Orofacial pain in cancer: part II--clinical perspectives and management

Neuropathic and nociceptive pain in head and neck cancer patients receiving radiation therapy

BACKGROUND

Pain is common in head and neck cancer (HNC) patients and may be attributed to the malignancy and/or cancer treatment. Pain mechanisms and patient report of pain in HNC are expected to include both nociceptive and neuropathic components. The purpose of this study was to assess the trajectory of orofacial and other pain during and following treatment, using patient reports of neuropathic pain and nociceptive pain and pain impact.

METHODS

124 consecutive HNC patients receiving radiation therapy (RT) (95 men, 29 women; mean age: 54.7 +/- 12.3 years) participated in a patient-reported outcome (PRO) assessment. Patients completed the McGill Pain Questionnaire three times during therapy and 3 months following study entry.

RESULTS

The majority of patients related their pain to the tumor and/or cancer treatment. Whereas 59% reported their pain to be less severe than they expected, 29% were not satisfied with their level of pain despite pain management during cancer therapy. Worst pain was 3.0 +/- 1.3 on a 0- to 5-point verbal descriptor scale. Pain intensity was present at entry, highest at 2-week follow-up, declining towards the end of treatment and persisting at 3-month follow-up. The most common neuropathic pain descriptors chosen were aching (20%) and burning (27%); nociceptive words chosen were dull (22%), sore (32%), tender (35%), and throbbing (23%), and affective/evaluative descriptors were tiring (25%) and annoying (41%). 57% of patients reported continuous pain, and combined continuous and intermittent pain was reported by 79% of patients.

DISCUSSION

This study provides evidence that patients with HNC experience nociceptive and neuropathic pain during RT despite ongoing pain management. The affective and evaluative descriptors chosen for head and neck pain indicate considerable impact on quality of life even with low to moderate levels of pain intensity. These findings suggest that clinicians should consider contemporary management for both nociceptive and neuropathic pain in head and neck cancer patients.

Antinoceptive effect of triterpenoid alpha,beta-amyrin in rats on orofacial pain induced by formalin and capsaicin

The effects of alpha,beta-amyrin, a pentacyclic triterpene isolated from Protium heptaphylum was investigated on rat model of orofacial pain induced by formalin or capsaicin. Rats were pretreated with alpha,beta-amyrin (10, 30, and 100mg/kg, i.p.), morphine (5mg/kg, s.c.) or vehicle (3% Tween 80), before formalin (20 microl, 1.5%) or capsaicin (20 microl, 1.5 microg) injection into the right vibrissa. In vehicle-treated controls, formalin induced a biphasic nociceptive face-rubbing behavioral response with an early first phase (0-5 min) and a late second phase (10-20 min) appearance, whereas capsaicin produced an immediate face-rubbing (grooming) behavior that was maximal at 10-20 min. Treatment with alpha,beta-amyrin or morphine significantly inhibited the face-rubbing response in both test models. While morphine produced significant antinociception in both phases of formalin test, alpha,beta-amyrin inhibited only the second phase response, more prominently at 30 mg/kg, in a naloxone-sensitive manner. In contrast, alpha,beta-amyrin produced much greater antinociceptive effect at 100mg/kg in the capsaicin test, which was also naloxone-sensitive. These results provide first time evidence to show that alpha,beta-amyrin attenuates orofacial pain at least, in part, through a peripheral opioid mechanism but warrants further detailed study for its utility in painful orofacial pathologies.