Chapter 22: Cancer pain assessment and management
Skip chapter table of contents and go to main content
Breakthrough cancer pain
Breakthrough cancer pain (BTCP) has been recognized as a burdensome, psychologically distressing symptom that is inadequately treated and often unresolved in many cancer patients. The scope guidelines developed by the European Oncology Nursing Society (EONS) describe and explain BTCP as an independent phenomenon with distinct clinical symptoms, and provide guidance on the assessment, identification and management of BTCP (EONS [65]). Although several definitions of BTCP exist, as yet there is no universally accepted definition, or agreed upon term, to describe BTCP. An expert group in palliative care defined BTCP as ‘A transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain”’ (Davies et al. [46]). BTCP is differentiated from background pain by being transient or episodic and breaking through the stable, controlled chronic background pain. Consequently, the treatment of BTCP demands a different management strategy. The term ‘breakthrough cancer pain’ is used in practice; however, other ways to describe this include ‘episodic’, ‘transient’ or ‘flare up’ pain.
Characteristics of BTCP
The two widely identified and accepted categories of BTCP are spontaneous pain and incident pain and these can be described as follows.
- Spontaneous pain (‘idiopathic pain’ – Davies et al. [46]). These episodes are not related to an identifiable trigger and so are more unpredictable.
- Incident pain (‘precipitated pain’). These episodes are related to an identifiable precipitant, and can be generally predictable in nature. Incident pain is usually sub‐classified into one of three categories:
- volitional incident pain which can be brought on by situations such as walking
- non‐volitional incident pain precipitated by an involuntary act such as coughing
- procedural pain related to an intervention such as changing of a wound dressing.
One of the key factors in the management of BTCP is that BTCP must not be confused with episodes of pain that occur in situations where the patient does not have controlled background pain. One example of such a situation is where episodes of pain occur during initiation or titration of opioid analgesics for the treatment of background pain – such episodes should be termed either a ‘background pain flare’, or simply an ‘exacerbation of background pain’. Another example is where episodes of pain occur before the administration of opioid analgesics in end‐of‐dose failure. It should be noted, however, that end‐of‐dose failure is regarded as a subtype of breakthrough pain by some experts in the field (Davies et al. [46]).
