A Growing Demand for Cancer Pain Specialists

November 2019 Issue

  1. Edward Podgorski, MD Anesthesia Resident, University of Miami / Jackson Health System Author


The current number of anesthesia-based pain physicians who specialize in the treatment of cancer pain appears to be inadequate to meet the demand of a growing cancer pain population. Of the approximately 2,300 American Board of Pain Medicine-certified physicians in the United States, the majority perform noncancer-related procedures.[1] Furthermore, the number of anesthesiologists who are also certified in hospice and palliative medicine, a major contributor to the treatment of cancer patients, is less than 0.3% (or 125 of approximately 50,000 board-certified anesthesiologists).[2],[3] Given the growing cancer patient population and the positive effect that anesthesiologists can have on outcomes and quality of life for cancer patients, the demand for cancer pain specialists will continue to be a priority.  


Given the growing cancer patient population and the positive effect that anesthesiologists can have on outcomes and quality of life for cancer patients, the demand for cancer pain specialists will continue to be a priority.  


An estimated 1.7 million new cancers were diagnosed in the United States alone in 2018. Although the percentage of new cases has fallen by 1.1% per year over the past 10 years, oncology’s landscape has shifted such that the total number of patients living with cancer continues to increase with an estimated 15.5 million cancer survivors in 2016.[4] As Levy et al. suggested, “What was once an explosive disease that led to a quick demise, cancer has now become a chronic disease.”[5] With that shift, pain specialists will undoubtedly encounter an increasing number of cancer patients with chronic pain.

 

Current data suggest a 24%–73% prevalence of pain in patients undergoing active treatment, 58%–69% in those with advanced or terminal disease, and 21%–46% in those in remission.[6] Although the majority of cancer pain can be managed via the World Health Organization (WHO) stepladder approach, 10%–25% remains refractory to conservative measures.[6] For that subset of patients, numerous studies suggest that an interdisciplinary approach is beneficial, with an increasing role for interventional pain specialists.[6]–[9] Interventional pain has even been proposed as the fourth step in the WHO stepladder.[10]

                   

Anesthesia-based pain specialists are uniquely positioned to care for patients with cancer pain. Their knowledge of analgesia and pharmacology, ability to titrate high-dose opioids, proficiency in interventional techniques, and understanding of complex comorbidities in critically ill patients provides them with multiple tools to effectively treat cancer pain. For example, intrathecal pumps can provide systemic pain relief at reduced doses to a patient with worsening systemic disease, increasing opioid requirements, and increasing side effects from oral opioid pain medications. In addition, neurolytic blocks, such as plexus blocks and sympathetic system blocks, have resulted in improved pain scores and reductions in opioid requirements and side effects. The combination of those skills and knowledge helps improve patients’ quality of life, ability to perform activities of daily living, and ability to tolerate treatment.

 

Despite the positive evidence that supports an increasing role of interventional pain specialists in the care of cancer patients, work still needs to be done to encourage increased involvement in the field. Looking toward the future, current cancer pain specialists can help in several ways. Highlighting the growing cancer patient population and the need for more cancer pain specialists is the first step. We can accomplish this by educating our peers through conferences, professional interactions, editorials, and research studies. Simultaneously, we have a shared responsibility to encourage the next generation of pain specialists to consider a career in treating cancer patients.

Treating cancer pain is rewarding: it offers the ability to improve quality of life for a vulnerable patient population as well as a technically and intellectually challenging career. Providing residents with opportunities to actively manage cancer pain may attract future colleagues to our field. Finally, it is important for interventionalists to improve their working relationship with other disciplines. Increasing participation in interdisciplinary patient care meetings, highlighting research that earlier intervention improves patient outcomes, and building better infrastructure for consultation will showase our unique skillset to patients who could benefit from our expertise. As a future cancer pain specialist, I hope this article encourages you to join me in achieving these goals.

 

Join the Cancer Pain and Supportive Care Special Interest Group at https://members.asra.com/cancer-pain-and-supportive-care/.


References

  1. American Board of Pain Medicine. Frequently asked questions. https://www.abpm.org/faq. Accessed April 15, 2019.
  2. Gebauer S. Hospice and palliative medicine as a specialty option for anesthesiologists. ASA Monitor. 2016;80(10):8–9. https://monitor.pubs.asahq.org/article.aspx?articleid=2555799
  3. American Board of Anesthesiology. Quick facts. http://www.theaba.org/ABOUT/About-the-ABA. Accessed April 23, 2019.
  4. National Cancer Institute. Cancer statistics. https://www.cancer.gov/about-cancer/understanding/statistics. Accessed April 15, 2019.
  5. Levy M, Chwistek M, Mehta RS. Management of chronic pain in cancer survivors. Cancer J. 2008;14(6):401–409. https://doi.org/10.1097/PPO.0b013e31818f5aa7
  6. Careskey H, Narang, S. Interventional anesthetic methods for pain in hematology/oncology patients. Hematol Oncol Clin N Am. 2018;32:433–445. https://doi.org/10.1016/j.hoc.2018.01.007
  7. Linklater G, Leng ME, Tiernan EJ, Lee MA, Chambers WA.Pain management services in palliative care: a national survey. Palliat Med. 2002;16:435–349. https://doi.org/10.1191/0269216302pm535oa
  8. Kay S, Husbands E, Antrobus JH, Munday D. Provision for advanced pain management techniques in adult palliative care: a national survey of aneasthetic pain specialists. Palliat Med. 2007;21:279–284. https://doi.org/10.1177%2F0269216307078306
  9. Fine PG. The evolving and important role of anesthesiology in palliative care. Anesth Analg. 2005;100:183–188. https://doi.org/10.1213/01.ANE.0000141061.74294.DE
  10. Miguel, R. Interventional treatment of cancer pain: the fourth step in the World Health Organization analgesic ladder? Cancer Control. 2000;7(2):149–156. https://doi.org/10.1177/107327480000700205