Most chronic pain associated with cancer can be treated effectively. There is a tendency to undertreat cancer pain because of:

1. Fear of addiction to opioids
2. Concern that tolerance will develop quickly, with loss of analgesic effect
3. Fear of respiratory depression

In fact:

1. Addiction rarely occurs in cancer patients treated with narcotics, and is not a practical problem
2. Tolerance to narcotics does develop but can be managed in various ways; poor pain control, with increased requirement of analgesic, is much more likely to be due to progression of disease than to development of tolerance
3. Pain is an antidote to the respiratory depressant effect of narcotics. Respiratory depression is very rarely encountered when the dose of narcotic is carefully titrated

Poor control of chronic cancer-related pain is usually caused by:

1. Lack of knowledge of the pharmacology of drugs used with "standard," rather than individually determined doses, given "prn" rather than regularly
2. Inaccurate diagnosis of cause of pain

The possibility of control or prevention of symptoms by the specific treatment of tumours by surgical, radiation or medical means should always be considered and may often be the most effective palliation even when cure of the disease may not be possible. Radiation treatment of painful bone lesions or impending fractures may prevent a great deal of pain and disability. Radiation or chemotherapy may be the most effective way of dealing with obstructing mediastinal or pelvic disease. Cerebral metastases may be usefully palliated with the short term use of dexamethasone and in a more definitive way with cranial radiation. Spinal, nerve root and plexus compression or invasion may, similarly, respond to dexamethasone and radiation treatment. The treatment of spinal cord or plexus lesions constitutes an oncologic emergency because of the risk of irreversible injury and paralysis.

When specific treatment modalities are not possible or have not been effective, a number of other relatively simple procedures may provide relief from distressing symptoms. Surgical fixation of an actual or impending fracture should always be considered. Insertion of stents by surgical endoscopic or percutaneous means may relieve biliary or ureteric obstructions. Pleural effusions and ascites may be easily drained and this procedure may provide a great deal of symptomatic relief. Effusions tend to recur unless the underlying process can be treated and reversed. Instillation of an irritant such as tetracycline after total hemithorax drainage may produce adhesions between visceral and parietal pleura, preventing recurrence of the effusion. This technique is not applicable to abdominal effusions, but the use of diuretics may slow or prevent recurrence. The optimal means of control is effective treatment of the underlying disease when possible.