Managing Cancer Pain

“I don’t give up,” says Brian Bruel, MD, assistant professor of pain medicine at the University of Texas MD Anderson Cancer Center in Houston, and president-elect of the Cancer Pain Research Consortium. “And my patients know that.”

Many people who live with cancer and chronic pain and who come to the world-renowned MD Anderson have already seen lots of doctors and tried many different treatments. Sometimes, MD Anderson is their last hope.

Dr. Bruel makes sure they know there is always hope.

A search for hope and pain-free life is the reason he went into pain medicine. During his residency in 2003, he kept seeing “patients who had experienced an injury and couldn’t get back to work, leisure or playing with their grandkids” because the pain was getting in the way. “Those are the people I want to help,” he says.

“We can’t always heal the injuries we see,” says Dr. Bruel. “We don’t know enough yet to cure paralysis.” But during his residency, he thought pain shouldn’t be the biggest impediment to getting back to life after an illness or injury.

It was about the time medical professionals were beginning to conclude that a multidisciplinary approach to pain management might be the wisest, most effective approach. “It really takes a team: psychologists, physical therapists, occupational therapists, and other physicians using their expertise to have an impact,” Dr. Bruel says.

In college, Dr. Bruel was a business major. When he took a science class, it set a new course for his life. He switched his major to premed but never lost interest in the business. After medical school, he earned an MBA.

Pain Advocacy & the Business of Medicine

Dr. Bruel says his MBA is one of the best tools he uses when taking care of patients. “The business of medicine is so important right now,” he says. “Most patients are concerned not only for their health but also with economic issues. They wonder how they’re going to pay for health care.

“My approach with my MBA has never been about finance or accounting,” he continues. “I’m more interested in the big picture. For me, that involves advocacy. “Patients need an advocate—someone who knows the economic environment in medicine,” he says. “I try to be that for them.

And Dr. Bruel advocates for them as patients and as people—people who have budget restrictions, existing financial hardships, spouses, and children.

Being a health care advocate includes helping people reduce pain, maintain an active life and improve their mobility. Dr. Bruel has seen the damage done when pain is managed by relying solely on medication. When it comes to overprescribed opioids, he says, “We’ve seen the good, bad and ugly.”

Dr. Bruel recalls that there was a time—during his medical school and residency days—when future doctors were taught that the best treatment for managing chronic, debilitating pain was to prescribe opioids. That used to be the standard … before doctors knew better.

“Then, we saw the ugly part of opioids,” Dr. Bruel says. “Physicians overprescribed and patients developed tolerance, behavioral issues, and more. Now the pendulum is swinging the other way. We’re trying to seek a balance. We don’t want to do back too far in the other direction. We don’t want to cut off access entirely.

“In the past decade, managing chronic pain using neuromodulation has also taken off,” Dr. Bruel says of the technological advance. “It’s very exciting and encouraging to see people in pain reclaim their life with less medication.”

Other new pain management modalities have been developed that make opioids one choice among several—rather than the only option, as they used to be. Dr. Bruel encourages physicians and people in pain to explore all available, effective modalities. Now more than ever, the options are growing and customized treatment plans can be developed by a team of health care providers. “A patient’s pain level should at least remain at a baseline of where it is when they first come to see you. It should never get worse during treatment.”

Is Managing Cancer Pain Different from Other Chronic Pain?

Cancer pain is one of Dr. Bruel’s specialties. “With cancer pain, we may offer certain modalities a little quicker than we would with other types of pain.” One such modality is opioids.

Particularly with aggressive forms of cancer—pancreatic cancer, for instance—doctors can be a little more liberal with pain meds. “In some cases, we tend to think that it may be okay to give high-dose opioids to get them comfortable,” he says. “Or we may consider implanting a device very early on.”

According to Dr. Bruel, if a person with cancer is expected to live for a year or less, the priority needs to be in reducing pain. If a patient has non-terminal cancer, he encourages doctors to think about the person’s life after cancer. “We’re taking the long view now,” Dr. Bruel says. “We’re thinking about 20 years down the road.

“There’s a gray area with cancer pain,” Dr. Bruel continues. He says oncologists have done such an outstanding job in treating cancer that patients may live for years and years after recovering from the disease. “You can now be here for decades after a diagnosis,” he says.

So Dr. Bruel encourages health care professionals and pain management specialists to think in terms of what happens when the cancer is in remission. “You can be cancer-free, but not pain-free,” he explains. “Chemo and radiation can cause long-term pain.”

Dr. Bruel says that if a woman overcomes breast cancer—and then goes on to live a life of constant pain, he doesn’t consider that successful cancer treatment.

The Cancer Pain Research Consortium:

A NEW Definition of Success: Managing Pain, after Curing Cancer

More doctors are adopting this innovative way of thinking—thinking beyond getting cancer into remission. In many cases, they know they can do that. But a cancer-free patient who still lives with pain, or one who is addicted to pain medication, isn’t Dr. Bruel’s definition of success.

Dr. Bruel and a group of other doctors who met at a conference in 2012 founded the Cancer Pain Research Consortium to develop protocols and standards of care that address the immediate and long-term needs of cancer patients. It started with a conversation about what they were each doing within their own field of study to combat pain in cancer patients. They realized they could accomplish more collectively than any one of them could alone.

“Each of us can be considered an expert in his or her field,” Dr. Bruel says. “We wondered why such a group hadn’t been formed before. We’d all been in our silos.”

On their Facebook page, the group describes itself as “a group of health care providers from diverse perspectives and disciplines dedicated to improving and understanding the care of cancer-related pain.”

According to Dr. Bruel, the group developed in part because doctors were frustrated that there aren’t any guidelines for treating pain in cancer patients—both those whose cancer is aggressive and those who will likely live for decades after their diagnosis.

The group seeks to develop guidelines that will create a multidisciplinary standard of care for cancer patients with pain. The long-term goal is to have different guidelines for each discipline; different standards of care for people with late-stage cancer than for those people whose cancer will likely go into remission after treatment.

Dr. Bruel says oncologists were trying to alleviate pain before the consortium formed, but they didn’t have a forum to discuss what worked well and what didn’t. And they weren’t necessarily talking to pain doctors. Now, thanks to the consortium, there’s a central “water cooler” where pain management physicians involved in cancer care can share their thoughts and experiences.

Hope for Cancer Pain Management

Dr. Bruel has plenty of reasons to be hopeful about the future of pain medicine. Not only has he helped start a dialogue with other doctors about cancer pain, but he imagines interdisciplinary, integrative care models and treatments—versus one single modality—as the future of managing pain.

He also thinks targeted therapies will become the norm. Today, for example, he says when a person with cancer has a tumor that metastasizes or a lesion that hurts, the oncologist may believe it’s time for more chemo. But a radiation oncologist may be able to zero in on the one lesion causing the pain and shrink it. The key to finding the best solution is forming a team of physicians and practitioners from a range of disciplines and reviewing all available treatment options with the care team.

“There are so many different ways to control pain these days,” Dr. Bruel says. “And we’d have never known it if we’d stayed in our silos.” {PP}