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Published in final edited form as: J Natl Compr Canc Netw. 2014 Apr;12(4):488–500. doi: 10.6004/jnccn.2014.0054

Survivorship: Pain Version 1.2014

Clinical Practice Guidelines in Oncology

Crystal S Denlinger, Jennifer A Ligibel, Madhuri Are, K Scott Baker, Wendy Demark-Wahnefried, Debra L Friedman, Mindy Goldman, Lee Jones, Allison King, Grace H Ku, Elizabeth Kvale, Terry S Langbaum, Kristin Leonardi-Warren, Mary S McCabe, Michelle Melisko, Jose G Montoya, Kathi Mooney, Mary Ann Morgan, Javid J Moslehi, Tracey O’Connor, Linda Overholser, Electra D Paskett, Muhammad Raza, Karen L Syrjala, Susan G Urba, Mark T Wakabayashi, Phyllis Zee, Nicole McMillian, Deborah Freedman-Cass
PMCID: PMC4465256  NIHMSID: NIHMS697131  PMID: 24717568

Pain in Survivors

More than one-third of posttreatment cancer survivors experience chronic pain, which often leads to psychological distress; decreased activity, motivation, and personal interactions; and an overall poor quality of life.1-5 Pain in survivors is often ineffectively managed. Barriers to optimal pain management in cancer survivors include health care providers’ lack of training, fear of side effects and addiction, and reimbursement issues.6

Pain has 2 predominant mechanisms: nociceptive and neuropathic.7,8 Injury to somatic and visceral structures and the resulting activation of nociceptors present in skin, viscera, muscles, and connective tissues cause nociceptive pain. Somatic nociceptive pain is often described as sharp, throbbing, or pressure-like, and often occurs after surgical procedures. Visceral nociceptive pain is often diffuse and described as aching or cramping. Neuropathic pain is caused by injury to the peripheral or central nervous system and might be described as burning, sharp, or shooting. Neuropathic pain often occurs as a side effect of chemotherapy or radiation therapy or is caused by surgical injury to the nerves.

Screening for and Assessment of Pain

All cancer survivors should be screened for pain at regular intervals. If pain is present, the intensity should be quantified by the survivor. Because pain is inherently subjective, self-report of pain is the current standard of care for assessment. Intensity of pain should be quantified using a 0 to 10 numeric rating scale, a categoric scale, or a pictorial scale (eg, Wong-Baker FACES Pain Rating Scale).9-12 In addition, the survivor should be asked to describe the characteristics of the pain (eg, aching, burning). Severe uncontrolled pain is a medical emergency and should be responded to promptly. An oncologic emergency also should be ruled out in these cases.

A comprehensive evaluation, as outlined in the NCCN Guidelines for Adult Cancer Pain (available at NCCN.org), is essential to ensure proper pain management. The cause and pathophysiology of the pain should be identified to determine the optimal therapeutic strategy. In addition, the survivor’s goals for comfort and function should be determined.

Management of Pain

The goals of pain management are to increase comfort, maximize function, and improve quality of life. A multidisciplinary approach is recommended, with a combination of pharmacologic treatments, psychosocial and behavioral interventions, physical therapy and exercise, and interventional procedures.2,13,14

The NCCN Survivorship Panel made recommendations for the management of 8 categories of cancer pain syndromes: neuropathic pain, chronic postoperative pain (ie, pain syndromes after amputation, neck dissection, mastectomy), myalgias/arthralgias, skeletal pain, myofascial pain, gastrointestinal/urinary/pelvic pain, lymphedema, and postradiation pain. Neuropathic pain commonly results from some systemic anticancer agents.1 The incidence of chronic pain after surgical treatment varies with the type of procedure and is as high as 60% in patients treated with breast surgery and 50% in those treated with lung surgery.1 Arthralgias, characterized by joint pain and stiffness, occur in roughly half of women taking aromatase inhibitors as adjuvant therapy for breast cancer.15 Pelvic pain often occurs after pelvic radiation, resulting from fractures, fistulae, proctitis, cystitis, dyspareunia, or enteritis.1

Pharmacologic interventions, local therapies, psychosocial support and behavioral treatments, physical therapy and exercise, and interventional procedures are discussed. For more information about the management of cancer-related pain, please see the NCCN Guidelines for Adult Cancer Pain (to view the most recent version of these guidelines, visit NCCN.org). These guidelines include information on opioid use and pain treatment agreements for patients at risk for medication misuse or diversion; adjuvant analgesics; and psychosocial support and behavioral interventions that may be modified to fit the individual survivor’s circumstances.

Pharmacologic Interventions

Pharmacologic measures are the foundation of treatment of many of the common pain syndromes in survivors. Pharmacologic recommendations in these guidelines vary depending on the pain syndrome and include opioids, adjuvant analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants.2,16-18 Topical medications are discussed in “Local Therapies” (see page 497).

Opioids

Opioids may be recommended for the treatment of neuropathic, postoperative, and skeletal pain. Data on the long-term use of opioids in survivors are lacking.14,17,19

The NCCN Guidelines for Adult Cancer Pain (available at NCCN.org) recommend screening survivors for risk factors of aberrant opioid use or diversion of pain medication, using a detailed patient evaluation or tools such as the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) or Opioid Risk Tool (ORT), before prescribing.20-24 In addition, if opioids are deemed necessary for any survivor (regardless of aberrant use risk level), the NCCN Survivorship Panel recommends using the lowest dose possible and reevaluating the effectiveness and necessity of opioids on a regular basis. Pain treatment agreements can also be considered.25

Adjuvant Analgesics

Adjuvant analgesics include antidepressants (eg, serotonin-norepinephrine reuptake inhibitors [SNRIs], tricyclic antidepressants), anticonvulsants (eg, gabapentin, pregabalin), and corticosteroids. These are recommended for the treatment of neuropathic and postoperative pain in survivors. The term adjuvant refers to the fact that they are often coadministered with an opioid to enhance analgesia or reduce the opioid requirement, but they may also be used as sole pain treatment. A recent systematic review found that antidepressants, anticonvulsants, other adjuvant analgesics, and opioids were all effective at reducing neuropathic pain in patients with cancer.17 Another review found that antidepressants and antiepileptics provide additional neuropathic pain relief when added to opioids in patients with cancer.26

Tricyclic antidepressants have been shown to relieve neuropathic pain in the noncancer setting.27,28 In addition, the SNRI duloxetine was recently shown to effectively reduce pain in a multiinstitutional, randomized, double-blind, placebo-controlled crossover trial of 231 patients with painful chemotherapy-induced neuropathy.29

The most commonly used anticonvulsant drugs for the treatment of cancer-related pain, gabapentin and pregabalin, have primarily been studied in noncancer neuropathy syndromes.30,31 Only limited data support the effectiveness of corticosteroids for cancer-related pain, and these may also have anti-inflammatory effects.32-34

NSAIDs

NSAIDs are recommended for the treatment of myofascial and skeletal pain and for myalgias and arthralgias. NSAIDs are nonopioid analgesics that block the biosynthesis of prostaglandins, which are inflammatory mediators that initiate, cause, intensify, or maintain pain. A recent systematic review found that data supporting the use of NSAIDs for control of pain in patients with advanced cancer are limited and weak, but suggest some efficacy at reducing pain and opioid dose requirement.35

A discussion of contraindications and safety precautions that should be considered before prescribing NSAIDs is provided in the NCCN Guidelines for Adult Cancer Pain (to view the most recent version of these guidelines, visit NCCN.org).

Muscle Relaxants

Muscle relaxants (eg, diazepam, lorazepam, metaxalone) reduce muscle spasm and are recommended for the treatment of skeletal pain, myalgias, and arthralgias. Evidence for their efficacy in providing pain relief in the noncancer settings is limited.36,37 No data could be found in the setting of cancer-related pain.

Psychosocial Support and Behavioral Interventions

Cognitive interventions are aimed at enhancing a sense of control over the pain or its underlying cause. Breathing exercises, relaxation, imagery or hypnosis, and other behavioral therapies can be very useful.3,38-43 Psychosocial support and education should also be provided.44 Some studies in patients with cancer suggest that psychosocial and behavioral interventions such as skills training, education, relaxation training, supportive–expressive therapy, and cognitive behavioral therapy may be effective at reducing pain.40,45 Hypnosis can also be considered for treatment of neuropathic pain. Overall, data support the benefit of hypnosis for controlling pain in cancer and other settings, but are lacking in the survivorship population.46

In general, studies regarding psychosocial support and behavioral interventions for reducing pain in survivors are limited. A recent systematic review and meta-analysis assessed the efficacy of psychosocial interventions for treating pain in patients with breast cancer and survivors.47 Although results suggest an effect, more studies are clearly needed in the survivorship population.

Physical Therapy and Exercise

Physical therapy and general exercise may also be effective for the treatment of pain in survivors, with the main goal of increasing mobility.3,13,48,49 Several randomized controlled trials have reported a reduction of neck and shoulder pain associated with exercise or therapy programs.50-52 In one study, 52 survivors of head and neck cancer were randomized to a progressive-resistance exercise training (PRET) program or standard therapeutic exercise for 12 weeks.52 Pain scores decreased more dramatically in the PRET group (P=.001). In another study of 66 survivors of breast cancer, those randomized to an 8-week water exercise program experienced a greater reduction of neck and shoulder pain than those randomized to usual care.50 In addition, group exercise in the community, with trainers specifically trained to work with cancer survivors, has been shown to reduce pain and other symptoms.53

Local Therapies

Local therapies, including heat, cold packs, massage, medicated creams, ointments, and patches, are recommended for the treatment of myalgias, arthralgias, and neuropathic and myofascial pain.3 Specifically, topical lidocaine, capsaicin, ketamine, and amitriptyline are recommended for treatment of some of the various cancer pain syndromes. Data are limited on the effectiveness of ketamine and amitriptyline,54-59 but the evidence for the effectiveness of lidocaine and capsaicin is stronger.54,56-58 In a randomized trial of 35 patients with non–cancer-related postherpetic, postoperative, or diabetes-related neuropathic pain, pain intensity was reduced with topical lidocaine but not with topical amitriptyline when compared with placebo.57 A larger trial with a similar population of 92 patients found no effect of topical amitriptyline, ketamine, or a combination of the two.60 Another study found that a higher dose of amitriptyline had some efficacy in reducing peripheral neuropathy, but also showed systemic effects.61 Lidocaine has been shown to reduce the severity of postherpetic neuropathy and cancer-related pain.62,63

Interventional Procedures

Referral to pain management services for interventional procedures, including transcutaneous electrical nerve stimulation (TENS), intercostal nerve blocks, and dorsal column stimulation, is recommended for refractory pain in survivors. Data on the efficacy of these interventions are mainly from patients with active cancer or the noncancer setting.3,64 TENS is a noninvasive procedure with electrodes placed in or around the painful area.3 A recent systematic review found that data supporting the efficacy of TENS for reducing cancer-related pain are inconclusive.65

The goal of invasive interventions, such as an intercostal nerve block, is to interrupt nerve conduction by either destroying nerves or interfering with their function.3 The data on these interventions are also limited.3

Acupuncture

Acupuncture is recommended as an option for the treatment of myofascial pain in survivors. Evidence supporting the efficacy of this technique for reducing cancer-related pain is extremely limited.66,67

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Clinical trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. All recommendations are category 2A unless otherwise indicated

Version 1.2014, 03-07-14 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

Individual Disclosures for the NCCN Survivorship Panel.

Panel Member Clinical Research
Support/Data
Safety Monitoring
Board		 Advisory Boards,
Speakers Bureau,
Expert Witness, or
Consultant		 Patent,
Equity, or
Royalty		 Other Date
Completed
Madhuri Are, MD None None None None 5/15/13
K. Scott Baker, MD, MS None None None None 11/22/13
Wendy Demark-Wahnefried, PhD, RD National Cancer
Institute; Harvest
for Health
Gardening Project
for Breast Cancer
Survivors; and
Nutrigenomic Link
between Alpha-
Linolenic Acid and
Aggressive Prostate
Cancer		 American Society of
Clinical Oncology		 None American
Society of
Preventive
Oncology		 11/13/13
Crystal S. Denlinger, MD Bayer HealthCare;
ImClone Systems
Incorporated;
MedImmune
Inc.; OncoMed
Pharmaceuticals;
Astex
Pharmaceuticals;
Merrimack
Pharmaceuticals;
and Pfizer Inc.		 Eli Lilly and Company None None 1/9/14
Debra L. Friedman, MD, MS None None None None 5/26/13
Mindy Goldman, MD Pending
Lee W. Jones, PhD None None None None 2/2/12
Allison King, MD None None None None 8/12/13
Grace H. Ku, MD None None None None 8/13/13
Elizabeth Kvale, MD None None None None 10/7/13
Terry S. Langbaum, MAS None None None None 8/13/13
Kristin Leonardi-Warren, RN, ND None None None None 1/6/14
Jennifer A. Ligibel, MD None None None None 10/3/13
Mary S. McCabe, RN, BS, MS None None None None 8/12/13
Michelle Melisko, MD Celldex
Therapeutics; and
Galena Biopharma		 Agendia BV;
Genentech, Inc.;
and Novartis
Pharmaceuticals
Corporation		 None None 10/11/13
Jose G. Montoya, MD None None None None 12/6/13
Kathi Mooney, RN, PhD University of Utah None None None 9/30/13
Mary Ann Morgan, PhD, FNP-BC None None None None 8/19/13
Javid J. Moslehi, MD None ARIAD
Pharmaceuticals,
Inc.; Millennium
Pharmaceuticals,
Inc.; Novartis
Pharmaceuticals
Corporation; and
Pfizer Inc.		 None None 1/27/14
Tracey O’Connor, MD None None None None 6/13/13
Linda Overholser, MD, MPH None Antigenics Inc.; and
Colorado Central
Cancer Registry Care
Plan Project		 None None 10/10/13
Electra D. Paskett, PhD Merck & Co., Inc. None None None 6/13/13
Muhammad Raza, MD None None None None 8/23/12
Karen L. Syrjala, PhD None None None None 10/3/13
Susan G. Urba, MD None Eisai Inc.; and Helsinn
Therapeutics (U.S.),
Inc.		 None None 10/9/13
Mark T. Wakabayashi, MD, MPH None None None None 6/19/13
Phyllis Zee, MD Philips/Respironics Merck & Co., Inc.;
Jazz Pharmaceuticals;
Vanda
Pharmaceuticals; and
Purdue Pharma LP		 None None 3/26/14
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The NCCN Guidelines Staff have no conflicts to disclose.

NCCN Survivorship Panel Members

*,a,cCrystal S. Denlinger, MD/Chair†

Fox Chase Cancer Center

*,c,dJennifer A. Ligibel, MD/Vice Chair†

Dana-Farber/Brigham and Women’s Cancer Center

fMadhuri Are, MD£

Fred & Pamela Buffett Cancer Center at The Nebraska Medical Center

b,eK. Scott Baker, MD, MS€ξ

Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

cWendy Demark-Wahnefried, PhD, RD≅

University of Alabama at Birmingham Comprehensive Cancer Center

b,dDebra L. Friedman, MD, MS€‡

Vanderbilt-Ingram Cancer Center

*,gMindy Goldman, MDΩ

UCSF Helen Diller Family Comprehensive Cancer Center

c,dLee Jones, PhDΠ

Memorial Sloan-Kettering Cancer Center

bAllison King, MD€Ψ‡

Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

Grace H. Ku, MDξ‡

UC San Diego Moores Cancer Center

b,hElizabeth Kvale, MD£

University of Alabama at Birmingham Comprehensive Cancer Center

aTerry S. Langbaum, MAS¥

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

gKristin Leonardi-Warren, RN, ND#

University of Colorado Cancer Center

bMary S. McCabe, RN, BS, MS#

Memorial Sloan-Kettering Cancer Center

b,c,d,gMichelle Melisko, MD†

UCSF Helen Diller Family Comprehensive Cancer Center

eJose G. Montoya, MDΦ

Stanford Cancer Institute

a,dKathi Mooney, RN, PhD#

Huntsman Cancer Institute at the University of Utah

c,eMary Ann Morgan, PhD, FNP-BC#

Moffitt Cancer Center

Javid J. Moslehi, MDλÞ

Dana-Farber/Brigham and Women’s Cancer Center

d,hTracey O’Connor, MD†

Roswell Park Cancer Institute

cLinda Overholser, MD, MPHÞ

University of Colorado Cancer Center

cElectra D. Paskett, PhDε

The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

f,hMuhammad Raza, MD‡

St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center

fKaren L. Syrjala, PhDθ

Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

*,fSusan G. Urba, MD†£

University of Michigan Comprehensive Cancer Center

gMark T. Wakabayashi, MD, MPHΩ

City of Hope Comprehensive Cancer Center

*,hPhyllis Zee, MDΨΠ

Robert H. Lurie Comprehensive Cancer Center of Northwestern University

NCCN Staff: Nicole McMillian, MS, and Deborah Freedman-Cass, PhD

KEY:

*Writing Committee Member

Subcommittees: aAnxiety and Depression; bCognitive Function; cExercise; dFatigue; eImmunizations and Infections; fPain; gSexual Function; hSleep Disorders

Specialties: ξBone Marrow Transplantation; λCardiology; εEpidemiology; ΠExercise/Physiology; ΩGynecology/Gynecologic Oncology; ‡Hematology/Hematology Oncology; ΦInfectious Diseases; ÞInternal Medicine; †Medical Oncology; ΨNeurology/Neuro-Oncology; #Nursing;; ≅Nutrition Science/Dietician; ¥Patient Advocacy; €Pediatric Oncology; θPsychiatry, Psychology, Including Health Behavior; £Supportive Care Including Palliative, Pain Management, Pastoral Care, and Oncology Social Work; ¶Surgery/Surgical Oncology; ωUrology

Footnotes

NCCN Categories of Evidence and Consensus

Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.

Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.

All recommendations are category 2A unless otherwise noted.

Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

Please Note

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representation or warranties of any kind regarding their content, use, or application and disclaims any responsibility for their applications or use in any way. The full NCCN Guidelines for Survivorship are not printed in this issue of JNCCN but can be accessed online at NCCN.org.

Disclosures for the NCCN Survivorship Panel

At the beginning of each NCCN Guidelines panel meeting, panel members review all potential conflicts of interest. NCCN, in keeping with its commitment to public transparency, publishes these disclosures for panel members, staff, and NCCN itself.

Individual disclosures for the NCCN Survivorship Panel members can be found on page 500. (The most recent version of these guidelines and accompanying disclosures are available on the NCCN Web site at NCCN.org.)

These guidelines are also available on the Internet. For the latest update, visit NCCN.org.

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