Neuropathic pain in cancer patients: Mechanisms, syndromes, and clinical controversies

The identification of a neuropathic pain syndrome in a cancer patient requires a focused clinical evaluation based on knowledge of common neuropathic pain syndromes. If a tumor is directly involved in the etiology of the pain, oncologic treatment is an initial consideration and may include surgery, radiation, or chemotherapy. There is no single accepted algorithm for the analgesic treatment of neuropathic pain and a systematic approach utilizing therapeutic trials of specific agents at gradually increasing doses is warranted. A trial of opioids, perhaps in combination with an NSAID, is warranted. If the pain is relatively unresponsive to an opioid, a trial with an adjuvant analgesic is reasonable. For example, a tricyclic antidepressant might be selected early for patients with continuous dysesthesia, and early treatment with an anticonvulsant might be used if the pain is predominantly lancinating or paroxysmal. Other adjuvant analgesics can be selected if there is insufficient response to these agents. A trial of sympathetic blockade, pharmacologic, anesthetic or surgical, should be considered in patients with evidence of causalgia or reflex sympathetic dystrophy. Physiatric modalities such as massage, heat, or cold; counterstimulation or transcutaneous electrical nerve stimulation (TENS), and orthopedic interventions, such as braces and splints may be useful. Epidural injections or neurostimulation of the spinal cord or brain can be considered in selected cases where appropriate expertise is available. Treatment of neuropathic pain remains a challenge for both clinicians and patients. The complexity of syndromes and underlying etiologic mechanisms warrants further clinical trials to determine the best treatment modalities for individual pain syndromes.