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FAQs about Pain in Head and Neck Cancer — What Patients Need to Know

Understanding Pain Helps Patients Gain Control of It and Lead Normal Lives

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Dr. David K. Lam

Outside of survival, pain is the most important concern for patients with head and neck cancer. These patients may suffer debilitating pain before, during, and after their cancer treatments.

The most frequent cause of pain during treatment is chemotherapy/radiation-induced oral mucositis, which involves 80% of patients. It worsens not only their quality of life but may also limit treatment.

Oral mucositis — inflammation from damage to the tissue that lines the inside of the mouth — is probably the most common, debilitating complication of cancer treatments.

This complication can lead to several problems in addition to pain, such as nutritional problems due to the inability to eat, and increased risk of infection due to open sores in the mucosa.

Oral pain in patients with head and neck cancer often inhibits speaking, eating, drinking or swallowing, and sometimes reduces treatment compliance and dose intensity, thus limiting the potential effectiveness of cancer treatments.

Here, David K. Lam, MD, DDS, PhD, professor of surgery and chief of oral and maxillofacial surgery, answers frequently asked questions about pain associated with head and neck cancer and how this pain is managed.

A specialist in head and neck cancer, Dr. Lam is internationally renowned for his expertise in pain management and research. He is a 2018 Mayday pain fellow.

Q: What are the different types of head and neck cancer pain?

A: There are generally three major causes of pain in patients with cancer: cancer-related (93%), treatment-related (21%), and/or unrelated to cancer or its treatments (2%).

Cancer-related pain may be a consequence of cellular, tissue, and systemic changes that occur during cancer proliferation, invasion, and metastasis (spread in body). Cancer progression may result in tissue damage and/or nerve injury through various mechanisms, such as infiltration, obstruction, compression, and fracture; and consequent exacerbation of cancer-related pain.

Cancer treatments such as surgery (e.g., postsurgical pain), radiation (e.g., mucositis), and medical therapy (e.g., chemotherapy-induced peripheral neuropathy) may contribute to treatment-related pain.

Patients with cancer may also suffer at the same time from various acute and/or chronic pain conditions unrelated to cancer or its treatments, such as sprains, toothaches, arthritis, and fibromyalgia.

At Stony Brook we appreciate the uniqueness of each individual person suffering with cancer pain.

Q: What do chemotherapy and radiation do to the body that results in pain?

A: Advances in cancer treatment, such as intensity-modulated radiation therapy, have significantly reduced treatment-related side effects. However, both radiation and chemotherapy still affect normal tissues, with oral mucositis being the most common painful complaint.

Oral mucositis starts as acute inflammation of the oral mucosa and pharynx after radiation or chemotherapy exposure that results in soreness, redness, and minor ulcers; but can progress to severe mucositis with extensive ulcers and redness that make swallowing difficult or impossible.

A secondary infection may occur that results in even more extensive tissue injury. Eventually the tissues heal and fibrose (toughen), with most lesions resolving within two to four weeks after stopping radiotherapy or chemotherapy.

Q: How is head and neck cancer pain managed?

A: The optimal management of head and neck cancer patients with pain requires the identification of the likely causes of pain. If the pain is from the cancer itself, treatment of the cancer can resolve the pain.

Maintaining good oral care and nutrition is the most effective way to lower the risk and minimize the progression of oral mucositis.

Locally applied agents (e.g., ice chips, local anesthetics, artificial saliva spray), systemically applied agents (e.g., opioids, indomethacin), and oral microbial load reduction agents (e.g., anti-bacterials, anti-fungals, anti-virals) may be used for symptomatic treatment.

Q: What medicines are used to treat head and neck cancer pain?

A: The World Health Organization has developed a three-step ladder for pain management in adult cancer patients (read more). This approach of administering the right medicine in the right dose at the right time is inexpensive and 80-90% effective.

Step 1 includes non-opioid analgesics, such as aspirin, non-steroidal anti-inflammatories, and acetaminophen, for mild pain; step 2 includes opioids, such as codeine or oxycodone along with non-opioids, for moderate pain; and step 3 includes stronger opioids, such as morphine or Dilaudid, along with non-opioids, for severe pain.

Adjuvant medications such as anti-depressants or anti-convulsants may be used to decrease the anxiety and fear associated with cancer pain. Specialized treatments, such as a nerve block, where a local anesthetic is injected around a nerve can also help.

The Stony Brook difference in pain management is the multidisciplinary approach used for it.

Q: What are the side effects of medicines?

A: Common side effects of analgesics for cancer-related pain may include nausea, vomiting, itching, constipation, and drowsiness. We can change the dosage, the time the medicine is taken, or the medicine itself to reduce side effects.

Our team can also work with patients to help manage any side effects experienced with cancer pain management, including nutrition therapy, complementary and alternative medicines, and other services.

Q: Is complementary/alternative medicine effective in treating head and neck cancer pain?

A: Various complementary and alternative medicine therapies have been demonstrated to improve quality of life, sleep, mood, stress, and anxiety in cancer patients, which may indirectly alleviate cancer pain.

Acupuncture, transcutaneous electrical nerve stimulation, supportive group therapy, self-hypnosis, and massage therapy may provide relief in cancer pain. Relaxation/imagery can improve oral mucositis pain.

Q: Are there ways patient themselves can control head and neck cancer pain?

A: Maintaining an open and regular dialogue about their pain with their cancer team helps optimize pain control and minimize side effects. Patients with head and neck cancer can maintain good oral hygiene and nutrition, be well-rested, and practice self-hypnosis, massage, and relaxation/imagery to better control their cancer pain.

Q: What is new in pain research that's improving management of head and neck cancer pain?

A: Although recent preclinical models of cancer pain appear to better reflect the complex pain states observed in cancer patients and have identified various potential therapeutic targets, it is unlikely that a single treatment will target all of the different cancer pain-related symptoms in patients, and so combined treatment strategies should be investigated in preclinical models.

The existence of multiple peripheral and central mechanisms in different cancers may not only provide a rational basis for the use of combination therapy in cases where a single agent is not sufficient, but may also serve to usher in the era of personalized cancer pain medicine.

Using advancements in genomics and proteomics, the development of diagnostics targeting an individual patient's unique cancer cell mediators and genetic makeup may not only provide targeted analgesic therapy but may potentially eliminate ineffective analgesics, reduce adverse drug reactions, lower costs, and improve quality of life.

At Stony Brook our physician-scientists are always working to advance pain management.

Q: What is the Stony Brook difference in treatment for head and neck cancer pain?

A: Multidisciplinary care. Through the broad training and experience of our multidisciplinary team of clinicians and scientists at the Stony Brook Cancer Center and Department of Anesthesiology Center for Pain Management, we appreciate the uniqueness of each individual person suffering with cancer pain.

The goal of our treatment is to help patients gain control over their pain and lead normal, active, and meaningful lives at home and in their community.

Our pain team includes dedicated experts in pain medicine who work closely with our patient's referring physician. Our program not only meets current standards for care of cancer pain, but also works to improve future care through education and research.

We study novel analgesic targets in preclinical and clinical studies, keep abreast of new advances, and, if appropriate, can refer patients to research studies on pain problems for which answers are still needed.

What is pain? — "Pain is an unpleasant sensation and emotional experience linked to tissue damage. Its purpose is to allow the body to react and prevent further tissue damage. We feel pain when a signal is sent through nerve fibers to the brain for interpretation. The experience of pain is different for everyone, and there are different ways of feeling and describing pain. This can makes it difficult to define and treat. Pain can be short-term or long-term, it can stay in one place, or it can spread around the body." — Medical News Today

Learn more about cancer and pain management. For consultations/appointments with Dr. Lam, please call 631-632-8975.