Ripamonti, C.I., Santini, D., Maranzano, E., Berti, M., Roila, F., & European Society for Medical Oncology (ESMO) Guidelines Working Group. (2012). Management of cancer pain: ESMO Clinical Practice Guidelines. Annals of Oncology, 23(Suppl. 7), vii139–vii154.

To provide clinical guidance regarding the assessment and management of pain in patients with cancer

The development process for these evidence-based guidelines was not described.

These guidelines are for use in patients undergoing multiple phases of care.

The search and full body of evidence were not described. Evidence and recommendation level relating to each management guideline was included.

• A visual analog scale, verbal rating scale, or numeric scale is recommended for assessment and reassessment.
• For mild pain, paracetamol or a nonsteroidal anti-inflammatory drug, or the two in combination, are recommended.
• For mild to moderate pain, weak opioids in combination with a nonopioid medication or low doses of strong opioids with nonopioid analgesics are recommended.
• For moderate to severe pain, the opioid of first choice is oral morphine and long-acting forms are acceptable alternatives. Transdermal fentanyl and buprenorphine are suggested for patients with renal failure and for those with poor tolerance of or compliance with oral opioids.
• All patients should have immediate-release formulations available to treat breakthrough pain. Oral, buccal, sublingual, and intranasal delivery systems are appropriate options.
• For bone pain, radiotherapy, radioisotopes, or targeted therapy in association with analgesics are recommended.
• For neuropathic pain, tricyclic antidepressants or anticonvulsants are recommended.
• Intrathecal and infraspinal approaches are recommended for refractory pain, as well as pain management by a specialized team.
• Celiac plexus block appears to be safe, effective, and better than standard techniques for patients with pain from pancreatic cancer.

• The authors provided limited information about the literature search, process of evidence categorization, and evidence-classification schema.
• Most levels and grades of evidence were low. The authors noted the lack of strong evidence from well-designed randomized controlled trials relating to patients with cancer.
• The underlying literature search appeared to be limited in the area of consistent paracetamol use and use of the World Health Organization ladder approach to mild and moderate pain. Recent evidence has suggested earlier use of strong opioids.

This resource provides general clinical practice guidelines regarding the management of pain of cancer. The authors note that cancer-related pain is generally undertreated. Nurses should be aware of the potential for the undertreatment of pain and advocate for effective pain management.