28 March 2022, Monday

How to Reduce Bone Cancer Pain?

Overview:

Pain is one of the most common and troubling symptoms of bone cancer, be it primary bone cancer (sarcoma) or secondary bone cancer (metastasis). Unlike many other more common causes of bone and joint pain, the pain of bone cancer progressively worsens in a relatively short time.

It may be quite transient, tolerable, vague and occasional to begin with. However, over a period, which may vary from days to weeks or months, it becomes more apparent, localised, frequent and prolonged. In the beginning, it may be noticed only during heavy or prolonged activity. But over time, it will manifest with simple activities, and at some point, it will be felt even at rest.

It becomes an almost continuous pain, which is felt all the time – even when lying down. As the pain progresses, it will eventually affect sleep. In some, it may be even worse at night. Some patients may present with vague, continuous pain unrelated to movement or activity. In a few of these patients, the disease can weaken the bone so that it can suffer microfracture or even a complete fracture.

This will manifest as a sudden aggravation in the pain that some trivial injury or activity may trigger. Bone is a very pain-sensitive organ. This is most obvious when we suffer an injury to any of the bony prominences of the body like the knee, shin bone, elbow, hip, etc. It is even more apparent when one suffers a fracture because of any injury.

When there is an abnormal growth in the bone, it does a few things. It elicits an inflammatory reaction as the body attempts to limit or heal the damage caused to the surrounding normal tissues.

The growing disease stretches pain-sensitive structures and receptors in the bone, triggering pain. As the stretch increases due to the growing disease, the pain worsens. As this disease grows, it also invades the pain-sensitive tissues and structures, adding to the worsening pain.

In some situations, the growing mass can stretch or compress sensory nerves or/and elicit an inflammatory response in them, which can trigger or add to the pain. Also, as discussed in the earlier paragraph, pain may exacerbate acutely due to a pathological fracture or deformation of a weakened bone. When the disease affects the spine, it can cause back pain, ranging from a vague complaint to a complete inability to sit or turn in the bed. In vertebral bone tumours, another cause of pain is irritation or compression of the spinal nerves.

Thus, bone cancer pain is a complex situation that needs to be managed sensibly. When it comes to cancer pain management, one must understand two important approaches to dealing with this problem.

The first approach is to treat the pain. The second one is to treat the cause of pain. Depending on the patient’s circumstances, the severity of the pain and the goal of their treatment, one or both of these approaches are used in managing the pain. Let us discuss each of these approaches in a little more detail.

Treating the Pain:

The first and most important step is avoiding, reducing, or stopping all pain-triggering activities. So, if walking causes pain, the patient should avoid putting weight on that limb. They can use a walking stick or walker if possible. One should stop all non-essential activities that trigger or worsen the pain.

If any essential activity causes pain, the patient should modify his ways and adapt to the situation so that the activity becomes tolerable. For example, instead of an Indian-style toilet, he can use a commode chair or western toilet. If that is troubling, then he can use a bedpan.

The patient should avoid all floor level activity and not squat or sit cross-legged. If pain is in the upper limb, he should limit the use of that extremity to only those that are comfortable to perform. If needed, one can use an arm pouch or sling. The patient should avoid all overhead activity with the affected arm. If the pain is in the back, the patient should not lift heavyweights.

The patient should also avoid twisting the spine (by keeping both the shoulders and hips in the same plane at all times). A spinal brace may be used to provide additional support if needed. The patient should be vigilant and avoid any accidental injuries and falls, especially in bathrooms, wet floors, staircases, uneven grounds, and getting out of bed at night.

Despite all of the above, pain may persist as rest pain. The patient must be started on pain-controlling medication in such a situation. Different pain medications work through different mechanisms and are administered in different ways. This could be in the form of injections, oral medication, transdermal patches, or nasal sprays. Most of these pains can be managed very effectively using a varying combination of these.

However, one must know the benefit of this will last as long as the medication is effective, and at some point, they may not work as well as they did initially. Besides, these will not alter the behaviour of the disease, and they may have side effects which limit the total dose and duration of their use.

So, generally, this is just a temporary measure to give relief to the patient while the actual treatment of the disease takes over and provides lasting relief. The treating doctor best decides the exact dosage, drug combination, duration of treatment, and delivery mechanism.

In difficult situations, we can seek the help of pain specialist doctors. In intractable pain, pain specialists can perform procedures that can block the signals of specific nerves from traveling to the brain, thus providing profound relief to the patient. Until now, what we have discussed is specifically about managing the pain as a symptom.

The relief with these methods will, in most cases, be incomplete or/and temporary. For lasting relief, one must treat the cause of pain.

Treating the cause of pain:

An important point needs to be clarified before deciding how to treat the cause of pain. This is whether one is treating the cause of pain only to deal with the pain or whether the cause of pain is being treated to eradicate the disease–i.e., whether the intention of treatment is palliative.

Based on this, the treating team of doctors will decide on medical oncology, surgery, and radiotherapy in the patient’s treatment. When the treatment is with palliative intent, the treatment is far less aggressive than when the treatment is with curative intent.

So, depending on the patient’s circumstances, any one or more of these modalities may treat the disease, which should provide relief from pain and help reduce or stop the use of pain medication.

For example, certain drugs can give a useful response in doses that are not toxic to the patient. Limited doses of radiotherapy give excellent and prolonged pain relief in terminal patients with multiple bone metastases. In patients with large extremity tumours, palliative surgery can restore excellent quality of life. In patients with severe back pain and spinal cord compression symptoms, limited spine surgery can turn their life around.

In patients with pathological fractures of the bone, immobilization of the affected bone and joint will give significant temporary relief till proper treatment is planned. Most pathological fractures will need surgical management.

However, it should be very clear that managing a pathological fracture is a completely different science than treating a routine fracture and is best managed by bone tumour experts. In cases with a very large disease, where other surgical options are ruled out, amputation surgery can significantly impact the patient’s life quality.

When the patient is being treated to cure, the treatment is more aggressive, and all relevant modalities are used to manage the disease. Besides knowing what can be done, it is a good thing to learn what not to do in this kind of situation.

Few important don’ts:

1. Do not wait over a persistent or worsening pain – seek help
2. Do not self-medicate – see your doctor
3. Do not under-investigate – earlier the diagnosis, better is the outcome with treatment
4. Do not persist with activities that trigger or worsen your pain
5. Do not injure yourself – avoid falls
6. NO MASSAGING – Unlike common aches and pains where it can provide
   relief, massaging a bone tumour will only worsen the pain. It can also risk fracturing an already weakened bone.

Conclusion:

Bone cancer pain is a challenging problem to deal with. It needs a multidisciplinary approach to manage it optimally. The best a patient can do is understand that pain is the most effective way the body can draw attention to any potentially serious problem.

So, besides lifestyle modification to avoid painful activities, the most important thing a patient can do is see his doctor early. That will go a long way in optimally managing his condition.