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

Pain is one of the most common symptoms in cancer patients. Pain can be caused by cancer, treatment for cancer, or a combination of factors. Tumors, surgery, intravenous chemotherapy, radiation therapy, targeted therapy, supportive care therapies such as bisphosphonates, and/or diagnostic procedures may cause you pain.

Younger patients are more likely to have cancer pain and pain flares than older patients. 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.

Different cancer treatments may cause specific types of pain.

Patients may have different types of pain depending on the treatments they receive, including:

• Spasms, stinging, and itching caused by intravenous chemotherapy.
• Mucositis (sores or inflammation in the mouth or other parts of the digestive system) caused by chemotherapy or targeted therapy.
• Skin pain, rash, or hand-foot syndrome (redness, tingling, or burning in the palms of the hands and/or the soles of feet) caused by chemotherapy or targeted therapy.
• Pain in joints and muscles throughout the body caused by paclitaxel or aromatase inhibitor therapy.
• Osteonecrosis of the jaw caused by bisphosphonates given for cancer that has spread to the bone.
• Pain syndromes, including mucositis, inflammation in areas receiving radiation therapy, pain flares, and dermatitis, caused by radiation.

Cancer pain may affect quality of life and ability to function even after treatment ends.

Pain that is severe or continues after cancer treatment ends increases the risk of anxiety and depression. Patients may be disabled by their pain, unable to work, or feel that they are losing support once their care moves from their oncology team back to their primary care team. Feelings of anxiety and depression can worsen cancer pain and make it harder to control.

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.

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

It's important that the cause of the pain is found early and treated quickly. Your healthcare team will help you measure pain levels often, including at the following times:

• After starting cancer treatment.
• When there is new pain.
• After starting any type of 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?
• Is there breakthrough pain (intense pain that flares up rapidly even when pain-control medicine is being used)?

Your healthcare team will also take into account:

• Past and current pain treatments.
• Prognosis (chance of recovery).
• Other conditions you may have, such as kidney, liver, or heart disease.
• Past and current use of nicotine, alcohol, or sleeping pills.
• Personal or family history of substance abuse.
• Your own choices.

This information will be used to decide how to help relieve your pain. This may include drugs or other treatments. In some cases, patients are referred to pain specialists or palliative care specialists. Your healthcare team will work with you to decide whether the benefits of treatment outweigh any risks and how much improvement you should expect. After pain control is started, the doctor will continue to assess how well it is working for you and make changes if needed.

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

Physical and neurological exams will be done to help plan pain control.

The following exams will be done:

• 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 psychological, social, 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 given 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 the drug. The doctor will adjust the drug dose for your needs.

A scale from 0 to 10 is used to measure how severe the pain is and decide which pain medicine to use. On this scale:

• 0 means no pain.
• 1 to 3 means mild pain.
• 4 to 6 means moderate pain.
• 7 to 10 means severe pain.

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

Acetaminophen and NSAIDs help relieve mild pain. They may be given with opioids for moderate to severe pain.

Pain relievers of this type include:

• Acetaminophen.
• Celecoxib.
• Diclofenac.
• Ibuprofen.
• Ketoprofen.
• Ketorolac.

Patients, especially older patients, who are taking acetaminophen or NSAIDs need to be closely watched for side effects. See Treating Cancer Pain in Older Patients for more information.

Opioids are used to relieve moderate to severe pain.

Opioids work very well to relieve moderate to severe pain. Some patients with cancer pain stop getting pain relief from opioids if they take them for a long time. 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:

• Buprenorphine.
• Codeine.
• Diamorphine.
• Fentanyl.
• Hydrocodone.
• Hydromorphone.
• Methadone.
• Morphine (the most commonly used opioid for cancer pain).
• Oxycodone.
• Oxymorphone.
• 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 and denosumab.

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

Bisphosphonates (pamidronate and zoledronic acid) are drugs that are sometimes used when cancer has spread to the bones. They are given as an intravenous infusion and combined with other treatments 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.

Denosumab is another type of drug therapy that may be used when cancer has spread to the bones. It is given as a subcutaneous injection and may help prevent and relieve pain. It is not used in certain patients, such as patients with myeloma.

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 insert 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.

Cordotomy

Cordotomy is a less common surgical procedure that is used to relieve pain by cutting certain nerves in the spinal cord. This blocks pain and also hot/cold feelings. This procedure may be chosen for patients who are near the end of life and have severe pain that cannot be relieved in other ways.

Palliative care

Certain patients are helped by palliative care services. Palliative care providers work in teams that include doctors, nurses, mental health specialists, chaplains, pharmacists, and dietitians. Some of the goals of palliative care are to:

• Improve quality of life for patients and their families.
• Manage pain and non-pain symptoms.
• Support patients who need higher doses of opioids, have a history of substance abuse, or are coping with emotional and social problems.

See the PDQ summary on Planning the Transition to End-of-Life Care in Advanced Cancer for more information.

Radiation therapy

Radiation therapy is used to relieve pain in patients with skin lesions, other tumors, or 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:

Physical medicine and rehabilitation

Patients with cancer and pain may lose their strength, freedom of movement, and ability to manage their daily activities. Physical therapy or occupational therapy may help these patients.

Physical medicine uses physical methods, such as exercise and machines to prevent and treat disease or injury.

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

• Exercise to strengthen and stretch 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.

Some patients may be referred to a physiatrist (a doctor who specializes in physical medicine) who can develop a personal plan for them. Some physiatrists are also trained in procedures to treat and manage pain.

Complementary therapies

Complementary and alternative therapies combined with standard treatment may be used to treat pain. They may also be called integrative therapies. Acupuncture, support groups, and hypnosis are a few integrative therapies that have been used to relieve pain.

Older patients with cancer pain may have special needs.

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

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Purpose of This Summary

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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Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change.

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National Cancer Institute: PDQ® Cancer 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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