Pharmacologic management of bone pain in the cancer patient

Cancer patients may experience acute or chronic pain caused by tumor infiltration of pain-sensitive structures or related to surgery, radiation, and chemotherapy. Acute bone pain, with or without associated neurologic deficits resulting from tumor metastasis to bone and contiguous neural structures (e.g., large peripheral nerve trunks or the spinal cord), is a common cause of intractable pain in cancer patients. Most often, treatment of bone pain involves the concomitant use of focal radiation therapy and analgesic drugs, especially steroids, nonsteroidal anti-inflammatory drugs (usually in combination with opioids), and adjuvant analgesic agents such as levodopa and calcitonin. However, pharmacologic therapy is not always efficacious and may have significant side effects. Less commonly, invasive therapies, such as resection of vertebral body tumor with spinal reconstruction or pituitary ablation and intraventricular opioid administration (for diffuse bone pain), are offered. In this article I discuss current approaches to the management of pain in cancer patients, emphasizing current hypotheses on the pathogenesis of bone pain and the rationale for its pharmacologic treatment.