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 Table of Contents  
Year : 2015  |  Volume : 29  |  Issue : 1  |  Page : 32-35

Evaluation of WHO guided pain management protocol in cases of cancer cervix

1 Department of Obstetrics and Gynecology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication1-Dec-2014

Correspondence Address:
Sabuhi Qureshi
G-36, Sanjaygandhi Puram, Faizabad Road, Lucknow - 226 016, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-5333.145942

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Introduction and Aims: Pain is a common debilitating symptom of cancer cervix. It occurs in 25-50% patients with newly diagnosed malignancies and in more than 75% of those with advanced disease. Yet, it is one of the most unattended problem. Henceforth, this study was planned to assess pain and to evaluate the response to pain management according to WHO step ladder protocol in cases of cancer cervix. Materials and Methods: This was a prospective cohort study that included patients of cancer cervix with pain. Patients of cancer cervix with severe systemic debilitating illness and those who had undergone major surgery in past 2 weeks were excluded from the study. The severity of pain was assessed by using visual analogue scale. Pain was managed according to WHO step ladder protocol for pain. Result: Total 61.5% patients of cancer cervix presented with pain. Success rate of WHO pain management protocol was 95.3%. Conclusion: Pain management was done effectively using WHO guided step ladder pain management protocol in 95.3% of cases. Oral Morphine is an effective drug for pain management. It is easily titratable and has a favorable benefit to risk ratio.

Keywords: Cancer cervix, diclofenac, morphine, pain, tramadol, WHO step ladder protocol

How to cite this article:
Goel S, Singh U, Qureshi S, Malik A, Singh N, Sankhwar PL. Evaluation of WHO guided pain management protocol in cases of cancer cervix. Indian J Pain 2015;29:32-5

How to cite this URL:
Goel S, Singh U, Qureshi S, Malik A, Singh N, Sankhwar PL. Evaluation of WHO guided pain management protocol in cases of cancer cervix. Indian J Pain [serial online] 2015 [cited 2021 Jan 28];29:32-5. Available from: https://www.indianjpain.org/text.asp?2015/29/1/32/145942

  Introduction Top

Cancer cervix is the commonest malignancy to affect women of all ages in the developing countries, accounting for an estimated 370,000 new cases and 160,000 deaths per year. In India, new cancer cervix patients are about 100,000 per year. [1] Pain is a common debilitating symptom associated with cancer cervix. It occurs in 25-50% patients with newly diagnosed malignancies, in more then 75% of those with advanced disease and in 33% of those undergoing treatment. [2] Pain has an impact on functional status and quality of life. Yet, it is one of the most commonly unattended and unsolved problem for cancer patient. WHO in 1986 laid down step ladder pattern algorithm as a guideline for control of pain. However, despite the availability of effective guidelines for pain control, most cancer patients live a poor quality of life, which increases their agony. Henceforth, this study was planned to assess pain and to evaluate the response to pain management according to WHO step ladder pattern in patients of cancer cervix.

  Materials and Methods Top

This was a prospective cohort study, carried out in the department of Obstetrics and Gynaecology of a tertiary care centre of north India, over a period of 1 year. Patients of cancer cervix of FIGO stage I, II, III, and IV having pain in abdomen, perineum, lower limbs, and back were recruited. Patient's with history of major surgery within past 2 weeks or with severe systemic debilitating disease like acute and chronic renal failure, HIV, respiratory disease, hepatobiliary disease, or with bleeding diathesis, thrombocytopenia or with epilepsy or history of seizures were excluded from the study.

After approval by institutional ethical committee, an informed consent was taken from all patients. Detailed history, physical examination, and relevant investigations including histopathological confirmation (of cancer cervix) were done for each patient.

Initial pain assessment was done by taking pain history including location of pain, character, duration, intensity, temporal pattern, aggravating and relieving factors. Pain intensity was measured by visual analogue scale [Figure 1]. After assigning baseline pain score, pain was managed according to WHO step ladder pattern [Figure 2]. The responder was defined as a patient whose pain score changed from mild (1-4) or moderate (5-6) or severe (> or equal to 7) to none (0) or mild (1-4), respectively. If pain score remained same or increased, the patient was considered as a non-responder. Step 1 analgesic drug (oral) diclofenac in the dose of 50 mg BD to 50 mg thrice daily was given for pain score of 1-6 (mild to moderate pain). Subsequent assessment of pain was done to evaluate the effectiveness of the drug after 48 hours of starting the treatment. A non-responder to first line of therapy (step 1) was given second line of therapy (step 2), and patients with initial pain score of severe (>7) were also given step 2 analgesic drug as first-line therapy. Step 2 included mild atypical opioid, oral tramadol 50 mg, 8 hourly to 50 mg, 3 hourly. The pain score was assessed after 48 hours of treatment. Patients who did not respond to step 2 drugs were given step 3 drug (oral) strong opioid-morphine 10-30 mg BD. Adjuvant drugs like amitriptyline (10-25 mg OD to 75 mg OD) and prednisolone (5 mg BD to 10 mg BD) were added along with step 2 and step 3 analgesics if needed. All the patients were evaluated for side effects of drugs and were managed accordingly. Once the patient's pain score declined to 0 (no pain), they were followed up to 2 weeks.
Figure 1: WHO step ladder pattern for pain management

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Figure 2: VISUAL ANALOGUE SCALE for assessment of severity of pain

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The statistical analysis was done using SPSS version 15.0 statistical analysis software. Variables recorded were age, residence (rural or urban), parity, stage of disease, pain score pre- and post-treatment assessed by visual analogue scale, individual response rate of each drug and side effects of drugs.

  Results Top

The study recruited 149 women of carcinoma cervix. Maximum patients (36.9%) were in 41-50 years of age group. In all, 69.5% of patients were Para 5 or more; 82.3% belong to low socioeconomic status; 85.1% patients were illiterate.

61.5% patients of cancer cervix presented with pain. Pain in lower abdomen was most common (73.2%) followed by pain in back (51%) and perineal region (33.6%). Most of the patients described pain as cramping (42.3%), pressure like (43.6%) or burning nature (14.1%). Majority 71.1% had pain of less than 6 months duration while 28.9% had pain of more than 6 months duration. The pain was intermittent in 52.3% and continuous in 47.7% patients. Visual analogue scale was used to quantify pain; 18 (12.1%) had a score of 1-4 (mild pain); 73 (49%) had a score of 5-6 (moderate pain) and 58 (38.9%), had a score of > or equal to7 (severe pain). The severity of pain increased as the stage of cancer increased. In Stage I, 70.8% did not have pain while in stage IV, 100% had severe pain.

The patients were managed for pain using WHO step ladder protocol [Table 1]; 91 patients with mild to moderate pain were given oral diclofenac (step 1). Of which, 67 (73.6%) responded and 24 (26.4%) did not respond (non-responders). Oral tramadol was given to 62 patients with severe pain and 24 patients with mild to moderate pain who did not respond to diclofenac. Out of 62 patients with severe pain, only 19 responded and 43 did not respond. Out of 24 patients(non responders of diclofenac), 19 (79.2%) responded, and 5 (20.8%) did not respond. Morphine was given to 43 patients. Of these, 41 responded and only 2 did not respond. 9 patients were given adjuvants with tramadol or morphine. Of these 7 responded and 2 did not respond. These were subsequently sent to institutional pain clinic. Overall pain relief could be done successfully in all but two patients out of 149 patients recruited in the study.
Table 1: Response to drug given in step ladder pattern

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The correlation between initial pain score and response rate was studied; 100% patients with mild pain responded and had no pain after treatment; 95.8% patients with moderate pain responded, and only 4.2% did not respond; 93.1% patients with severe pain responded, and 6.9% patients did not respond.

On comparing pain relief in various stages of cancer cervix, a positive correlation of complete response in early stage disease was seen as compared to in late stage disease (100%in stage I and II, 33.3% in stage IV).

The side effects of analgesics were studied. With diclofenac, a small group of 10.9% had nausea and vomiting, and 16.5% had epigastric pain. With tramadol, nausea and vomiting was in more patients (25%), whereas 8.5% had constipation. Total 30.2% patients on morphine had nausea; whereas 25.6% had vomiting and constipation. All the side effects responded to symptomatic treatment.

  Discussion Top

Pain is a subjective multi-dimensional experience unique to the individual and affects all aspects of life. Pain is also a common symptom in patients with cancer cervix. Yet, it is one of the most common unsolved problems for cancer patients. Pain in cancer cervix is a complex process and occurs from tumor invasion and spread in about 90% patients. Some patients experience pain due to radiotherapy and chemotherapy; 10% of pain is due to unrelated illness.

We evaluated a cohort of 249 women in different stages of cancer cervix. The mean prevalence of pain was 61.5% in all cancer stages. Majority of patients (76.8%) presenting with pain were in advanced stage (III and IV) followed by 53% of stage II and 29.2% of stage I of cancer cervix. With increasing stage, prevalence of pain increased and the difference was statistically significant too (P < 0.001). Van Den Beuken et al. (2007) [2] found that mean pain prevalence was 50% in all cancer stage, 64% in patients with metastatic or advanced stage disease, 59% in patients on anticancer treatment and 33% in patients after curative treatment. Bonica et al. (1995) [3] found 50% pain prevalence in various stage of cancer and 71% in advanced stages of cancer.

In cancer cervix, the common site of pain are back and lower abdomen due to pressure or involvement of upper lumbosacral plexus and pain in buttocks and perineal region due to lower lumbosacral plexus involvement. The most common site of pain was lower abdomen (73.2%), followed by back pain (51%) and pain in perineum (33.6%).

The intensity of pain was measured by Visual Analogue Scale (VAS). While 12.1% had mild pain, 49% patient had moderate pain, and 38.9% had severe pain. Total 149 patients of cancer cervix with pain were managed according to WHO step ladder for pain relief. Drug therapy by oral route was the corner stone of pain management. In present study, 95.3% patients of cancer cervix with pain responded to WHO-guided pain management protocol. Diclofenac, tramadol, and morphine were used as principal analgesic drugs.

It was observed that diclofenac was effective for majority of patients (73.63%) with mild to moderate cancer pain. Tramadol was effective in 69.56% of patients with mild to moderate cancer pain who were non-responders of diclofenac, but it was less effective in patients with severe pain (29.31%). Morphine was successful in 95.3% patients with severe pain. Thus, morphine was found to be most effective drug in cancer pain management.

MC Nicol E et al. (2004) [4] found that NSAIDS were preferred for mild to moderate cancer pain. Wilder Smith C et al. (1994) [5] observed that morphine was more effective than tramadol for cancer-related severe pain. Hanks G, Hawkins C et al. (2000) [6] have also concluded morphine as the mainstay and gold standard strong opioid of choice for severe pain not responsive to non-opioid or a non-opioid to weak opioid combination. Grond S et al. (1993) [7] has also reported adequate analgesia in 95% of patients with cancer pain.

Morphine has been underutilized in the past for number of reasons, including misconceptions regarding its use and side effects. It needs to be used more liberally for cancer pain management. Long-term use of opioids is associated with physical dependence and tolerance. Friedman (1990) reported that addiction rarely occurs in patients with cancer pain when drug use is appropriate. In the present study, morphine effectively took care of severe pain. We did not find addiction as it was a short-term study. The side effects noted were mild like nausea, vomiting, and constipation, which were managed symptomatically.

  Conclusion Top

Pain is a common symptom in cancer cervix patient. Delayed treatment, poverty, and poor status of women in society contribute to a high prevalence of pain from cancer cervix. Pain can be effectively managed by using WHO step ladder algorithm. Diclofenac provided pain relief in 73.63% patients of mild to moderate pain. Tramadol was effective in 44.2% patients. Morphine was most effective and provided analgesia in 95.3% patients. The overall success rate of WHO-guided pain management protocol was 95.3%. Morphine was the most useful drug in cancer pain management.

  References Top

Nandakumar A, Anantha N, Venugopal TC. Incidence, mortality and survival in cancer cervix in Bangalore India. Br J Cancer 1995;71:1348-52.  Back to cited text no. 1
van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J. Prevalence of pain in patients with cancer: A systematic review of the past 40 yrs. Ann Oncol 2007;18:1437-49.  Back to cited text no. 2
Bonica JJ. Advances in Pain Research and Therapy. In: Fields HL, Dubner F, Cevero F, editors. Treatment of Cancer Pain: Current Status and Future Needs. New York: Raven Press; 1985;9:589-616.  Back to cited text no. 3
McNicol E, Strassels SA, Goudas L, Lau J, Carr DB. Nonsteroidal anti-inflammatory drugs, alone or combined with oipoids, for cancer pain: A systematic review. J Clin Oncol 2004;22:1975-92.  Back to cited text no. 4
Wilder-Smith CH, Schimke J, Osteralder B, Senn HJ. Oral tramadol, a mu-opioid agonist and monoamine reuptake-blocker, and morphine for strong cancer pain. Ann Oncol 1994;5:141-6.  Back to cited text no. 5
Hanks GW, Hawkins C. Agreeing a gold standard in the management of cancer pain: The role of opioids. In: Hillier R, Finlay I, Welsh J, Miles A, editors. 1 st ed. The Effective Cancer Pain. London: Aesculapius Medical Press; 2000. vol. 1. p. 57-77.  Back to cited text no. 6
Grond S, Zech D, Lynch J, Diefenbach C, Schug SA, Lehmann KA. Validation of the World Health Organization guidelines for pain relief in cavncer patient. A prospective study. Ann Otol Rhinol Laryngol 1993;102:342-8.  Back to cited text no. 7


  [Figure 1], [Figure 2]

  [Table 1]


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