Cancer Pain Management

Chapter 66 Cancer Pain Management




Clinical Case Problem 1 A 75-Year-Old Man with Metastatic Bone Pain Secondary to Advanced Prostate Cancer


A 75-year-old man diagnosed with stage D cancer of the prostate 6   months ago comes to your office. He has been asymptomatic for the past 6   months, but last week he began to develop severe pain in the lower lumbar spine. He also appears quite pale.


On examination, his prostate is hard. He has tender lumbar vertebrae L2-5. Your suspicions of metastatic bone disease are confirmed when a technetium – 99   m bone scan shows increased uptake of radionuclide in L2-5 and in both femurs, both tibias, and both humeri.



Select the best answer to the following questions




1. What is the treatment of first choice at this time?


a. high-dose morphine sulfate

b. high-dose hydromorphone

c. transdermal fentanyl

d. palliative radiotherapy to the lumbar spine

e. acetaminophen-hydrocodone

2. You institute appropriate therapy for this patient. He quickly becomes pain free and remains that way for 6   months. He then returns with cervical, thoracic, and lumbar back pain; bilateral thigh pain; bilateral knee and leg pain; and pain in both shoulders and both arms (diffuse). Therapeutic options at this time include which of the following?


a. intravenous (IV) chlorinate

b. IV radioactive strontium

c. morphine sulfate

d. hydromorphone

e. naproxen

f. all of the above

3. Which of the following pharmacologic agents is the drug of first choice for the treatment of mild metastatic bone pain?


a. morphine sulfate

b. hydromorphone

c. fentanyl

d. a nonsteroidal antiinflammatory drug (NSAID)

e. carbamazepine

4. Which of the following drugs should not be used in the management of chronic pain?


a. codeine

b. meperidine

c. levorphanol

d. methadone


Clinical Case Problem 2 A 52-Year-Old Man with Metastatic Renal Cell Carcinoma


A 52-year-old man with metastatic renal cell carcinoma presents for assessment of a pain beginning in the buttocks and traveling down the left leg. It has a sharp, stabbing, burning, or “zinger-like” quality, according to the patient. The patient indicates that the baseline pain is 5 on a 10-point scale, with a range from 3 to 7.



5. What is (are) the drug(s) of first choice for the management of this patient’s cancer pain?


a. carbamazepine

b. hydromorphone

c. morphine sulfate

d. amitriptyline

e. desipramine


Clinical Case Problem 3 A 66-Year-Old Woman with Metastatic Renal Cell Carcinoma


A 66-year-old woman with metastatic renal cell carcinoma presents for assessment of a pain also beginning in the buttocks and traveling down the left leg. The only difference between this patient’s pain and that of the patient in Clinical Case Problem 2 is that this patient describes the pain as dull and throbbing.



6. What is (are) the drug(s) of first choice for the management of this patient’s cancer pain?


a. carbamazepine

b. hydromorphone

c. morphine sulfate

d. desipramine

e. valproic acid

7. The location of the lesions described in the two patients presented in Clinical Case Problems 2 and 3 is best portrayed as which of the following?


a. retroperitoneal

b. lumbar-sacral plexopathy

c. intraabdominal–visceral

d. a and b

e. b and c

8. What percentage of patients with cancer pain responds well to first-line analgesic therapy such as acetaminophen or NSAIDs?


a. 1%

b. 5%

c. 10%

d. 15%

e. 20%

9. Which of the following agents would be classified as second-line analgesic therapy for the management of cancer pain?


a. hydrocodone

b. acetaminophen

c. morphine sulfate

d. levorphanol

e. hydromorphone

10. Which of the following agents is not classified as a third-line pharmacologic agent in the management of cancer pain?


a. methadone

b. morphine sulfate

c. hydromorphone

d. fentanyl

e. codeine

11. A patient comes to your office with moderately severe cancer pain. You prescribe the third-line agent (because of the description of the pain as moderately severe). Which of the following best describes the preferred approach to management of this patient’s cancer pain?


a. begin with a twice-daily oral dose of long- acting morphine

b. begin with a twice-daily oral dose of long- acting morphine plus short-acting oral morphine for breakthrough pain

c. begin with a dose of short-acting oral morphine every 4 hours

d. begin with a transdermal fentanyl analgesic patch

e. begin with a dose of 200   mg morphine/day in any form

12. A patient who is maintained with long-acting morphine and short-acting morphine for breakthrough pain presents with a 1-week history of an increasing need for short-acting morphine. He is now taking three times the number of short-acting tablets as previously. What should you do at this time?


a. prescribe more short-acting morphine; keep the amount of long-acting morphine the same

b. transfer the increased requirement into long-acting morphine and maintain a supply of short-acting morphine

c. transfer the increased requirement into both increased amounts of long-acting morphine and increased amounts of short-acting morphine

d. switch to another third-line oral agent

e. switch to a transdermal delivery system

13. What is the average starting daily dose of morphine sulfate in the treatment of a patient with moderately severe cancer pain?


a. 10 to 15 mg

b. 15 to 30 mg

c. 30 to 60 mg

d. 60 to 120 mg

e. 120 to 240 mg

14. Which of the following statements regarding the use of morphine in the treatment of terminal cancer pain is (are) relevant to the patient in question?


a. morphine produces rapid tolerance

b. morphine produces euphoria

c. morphine produces respiratory depression

d. none of the above

e. all of the above

15. When a narcotic analgesic is prescribed for a patient, what is the single most important agent that should be started at the same time?


a. an agent to prevent constipation

b. an agent to prevent nausea and vomiting

c. an agent to enhance sedation

d. an agent to prevent drowsiness

e. an antidepressant

16. Which of the following is (are) essential to cancer pain management?


a. a collaborative, interdisciplinary approach to care

b. an individualized pain control plan developed and agreed on by the patient

c. ongoing assessment and reassessment of the patient’s pain

d. the use of both pharmacologic and nonpharmacologic therapies to prevent or to control pain

e. all of the above

17. Which of the following is (are) an aim(s) of pain management in palliative care?


a. to identify the cause of the pain

b. to prevent the pain from recurring

c. to maintain a clear sensorium

d. to maintain a normal affect

e. all of the above

18. Which of the following factors modify the pain threshold in patients with cancer pain?


a. insomnia

b. fear

c. anxiety

d. sadness

e. all of the above

19. A patient develops severe nausea and vomiting as the dose of morphine being used for terminal cancer pain (endometrial) is increased. The patient is undergoing triple antinauseant therapy, which includes dimenhydrinate, metoclopramide, and prochlorperazine. Which of the following statements regarding this situation is true?


a. you should add a fourth antinauseant to the regimen at this time, preferably a corticosteroid or ondansetron

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Cancer Pain Management

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