Cancer Pain Management

Pain is the body’s warning signal. The brain processes, interprets and uses pain to warn our bodies of danger and threat.  

Unlike your temperature or blood pressure, however, pain can be difficult to measure. Because of this, it can be hard for many individuals to express or get help for their pain. But even though pain isn’t something others can see or calculate, that doesn’t mean it's not real. Pain is a valid symptom our team works hard to treat.

As a pain psychologist at MD Anderson, I am interested in all the pieces that make up a person’s pain experience. 

Ahead, I answer common questions about pain psychology and its role in cancer care.

What is pain psychology? 

In the field of pain psychology, we find ways to help people manage or cope with pain.

Pain can be distressing. In our outpatient clinic, I work mainly with patients who are experiencing chronic pain, or pain that lasts longer than is helpful for our bodies to detect or protect injuries. However, many of the strategies that pain psychologists teach can also be applied for acute, or shorter-term, pain. 

Pain psychology addresses many of the factors that may be contributing to a person’s pain experience. Pain psychologists help people understand how the brain processes pain signals in different situations. For example, imagine stubbing your toe. Ouch, right? Different environments and events might change how you respond to that pain. Stubbing your toe might hurt more when you're already stressed or angry than it would when you are excited or focused on something else. 

Pain psychologists can also help patients navigate and reduce emotional distress. This can help the brain lower the threat level it uses to process pain signaling. This doesn’t mean pain isn’t real or is all in your head, but rather that experience, emotion and stress level can impact how pain is experienced. 

How is pain psychology used in cancer care?

There are a number of pain psychology techniques that can assist patients experiencing pain from cancer symptoms, treatment or side effects.

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy can give us a way to understand how thoughts, emotions, behaviors and sensations, like pain, may be connected. In pain management, CBT strategies are used to help calm the brain's fight or flight mode without medications or procedures.  

Some strategies that may be part of cognitive behavioral therapy for pain are:

• Diaphragmatic breathing
• Progressive muscle relaxation
• Guided imagery 
• Mindfulness
• Reframing thought patterns
• Biofeedback 
• Clinical or medical hypnosis 

When patients learn strategies they can use to manage and cope with pain, it can be very empowering and allow patients to feel less helpless about pain.

Managing emotional distress

Pain and mental health are often connected. 

When we’re in pain, it can increase emotions like frustration, sadness and worry. These emotions can increase the threat level in the brain. This can create a loop where pain and emotional distress are making each other worse.  

Pain psychologists can help individuals learn how to manage and decrease this emotional distress, which also helps with managing pain.

Improving quality of life

Psychologists can help those with chronic pain set goals and improve their quality of life. 

For example, maybe a patient really enjoys fishing, but pain is preventing them from fishing regularly. We can talk about what they value most about fishing – whether it be nature, time with family, or quiet reflection – and help them find ways to live out these values. While it may not always look the same as before, we can often help patients restore some function and continue to find meaning in their lives.  

Helping patients and care teams communicate 

Psychologists can help patients talk about their pain experiences so their care team better understands what they are going through.

What happens at a pain psychology appointment? 

MD Anderson patients are referred to Pain Medicine by their care team or can ask their care team for a referral. 

At the first appointment, a pain psychologist meets a patient and sometimes their family. 

We talk about a patient's pain experience, how pain has affected life for them, and how they are doing socially, emotionally and cognitively. Then, we explore how pain psychology might support their pain management plan.

Often, pain psychologists work alongside the pain medicine team to understand a patient's personal pain goal and equip them with multiple tools to manage their pain experience.  

When we treat chronic pain, we also measure success by asking about quality of life, how much a patient can do despite pain or discomfort and how we can continue to bring meaning and value to the things they are pursuing.

Sometimes, patients only have one appointment to help understand their pain experience or to determine if a procedure with their pain physician would be a good option. Other times, they might come back to work on techniques like relaxation training, cognitive skills or clinical hypnosis. Some patients also benefit from longer-term stress management support or supportive therapy for emotional distress.

One of our goals is for patients to feel confident they have pain management strategies – including ones they can use on their own. It can be helpful for patients to know relaxation strategies or different ways to think about pain-related worries so that they can manage pain without medication or other interventions. I think that's important and empowering for people.

What is an example of pain psychology that can be used in daily life? 

Diaphragmatic breathing is a simple strategy that changes the way we breathe. It can help open the lungs and signal our nervous system to dial up our relaxation response.  

Here are some steps to get started:

1. Start by putting one hand on your chest and one hand on your stomach.
2. Next, imagine a balloon in your stomach. As you inhale, imagine filling that balloon up. As you exhale, imagine gently letting the air out. As this happens, the hand on your stomach should be moving up and down. Breathe in through your nose and out through your mouth to deepen your breath.
3. Keep your breath steady by counting at a rhythm that feels comfortable for you. For example, “In-2-3, Out-2-3-4-5.” 
4. Mental images can also help you relax. Visualize what comfort looks like to you as you breathe in. Visualize what relaxation looks like as you breathe out.

As you continue taking in air and filling that balloon up, you might notice your breath reaches lower and gets slower. You might find your body gets more relaxed simply because of the way you are breathing. You might find that discomfort lessens as comfort grows.

Request an appointment at MD Anderson online or call 1-877-632-6789.

Many types of cancers can spread to the bone, leading to areas of damage called lesions. 80% of patients with metastatic prostate cancer develop bone lesions, but it’s also common in patients with many other types of cancer including metastatic breast cancer and metastatic renal cell carcinoma. These lesions leave patients in pain and sometimes impact mobility. They’re most commonly found in the ribs, the pelvis and the spine. Bone metastases occasionally occur in the shoulders and legs.

Usually, chemotherapy or immunotherapy can treat a bone lesion, and radiation therapy and pain medicine help manage their associated cancer pain. But these traditional methods don’t always work or aren’t an option for all patients.

MD Anderson is leading a new approach for patients with bone metastases that uses interventional radiology. These techniques offer patients a new option for pain management that can provide fast relief with few side effects. Interventional radiologist Rahul Sheth, M.D., shares how these minimally invasive procedures are changing the way we manage cancer bone pain.

What is interventional radiology?

Interventional radiology combines diagnostic imaging techniques like X-rays or CT scans with therapeutic procedures done inside the body. The procedures are performed through small pinholes in the skin and can help address a variety of medical concerns – not just cancer. The diagnostic imaging tools allow us to take pictures in real-time during the procedure. That way, we know exactly where everything is at all times without having to make a big incision to open the patient up.  

Instead, patients receive small punctures, similar to needles through the skin. And, there are no stitches afterward. We essentially put a Band-Aid on top while the punctures heal over the next couple of days.

For patients with bone metastases, interventional radiology can provide a real benefit in managing pain. Although each patient is different, most people go home the same day or the next day, and they feel relief a few days after the procedure.

Reasons for cancer bone pain 

Bone tumor-related pain can be caused by one or a combination of three things. The first is the cancer cells themselves. When the tumor’s cells take root inside the bone, their presence releases inflammatory proteins, which cause local inflammation. The brain perceives that inflammation as pain.

Second, as the cancer cells erode the bone, they can cause inflammation at the lining of the bone, which is where nerve fibers are found. As the tumor grows and the lining of the bone stretches, and the tumor can break out of the bone and cause pain.

Lastly, if the tumor is on a weight-bearing bone like the spine or the pelvis, it can cause pain. It’s just like when you break your wrist: There are fractures in the bone, and the fragments move around. As you move, the fragments rub against each other and can’t heal. This leads to inflammation that causes pain.

With interventional radiology, we tailor our treatment approach to address which of these three – or all three – are causing the pain.

When pain medicine and radiation therapy aren’t an option, interventional radiology may be

Even when prescribed at a high dosage, an opioid may not relieve bone cancer pain for a patient. Interventional radiology procedures can help wean patients off opioids while offering long-term pain relief.

Radiation therapy is another common approach for addressing pain, but it’s not an option for everyone. If a patient has already received radiation in that area, this treatment can’t typically be used again. But another benefit of interventional radiology is that the procedures can be repeated. Also, if a patient is receiving chemotherapy, they may have to pause the drugs to schedule radiation therapy. If the cancer is aggressive, this could be an issue. Interventional radiology is conveniently combined with other treatments since the procedures and recovery are quick.

Some cancer types are known to be resistant to radiation therapy. In those cases, we try to be more aggressive with treatment. At MD Anderson, we’re conducting a clinical trial that’s investigating stereotactic body radiation therapy combined with interventional radiology techniques. Our goal is to speed up how soon patients feel relief and maximize how long that relief lasts.

Interventional radiology helps destroy a bone tumor

The best way to address pain directly caused by a tumor on the bone is to eliminate the tumor. Two interventional radiology approaches we commonly use are ablation and embolization.

• Ablation: We destroy a tumor by subjecting it to extreme temperatures – either hot or cold. We insert a needle through the skin and into the tumor. That needle generates heat at its tip to heat the tumor, or it freezes the tumor into a ball of ice. We monitor the size of the ice ball with imaging techniques. This allows us to ensure we’re treating the entire tumor and avoiding surrounding normal tissue. At MD Anderson, we’re also exploring using ablation to improve systemic cancer treatments like immunotherapy.
• Embolization: By working with a patient’s blood vessels, we can destroy a tumor. Like the way cardiologists place stents in the blood vessels supplying blood to the heart, we do the same thing to the blood vessels supplying blood to a tumor. We enter the body, often through the leg or the wrist, and navigate to the tumor inch by inch, using X-rays to follow along. Next, we pack the blood vessels with thousands of microscopic plastic beads that float deep into the tumor and block the blood flow. This cuts off oxygen and nutrients and leads to the tumor’s death.

We often combine these techniques to maximize their benefit.

Bone cement stabilizes the bone to relieve pain

If the pain is caused by a tumor destroying the bone, we have a different approach. Much like a cast helps hold together broken bone so that it can heal, we do the same thing on the inside with bone cement. We glue together the bone fragments to hold them in place and speed up healing. The cement stops the constant motion of the fractured bone, and the patient feels relief soon after the procedure. In our recovery area, patients often already start to feel improvement in their pain levels.

This pain is a huge quality of life factor for our patients, and it’s gone within a few hours, thanks to these approaches. Personally, it's very fulfilling and rewarding work.

Request an appointment at MD Anderson online or by calling 1-877-632-6789.

If you’ve ever had a charley horse — or a severe sudden spasm in your calf — you know that muscle cramps are no joke.  

But did you also know that muscle cramps can be a side effect of cancer treatment? Below, I’ll explain why these uncomfortable spasms sometimes happen to cancer patients, how we treat them, and whether they’re temporary or permanent. 

Why do muscle cramps occur in cancer patients?

There are many possible causes. 

Chemotherapy

Several classes of chemotherapy can cause muscle cramps. These include:  

• platinum-based drugs (cisplatin)  
• vinca-alkaloid drugs (vincristine and vinblastine)  

But cramps can also be a side effect of some hormonal therapies, including the aromatase inhibitors used to treat breast cancer. All of these can damage the roots of our nerves, which may lead to muscle cramps and neuropathy. 

Electrolyte imbalances

A lot of chemotherapy drugs make patients dehydrated, which can result in electrolyte imbalances. If your potassium, magnesium or calcium levels get out of whack, that can lead to muscle cramps. Other causes of electrolyte imbalances include diuretics (fluid pills), kidney dysfunction and kidney failure.  

Anti-fungal medication

Amphotericin-B is a very potent antifungal medication used to treat opportunistic infections in neutropenic patients. It is also known to cause muscle cramps as a side effect. 

Lithium

This drug is used to treat bipolar disorders, but if you get too much or too little of it, you start seeing side effects very quickly. 

Hypothyroidism

Patients undergoing immunotherapy sometimes have this condition due to their treatment. 

Polymyositis

This is a rheumatological disorder associated with an increased risk of having cancer. Muscle cramps are an active symptom of the disease. 

Metastatic disease 

Some patients experience muscle cramps because they have metastatic cancer that has spread to the central nervous system and is now pressing on their nerves. This includes leptomeningeal disease, in which cancer spreads to the fluid surrounding the brain and spinal cord and/or the leptomeninges, the lining of the brain and spinal cord.  

Diabetes

This condition can sometimes cause muscle cramps. 

Anemia 

Red blood cells carry oxygen to the muscles. When there are not enough of them to do that job effectively, and your blood oxygen level drops, the result can be muscle cramps. 

Do muscle cramps only occur in certain locations?

No. It depends on what’s causing them. People can get them in their arms, legs, abdomen or other areas.  

How are muscle cramps typically treated? 

Again, it depends on the source. Here are a few things we suggest or prescribe: 

• exercise 
• oral and/or IV supplements 
• stretching 
• heating pads 
• muscle relaxers 

Are muscle cramps ever permanent? 

Some cancer survivors experience side effects for years after finishing treatment. But if we can identify the underlying source of your muscle cramps — such as an electrolyte imbalance or a thyroid problem — they typically get better as soon as we fix it. The cramps might not go away completely, but they definitely improve. 

Lucy Potter, M.D., is an internist in MD Anderson’s Supportive Care Center with a special interest in cancer-related fatigue. 

Request an appointment at MD Anderson online or call 1-877-632-6789.