Bone pain in palliative care

Cancer induced bone pain

Cancer induced bone pain (CIBP) is a common problem amongst the patients diagnosed with cancer and is associate with reduced quality of life, increased psychological distress and decreased physical and social functioning.

• it is the most common type of pain seen in cancer patients
• seen in around one third of patients with bony metastasis

Cancer induced bone pain can be considered as a mixture of

• background pain
  
  
• breakthrough pain
  • defined as exacerbation of pain in patients with relatively stable and adequately controlled baseline pain
  • seen in around 75% of patients with CIBP
  • pain episodes are rapid in onset (<5 min) and short in duration (<15 min) in almost half of the patients
  • can be
    • spontaneous pain at rest
    • incident pain - pain that is exacerbated by weight bearing or movement (1,2)

CIBP may be seen in any part of the skeletal system where a cancer has metastasised.

• bone metastases are more common in axial skeleton than in the appendicular skeleton
• ribs, pelvis and spine are generally involved early (2)

Incidence of CIBP is estimated to be around 30,000 patients in the UK each year. With the improvement of cancer treatment, life expectancy of patients with cancer has increased. This means that the prevalence of CIBP is likely to be much greater than the annual incidence.

CIBP has features of both inflammatory and neuropathic pain. Changes occur in the bone homeostasis together with corresponding events in the peripheral and central nervous system causing a mixture of ongoing inflammatory and neuropathic processes.

Important considerations:

• Hypercalcaemia is the commonest cause of increased bone pain in palliative care
• Fracture or impending fracture should be suspected if the pain is of sudden onset
• Bone metastases may be single or multiple
• Spinal cord compression is a possibility if the patient develops a new back pain with leg symptoms

Non-malignant causes of pain in cancer pateints include:

• osteoporotic fracture
• inter-vertebral disc lesions
• osteomyelitis
• arthritis

Reference:

• (1)Kane CM, Hoskin P, Bennett MI. Cancer induced bone pain. BMJ. 2015;350:h315
• (2) Smith HS. Painful boney metastases. Ann Palliat Med. 2012;1(1):14-31.
• (3) West Midlands Palliative Care Physicians (2003). Palliative care - guidelines for the use of drugs in symptom control.
• (4) West Midlands Palliative Care Physicians (2007). Palliative care - guidelines for the use of drugs in symptom control.