM) therapies that have been shown to be safe and to work. CAM therapies treat the mind, body, and spirit.

Some methods help relieve pain by changing how you think about pain and teaching you ways to relax.

Treatments that change how you think about pain and respond to it are also helpful in treating pain. These are called psychological interventions. Psychological interventions give you a sense of control and teach you coping skills to deal with the disease and its symptoms. Staying calm when you feel pain may keep you more comfortable. You may try several methods and choose one or more to use regularly.

• Hypnosis: Hypnosis may help you relax and may be combined with other thinking and behavior methods. Hypnosis to relieve pain works best in people who are able to concentrate and use imagery and who are willing to practice the technique.
• Redirecting thinking: In redirecting thinking, you focus your attention away from pain by thinking about other things. Methods may be internal (for example, counting, praying, or saying things like "I can cope") or external (for example, music, television, talking, listening to someone read, or looking at something specific). You can also learn to replace negative thoughts with positive thoughts and images.
• Talk therapy: Talk therapy may help you focus your attention away from the pain.
• Support groups and religious counseling: Support groups help many patients. Religious counseling may also help by offering spiritual care and social support.
• Imagery: Imagery is imagining positive, calming images. This can help you relax, reduce stress, and give you a sense of well-being.
• Relaxation exercises: Simple relaxation exercises may be used for short periods of pain (for example, during cancer treatment procedures). Short, simple techniques are helpful when it's hard to concentrate because of severe pain, high anxiety, or fatigue.
  The following relaxation exercises may help relieve pain:

  Exercise 1. Slow rhythmic breathing for relaxation

  • Step 1. Breathe in slowly and deeply, keeping your stomach and shoulders relaxed.
  • Step 2. As you breathe out slowly, feel yourself begin to relax; feel the tension leaving your body.
  • Step 3. Breathe in and out slowly and regularly at a comfortable rate. Let your breath come all the way down to your stomach, as it completely relaxes.
  • Step 4. To help you focus on your breathing and to breathe slowly and rhythmically: Breathe in as you say silently to yourself, "in, two, three." OR Each time you breathe out, say silently to yourself a word such as "peace" or "relax."
  • Do Steps 1 through 4 only once or repeat Steps 3 and 4 for up to 20 minutes.
  • Step 5. End with a slow deep breath. As you breathe out, say to yourself, "I feel alert and relaxed."

  Exercise 2. Receiving touch, massage, or warmth for relaxation

  • Touch and massage are traditional methods that caregivers use to help patients relax. Some examples are:

    -

    Brief touch or massage, such as hand holding or briefly touching or rubbing the patient's shoulders.

    -

    Soaking the patient's feet in warm water or wrapping the feet in a warm, wet towel.

    -

    Massage (3 to 10 minutes) of the whole body or just the back, feet, or hands. If the patient is modest or cannot move or turn easily in bed, just the hands and feet can be massaged.

    -

    Use warm lotion. A small bowl of hand lotion may be warmed in a microwave oven or a bottle of lotion may be warmed in a sink of hot water for about 10 minutes.

    -

    Massage for relaxation is usually done with smooth, long, slow strokes. Try different amounts of pressure along with different types of massage, such as kneading and stroking, to find out what the patient likes.

    Especially for the elderly person, a relaxing back rub may be no more than 3 minutes of slow, rhythmic stroking (about 60 strokes per minute) on both sides of the spine, from the crown of the head to the lower back. Keep one hand on the body at all times by starting one hand down the back as the other hand stops at the lower back and is raised. Set aside a regular time for the massage. This gives the patient something pleasant to look forward to.

  Exercise 3. Peaceful past experiences

  • Something may have happened to you a while ago that brought you peace or comfort. You may be able to remember that experience to bring you peace or comfort now. Think about these questions:

    -

    Can you remember any situation, even when you were a child, when you felt calm, peaceful, secure, hopeful, or comfortable?

    -

    Have you ever daydreamed about something peaceful? What were you thinking?

    -

    Do you get a dreamy feeling when you listen to music? Do you have any favorite music?

    -

    Do you have any favorite poetry that you find uplifting or reassuring?

    -

    Have you ever been active religiously? Do you have favorite readings, hymns, or prayers? Even if you haven't heard or thought of them for many years, childhood religious experiences may still be very soothing.

    Some of the things that may comfort you, such as your favorite music or a prayer, can probably be recorded for you. Then you can listen to it whenever you wish. Or, if your memory is strong, you may simply close your eyes and recall the events or words.

  Exercise 4. Active listening to recorded music

  • Step 1. You will need the following:

    • An MP3 player, CD player, or iPod®.
    • Earphones or a headset. (This helps focus the attention better than a speaker does, and avoids disturbing others.)
    • A recording of music you like. (Most people like fast, lively music, but some select relaxing music. Others like comedy routines, sporting events, old radio shows, or stories.)
  • Step 2. Mark time to the music; for example, tap out the rhythm with your finger or nod your head. This helps you think about the music instead of your discomfort.
  • Step 3. Keep your eyes open and focus on a fixed spot or object. If you wish to close your eyes, picture something about the music.
  • Step 4. Listen to the music at a comfortable volume. If the discomfort increases, try increasing the volume; decrease the volume when the discomfort decreases.
  • Step 5. If the music is not helping enough, try adding or changing one or more of the following:

    • Massage your body in rhythm to the music.
    • Try other music.
    • Mark time to the music in more than one manner, such as tapping your foot and finger at the same time.
    Many patients have found listening to music to be helpful. It tends to be very popular, probably because playing music is a part of daily life and easy to do. If you are very tired, you may simply listen to the music without marking time or focusing on a spot.
  These exercises were adapted and reprinted with permission from McCaffery M, Beebe A: Pain: Clinical Manual for Nursing Practice. St. Louis, Mo: CV Mosby: 1989.

Older patients with cancer pain may have special needs.

Some problems are more likely in older patients. For caregivers of older patients, the following possible problems should be kept in mind:

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This PDQ cancer information summary has current information about the causes and treatment of pain. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

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National Cancer Institute: PDQ® Pain. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/about-cancer/treatment/side-effects/pain/pain-pdq. Accessed <MM/DD/YYYY>.

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