New WHO guidelines for cancer pain in adults and adolescents

In this article we performed publication analysis devoted to pain medicine in oncology during anticancer therapy and in palliative setting. Until recently, the main WHO guidelines for pain management in oncology were the recommendations of 1996, which included only pain relievers, as well as adjuvant and symptomatic drugs, which were applied according to the WHO analgesic ladder. These recommendations were based on the collective expert opinion of leading clinicians and scientists. The new WHO clinical guidelines were published in 2019. They are based on the principles of evidence-based medicine, including modern concepts of the etiology and pathogenesis of tumor pain syndrome. This recommendations contain sections on the analgesic efficacy of radiation therapy and antitumor drug therapy. The new WHO recommendations have not yet been published in Russian and are not sufficiently available for a wide range of oncologists and palliative specialists in our country. The purpose of this publication is to present within one volume a concise but complete and comprehensible discussion of the latest trends in pain therapy in oncology, published by WHO experts.

1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jema A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2018 Nov;68 (6):394–424. https://doi.org/10.3322/caac.21492

2. van den Beuken-van Everdingen MHJ, Hochstenbach LMJ, Joosten EAJ, Tjan-Heijnen VCG, Janssen DJA. Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis. J Pain Symptom Manage. 2016 Jun;51(6):1070– 1090. https://doi.org/10.1016/j.jpainsymman.2015.12.340

3. Cancer pain relief. Geneva: World Health Organization, 1986. Available at: https://apps.who.int/iris/handle/10665/43944

4. Cancer pain relief, second edition. With a guide to opioid availability. Geneva: World Health Organization, 1996. Available at: https://apps.who.int/iris/handle/10665/37896

5. Cancer pain relief and palliative care in children. Geneva: World Health Organization, 1998. Available at: http://apps.who.int/iris/bitstream/handle/10665/42001/9241545127.pdf

6. WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. Geneva: World Health Organization, 2018. Licence: CC BY-NC-SA 3.0 IGO. Available at: https://www.who.int/ncds/management/palliative-care/cancer-pain-guidelines/en

7. Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician. 2010 Jun;56(6):514–517.

8. Schmidt-Hansen M, Bromham N, Taubert M, Arnold S, Hilgart JS. Buprenorphine for treating cancer pain. Cochrane Database Syst Rev. 2015 Mar 31;(3):CD009596. https://doi.org/10.1002/14651858.CD009596.pub4

9. Skaer TL. Transdermal opioids for cancer pain. Health Qual Life Outcomes. 2006 Mar 31;4:24. https://doi.org/10.1186/1477-7525-4-24

10. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006 Jul;15(4):420–427. https://doi.org/10.4037/ajcc2006.15.4.420

11. Fizazi K, Carducci M, Smith M, Damião R, Brown J, Karsh L, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011 Mar 5;377(9768):813–822. https://doi.org/10.1016/S0140-6736(10)62344-6

12. Lippuner K, Pollock RF, Smith-Palmer J, Meury T, ValentineWJ. A review of the cost effectiveness of bisphosphonates in the treatment of post-menopausal osteoporosis in Switzerland. Appl Health Econ Health Policy. 2011 Nov 1;9(6):403–417. https://doi.org/10.2165/11592210-000000000-00000

13. Gutierrez Bayard L, Salas Buzón MDC, Angulo Paín E, de Ingunza Barón L. Radiation therapy for the management of painful bone metastases: Results from a randomized trial. Rep Pract Oncol Radiother. 2014 Nov;19(6):405–411. https://doi.org/10.1016/j.rpor.2014.04.009

14. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singap. 1994 Mar;23(2):129–138.

15. International Association for the Study of Pain. IASP Terminology. Available at: https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698

16. Mills S, Torrance N, Smith BH. Identification and Management of Chronic Pain in Primary Care: a Review. Curr Psychiatry Rep. 2016 Feb;18(2):22. https://doi.org/10.1007/s11920-015-0659-9

17. Krakauer EL, Wenk R, Buitrago R, Jenkins P, Scholten W. Opioid inaccessibility and its human consequences: reports from the field. J Pain Palliat Care Pharmacother. 2010 Sep;24(3):239–243 https://doi.org/10.3109/15360288.2010.501852

18. Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain. 1990 Jun;41(3):273–281. https://doi.org/10.1016/0304-3959(90)90004-W

19. Mercadante S, Bruera E. Opioid switching: a systematic and critical review. Cancer Treat Rev. 2006 Jun;32(4):304–315. https://doi.org/10.1016/j.ctrv.2006.03.001

20. Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012 Feb;13(2):e58–68. https://doi.org/10.1016/S1470-2045(12)70040-2

21. Fallon MT. Neuropathic pain in cancer. Br J Anaesth. 2013 Jul;111(1):105–111. https://doi.org/10.1093/bja/aet208

22. Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F, ESMO Guidelines Working Group. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol. 2012 Oct;23 Suppl 7:vii139–154. https://doi.org/10.1093/annonc/mds233

23. Wong R, Wiffen PJ. Bisphosphonates for the relief of pain secondary to bone metastases. Cochrane Database Syst Rev. 2002;(2):CD002068. https://doi.org/10.1002/14651858.CD002068

24. Hoskin P, Sundar S, Reczko K, Forsyth S, Mithal N, Sizer B, et al. A Multicenter Randomized Trial of Ibandronate Compared with Single-Dose Radiotherapy for Localized Metastatic Bone Pain in Prostate Cancer. J Natl Cancer Inst. 2015 Oct;107(10):djv197. https://doi.org/10.1093/jnci/djv197

25. Sopata M, Katz N, Carey W, Smith MD, Keller D, Verburg KM, et al. Efficacy and safety of tanezumab in the treatment of pain from bone metastases. Pain. 2015 Sep;156(9):1703–1713. https://doi.org/10.1097/j.pain.0000000000000211

26. De Felice F, Piccioli A, Musio D, Tombolini V. The role of radiation therapy in bone metastases management. Oncotarget. 2017 Apr 11;8(15):25691–25699. https://doi.org/10.18632/oncotarget.14823

27. Clinical guidelines "Chronic pain syndrome in adult patients requiring palliative care" (revised in 2019). (In Russian). Available at: http://cr.rosminzdrav.ru/#!/recomend/708. Accessed 25.01.2021.

28. Nevzorova DV, Abuzarova GR, Polevichenko EV, Shcherbakova LV. Availability of opioid analgesics in the treatment of chronic pain in Russia. The current state of the problem. Review., Pallium. Palliative and hospice care 2020;2(7):4–11. (In Russian). https://www.pro-hospice.ru/zhurnal-pallium. Accessed 21.04.2021.