GPAtlas🧭 When to suspect
Suspect significant cancer-related pain in any patient with a known cancer diagnosis who presents with new or worsening pain. Pain is reported by the majority of patients with advanced cancer, is frequently undertreated, and is usually controllable with a systematic approach built around the World Health Organization (WHO) analgesic ladder: assess the pain, give regular background analgesia, and provide rescue doses for breakthrough.
The first task is to characterise the pain, because the type largely determines the choice of analgesic and adjuvant. The second, non-negotiable task is to exclude an oncological emergency – in particular metastatic spinal cord compression, raised intracranial pressure from cerebral metastases, and an impending pathological fracture.
| Pain type | Typical character |
|---|---|
| Somatic (soft tissue) | Dull, aching, throbbing and well-localised. |
| Bone | Localised and tender, worse on movement or weight-bearing. |
| Visceral | Deep, squeezing, crampy and poorly localised (e.g. liver capsule stretch). |
| Neuropathic | Burning, shooting, tingling or numbness in a nerve distribution. |
| Colic | Crampy and intermittent (bowel or ureteric). |
| Muscle spasm | Cramping, often accompanying bone pain or immobility. |
Distinguish continuous background pain from incident pain (predictable flares on movement or with care, e.g. dressing changes) and breakthrough pain (transient flares on a background of otherwise controlled pain), as each is managed slightly differently.
Source: NICE CG140 · WHO analgesic ladder
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