title: Interventional options for the management of refractory cancer pain--what is the evidence?
abstract: OBJECTIVE
  Pain is the most common symptom in cancer patients. Standard pain treatment according to the WHO three-step analgesic ladder provides effective pain management in approximately 70-90% of cancer patients. Refractory pain is defined as not responding to "standard" treatments. Interventional analgesic techniques can be used in an attempt to control refractory pain in patients in whom conventional analgesic strategies fail to provide effective pain relief or are intolerable due to severe adverse effects. This systematic review aims to provide the latest evidence on interventional refractory pain management in cancer patients.
  
  
  METHODS
  Systematic literature search in Cochrane, EMBASE and PubMed including reviews and randomised controlled trials (RCTs) and non-randomised controlled trials in the absence of reviews.
  
  
  RESULTS
  Neuraxial analgesia may play a role in refractory cancer pain management. Paravertebral blocks decrease the incidence of persistent post-surgical pain after breast cancer. Coeliac plexus blocks improve pain scores in refractory pancreatic cancer pain for up to 4 weeks after the intervention with fewer burdensome side effects as compared to opioids. Cordotomy has mainly been studied in mesothelioma, and the case series suggest possible benefit for pain at the expense of a relatively high risk of side effects.
  
  
  CONCLUSIONS
  Overall, very few RCTs have been conducted on interventional pain techniques. In reality, it is very difficult to undertake large controlled trials for a number of reasons. Therefore, today's best evidence for practice may be from large case series of comparable patients with careful response and toxicity evaluation and follow-up.
authors.affiliation: Readaptation and Palliative Care, University Hospital of Geneva, Geneva, Switzerland.|Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia.
authors.forename: Petra
authors.initials: P
authors.lastname: Vayne-Bossert
authors.affiliation: Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia.
authors.forename: Banafsheh
authors.initials: B
authors.lastname: Afsharimani
authors.affiliation: Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia.|Palliative Care Services, St Vincent's Private Hospital Brisbane, Kangaroo Point, Australia.
authors.forename: Phillip
authors.initials: P
authors.lastname: Good
authors.affiliation: School of Medicine, University of Queensland, St Lucia, Australia.|Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Australia.
authors.forename: Paul
authors.initials: P
authors.lastname: Gray
authors.affiliation: Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia. janet.hardy@mater.org.au.|School of Medicine, University of Queensland, St Lucia, Australia. janet.hardy@mater.org.au.
authors.forename: Janet
authors.initials: J
authors.lastname: Hardy
mesh_terms: D000700:Analgesics / Q000627:therapeutic use*; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D006801:Humans; D009369:Neoplasms / Q000150:complications* / Q000188:drug therapy; D059408:Pain Management / Q000379:methods*; D010148:Intractable Pain / Q000188:drug therapy*
chemical_list: D000700:Analgesics; D000701:Analgesics, Opioid
keywords: Cancer; Interventional techniques; Pain management procedures; Refractory pain