Cancer pain

A 54-year-old man presents for resection of a metastatic lesion in his distal humerus. He has disseminated prostate cancer, hypertension, hypercholesterolemia, and chronic pain. His daily medications include hydrochlorothiazide 25 mg daily, atorvastatin 20 mg daily, and oxycodone ER 240 mg BID. Objectives 1. Describe perioperative concerns in patients with metastatic cancer and associated pain. 2. Review the options available for controlling this patient's postoperative pain. 3. List intraoperative factors that may promote tumor metastasis and discuss prevention. 4. Discuss the current literature regarding regional anesthesia and cancer recurrence. 1. Describe perioperative concerns in patients with metastatic cancer and associated pain Patients with metastatic cancer present with unique perioperative challenges. Before proceeding with surgery, one should consider the patient's functional status, nutritional status, neo-adjuvant therapies, and pain state. All of these factors can lead to loss of functional abilities secondary to deconditioning [1]. As shown in colorectal patients, recreational activity and avoidance of sedentary lifestyle have been shown to increase survival and improve quality of life. Intraoperatively, positioning may need special attention. Many primary cancers metastasize to the bone, increasing the risk of pathologic fractures. Therefore, proper positioning and padding are crucial to prevent unintended injury. However, one of the greatest challenges in patients with metastatic disease is controlling postoperative pain. Pain upregulates the hypothalamic-pituitary axis, triggering cortisol and glucocorticoid production and consequent immunosuppression [3]. Therefore uncontrolled pain can promote tumor spread and lead to cancer recurrence and metastasis [4]. Patients with pain secondary to metastases often require a high-dose opioid therapy to alleviate baseline pain. Any additional acute pain can be difficult to control secondary to tolerance and utilization of multimodal analgesics is important. 2. Review the options available for controlling this patient's postoperative pain The options for controlling cancer patients’ postoperative pain include regional anesthesia, pure opioids, mixed-mechanism opioids, and non-opioid analgesics. The ideal regimen is multimodal, combining RA and diverse analgesics.