COMMENTARY

Cancer vs Noncancer Pain: Time to Shed the Distinction?

Charles E. Argoff, MD

Disclosures

July 23, 2013

In This Article

Is Chronic Pain Just Chronic Pain?

What about the next scenario? Another woman with breast cancer has persistent pain associated with radiation and chemotherapy-related treatment 20 years after her treatment. Over the past few years, she has developed diabetes apparently unrelated to her breast cancer history, and now has diabetic neuropathy-related symptoms. Would we approach her as having a mixture of cancer- and non-cancer-related pain? How would that influence our ability to help her? Would we choose different treatments because of her history of cancer? Would it be appropriate in the first instance to think about using opiates or other treatments in a more open manner because the pain is cancer-related? Is it still cancer-related 15 or 20 minutes after the cancer has been cured?

What about a third situation -- someone with breast cancer and persistent pain associated with recurrence of cancer? That's clearly different in most of our minds, so I'll go to the next situation: a woman with breast cancer and persistent pain associated with both radiation and chemotherapy, who was recently involved in a car accident. She has been on a regimen that has included various types of opiate and opioid therapies during the 10 years following treatment with radiation and chemotherapy, but now has been in a motor vehicle accident. How would we treat her? How would we treat a patient who is in the same situation of persistent pain from breast cancer radiation therapy and chemotherapy who now has developed significant osteoarthritis, perhaps unrelated to her history of breast cancer?

Contrast that with an individual without cancer-related issues who also develops, over time, chronic pain due to diabetic neuropathy or who may develop chronic pain associated with osteoarthritis or a motor vehicle accident.

What is very interesting and troubling at the same time is that in several instances, the US Food and Drug Administration (FDA) has approved analgesics specifically for the treatment of cancer-related pain, and particularly for breakthrough pain, and these medicines are now available for these indications. To the best of my knowledge (and this has been confirmed by several sources in the past), in at least several of those studies leading to FDA approval, there was no requirement to prove that the individual who was enrolled in that study had active cancer or that what was being treated -- and what we then developed an FDA-approved drug for -- was pain associated with an active cancer problem. It was up to the investigator whether to include that person.

It's time to consider not focusing on a dichotomy between cancer- and non-cancer-related pain, but realize that there are ways to approach each category of pain and that in fact, the categories of pain are often not distinct categories. Many people with chronic cancer-related pain will also have non-cancer-related pain, and many people with non-cancer-related pain who have been treated for years will develop cancer. Many people may have lingering effects of cancer-related treatments that are not clearly related to active cancer.

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