Cancer Therapy Vol 2, 365-374, 2004

1Hematology/Oncology, Lung Cancer Clinic and Pain & Palliative Care Clinic,

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*Correspondence: Frank E. Mott, MD FACP, Assistant Professor of Medicine, Hematology/Oncology, Director, Medical Oncology Fellowship Program, Director, Lung Cancer Clinic, Attending, Pain & Palliative Care Clinic, Scott & White Clinic, Texas A&M University HSC, Temple, TX; Tel: 254-724-7048; Fax: 254-724-4904; e-mail: fmott@swmail.sw.org

Key words: cancer pain, assessment, treatment, hypnosis

Abbreviations: Brief Pain Inventory, (BPI); nonsteroidal anti-inflammatory drugs, (NSAIDS); Psychosocial Collaborative Oncology Group, (PSYCHOG); World Health Organization, (WHO);

Pain is a common symptom in an Oncology practice. Surveys have indicated that pain is experienced by 30-60% of cancer patients during active therapy and by more than two-thirds of those with advanced disease (Bonica et al, 1990). In addition to pain, patients with advanced cancer also report a high prevalence of fatigue, generalized weakness, dyspnea, delirium, nausea, and vomiting (Reuben et al, 1988; Coyle et al, 1990; Curtis et al, 1991; Donnelly and Walsh, 1995). Psychiatric disturbances occur in over 60% of this group, with adjustment disorders, depression, anxiety, and delirium being the most common (Massie et al, 1983; Bukberg et al, 1984; Beitbart and Passik, 1993).

Regardless of the technological advances that medicine may have achieved or expects to see in coming years, the relief of suffering has been and always will be at the very core of its endeavors and should be the guiding principle in anything a physician or other health care provider does. In Oncology, where over 50% of patients will die of their disease (Walker and Bruera, 2002), debilitating symptoms are common and programs that focus on the appropriate assessment and management of these symptoms are important. This is the underlying reason for the emergence of palliative care and supportive oncology. The term palliative is derived from the Latin pallium: to cloak or cover. Many definitions of palliative care exist, but the common theme is its goal of delivering the utmost quality of life to patients and their families when dealing with an incurable illness.

The definition of palliative care put forth by the Canadian Palliative Care Association in 1995 takes into account this broad scope (Canadian Palliative Care Association, 1995):

It is quite obvious from this that patients with advanced cancer who also suffer from pain do not do so in a void, free of other symptoms. Pain leads to emotional distress and sleep disturbance, which in turn create fatigue. Pain medications can cause nausea and/or constipation. Appetite is affected and dysphoria can result from the central nervous system disturbances. Thus, managing cancer-related pain is a complex, inter-related program that incorporates a number of disciplines.

There is more to pain management than simply writing a prescription for an opiate analgesic. As such, the litany of physical and psychological influences that affect or result from the pain need to be addressed as well. Most cancer centers now provide pain management as part of their program, often in the format of a separate, multi-disciplinary team that addresses the global needs of the patient with cancer-related pain and its associated symptoms. These teams comprise personnel with expertise in the requisite disciplines that are vital to attain successful pain management with a balance of quality of life. These include medical and radiation oncologists, often with special interest and focused expertise in pain management and palliative care. There are now accredited societies in Hospice and Palliative Care with one-year fellowships leading to board certification in this subspecialty. Pharmacists are critical and provide proper dosing recommendations, help prevent serious drug interactions in a population of patients who are often taking multiple medications, and offer helpful counseling to patients and, more importantly, family members who are often primary care-givers and monitor the administration of medications at home. Nursing personnel, social workers, physical therapists, and chaplains are also important members of the team. Psychologists, often with focus in the area of Psycho-oncology, can provide significant benefit by helping patients cope with anxiety, depression, and fear of death. The gradual and successful transition to more palliative care includes close interaction with hospice personnel. Ancillary services, such as pain block clinics, interventional radiology, complementary and alternative medicine experts, acupuncturists, hypnosis, etc. all have a potential role in the overall care of patients with cancer-related pain.

Pain, if not reported by the patient and not asked about by the physician or nurse, will be overlooked and under-treated. The prevention of and relief from pain is vital to optimal health status. A number of palliative care programs have endorsed the concept of pain as the "fifth vital sign", as integral to the care of a patient as their temperature, pulse, respirations, and blood pressure (Abrahm and Snyder, 2001; Lynch, 2001). The National League of Nursing has promoted it and in many centers, it is a common part of the nursing assessment of not only the cancer patient, but also any patient with chronic pain.

The development of an appropriate, reproducible pain scale is critical to the assessment of pain. Asking the patient to quantify the severity of their pain on a scale of one to five or one to ten, with the higher number representing more severe pain, is a useful method of determining how much pain a patient has. We find that one to ten is more reliable since the increased gradations allow a patient to better discriminate subtle changes in their pain character. It also helps the health care provider better quantify the effect of their intervention.

In addition to the level of pain, several associated factors are important in the overall assessment. These include the quality of the pain, its timing and relation to other activities or events, the location and distribution of the painful area(s), and the effect of any interventions on either relieving or, perhaps producing the pain.

The patient's description of the pain can be very helpful in determining its cause, as well as what diagnostic and/or therapeutic interventions are indicated. Somatic pain is usually focal, sharp, aching, throbbing, or pressure-like. Isolated bone metastases can produce this type of pain. Visceral pain is more diffuse and described as crampy or gnawing and is seen with soft tissue involvement such as diffuse liver metastases or bowel obstruction. Neuropathic pain is burning, tingling, and often radiating or lancinating. This type of pain is common when nerve plexuses are involved or spinal cord lesions press on nerve roots. It can also be seen as a consequence of some chemotherapy agents, which damage peripheral nerve endings.

When the pain occurs, either during the day or night, can be helpful for making recommendations to modify behavior so as to reduce the pain syndrome. Most pain is divided into acute and chronic. Acute pain is characterized by a recent onset, usually well defined by the patient or family, often associated with a temporal event such as a fall or other injury, and usually transient in nature. Chronic pain has been defined as usually more than three months in duration, constant or even progressive, and often associated with a chronic pathologic process, such as cancer (Bonica et al, 1990). Chronic cancer-related pain can have acute exacerbations, which may indicate progression of the underlying disease.

Pain location is helpful in discerning its cause. Most cancer patients will experience pain in more than one site (Portenoy et al, 1992). Focal pain usually is due to an underlying, localized lesion; however, focal pain may also be referred from another site. For example, shoulder pain that is not due to pathology involving the shoulder itself requires investigation of the apical lung area to exclude tumors invading the underlying brachial plexus, and the region immediately above and below the ipsilateral diaphragm, which can produce referred pain to the shoulder.

Asking the patient to point to the area(s) of pain is one method, but a more useful approach is to use a drawing of the front and back of the body. The patient can mark the involved area. This method is simple and provides an easy means for tracking changes in pain locations. It also provides a way to show if the pain is focal or diffuse.

Patients may have already tried their own remedies to treat the pain and it is important to ascertain their effectiveness. Over-the-counter analgesics are the most common agents employed, but it is not unusual for a well-intentioned friend or family member to provide the patient with one of their unused prescription analgesics. Non-pharmacologic approaches such as topical ice packs or heating pads, range of motion exercises or immobilization, etc. are all likely to have been tried in one fashion or another. The use of complementary and alternative therapies is popularly accepted by many patients and they may have resorted to some of these interventions. If the health care provider does not ask, the patient may not mention them.

Even when asked, patients may be reluctant to accurately describe pain, or even report it at all. Reasons for this vary and probably range from denial to stoicism. The following list includes some of the reasons why patients may be reluctant to report pain (Ward et al, 1993).

• Do not want to be perceived as complainers or "whiners"
• May think reporting pain will draw attention away from the disease itself
• Acknowledging increased pain will indicate a worsening of their condition
• May view pain as an "inevitable" part of cancer
• Concern about the treatment of pain, e.g. opiates, radiation, etc
• Potential side effects of pain medications
• Fear that taking opiates too early will prevent adequate future pain control
• Concerned about the costs of pain medications
• May not want to distress or burden family members

In addition, cultural backgrounds may affect a patient's attitude about pain and its treatment. There may be a fear of "addiction" to opiates or that once an opiate is started that means the "end is near" or the patient is "giving up". Patients need to be reassured often and encouraged to report pain.

It is important to assess the person with pain and not just the pain itself (Turk et al, 2002). It has been established that pain rated at four or greater on an 11-point scale can significantly reduce the ability of patients to function (Serlin et al, 1995). Pain, or the anticipation of it, can create anxiety, which, in turn, can lead to a number of physiologic disturbances such as fatigue, sleep disturbance, anorexia, nausea, and additional sensation of pain.

In an effort to address the impact of pain on the patient's functional ability, several scales have been developed. The McGill Pain Questionnaire (Melzack, 1975) addresses pain quality with no less than 78 adjectival descriptors. A more reasonable modification of this that uses just 15 descriptors was described by Melzack (1987). The Brief Pain Inventory (BPI) is a 16-question, comprehensive self-reporting survey that includes numeric ratings of pain severity at its worst, least, currently, and average; a figure drawing to locate pain, and pain impact (Daunt et al, 1983).

By incorporating these and/or similar scales into the initial and subsequent assessments of cancer-related pain, the clinician can gain valuable information about the impact of pain on the patient's mood, work, interactions with family and friends, sleep, and quality of life. In so doing, the management of the pain and its associated factors will be more easily facilitated.

It can often be a difficult decision when attempting to determine the most appropriate medical regimen to alleviate a patient's suffering. A basis by which pain management may be approached was created by the World Health Organization (WHO), (1996) in Geneva, Switzerland. This logical approach to pain management has been endorsed by the Royal College of Physicians, the European Association for Palliative Care, and the Education for Physicians on End-of-Life Care (Emanuel et al, 1999; Medicine Committee of the Royal College of Physicians, 2000; Hanks et al, 2001; Thomas and von Gunten, 2003).

In this summary a "three step ladder" is described. Step 1 is characterized by mild pain. Mild pain would be classified as a one to three on a ten point scale by the patient. Step 2 is moderate pain, which would be a four to six on a ten point patient verbal scale. Finally, step 3 is severe pain which would be described as a seven to ten on a ten point scale (World Health Organization, 1996; Thomas and von Gunten, 2003). Each step of the ladder is associated with specific medications which should be utilized. In addition, adjuvant pain medications may be used alone or more commonly in combination with the recommended medications at any step to achieve better pain control. It is important to note that the ladder is not a concrete demarcation between pain levels, but more a transition. It provides a broad approach to pain management, but by no means does it imply a rigid recipe.

The first step of the WHO ladder primarily recommends use of non-opioid analgesic medications. Non-opioid analgesics include nonsteroidal anti-inflammatory drugs (NSAIDS) and acetaminophen. Non-opioid analgesics are especially useful (alone or in combination) for painful bony metastases or pain secondary to infiltration of muscle or soft tissue. NSAIDS and acetaminophen are subject to a "ceiling effect." In other words, increasing the dose above recommended levels will not provide further analgesic effect but may only increase the likelihood of experiencing side effects (World Health Organization, 1996; Thomas and von Gunten, 2003). NSAIDS mechanism of action is inhibition of the cyclo-oxygenase enzyme. This decreases the production of pro-inflammatory cytokines. The main side effects associated with NSAIDS include renal insufficiency, platelet inhibition and gastrointestinal upset. It is believed that the severity of the latter two side effects may be decreased with the use of newer generation NSAIDS that are selective in the inhibition of the cyclo-oxygenase two enzyme (Thomas and von Gunten, 2003). The WHO dosing guidelines references ibuprofen (a commonly used NSAID) at a dose of 400 mg every 4-6 hours with a maximum cumulative dose of 3 grams in a twenty-four hour period (World Health Organization, 1996).

Acetaminophen is metabolized in the liver. Maximum dosing should be up to 4 grams in a twenty-four period. In patients with liver disease, 2 grams should not be exceeded in a twenty-four hour period.

The second step of the WHO ladder recommends the use of opioid analgesics with or without concurrent use of non-opioid analgesics or adjuvant medications for the treatment of moderate pain. The medications primarily included in the second rung of the WHO ladder are codeine, hydrocodone and tramadol (Thomas and von Gunten, 2003). These three drugs are classified as analgesic opioids. Common side effects in this class include drowsiness, constipation and nausea (Micromedex Helthcare Series, 2004).

Codeine sulfate is supplied in 15 mg, 30 mg and 60 mg tablets (Micromedex Helthcare Series, 2004). It may be administered orally in doses up to 120 mg every 4 hours. Above this dose, side effects begin to outweigh the benefits of analgesic relief (World Health Organization, 1996). Appropriate dose adjustments should be made in patients with renal impairment (Micromedex Helthcare Series, 2004). In addition, codeine is metabolized to morphine and, in some patients, this ability is impaired or inhibited by other drugs, such as fluoxetine.

Oxycodone, when used alone, is a potent opiate and a schedule II narcotic. However, in combination with acetaminophen (Percocet), it may be a useful agent in this stage of pain management.

Tramadol is supplied in a 50mg tablet. It has both opioid and nonopioid properties allowing it to cause less constipation in addition to reducing the other opioid side effects as well. It is estimated to be twice as potent as codeine and have one fifth the potency of morphine (World Health Organization, 1996). Usual doses are 50-100 mg every four to six hours. Appropriate dose adjustments should be made in elderly patients and those with renal or hepatic impairments (impairment (Micromedex Helthcare Series, 2004). In our experience, tramadol is a relatively weak opioid analgesic.

Hydrocodone is supplied in 5-10 mg increments in combination with acetaminophen or ibuprofen. This can be a very effective medication for patients with moderate pain. Dosing is usually limited by the acetaminophen or ibuprofen component of the medication.

The final step of the WHO ladder endorses the use of potent analgesic opioids with or without concurrent use of non-opioid analgesics or adjuvant medications in the treatment of severe pain. Morphine, oxycodone, fentanyl, hydromorphone and methadone provide the pharmaceutical foundation for the treatment of severe pain. Side effects of these medications include nausea, emesis, constipation, pruritis, sedation, urinary retention, dry mouth, and respiratory depression (Micromedex Helthcare Series, 2004).

Morphine sulfate should really be considered the "backbone" of opioid analgesics. It may be administered via multiple routes to include oral, sublingual, rectal, subcutaneous, intravenous, intramuscular or epidural/intrathecal. Oral preparations come in immediate release (pill or elixir) and extended realease formulations. Dose adjustments should be made in renal impairment and cirrhotic patients (Micromedex Helthcare Series, 2004). The dose of the morphine sulfate should be titrated upward until pain control is achieved. The oral to intranvenous conversion factor is three to one.

Oxycodone is structurally similar to codeine. It has good oral bioavailability, but can be administered rectally as well. It also is manufactured as a long acting or immediate release preparation. Potency is similar to morphine sulfate (World Health Organization, 1996). Dose adjustments should be made accordingly for the following populations: liver disease, renal impairment, geriatric patients, and patients requiring the use of other central nervous system depressants.

Fentanyl is yet another opioid analgesic. It is unique because it is supplied as a transdermal patch. This gives it a special niche for patients without intravenous access who are unable to swallow a pill. It is also supplied as a "lollypop" which is absorbed across the oral mucosa and an intravenous formulation that provides effective analgesia with a short half-life.

Hydromorphone is a particularly potent opiate. When administered orally, the potency is about eight-fold greater than morphine. The intravenous preparation is approximately six-fold greater than intravenous morphine (World Health Organization, 1996). Hydromorphone has metabolites that are cleared renally and, in the face of renal insufficiency, can accumulate and lead to neurotoxicity.

Methadone may often be overlooked by physicians because it is also approved for narcotic detoxification and treatment. However, it has been very effective for use in patients with pain that is requiring large amounts of other opiates like morphine or hydromorphone; or in patients developing analgesic tolerance to increasing doses of other opiates. It is a synthetic opioid analgesic. The plasma half-life is variable (World Health Organization, 1996). In our practice, it is typically prescribed every eight hours. Methadone offers the following advantages: no neuroactive metabolites, low cost, good oral bioavailability (~80%) (Walker and Bruera, 2002). Methadone does have a unique pharmacodynamic profile which affects its equianalgesic conversion from morphine as the morphine doses increase, (see opioid conversion table).

Drugs that should be avoided in the management of chronic cancer pain include meperidine, pentazocine, butorphanol, and propoxyphene. Meperidine has a very short half-life and its metabolite, nor-meperidine, can accumulate, especially in the face of renal insufficiency, and lead to seizures. Both pentazocine and butorphanol have agonist and antagonist narcotic properties, which diminish their effectivenss and can lead to acute withdrawal symptoms. Propoxyphene is an extremely weak opioid. The analgesic benefit of propoxyphene products usually is derived more from the acetaminophen that is included in the formulation.

As described above, adjuvant analgesics may be given in conjunction with Step 1, Step 2, or Step 3 medications to optimize pain control. Alternative causes of pain such as neuropathic pain are not very responsive to opioid therapy (Walker and Bruera, 2002), with the exception perhaps of levorphanol and methadone, both of which have activity via NMDA receptors, which modulate neuroapathic pain stimuli. Antiepileptic drugs, antidepressants and corticosteroids are the main classes of medications utilized either alone or in combination with opioids or nonsteroidal anti-inflammatories.

Antiepileptic drugs have primarily been studied in the treatment of nonmalignant forms of neuropathic pain (Walker and Bruera, 2002). The believed mechanism of action lies in their effect on neuronal discharge (Thomas and von Gunten, 2003). Antiepileptic drugs used include gabapentin, carbamazepine, phenytoin and clonazepam. Gabapentin is the most commonly used drug in this class. It is well tolerated with the most troubling side effect being lethargy (Thomas and von Gunten, 2003). It should be started at a low dose of one hundred to three hundred milligrams per day and titrated upward as tolerated (Walker and Bruera, 2002).

Tricyclic antidepressants are the most frequently utilized class of anidepressants with regard to neuropathic pain. The most troubling side effects of tricyclic antidepressants are the anticholinergic properties that include dry mouth, fatigue, constipation, and urinary retention (Walker and Bruera, 2002, Thomas and von Gunten, 2003). Although amitriptyline has been the most frequently studied drug in this class, it is also known to have the most anticholinergic properties. For this reason, other tricyclics such as desipramine and nortriptyline have been effectively administered for control of neuropathic pain (Max et al, 1992; Watson et al, 1998; Thomas and von Gunten, 2003).

Corticosteroids play an important role in adjuvant analgesia in oncologic patients. They are potent anti-inflammatory agents that may be helpful for neuropathic or nociceptive pain (Thomas and von Gunten, 2003). Corticosteroids are indicated for use in pain control in the following situations: nerve or spinal cord compression, headache secondary to increased intracranial pressure, bone pain, pain secondary to capsular distension or duct obstruction (World Health Organization, 1996; Walker and Bruera, 2002). Dexamethasone has minimal mineralocorticoid properties compared to other steroids, making it an ideal option in terminal patients (Swartz and Dluhy, 1978; Demoly and Chung, 1998; Thomas and von Gunten, 2003).

To effectively manage a patient's pain, it is imperative to understand the concept of opioid conversions. Many references provide conversion tables to assist clinicians in the care of their patients. Table 1 shows the conversion ratios employed at our institution.

*The approximate ratio for a fentanyl patch is as follows: 50 microgram/hour patch: 90 mg per day of oral morphine.

**As noted above, the conversion factor from morphine to methadone is variable. For patients requiring 30-90 mg of oral morphine per day, the conversion factor is 4:1 (morphine to methadone). For those who require 90-300 mg of oral morphine per day, the conversion factor is 8:1 (morphine to methadone). Finally, those requiring greater than 300 mg of morphine per day, the conversion factor is 12:1 (morphine to methadone).

percent six hours after the administration of the first oral dose and discontinued twelve hours after the first oral dose.

Opiate side effects such as nausea and sedation are usually transient and can be managed by carefully introducing the opiate and titrating gradually as needed. Patients need to be counseled and reassured regarding the self-limiting nature of these side effects. In some cases, concurrent use of anti-emetics for the first few days can reduce the nausea associated with a new opiate or a dosage increase. Sedation can be off-set by timing the dosage administration; in some cases brief use of a stimulant such as methylphenidate may be helpful. Constipation is a common side effect of opiates that does not usually dissipate with time and, therefore, requires continuous and concurrent use of laxatives like senna. In cases of severe obstipation, orally administered naloxone may improve bowel function, again without systemic withdrawal. Respiratory depression with opiates is rare, if dosing guidelines are followed and dosage increments are done gradually. Severe respiratory depression can be reversed by inhaled naloxone without precipitating a systemic withdrawal.

Cancer pain can cause suffering that is both physically and psychologically devastating. Distress is the term used to characterize the adverse psychological components of cancer care. While distress is an umbrella term, it can help the patient to define their subjective level of discomfort surrounding the disease and its treatment. Holland described distress as follows (Holland, 1999): Distress is a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment. Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and existential and spiritual crisis

Twenty to forty percent of cancer patients will demonstrate significant distress (Roth et al, 1998; Zabora et al, 2001). The levels of distress correlate with the cancer site and type, age, and other variables. Under-treated cancer pain negatively affects sleep, energy and normal activity. It can lead to anxiety, depression, and an adverse quality of life that further exacerbates the patient's distress (Montour and Chapman, 1991).

Non-pharmacologic pain relief methods can be integrated within cancer pain treatment programs (Clinical Practice Guidelines, 1994). This is consistent with the consensus statement from the National Cancer Institute Workshop on cancer pain (National Cancer Institute, 1990): Under treatment of pain and other symptoms of cancer is a serious and neglected public health problem and ...every patient with cancer should have the expectation of pain control as an integral aspect of his/her care throughout the course of the disease

The use of non-pharmacologic methods to reduce distress and help patients cope with their cancer and its related symptoms is an important part of the palliative care team. As such, clinical psychologists play a significant role in the care of cancer patients. At our institution, we have incorporated such personnel into the program under the global auspices of "Psycho-Oncology". A number of methodologies are utilized, including psycho-social assessment, bio-feedback, relaxation exercises, and hypnosis. We have found that, for many patients, hypnosis can play an important role in developing helpful coping strategies.

Working with cancer patients requires the clinician to see the patient and their symptoms on a multitude of levels. To conceptualize the patient, their disease, distress and pain the clinician must see the patient in their totality. A cognitive behavioral assessment will lend itself to the development of specific interventions that will address the entirety of the patient.

Using the DSM III criteria (American Psychiatric Association, 1980), the Psychosocial Collaborative Oncology Group (PSYCHOG) studied the psychiatric disorders in cancer patients in three cancer centers (Derogatis et al, 1983). Of the 215 randomly studied patients, 47% met the criteria for a psychiatric diagnosis. Ninety percent of those were in response or manifestation to the cancer diagnosis or treatment. Thirty-nine percent of the cancer patients diagnosed with a psychiatric disorder were also experiencing significant pain.

Anxiety may be assumed to be present whenever the patient presents for therapy with the diagnosis of a possibly life-threatening disease. While it may never reach the threshold of diagnostic credence, that does not mitigate its existence nor its impact on the patient. On occasion, overt symptoms of anxiety may not be evident. Further probing may reveal a more typical constellation of symptoms of chronic anxiety such as sweating, sleeplessness, muscle tension, tachycardia, and so on. Constant repeated exposure of the body to these anxiety symptoms will produce a stress reaction within the patient that can further debilitate their physical condition, frequently manifesting itself in greater fatigue. This, in turn, further aggravates the anxiety, leading to more stress. These symptoms are all very amenable to hypnotic intervention.

Hypnotic relaxation is the most frequently cited form of non-pharmacologic cognitive pain control. Hypnotic relaxation may be defined as a deeply relaxed state involving mental imagery (Woody et al, 1992; Hammond and Elkins, 1994; Elkins, 1997). Hypnotic relaxation in the treatment of cancer patients involves the use of relaxation and mental imagery to induce relaxation, reduce anxiety and distress, and help patients detach themselves from obsessional thoughts (Araoz, 1983). Hypnotic relaxation has been found to be of significant benefit in reducing anxiety (Wadden and Anderton, 1982; Elkins, 1986). Furthermore, patients who develop anxiety disorders may be more hypnotizable than others (Frankel, 1974).

In the use of hypnotic relaxation for pain management, the focus is on instructing the patient in relaxation and mental imagery. The patient learns a cognitive method of pain management which is utilized at the discretion of the patient and within the patient's own control. The successful effect is to introduce a non-pharmacologic method of pain control that may decrease unnecessary dependency on analgesics for pain. Hypnotic relaxation is a safe method, which, when properly used, has no harmful side effects.

Cancer patients frequently experience anxiety due to anticipation about the illness, anticipation of potential treatment-related side effects such as nausea and vomiting, or anticipation of entering the final stages of life (Roberts et al, 1997). Kraft studied hypnotic relaxation in the management of 12 terminally ill cancer patients and reported a reduction in anxiety and depression (Kraft, 1990). Our experience has indicated that hypnotherapy is well accepted by cancer patients and is a powerful adjunct to the usual standard of oncology care (Marcus et al, 2003 a, b, c, d; 2004 a, b, c).

Pain should be considered in its totality of impact. Pain must also be considered in its temporal existence. Every patient will be able remember a time prior to the advent of the cancer and its attendant pain. Pain exists in the moment, and that is generally the patient's primary concern. The clinician needs to keep in mind that the pain should be treated in a prophylactic manner. When pain is present, a certain amount of anxiety must be considered to be in evidence. The anxiety may be overtly visible or it may be covertly in evidence by its conspicuous absence. Anxiety may manifest itself in the family. Understanding and awareness of the patient's anxiety about impending pain and the clinician's role in preventive management needs to be conveyed to the patient to allay this anxiety.

Interventions such as hypnosis can increase the patient's feeling of self-efficacy and mastery of their internal and external environments. As the patient becomes less anxious and increasingly competent in their use of self-hypnosis to manage their pain, their attendant anxiety frequently is diminished. This may have a similar effect on the family system as family members see their loved ones coping better with the pain.

Cancer pain management requires a directed history to localize, quantify, and qualify the pain. The assessment should include all ancillary symptoms as well as effects on family members and immediate caregivers. The patient's co-morbidities must be considered. Psychological symptoms like depression, anxiety, remorse, guilt, and other components of "distress" need to be addressed as part of the global management of cancer pain. A multi-disciplinary team incorporating medical, nursing, psychology, and social services can best facilitate this protocol.

The World Health Organization Analgesic Ladder can provide a simple approach to the initial medical regimen that is selected. Opiates play a vital role in the medical management of pain, but the use of adjunctive agents provides valuable integration in the relief of pain and ancillary symptoms.

By assessing the patient and their pain in a holistic fashion, appropriate palliation can be achieved more effectively. Adequate analgesic relief improves one's quality of life. Integrating mind-body interventions can assist the patient in controlling pain and help develop a sense of mastery and self-efficacy that can improve the treatment process.