The impact of pain on the patient with cancer.

Pain is one of the most feared consequences of cancer. Until recently, however, little has been known about its prevalence, severity, and impact on the patient with cancer. The presence of pain, despite efforts to treat it, represents a continued source of frustration for patients, their families, and the health care team. Although often one of the early indicators of the presence of disease, pain is not a significant problem for the majority of patients in the early stages of disease, with 5% to 10% of patients with solid tumors reporting pain at a level that interferes with mood and activity. But when metastatic disease is present, about one in three patients reports significant pain, and our data and those of others indicate that the majority of patients with end-stage disease will report pain of a severity that interferes with several aspects of the patient's quality of life. Site of tumor is also significantly related to the progression of pain. The relationship between pain intensity and depression and anxiety is examined in detail, and the treatment implications of this relationship discussed. Whereas a modest relationship between pain intensity and depression has been found across several studies, the possibility that depression is a causative factor in the pain experienced by the cancer patient may have been overemphasized. Data on the relief of pain in cancer are reported from the perspective of patients as well as the physicians and nurses who treat them. The majority of physicians and nurses specializing in cancer treatment whom we have surveyed believe that cancer patients in general are undermedicated for pain. Patient survey data indicate that only 50% of cancer patients with pain report 70% or greater pain relief with analgesic medication. Although a number of nonsystemic treatments may be useful for cancer pain management (such as nerve blocks, neurosurgery, and behavioral treatments), they are not widely available and there are few controlled studies of their effectiveness. Teaching patients to report the level of their pain on simple pain intensity scales has proven useful in monitoring the effectiveness of pain management, as well as in helping establish pain control goals for the individual patient.