Book Review

Management of Cancer-Related Pain

N Engl J Med 1994; 331:1245-1246November 3, 1994

Article

Management of Cancer-Related Pain
Edited by Ehud Arbit. 534 pp., illustrated. Mt. Kisco, N.Y., Futura, 1993. $90. ISBN: 0-87993-552-9

Uncontrolled pain is understandably a predominant concern of patients with cancer. The difficulties in its management make it a major challenge to clinicians as well. This excellent and comprehensive book admirably addresses and illuminates the decisions that physicians make daily in the diagnosis and management of pain. The core of the book is a group of chapters written by specialists trained or currently at the Memorial Sloan-Kettering Cancer Center. This is appropriate, because the work of Dr. Kathleen Foley at that institution established the guidelines for clinical practice that remain the standard of care. Her work is the paradigm for the contemporary management of cancer-related pain. In a felicitous pairing of authors and subjects, nationally recognized authorities summarize and evaluate the state of the art in their particular areas of expertise.

The first two sections lay out the epidemiology, mechanisms, assessment, and scientific foundation of pain from cancer. Dr. Foley analyzes and provides tabular summaries of recent epidemiologic data on the character and intensity of pain related to particular cancers, neurologic presentation, activities of living, and outcome. This type of epidemiologic research is yielding important observations. An understanding of pain from cancer enables the clinician to be sensitive to the patient's needs and clears the way for the selection of the most appropriate treatment. For example, the most common type of pain in children is related to procedures. A physician who knows this will order analgesics before testing. It has also been shown that 75 percent of ambulatory patients with lung or colon cancer experience their worst pain more than 25 percent of the time. These patients can benefit from a medication providing continuous and strong analgesia.

The focus on therapeutic interventions makes this book a valuable resource. It discusses multimodal management and examines in detail analgesic, psychiatric, psychological, and physiatric management. The management of pain by surgical means is a thesis advanced by the editor, Dr. Ehud Arbit, who states in the book's preface, “In many instances, the most effective and expeditious way to alleviate pain is by a neurosurgical procedure or an anesthetic block.” Overall, only 10 to 15 percent of patients with pain from cancer receive this type of treatment. However, refinements in radiographic imaging now allow percutaneous or stereotactic techniques that are worthy of consideration by physicians interested in minimizing pain. Indeed, the engrossing presentations made me reconsider the value of some of these procedures.

The chapters include historical background, technical details, and the results of the authors' own studies. The tone is academic, balanced, and in some cases, quite candid. In the medical world, where physicians too often have to walk the rocky road of learning alone, Dr. Arbit shares his own precarious learning curve for cordotomy. He discloses that he learned the technique from books and that his first bilateral cordotomy resulted in the death of a patient from sleep-induced apnea.

I found the fifth section, on anesthetic procedures, disappointing, because important topics, such as intraspinal opioids and celiac plexus block, are not given the attention commensurate with their clinical use but instead are condensed into a few pages.

The sixth section deals with surgical treatment of specific types of pain -- for example, pain from head and neck cancer and gastrointestinal obstruction and pelvic pain. This discussion provides a particularly valuable perspective, because it helps integrate the available therapeutic interventions in patient care. Diagnostic considerations are presented in detail, and sound advice is given.

This book has been extensively researched, and the information provided is up to date. It makes a useful and informative reference for physicians in all specialties who try to relieve the suffering of patients with cancer-related pain.

Marc L. Citron, M.D.
Long Island Jewish Medical Center, New Hyde Park, NY 11042