A Conceptual Solution to Improve the Management of Cancer-Related Breakthrough Pain

Effective pain management is an essential component of the comprehensive care of patients with advanced cancer. Rhiner and von Gunten have written a review examining the roles the health-care practitioner and patient/family play in the undertreatment of breakthrough pain. The highlight of their article is a suggestion for a compelling new way to think about persistent and breakthrough cancer pain as distinct clinical entities. In addition, they identify technical, communication, behavioral, and regulatory barriers to effective evaluation and management. Because of these barriers, breakthrough cancer pain is often underappreciated and inadequately managed.

While the authors focus on the use of transmucosal fentanyl as the optimal opioid for addressing the challenges of breakthrough pain management, our experience suggests that all oral short-acting opioids are appropriate and effective. More important than the choice of opioid, all those who manage patients with cancer must be capable and committed to managing chronic and breakthrough cancer pain.

Breakthrough cancer pain is common. The phenomenon was first characterized by Portenoy and Hagen in 1990,¹ and its prevalence has been estimated in several studies and ranges from 19% to 95%.² The considerable variation in prevalence can be, in part, attributed to different definitions of “breakthrough pain.” Rhiner and von Gunten review various definitions and suggest that breakthrough cancer pain and persistent cancer pain should be perceived as distinct clinical entities. We find this conceptual separation an interesting and compelling argument, which could conceivably improve a provider's ability to manage cancer pain. For example, physicians may more easily realize the necessity for both long-acting and short-acting opioids to adequately control cancer pain if they understand they are treating two separate conditions. In addition, patients often struggle to understand the reason they have two different types of opioid pain relievers. By teaching patients that they are managing two different types of pain, they may more easily understand the role the different opioid formulations play in their care. Their improved understanding may improve medication compliance.

In conclusion, Rhiner and von Gunten provide an overview of breakthrough pain and the barriers to appropriate management which is timely and important. Notably, they introduce a new way of thinking about breakthrough pain which may improve the evaluation and management of cancer pain.