Cancer pain

What is cancer pain?

Pain caused by a mass, such as a tumor, is referred to as cancer pain. In principle, both benign and malignant tumor masses can cause pain, but the term is most used in connection with cancer.

The symptoms may be acute or chronic. Around 30% of patients experience cancer pain early in the disease as one of the initial symptoms, and more than 70% of affected individuals suffer from cancer pain as the disease progresses. Although the causes and types of pain are varied, nowadays they can generally be managed well using potent medication and multimodal therapy approaches.

When does cancer pain occur?

In some cases, cancer pain is the first symptom of a malignant disease that brings the patient to a doctor. Nevertheless, there are also cases of tumor diseases that are entirely painless and only cause complaints at a very advanced stage.

To summarize, cancer pain may be due to the tumor (due to the growth of the tumor into surrounding tissue or compression of neighboring structures), tumor-associated (due to thrombosis or paraneoplastic syndromes) or treatment-related (due to post-operative pain, inflammation following radiation or chemotherapy, side effects of medications, and so on).

Cancer pain itself is a form of nociceptive pain that is caused by the tumor growth and the resulting tissue irritation. As the tumor grows, it displaces and invades the surrounding tissue, leading to the activation of pain receptors (nociceptors). The level of pain depends on the tissue in which the tumor grows. For example, in the brain there are hardly any pain receptors meaning that brain tumors often spread without pain at first.

There is also neuropathic pain which is caused by nerve damage or irritation, such as when the tumor compresses a nerve or the spinal cord.

Pain may also be caused by accompanying cancer-related diseases such as infections, inflammation or circulatory disorders, or it may be triggered by the side effects of cancer treatment.

Chronic pain can occur repeatedly or permanently throughout the disease (persistent pain), or it may occur acutely in the form of pain flare-ups. This is also termed breakthrough pain. These sudden pain flares happen very quickly and can be triggered by specific movements or activities for instance. The pain flare-ups normally last for around 30-60 minutes.

The psychological aspect of pain perception is also relevant, particularly in the case of cancer, due to the enormous strain of the disease.

Keeping a pain diary with information about the intensity of the pain (for example, as a pain scale from 0-10), potential triggers, quality of the pain and subsequent treatment can be helpful.

How does cancer pain manifest itself?

Cancer pain can present itself in many ways and depends on the localization of the cancerous tumor and the underlying type of pain.

Somatic pain, which originates in the skin, connective tissue, muscles or bones, can usually be well localized by the patient and is described as stabbing, piercing or sharp. These complaints can be triggered or intensified by certain movements, pressure or physical strain.

When internal organs are involved, we refer to this as visceral pain. This pain is described as rather dull and diffuse, it may be colicky and more difficult to localize. Pain may also be referred to other areas of the body, an example being pain in the right shoulder in the case of liver or gallbladder disease.

Neuropathic pain due to nerve irritation is felt as burning, stabbing or even electrifying and can also be accompanied by a changed perception of pain (e.g. even lightly stroking the skin can elicit pain) or paresthesia’s. Furthermore, the pain can radiate into the areas innervated by the affected nerve.

Continuous pain exists regardless of the patient's physical activity and is often constant throughout the day. Alongside chronic or permanent pain, breakthrough pain may occur, which differs considerably in intensity from the otherwise existing pain level. The flare-ups of pain are sudden and often unexpected, but they may be triggered by movement, coughing or eating for example. The pain is described as intolerable and can last for minutes to an hour.

What helps with cancer pain?

In the case of cancer, pain management should take place early to spare patients from the additional burden of chronic pain.

Management of cancer pain is generally based on the WHO analgesic ladder. Depending on the intensity of the pain, this involves treatment with non-opioid analgesics (e.g. ibuprofen, paracetamol) first, followed by low-potency opioids (e.g. tramadol, tilidine). Finally, high-potency opioids (e.g. morphine, fentanyl, piritramide) can also be administered. In the case that the strength of the medication at one stage is no longer sufficient to effectively manage the pain the next stage is started.

Coanalgesics can also be used at each stage. These are drugs used to treat neuropathic pain or bone pain, for example. Adjuvants are also recommended. These substances are used to prevent or treat side effects of the pain medication (for example, medication against constipation, nausea or an upset stomach).

Generally, patients receive a base medication that is always taken according to a set schedule. On top of this, an on-demand medication is prescribed, which is only taken during pain flare-ups.

The administration method of medications can vary. Tablets, capsules, injections or even patches are some of the options.

Individual measures can also help to provide relief, like cooling or warming, massages, acupuncture, physiotherapy or psychotherapeutic methods (e.g. progressive muscle relaxation, autogenic training).

Another option for pain treatment is to treat the cancer itself. The surgical removal or reduction of the tumor size through chemotherapy and radiation helps to combat the cause of the pain.

Multimodal pain therapy, which involves the use of medications, and all the other treatments mentioned above, individually tailored to the patient, is especially beneficial for more complex clinical situations.

Is a tumor sensitive to pressure?

A tumor itself is generally not very sensitive to pressure. The problems arise from the displacement, irritation, and infiltration of the surrounding tissue. The neighboring tissue becomes more sensitive to pressure and pain due to the mechanical stress, destruction, and specific molecular changes induced by the cancer cells. Nerve cells especially become increasingly sensitive due to certain signals from the tumor.

Patients often then perceive these changes as a pressure-sensitive tumor.

Can benign tumors also cause pain?

Benign tumors that are not destructive to the surrounding tissue and do not spread to other areas of the body can also provoke pain. Benign tumors can grow and exert pressure on neighboring structures or displace them. The pain therefore depends on the location and how it grows.

For example, a benign brain tumor can still lead to headaches by compressing the cerebrospinal fluid outflow, or a benign bone tumor can lead to movement-induced bone pain due to pressure on the sensitive periosteum. Even neuropathic pain is possible if the tumor presses on adjacent nerves or discomfort can arise from compression of the blood vessels.

Which specialists and clinics specialize in cancer pain? 

Patients with a tumor have the option to receive specialized pain therapy, often managed by oncology departments in many locations. Some doctors are specifically trained in pain therapy and additionally there are also pain centers. Every qualified doctor (often specialists in anesthesiology or palliative medicine) can gain this additional qualification through further training. This training provides in-depth knowledge of pain management concepts and individual multimodal therapy planning.

At centers or larger clinics, treatment is often provided collaboratively by oncologists, surgeons, pain therapists, psychotherapists and other pain specialists from the beginning on.

Anyone in need of a doctor would expect the best possible medical care for themselves. Therefore, patients are looking for the most suitable clinic for their needs. Since this is not an objective decision and a respectable doctor would refrain from claiming to be the best, patients must trust the experience of a doctor.

We can help you find an appropriate expert for your condition. All the doctors and clinics listed have undergone extensive review and have been verified by us for their outstanding expertise in the field of cancer pain. They are looking forward to and are ready to address your questions and treatment requests.