Surgical management of cancer pain.

Although the technology has improved rapidly and provided many different techniques, information is lacking concerning the application of the technology. These techniques are applied, for the most part, only to patients with severe pain, because many of the nonsurgical options adequately manage pain that is minimal or mild in severity. Decisions for selection of a specific technique can be based on expected survival time, need for focal or diffuse pain control, or preference for ablative or augmentative options. For patients with good prognosis, augmentative techniques or simple ablative techniques are used more frequently, whereas ablative procedures with higher risk or destruction of more tissue are used later. Patients with severe pain and a poor prognosis represent the most difficult treatment group for three reasons: (1) the severity of the pain and the tendency of the pain to worsen significantly during the patient's remaining time, (2) the limited expected survival time of the patient, which some-what limits the use of an expensive, complicated intervention or operation, and (3) the considerable controversy that has been generated by the large number of different treatment options for this group. Because of these issues, there is not a general consensus concerning a treatment algorithm for this group of patients. This emphasizes the need for controlled, comparative studies of systemic treatments and interventional treatments as well as side-by-side comparisons of the efficacy and complications of the different types of surgical techniques. In light of the recently released cancer pain guidelines from the United States Agency for Health Care Policy Research, one would hope that the research of the next 5 years would focus on providing many of the answers to these problems.