Cancer, Pain, and the Role of the Neurosurgeon
With the exception of certain pain syndromes, such as trigeminal neuralgia, the treatment of pain has fallen out of the purview of mainstream neurosurgery. This loss is to the detriment of both neurosurgeon and patient, as nothing is more paradigmatic of it than cancer pain. Fortunately, forces both within and without neurosurgery are gathering. A perfect storm of clinical and societal changes is resulting in improved care, expanded opportunities, and the emergence of an important role for the neurosurgeon in caring for cancer pain patients.
The clinical need for effective management of cancer pain is great and growing. In 2012 there was a worldwide prevalence of approximately 32 million patients with cancer, with an annual incidence of over 13 million newly diagnosed solid tumors per year (American Cancer Society, Cancer Research UK). It has been reported in numerous studies that 30 to 60% of those patients will suffer from severe pain at some point in their clinical course, especially toward the end of life.1 Equally true—and widely reported—is the lack of effective pain care for these patients, caused by an amalgam of access difficulties, lack of physician knowledge, and inadequacy of currently accepted therapies.2, 3 A prominent neurosurgeon who specializes in pain care recently wrote of his frustration in getting adequate pain treatment for his own wife.4 For those lacking this level of personal advocacy, the outlook can be dismal. The stakes are not only quality of life and dying with dignity, but actual survival.5-7
Neurosurgery can play a major role in filling this great clinical need. There is a long history of neuroablative procedures used in the treatment of pain,8 largely ending with the advent of synthetic opioids in 1932. It is now clear that the relative abandonment of this approach was premature, as demonstrated by a growing body of clinical evidence associating opioids with ineffectiveness, toxicity, and even possible tumor promotion. Moreover, the historical neuroablation procedures are being modernized and re-engineered, resulting in such low-risk/high-benefit procedures as percutaneous cordotomy and myelotomy,9 continuous intraventricular drug delivery,10 and radiosurgical hypophysectomy.11 These procedures, and others such as dorsal root entry zone lesioning,12 trigeminal nucleotractotomy, 9, 13 intrathecal pharmacotherapy,14 and neurostimulation,15 offer potent adjuncts and alternatives to the standard cancer pain care armamentarium.
Cancer pain is complex, and there is multidisciplinary interest in its treatment, including medical and radiation oncology, physiatry, anesthesiology, palliative care, psychology, interventional radiology, and other specialties. We have entered the Post-Discipline Era of Medicine in which, to be truly patient-centered, we need to focus our organizing principles around the patient’s disease, symptoms, and experience rather than the advancement of any one profession or technique. The need for this is palpable amongst those who treat cancer patients in pain.
It is in this spirit that the Cancer Pain Research Consortium (www. CancerPainResearchConsortium.org) was formed, with significant participation of neurosurgeons from across the United States. The Consortium, a 501(c)3 nonprofit, is an international group of diverse specialists who have come together over this important symptom. Its mission is to generate and promote interdisciplinary, patient-centered, evidence-based care for cancer-related pain and suffering. All who are interested are welcome to join the Consortium as well as to attend the CPRC Scientific Meeting in Scottsdale, Arizona, on April 23-26, 2015 (www.cancerpainconference.org).
Neurosurgery can and must take its place on the multidisciplinary cancer pain team. Providing relief to those desperately suffering is one of the most rewarding endeavors in medicine, and doing so through modification of the nervous system touches on the essence of neurosurgery.
- Daut RL, Cleeland CS. The prevalence and severity of pain in cancer. Cancer. 1982;50:1913–8.
- Breuer B, Fleishman SB, Cruciani RA, Portenoy RK. Medical oncologists’ attitudes and practice in cancer pain management: a national survey. J Clin Oncol. 2011;29:4769-4775.
- Fisch MJ, Lee JW, Weiss M, et al. Prospective, observational study of pain and analgesic prescribing in medical oncology outpatients with breast, colorectal, lung, or prostate cancer. J Clin Oncol. 2012;30:1980-1988.
- Levy RM. Cancer Pain in America: Missing the Target of Relieving Suffering. Neuromodulation: Technology at the Neural Interface. 2013;16:391-394.
- Liebeskind JC. Pain can kill. Pain. 1991;44:3-4.
- Lillemoe KD, Cameron JL, Kaufman HS, et al. Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial. Ann Surg. 1993;217:447-55; discussion 456.
- Smith, TJ, Staats PS, Deer T, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002;20:4040- 4049.
- Rawlings C, Rossitch E, Nashold BS. The history of neurosurgical procedures for the relief of pain. Surgical neurology. 1992;38:454-463.
- Raslan AM, Cetas JS, McCartney S, Burchiel KJ. Destructive procedures for control of cancer pain: the case for cordotomy. J Neurosurg. 2011;114:155-170.
- Karavelis A, Foroglou G, Selviaridis P, Fountzilas G. Intraventricular administration of morphine for control of intractable cancer pain in 90 patients. Neurosurgery. 1996;39:57-61;discussion 61.
- Hayashi M, Taira T, Chernov M, et al. Role of pituitary radiosurgery for the management of intractable pain and potential future applications. Stereotact Funct Neurosurg. 2003;81:75-83.
- Gadgil N, Viswanathan A. DREZotomy in the treatment of cancer pain: a review. Stereotact Funct Neurosurg. 2012;90:356-360.
- Teixeira MJ, de Almeida FF, de Oliveira YS, Fonoff ET. Microendoscopic stereotactic-guided percutaneous radiofrequency trigeminal nucleotractotomy. J Neurosurg. 2012;116:331-335.
- Stearns L, Boortz-Marx R, Du Pen S, et al. Intrathecal drug delivery for the management of cancer pain: a multidisciplinary consensus of best clinical practices. J Support Oncol. 2005;3:399-408.
- Bhaskar AK. Interventional management of cancer pain. Curr Opin Support Palliat Care. 2012;6:1-9.