Early Interventional Treatments for Patients with Cancer Pain: A Narrative Review

Abstract

Between 10% and 20% of patients with cancer-related pain cannot achieve adequate control following the three-step ladder guidelines by the World Health Organization. Therefore, a “fourth step”, including interventional approaches, has been suggested for those cases. Systematic reviews support the early use of interventional procedures to treat refractory cancer pain, control symptoms and prevent opioid dose escalation. There is strong evidence of the efficacy of celiac plexus or splanchnic neurolysis, vertebroplasty, kyphoplasty and intrathecal drug delivery. Those procedures have been found to be associated with a decrease in the symptom burden and opioid consumption, improved quality of life, and suggested as having a potentially positive impact on survival. Several studies have recommended using specific interventional techniques at earlier stages, possibly even when opioid treatment is first being considered. Conversely, leaving these options as a last analgesic resource might not be advisable since the burden these procedures might impose on too ill patients is significant. The objective of this review was to collect the available evidence published on the use of interventional treatments for refractory cancer pain with a particular interest in comparing early versus late indications. The results of the search demonstrated a very low number and quality of articles particularly addressing this question. This scarce number of evidence precluded performing a systematic analysis. A detailed and narrative description of the potential benefits of integrating interventional techniques into clinical guidelines at the early stages of the disease is provided.

Keywords:

• cancer pain
• interventional pain
• neurolysis
• cement augmentation
• intrathecal drug delivery
• early
• timing

Ethics Statement

Permission for publication of clinical images was duly obtained from patients or their carers.

Acknowledgments

Authors want to thank the Louise and Alan Edwards Foundation for their generous support to the Alan Edwards Pain Management Unit of the Montreal General Hospital, the Cancer Pain Clinic at the Cedars Cancer Center, and the Edwards Family Interdisciplinary Centre for Complex Pain of the Montreal Children Hospital, all three programs part of the McGill University Health Center. JM’s work is supported by ICREA Acadèmia, the Government of Catalonia (2017SGR-1321) and the Spanish Ministry of Science.

Author Contributions

All authors made a significant contribution to the work reported, whether that was in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.