Special Report

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Cancer pain management:

recommendations from a Latin-American
experts panel
Yolanda Escobar Alvarez*,1, Claudia Agamez Insignares2, Monica Ahumada Olea3,
Olga Barajas4, German Calderillo R5, Jenny Cecilia Calvache Guamán6, Ricardo
Caponero7, Benjamín A Cavenago Salazar8, Auro del Giglio9, Ana Rocío Pupo Araya10,
Ricardo Villalobos-Valencia11, Andrés Yepes Pérez12 & Nilda Zumelzu Delgado13

Generating a consensus in the Latin-American region on cancer pain management is a

current need. Thus a panel of Latin-American experts met in Madrid in March 2017 in order to
review the published literature, discuss the best approach for cancer pain classification and
evaluation and also make recommendations of pharmacological and nonpharmacological
therapies for cancer pain management improvement in Latin-American countries. The result
of that meeting is presented in this document. The experts participating were from Costa
Rica, Mexico, Chile, Colombia, Peru, Brazil and Ecuador, and the project coordinator was from
Spain.

First draft submitted: 26 June 2017; Accepted for publication: 21 July 2017; Published online:
4 August 2017

Pain is a common symptom in cancer patients and although accurate prevalence estimates of pain
in cancer patients are not available, a systematic review of the literature showed that prevalence can
reach up to 70% in patients with advanced disease [1] , impacting directly their quality of life and
well-being. This high prevalence of pain in cancer patients compels all physicians who treat them
to also be trained in effective pain therapy.
The level of evidence and the grade of recommendation for cancer pain management are not
strong but the published guidelines recommend the use of opioids [2] . However, due to regulatory
barriers, among other reasons, in many countries, including the Latin-American region, the avail-
ability and use of opioids is suboptimal [3,4] leading to insufficient symptomatic relief of cancer pain.

1
Oncología Médica, Hospital General Universitario Gregorio Marañón, Madrid, Spain
2
Instituto Nacional de Cancerología/Universidad Militar Nueva Granada. Fondo Nacional de Estupefacientes en Políticas Públicas en
medicamentos de control especial. Asociación Colombiana de Cuidados Paliativos, Colombia
3
Oncología Médica, Hospital Clínico Universidad de Chile, Clínica Dávila, Chile
4
Oncología Médica, Hospital Clínico Universidad de Chile, Fundación Arturo López Pérez, Santiago, Chile
5
Instituto Nacional de Cancerología – Oncología Médica, Ciudad de México, México
6
Oncología Clínica, Hospital Solca-Núcleo Pichincha, Ecuador
7
Coordinator Supportive Therapy & Integrative Medicine, Hospital Alemão Oswaldo Cruz, Brazil
8
Jefe de la Unidad de Oncopaliativos del Programa ADAMO, Perú
9
Faculdade de Medicina do ABC, Setor de Oncologia Clínica do IBCC e do HCOR, Brazil
10
Unidad de Dolor del Hospital México/Unidad de Dolor Clínica Católica, Costa Rica
11
Centro Médico Nacional La Raza – Hospital de Ginecología, Ciudad de México, México
12
Oncología Clínica, Fundación Colombiana de Cancerología Clínica Vida, Colombia
13
Oncólogo Médico, Oncólogo Radioterapeuta, Hospital Base Valdivia, Clínica Alemana Valdivia, Chile
*Author for correspondence: yolandaesco@yahoo.es part of

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Special Report  Escobar Alvarez, Agamez Insignares, Ahumada Olea et al.
The recommendations agreed by this panel
of experts are summarized in the need to start
pain treatment early after diagnosis, the treat-
ment must be adjusted to the intensity of the
pain, adapted to the patient characteristics and
managed by a multidisciplinary trained team.
Opioid drugs are approved and recommended
for the cancer pain treatment and barriers to its
use should be eased.
Background
Cancer is a major public health issue in Latin-
America and the Caribbean. It is estimated that
by 2030 approximately 1.7 million people will
have been diagnosed with cancer in the region
and more than 1 million people per year will die
from the disease [4] . Consequently, major dif-
ficulties will arise when addressing the increas-
ing morbidity and mortality associated with the
disease, especially in advanced stages. Overall,
the region is poorly equipped to deal with the
alarming rise in cancer incidence and dispro-
portionately high mortality rates compared with
other world regions, underscoring the magnitude
of the cancer-control problem. However, there
have been several initiatives to implement pal-
liative services. Since 1998, the Pan-American
Health Organization has included palliative
care as a component of the Non-Communicable
Diseases Program and access to palliative care
has improved in the Latin-American region.
However, there are barriers that impede progress,
such as lack of health legislation regarding end-
of-life care, socioeconomic disparities, poverty
levels, ethnic and cultural diversities, low edu-
cational levels, lack of information on diagno-
sis and prognosis, limited availability of potent
analgesics, fear of diversion of opioids to illegal
markets and inadequate palliative-care policies.
Table 1. Regional per capita use of morphine in 2005.
Region Population (million)
North America 331
Latin America 549
Western Europe 387
Eastern Europe and Central Asia 495
Asia and Pacific 3620
Northern Africa and Middle East 350
Sub-Saharan Africa 741
Global 6473
Reprinted with permission from the International Council on Security and Development.
Reprinted with the permission from [7].
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Furthermore, in many Latin-American countries
resources are mainly directed to curative rather
than palliative treatment [5] .
Although pain is a common symptom in
cancer patients, currently there are no robust
epidemiological data to define the prevalence
accurately. The prevalence ranges in the Van den
Beuken review from 2007 from 43 to 63% at all
stages of the disease, 59% in patients undergo-
ing treatment for cancer, up to 70% in patients
with advanced or terminal disease and 33%
in survivors [1] . In a pan-European survey by
Breivik from 2009, 56% of the patients suffered
moderate-to-severe pain at least monthly, and
of those prescribed analgesics, 63% experienced
breakthrough pain (BTP) [6] .
The pain is caused either by the growing
tumor pressure over bones, nerves and other
organs or by the treatment itself (surgery, radio-
therapy, chemotherapy, hormonotherapy) and
directly impacts patients’ quality of life, affect-
ing their physical and psychological wellbeing.
The WHO developed the first guidelines on
cancer pain relief in 1986 (with updates in 1996
and 2016) based on the analgesic ladder concept,
meaning that the choice of the analgesic should
be determined by the intensity of the pain,
including the use of opioids and integrated in
the overall control of the patient diagnosis and
treatment [2] . But despite international efforts to
improve pain control, still the use of opioids is
suboptimal, leading to insufficient symptomatic
relief of cancer pain. Inadequate pain manage-
ment is a result of several factors such as the
biological behavior of the tumor itself, specific
patient features, lack of clinical practice or fear
of adverse effects and addiction to opioids by
physicians, all of which lead to restrictive health
regulations [3,4] .
Total morphine use Consumption per
(Kg) capita (mg)
18,402 55.5
573 1.04
9296 24.02
681 1.37
2431 0.67
103 0.29
228 0.3
31,714 4.9
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 Cancer pain management: recommendations from a Latin-American experts panel  Special Report

Total opioid consumption (morphine equivalence mg/capita)

2014

600
Consumption (mg/capita)

400

200

USA Spain Argentina Chile Brazil Peru Mexico Ecuador Bolivia

Sources: International Narcotics Control Board; World Health Organization population data
By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2017
Reprinted with the permission from the pain & policy studies group University of Wisconsin

Figure 1. Opioid consumption in Latin-America.

Reprinted with the permission from the Pain & Policy Studies Group, University of Wisconsin [8].

There is currently no cancer patient registry in
the Latin-American countries, and opioid drug
consumption is variable and their average use
remains far below international levels, suggesting
that pain management could be improved in the
Latin-American region. One of the challenges to
managing cancer pain in Latin-America is imple-
menting effective opioid use. Opioids are needed
to manage moderate and severe pain, and WHO
has included them on the list of essential medi-
cines, but not all countries in the region have the
same availability. Argentina and Brazil have the
highest medical use of opioids and there has been
reported good availability of short-acting mor-
phine and milder analgesics in Brazil, Argentina,
Mexico, Cuba and Peru. However, there is limited
availability of long-acting opioids and other step 3
analgesics (according to the WHO pain ladder),
which has a negative impact on the appropriate
management of pain in patients with advanced
cancer disease [5] (Figure 1 & Table 1) .
●●Barriers & difficulties that impede a correct
cancer pain management in Latin-America
& measures to overcome them according to
the participating experts
Despite some recent advances in opioid drugs use
for pain control in Latin-America, average con-
sumption remains below average levels in other
regions, which translates into inadequate can-
cer pain management. Entities such as the Pain
and Policy Studies Group and the International
Association of Hospices and Palliative Care have
worked to identify barriers to adequate supply
of opioids in different countries. Factors iden-
tified include restrictive legislation, inadequate
health systems, poor knowledge and training
among health professionals regarding use of
these drugs, and fear of addiction and adverse
drug events. The Pain and Policy Studies Group
and International Association of Hospices and
Palliative Care have organized workshops
in Colombia, Peru and Chile with doctors,

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Special Report  Escobar Alvarez, Agamez Insignares, Ahumada Olea et al.

Box 1. The panel of experts has agreed on the following measures to help overcome barriers related
to patients.
●● On-going physical examination and anamnesis in every treatment follow-up appointment, asking
specifically about pain
●● Inform the patient about the pain therapy, side effects, and so on
●● Extensive communication with the patient and family to let them know they don’t need to suffer in
silence
●● Educate and involve nurses in pain management
●● Foster Patient Associations for correct pain management which help improve and spread general
knowledge through awareness campaigns to communicate that every patient is entitled to pain relief

ministers of health, insurance companies man- are functional differences between the different
agers and patients to find solutions applicable to oncology units throughout the country, with
each country and conclusions are that training different pharmacological options available
of health professionals in the administration of depending on the management of each unit and
opioid drugs and prescription management are their respective hospitals or insurance coverages.
important actions needed to achieve optimum Therefore, it is important that the oncologist,
use of these drugs [5] . according to his pharmacological experience,
Currently pain in cancer patients is managed makes the case to his or her respective authority
in different ways depending on the country [6] the need for a pharmacological arsenal for the
and a summary of each situation according to palliative care and oncology departments.
the expert panel in some of the region countries The oncologist takes care of the pain manage-
is showed. ment only during steps 1 and 2 of the WHO
analgesic ladder. If step 3 is needed, the patient
Chile is referred to the palliative care unit, as opioid
The registry of tumors started more than drugs can only be prescribed there. In addition,
30 years ago in the South of Chile (Valdivia), prescriptions from the oncologist have to be
in 1989 as a Population Registry of Cancer in the paid by the patient while the prescriptions from
Region of Los Ríos (Southern Chile, Valdivia) the palliative care unit physicians are provided
and in 2004 new population registries in some free. This is difficult to manage since pain can
other regions. be diagnosed in early stages and be heightened
Cancer pain management has improved by chemotherapy; therefore, the oncologist
enormously in the last years and palliative care should be entitled to prescribe analgesic drugs
is guaranteed for all patients. The National as appropriate.
Program of pain relief and palliative care pro-
moted by the Ministry of Health was created in Mexico
1995, and in 2006 a guaranteed health system The Mexican Society of Oncology is just start-
was established that benefits the patient, includ- ing to collect epidemiological data from some
ing quality care in defined times and financial of the tumors. Besides, the oncologists are not
support. trained in pain management, there is lack of
In the public healthcare system users do not pain management diffusion and its impact on
pay for services while in the private one there patients in quality of life, there is no global access
is a 20% co-payment of the total cost. There to all drugs recommended by international
Box 2. The panel of experts has agreed on the following measures to help overcome barriers related
to healthcare providers.
●● On-going education on pain management after graduation
●● Awareness of cancer pain therapy
●● Global management of the patient by the oncologist with continuous care
●● Time optimization of the medical appointment
●● Ask for support from other consultants in case that the oncologist is not well trained in pain
management
●● Promote projects and leadership to improve coordination between consultants
●● Pain management led by the oncologist

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 Cancer pain management: recommendations from a Latin-American experts panel  Special Report

Box 3. The panel of experts has agreed on the following measures to help overcome barriers related
to the healthcare system.
●● Foster the patient’s continuous care between consultants and different levels of care
●● Guarantee pain treatment to all cancer patients
●● Oncologists should be able to prescribe opioid drugs, with public funding available in each country as
well as in palliative care units
●● Promote education in pain management at the public universities and ensure it is also included in the
private universities
●● Supervise the implementation of pain management protocols
●● Facilitate the approval of pain drugs and simplify the administrative prescription procedures
●● Implement a nationwide palliative care policy

management guides and no access of the patients Ecuador

to healthcare by specialists in pain. Therefore,
it would be necessary to increase awareness of
pain management training for the health profes-
sionals who are in contact with patients. Finally,
there are no palliative care and pain manage-
ment units in every cancer hospital, thus subse-
quent assessments are not always possible. This
situation shows that there are currently many
difficulties in Mexico hampering appropriate
cancer pain management.
Colombia
In Colombia, there has been a formal program
for the past 20 years offering a second specialty
in pain and palliative care for five base specialties
(Internal Medicine, Geriatrics, Rehabilitation,
Family Medicine or A nesthesiolog y).
Additionally, the National Institute of
Cancerology has developed educational pro-
grams for Radiotherapy, Medical Oncology
and Surgery that include pain management and
palliative care. Cancer patients are managed by
the oncologist and the support unit, requiring a
close coordination between both departments.
A palliative care law has recently been approved
which guarantees the multidisciplinary manage-
ment of the cancer patient’s pain and symptoms
and there are currently information campaigns
to help understand the patient’s right for a better
quality of life; however, opioid drugs can only
be prescribed for 30 days.
According to data from Tumor Registries in the
country, unfortunately, the cancer in most of
the locations is diagnosed late, which makes it
difficult to manage pain in a timely manner.
The Ministry of Public Health of Ecuador has
brought together specialists in the subject for the
implementation of clinical practice guides. The
first Palliative Care guidelines were published
in 2014 [9] and the guidelines for Management
of Adult Pain were developed in 2016. The
objective is to provide clinicians with clinical
recommendations based on the best available
scientific evidence on the treatment of pain in
adult cancer patients. Unfortunately, the lack
of global access to all the drugs recommended
by the international guidelines is evident and
the actual management is based depending on
the pharmacological options of each unit, which
translates into significant differences in treat-
ment between units. Oncologists often manage
the pain of the cancer patient, although there are
also some anesthesiologists treating pain.
Not all hospitals have a Pain Therapy
Department who perform pain management
with intervention if necessary. Unfortunately,
the number of pain specialists in Ecuador is
small compared with the needs (it is estimated
that in 2020 there will be 31,420 new cancer
cases in Ecuador according to the projections
by the registry of tumors of the Hospital Solca
Quito).

Table 2. Pain classification.

Duration Pathophysiology Type Intensity
• Acute • Nociceptive • Continuous or basal • Mild
• Chronic or basal   Somatic • At the end of the dose • Moderate
• Breakthrough:   Visceral • Breakthrough • Severe
 Incidental • Neuropathic
  Volitional • Combination of both
  Involuntary
 Idiopathic

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Special Report  Escobar Alvarez, Agamez Insignares, Ahumada Olea et al.
0 1 2 3
No pain Mild pain
Figure 2. Numerical scale.
Costa Rica
Oncologists do not treat cancer pain as patients
are referred early to the palliative care unit. The
main barrier in Costa Rica for the good control
of cancer pain is that there are few alternatives
of opioids for drug rotating. The only options
available are morphine (oral, subcutaneous and
intravenous), methadone (oral and subcutane-
ous), fentanyl (25, 50, 100 mc patches 25, 50,
100 and intravenous), tramadol (oral, subcuta-
neous and intravenous) and oxycodone (only in
private healthcare). Another issue relates to the
fact that patients are usually referred to pain or
palliative care clinics in the late cancer disease
stages. In addition, there is low access in the pub-
lic healthcare sector to the intervention treat-
ments for cancer (such as celiac plexus block)
– these kind of treatments are performed only
in the private healthcare sector.
There are 45 pain and palliative care public
clinics in Costa Rica all around the country and
8 NGOs that work independently and 130 pain
Sin
dolor
0 1 2 3 4 5
Sin
dolor
Sin
dolor
Figure 3. Analog visual scale.
Reprinted with permission from [10].
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4 5 6 7 8 9 10
Moderate pain Severe pain
specialists registered in the Costa Rican Medical
Society with a 4-year residency education. There
are also two universities that offer the Masters in
Palliative Care with a duration of 1 year and 1.5
years, respectively. All pain and palliative care
clinics are led by palliative specialists. There is
only one clinic in the capital that has a part-time
oncologist.
Peru
Oncologists frequently manage cancer patients’
pain but other medical specialties, especially
anesthesiology, also manage the pain of can-
cer patients. In this aspect, a considerable and
increasing number of anesthesiologists are focus-
ing on palliative care, especially in pain man-
agement. There is a home based palliative care
program in Callao that does include oncolo-
gists, where part of the job is to fully inform the
patients and family about treatment compliance,
outcomes and prognosis. However, this domi-
ciliary palliative care program is still confined
Peor dolor
(anverso)
6 7 8 9 10
Peor dolor
(reverso)
Peor dolor
que haya
sentido
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 Cancer pain management: recommendations from a Latin-American experts panel  Special Report
to a very small region of the country. Armed
forces hospitals and the social security system
are also developing similar domiciliary programs
with interesting results. Oncologists and pallia-
tive care units, in some cases, work in complete
coordination and communication.
Brazil
Most of the pain management is still under the
care of medical oncologists. The more difficult
cases that need to be controlled with certain
medications are referred to pain specialists who
can sometimes execute some procedures such as
nerve blocks, epidural catheters, etc.
Opioid drugs are potentially available through
a restricted prescription policy to all physicians,
including those who care for cancer patients.
Unfortunately, the number of pain special-
ists is small relative to our overall population.
Furthermore, the private healthcare system still
lacks of many of the newer opioid formulations
and our public healthcare system may not be able
to offer basic opioid medications to all patients
at all times.
The main common barriers in the region for
the cancer pain treatment with opioid drugs are:
●● Related to patients (Box 1) :
●● Minimization of the symptoms;
●● Sociocultural factors and family environment;
●● Opiophobia/fear of addiction;
●● Cost of the drug.
●● Related to healthcare providers (Box 2) :
●● Lack of awareness about patient’s continuous
care needs;
●● Low level of knowledge, skills and training in
cancer pain management with opioids;
●● Lack of commitment to control symptom;
●● Prioritization of tumor treatment;
Box 5. Basic principles in the pain evaluation.
●●   Assessment always before treating, only after a thorough evaluation of the pain can we establish the
appropriate treatment
●●   The intensity of the pain must be quantified by the patient
●●   Thorough clinical history and physical examination must be done
●●   Identify the type of pain (nociceptive or neuropathic) and if it has breakthrough character
●● Assess the physical and emotional impact on the patient
●●   Involve the patient in the therapeutic decisions
●●   On-going follow-up of the treatment outcome
future science group
Box 4. The questions included in the patient
assessment are.
●● How intense is your pain?
●● How would you describe your pain?
●● Where do you place your pain?
●● Does your pain transfer to other body regions?
●● When does the pain appear?
●● What makes your pain improve or worsen?
●● How does this pain affect your daily life?
●● What does your pain mean to you?
●● Opiophobia;
●● Lack of coordination between specialty
departments;
●● No continuity of care;
●● Lack of time.
●● Related to the healthcare system (Box 3) :
●● Low economic resources;
●● Lack of healthcare personnel;
●● Cancer pain management not included in the
cancer treatment protocols;
●● Lack of education programs on oncological
pain at all levels (undergraduate and post-
graduate);
●● Institutional barriers to the prescription of
opioids and access limitations for some medi-
cal specialties;
●● Insufficient or inexistent legislation enforcing
and implementing a nationwide palliative care
policy.      
General aspects of oncological pain
●●Pain classification
Pain can be defined as a sensory, emotional
and cognitive unpleasant experience associated
with a tissue injury where multiple physical,
psychological and social factors can influence
amplifying or diminishing the sensation as
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Special Report  Escobar Alvarez, Agamez Insignares, Ahumada Olea et al.
Table 3. Pain scales.
One dimension† tools
- Visual Analogue Scale (VAS)
- Numerical Rating Scale (NRS)
- Verbal Rating Scale (VRS)
†
One-dimension tools refer to physical factors only and multidimension tools refer to physical, psychological and social factors.
Data taken from [15,17–18].
well as the response to the treatment. Cancer
pain is a chronic, destructive, useless, harmful
and unlimited pain frequently accompanied
by depression and mood swings with an enor-
mous psychological, emotional and sociofamilial
impact.
The most frequent pain is caused by the
tumor due to infiltration or compression by the
tumor itself, adenopathy or metastasis in bones,
nerves, viscera, soft tissues, vessels, etc., but it
can also be related to the treatment aimed at
eradicating the tumor (surgery, radiotherapy,
chemotherapy, hormone-therapy triggering
acute and delayed toxicity) or to other causes
such as infections (e.g., postherpetic neuralgia)
or muscle spasticity.
Pain can be classified taking into account dif-
ferent criteria [10,11] (Table 2) .
According to the intensity
Pain intensity can be measured through the
use of validated assessment tools: the Visual
Analogue Scale (VAS), the Verbal Rating Scale
and the Numerical Rating Scale are the most
simple and used in the clinical practice [12,13] .
VAS is a psychometric response scale which
can be used in questionnaires, consisting of a
horizontal 10 cm long line at the ends of which
lie the extreme pain expressions, with no pain on
the left side and worst possible pain on the right
side. The patient is asked to indicate the pain
intensity he is suffering. Following the criteria
Second step
First step Weak opioids
Non-opioids and
Non-opioids and
adjuvants
adjuvants
Figure 4. Analgesic ladder steps.
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Multi-dimensional† tools
- Brief Pain Inventory
- McGill Pain Questionaire
- Edmonton staging system for cancer pain
- Lattinen Test
of the WHO analgesic ladder we can classify the
pain according to its intensity:
●● Mild pain: VAS from 0 to 3;
●● Moderate pain: VAS from 4 to 6;
●● Severe pain: VAS from 7 to 10.
According to the duration
●● Acute: pain lasting less than 3–6 months with
a well-defined onset and objective signs and
symptoms;
●● Chronic: pain lasting more than 6 months and
not usually accompanied with objective signs;
Persistent pain progressively impairs both
the physical and the psychological state of the
patient. The level of tolerance to pain decreases
perhaps due to the depletion of endorphins
and loss of sleep and appetite may also occur,
­resulting in a quality of life decrease.
●● BTP has been established as transitory exac-
erbations of pain that occur on a background
of stable pain otherwise adequately controlled
by around-the-clock opioid therapy, although
there is no widely accepted definition or well
validated assessment tools. BTP is classified
as:
-- Incidental: triggered by known causes
(movement, cough, defecation) and it can be
predictable or unpredictable depending on
the cause being voluntary or involuntary;
Fourth step
Third step Spinal
Strong opioids Analgesia
Non-opioids and and other
adjuvants techniques
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 Cancer pain management: recommendations from a Latin-American experts panel  Special Report
-- Idiopathic: appears spontaneously without
a triggering factor and it usually has a neuro­
pathic origin.
According to the pathophysiology
●● Nociceptive pain which, in turn, is divided in
two further categories:
-- Somatic pain is caused by the involvement
of dense organs like bones, muscles and
subcutaneous cellular tissue. It is character-
ized by being located in the affected area,
by increasing with the pressure of the
affected area and by being a dull and con-
tinuous pain (although there may be tem-
porary exacerbations of pain intensity). An
­example is the pain produced by a bone
­metastasis.
It responds adequately to nonopioid and
opioid analgesics.
-- Visceral pain is a dull, deep, oppressive and
poorly located pain. It is caused by damage
or pressure of organs and viscera and it is
expressed as a continuous pain or colic,
located in a large area due to the wide vis-
cera innervations. Pressure over the area
may or may not trigger the pain and may
occasionally present as referred pain (liver
and bile ducts: in scapula and right shoul-
der, pancreas and retro-peritoneum: at the
waist etc.).
It responds adequately to NSAIDs, opioids
and spasmolytic drugs when there is a colic
component.
●● Neuropathic pain: Neuropathic pain is
caused by tumor infiltration of the peripheral
nerves, the spinal cord or the central nervous
Table 4. Step three drugs conversion.
Opioids conversion table
Morphine o. 30 mg 40 mg
Morphine sc. 15 mg 20 mg
Morphine iv. 10 mg  
Oxycodone o. 15 mg 20 mg
Buprenorphine TD 10 mcg/h 20 mcg/h
Fentanyl TTS 12,5 mcg  
Hydromorphone 4 mg  
o.
Tapentadol o.   100 mg
i.v.: Intravenous; O.: Oral; s.c.: Subcutaneous; t.d.: Transdermal; TTS: Transdermal therapeutic system.
Adapted with permission from [22]. Pharmacological Management of Cancer Pain in Adults. National Clinical Guideline No. 9.
Department of Health An Roinn Sláinte. ISSN 2009–6259. Published November 2015. Pages 104 and 106.
future science group
system or due to paraneoplastic or treatment-
induced polyneuropathy. It can be expressed
as continuous paresthesia, episodes of excru-
ciating pain, or both, and can be accompa-
nied by hyperalgesia or allodynia due to the
anatomical and neurophysiological changes
produced with the stimulus transmission. It
is described as an electric discharge, unpleas-
ant, burning, stabbing, tingling, cramping,
itching and straining and may be adequately
controlled by non-opioids and opioids alone
or combined with tricyclic antidepressant
drugs or a­ nticonvulsants.
●●Assessment of patients with pain
In the context of cancer it is not uncommon
for pain to be underestimated. Patients can feel
that their oncologists prioritize first the treat-
ment of cancer, forgetting or minimizing the
importance of pain management, or the patients
themselves do not clearly communicate about
the pain intensity, fearing that this can be linked
to therapeutic failure and illness progression.
For this reason, all patients should be examined
and asked about pain at each visit. The objec-
tive includes not only a greater sense of comfort
but also a better ability to perform everyday
activities. In case that pain is confirmed, it has
to be quantified and characterized in terms of
intensity, localization, frequency, physical char-
acteristics, rhythm, triggers and relief factors, as
well as response pattern to current and previous
treatments. In addition to evaluating pain inten-
sity, it is necessary to determine the underly-
ing pathophysiological mechanism (nociceptive
or neuropathic) in order to establish the most
adequate treatment options. Furthermore, an
exhaustive evaluation of the pain can contribute
60 mg 80 mg  
30 mg 40 mg 45 mg
20 mg   30 mg
30 mg 40 mg 45 mg
35 mcg/h   52,5 mcg/h
25 mcg   37,5 mcg
8 mg   16 mg
  200 mg  
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Box 6. Characteristics of the breakthrough pain.

●● The highest intensity appears at 10 min (only 5 min if incidental BTP)
●● The average duration of the episodes is 60 min
●● Average number of episodes per day is 1–3
●● Incidental pain predominates
●● The average intensity is HIGH (VAS 7)
●● VAS must descend ±4 points to be considered relieved
●● Only the HALF of patients suffering from BTP receive appropriate treatment
VAS: Visual Analogue Scale.
Data taken with permission from [31–33].

to detecting new tumor lesions and improving
the follow-up of the patients.
The pan-European survey by Breivik in 2009
indicated that many patients with moderate to
severe cancer pain received no analgesic medica-
tion, and among patients reporting severe pain,
only 24% received strong opioid monotherapy.
The use of weak opioids was prevalent, suggest-
ing that several reasons may have accounted for
the poor care of cancer pain including inad-
equate appreciation for or lack of knowledge
by the physician of the intensity of the pain,
fear of the adverse effects of strong opioids and
regulatory barriers to opioid prescription and
dispensing [14] .
The International Association for the Study
of Pain describes pain as an unpleasant sensory
and emotional experience that is associated with
actual or potential tissue injury. The pain experi-
ence is always subjective and adequate measure
is difficult. Given that there is no international
consensus on classification of cancer pain and
that specific tools are lacking, the conventional
scales used for other forms of chronic pain are
commonly applied for initial and ongoing assess-
ment of pain and of patients with pain at any
disease stage. These scales are equivalent in
terms of simplicity, clarity and ease of applica-
tion. Clinical trials have demonstrated that the
Numerical Rating Scale is more reliable than
the VAS [15] . These scales have limited sensitiv-
ity owing to wide interindividual variability and
different emotional, affective, cognitive, cultural
and behavioral responses [16] .
The patient assessment should also include
questions about onset of pain, site affected, irra-
diation, quality (pressure, throbbing, muscle-
cramps, colic, visceral pain, burning sensation,
electrical current and tingling), intensity in
the previous 24 h and week, both at rest and
in motion, attenuating and exacerbating fac-
tors, duration, response to analgesics, as well as
an evaluation of functional, psychological and
social consequences [13] .
It is important to record previous analgesics
and the treatment outcomes, additional informa-
tion that can modify perception of pain should
be taken into account (e.g., psychiatric history,

Breakthrough

Pain at the end Incidental pain Idiopathic pain

of the dose stimulus dependent stimulus independent

Predictable: Unpredictable:
movement ischemia, cough,
bladder spasm

Figure 5. Breakthrough pain.

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 Cancer pain management: recommendations from a Latin-American experts panel  Special Report
Breakthrough pain
• Exacerbation of pain (VAS > 7)
• Rapid onset 1–5 min
• Short duration < 10–20 min
• Quick release
• Strong painkillers
• Short duration
• Easy to use Breakthrough pain
10
9
8
7
Pain level
6
5 Basal
4 pain
3
2
1
0
Figure 6. Basal and breakthrough pain differences.
potential current or previous opioid addiction
and risk factors that may lead to inadequate pain
management).
Therefore, more complete multidimensional
scales may be more appropriate for use as they
measure three dimensions (sensory, affective and
evaluative) as well as intensity of pain and patient
status, and have been validated for various cul-
tures and languages, including Spanish [17–19] .
Neuropathic pain should be identified using the
tools suggested by the International Association
for the Study of Pain (i.e., Lanss Pain Scale,
DN4, Neuropathic Pain Questionnaire, pain-
DETECT) [20,21] (Boxes 4 & 5, Tables 3 & 4, Figures
2 & Figure 3) .       anxiolytics) play a key role and are commonly
●●Pain management
The WHO developed the first guidelines on can-
cer pain management in 1986 based on the anal-
gesic ladder concept, meaning that the choice of
the analgesic should be determined by the inten-
sity of the pain, including the use of opioids and
integrated in the overall control of the patient
diagnosis and treatment. The ladder is divided
into three steps depending on the intensity of
the pain [2] . Therefore, the evaluation of the dif-
ferent therapeutic options requires quantifying
the pain previously felt, and decision-making in
relation to pain must be adjusted to its intensity.
The fourth step is not included in the WHO
guidelines that refers to invasive techniques and
other routes of administration (Figure 4) .
future science group
Basal pain
• Background pain
• Continuous
• Long duration
• Regular schedule
• Fixed dose
• Individual titration
Time
Once the underlying pathophysiology and the
intensity are defined, specific treatment should
be initiated.
The pain can present with nociceptive or
neuropathic components or both. In situations
of nociceptive pain, the treatments used can
include nonsteroidal anti-inflammatory agents
[NSAID] (diclofenac, ibuprofen, naproxen),
adjuvants (corticoids and biphosphonates) and
associated with weak opioids (tramadol) or even
strong opioids (buprenorfine, hydromorphone,
methadone, morphine, oxycodone). For neuro-
pathic pain, adjuvant treatments (such as anti-
convulsants, antidepressants, antipsychotics and
used; opioids should also be used.
Treatment of mild pain
Nonopioid analgesics, such as paracetamol or
an NSAID, are indicated for the treatment of
mild pain (VAS 1–3) and are commonly used for
the treatment of cancer pain as the first step, if
necessary to the maximum recommended dose,
and if the nonopioid no longer relieves the pain,
an opioid drug should be prescribed in addition
to the nonopioid [2] .
Treatment of moderate pain
In case of moderate pain (VAS 4–6), patients
are usually treated with a combination of
paracetamol, aspirin or NSAID plus a weak
opioid (codeine or tramadol) [2] . The level of
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Box 7. Situations that can trigger incidental predictable breakthrough pain are:
●● Swallow in patients with oral mucositis
●● Diagnostic tests (PET, CT scan, bone scan)
●● Treatments that require posture or painful technique – radiotherapy
●● Mobilization maneuvers: get up, turn around
●● Wound healing of pressure ulcers

recommendation for the use of weak opioids is
not strong and low-dose third-step opioid substi-
tution could be a better choice because weak opi-
oids have analgesic ceiling and the adverse events
are common to opiates. The European Palliative
Care Association also recommends the use of
strong opioids in low dose [23] . Options to be
used could be morphine, buprenorphine, fenta-
nyl, hydromorphone, tapentadol or oxycodone.
Treatment of severe pain
Strong opioids (morphine, oxycodone, hydro-
morphone, fentanyl, buprenorphine, tapent-
adol) are the cornerstone of treatment for severe
chronic oncologic pain (VAS 7–10), sometimes
in combination with adjuvants and with no anal-
gesic ceiling, the dose limit is marked by the
appearance of side effects.
Any of them can be used as opioid of first
choice in the third step because the analgesic
strength is very similar and the availability of
different drug options is an advantage in offer-
ing the patient the pathway, interval and toxic-
ity profile best suited to his or her situation and
needs. The rotation of opioids (replacement of
one opioid by another using the equivalent dose
in case of poor analgesic response or intolerable
toxicity) may be needed and the treatment pre-
scribed must be tailored to every patient (Table 4) .
Although the oral route of administration is
commonly chosen, when urgent relief is needed
other routes (subcutaneous or intravenous)
can be more useful. Additionally, transdermal
treatments (fentanyl, buprenorphine) are pre-
ferred for patients whose opioid requirements
are stable, are unable to swallow or have poor
compliance [24] .
●●Breakthrough pain
A special mention must be referred to BTP
(Figure 5 & Box 6) , which is defined as an acute
exacerbation of pain with sudden onset, short
duration, and moderate-to-high intensity in
patients who experience stabilized baseline
pain controlled with opioids [25] . It should be
not confused with other types of pain in order
to manage it correctly, because the diagnosis
and adequate management remain challeng-
ing  [26–29] (Figure 6) . The average prevalence
of the BTP in a 2012 multicenter trial was
66%  [30] , although the estimate of episodic
or BTP depends strongly on the definition of
the phenomenon and the methods applied to
­diagnose it  [30] .
The main features of BTP are as follows [34] :
●● Fast onset;
●● Short duration;
●● Moderate-to-severe intensity.
Box 7 shows the situations that can trigger
incidental predictable BTP.

Box 8. Requirements to be met by the medical oncologist.

●● Oncologists must be educated and trained in epidemiology, etiology, pathophysiology, drug
treatments both for pain and continuous care in cancer patients
●● Education for the nurses to improve pain diagnosis and treatment
●● Anamnesis of pain in all cancer patients, regardless of the stage of the tumor and the intention of the
specific tumor treatment (location, irradiation, duration, worsening and relief factors, response to
analgesics used)
●● Periodic physical exploration of the pain if detected
●● Additional analytical or radiological tests if considered necessary to better define the pain (fractures,
compressions, obstructions)
●● The objective is to obtain an etiological (tumor, toxicity, others) and pathophysiological (nociceptive,
neuropathic or mixed pain) diagnosis
●● Cancer pain assessment ideally using multidimensional tools although in clinical practice only one-
dimensional tools to measure pain intensity are used (VAS, faces, numerical scale)

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 Cancer pain management: recommendations from a Latin-American experts panel  Special Report

Table 5. Treatment options.

First step Second step Third step Fourth step
Nonopioids Weak opioids Strong opioids Intervention techniques
• Aspirin • Tramadol • Morphine • Pain units
• Paracetamol • Codeine • Buprenorphine
• Ibuprofen • Hydrocodeine +Transdermal
• Indomethacin • Dextropropoxyphene +Intravenous
• Naproxen +Oral
• Diclofenac • Oxycodone
• Oxycodone+ Naloxone
• Fentanyl
+ Transdermal
+Transmucosal
• Hydromorphone
• Methadone
• Tapentadol

Discussion Being free from pain should be considered

The global burden of cancer has doubled in the
last 30 years of the 20th century and is esti-
mated to double again between 2000 and 2020
and is likely to triple by 2030 [35] . By 2030, it is
projected that there will be worldwide around
26 million new cancer cases, driven largely by
growth and aging of populations and will be
largest in low- and medium-resource coun-
tries [36] . Pain occurs in 20–50% of the patients
with cancer at the time of diagnosis [37] and the
prevalence of chronic pain in populations with
solid tumors is 15–75% [38] , with approximately
80% of the patients with advanced metastatic
disease suffering moderate to severe pain [37,39] .
Although there are many international rec-
ommendations on the management of cancer
pain, inadequate pain relief still exists [40] . The
quality of life of the patients suffering chronic
pain is impacted enormously as cancer pain
is usually associated with depression, anxiety
and fatigue [12,14] and 69% of cancer patients
have reported that pain limits their daily
activities  [12] .
as a right for all cancer patients and access to
therapeutic measures as a way to respect that
right [41] . Thus the objective of this consensus of
cancer pain management by the Latin-American
panel of experts is to help understand the need
to train all the oncologists in pain management
and the importance to have available an array
of therapeutic options to best provide relief of
cancer pain in all patients.
Cancer pain has a strong impact on patient’s
quality of life and thus correct pain management
should be as important as the tumor treatment.
The first thing to highlight is the importance to
diagnose the pain early in order to initiate the treat-
ment as soon as it appears with the right approach
depending on the its nature. Second, it is also
remarkable to mention the need to carry out the
patient management by a multidisciplinary team.
There is a great variability in terms of environ-
ment, health benefits, patient management pro-
tocols, approved drugs, etc., among the different
countries in the Latin-American region, but there
is a willingness to reach a minimum consensus

Table 6. Treatment options.

Adjuvants
Antagonists  Antidepressants  Anticonvulsants  Corticoids  Other 
• Naloxone • Amitriptiline • Gabapentine • Dexamethasone • Bisphosphonates:
• Imipramine • Pregabaline • Prednisone     Zoledronic acid
• Venlafaxine • Prednisolone Denosumab
• Duloxetine • Radiotherapy
• Surgery
• Rehabilitation
• Psychology

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Special Report  Escobar Alvarez, Agamez Insignares, Ahumada Olea et al.
Box 9. The therapeutic strategy must include all
the following steps:
●● Select the appropriate drug;
●● Prescribe the adjusted dosage;
●● Select the route of choice;
●● Indicate the appropriate dose interval;
●● Prevent persistent and irruptive pain;
●● Titrate the dosage;
●● Prevent and treat adverse effects;
●● Use the right adjuvant drugs;
●● Evaluate the response to treatment regularly.
that can be put into practice and that helps to
manage the cancer patient with chronic pain.
The main recommendations from the Expert
Panel about cancer pain treatment are:
●● Cancer pain should be treated by the medical
oncologist (who should meet a series of
requirements) (Box 8) ;
●● Cancer pain treatment must start early after
diagnose;
●● The three steps from the WHO guidelines
should be managed by the oncologist;
●● Treatment should be specific and adapted to
patient characteristics:
-- The treatment begins by giving the patient
and their relatives clear and correct informa-
tion about potential toxicities and the dos-
ing schedule because it may improve thera-
peutic compliance.
●● Treatment must be adjusted to the intensity of
pain, taking into account the WHO analgesic
ladder:
-- Use NSAIDs at any steps recalling their
toxicity;
-- The second step is indicated for moderate
pain and the main drug used is tramadol;
Table 7. Opioids’ adverse events comparison.
Opioid Constipation CNS-sedation Respiratory
distress
Morphine ++++ ++++ ++++
Oxycodone ++++ ++++ ++++
Hidromorphone   ++++ ++++
Transdermal fentanyl ++ ++++ ++++
Transdermal buprenorphine ++ + ++
Table adapted with permission from [46].
++++ Very high intensity; +++ High intensity; ++ Moderate intensity; + Low intensity; - No intensity.
CNS: Central Nervous System.
10.2217/fon-2017-0288 Future Oncol. (Epub ahead of print)
-- Considering treatment start from WHO
Step III using low doses of opioids in case
of intense pain;
-- When the etiology of pain is related to can-
cer and its intensity is moderate to severe,
there is consensus about the use of opiates
as first-line therapy [38];
-- Adaptive use of the analgesic ladder helps
manage effective analgesia in 70–90% of
patients [37] .
●● BTP and basal pain usually have the same
causes and the location also usually coincides;
however, treatment and management are dif-
ferent:
-- Basal pain is an acute pain which is stabi-
lized and under control with appropriate
periodic treatment;
-- Pain at the end of the dose is no longer con-
sidered as BTP;
-- Rescue treatment in the opioid titration
phase intended to correct the poor control
of basal pain with the prescribed doses
should not be confused with breakthrough;
-- BTP is classified as incidental (caused by
something) and can be volitional, (e.g., with
walking, chewing or involuntary – by def-
ecation, by hypo) and idiopathic (cause and
trigger are unknown);
-- The incidental volitional pain is predictable
and therefore preventable with short-acting
oral opioids because their intake can be
adapted to the time that the maneuver or
test that will trigger the BTP;
-- For involuntary incidental and idiopathic
BTP there is no prevention and the treat-
ment consists of a rapid relief adequate to its
intensity with fast-acting, oral, sublingual
or nasal transmucosal opioids.
Immune Addiction/ Hyperalgesia
suppression dependence
++++ Yes Yes
– Yes  
– Yes  
++++   Yes
– Limited Antihyperalgesia
future science group
 Cancer pain management: recommendations from a Latin-American experts panel  Special Report
●● The best route of administration should be
selected in each patient:
-- The majority of patients on cancer treat-
ment will remain out-patients, so the ideal
route to begin the opioid treatment with is
oral or transdermal;
-- Parenteral opioids are usually used in hos-
pitalized patients with severe pain;
-- Oral route allows the administration of
short-acting fixed doses (nonimmediate)
every 4–6 h and introduce rescue therapy
with the same drug as many times as neces-
sary throughout the day;
-- Long-acting opioids – oral or transdermal –
are usually prescribed when basal pain is con-
trolled but they can also be used at the begin-
ning of the treatment associated with the
appropriate rescue with short-acting opioids;
-- Transdermal opioids (buprenorphine, fen-
tanyl) fit well in the WHO three-step ladder
for pain relief, particularly in steps 2 and 3,
in its mean dosage range of morphine equiv-
alents, providing the stable plasma levels
required by WHO guidelines and also com-
plying with recommendations that the anal-
gesics used to treat chronic pain should be
easy to self-administer [42];
-- Transdermal buprenorphine or fentanyl are
usually the treatment of choice in patients
who cannot swallow, patients with poor tol-
erance to morphine and patients with poor
adherence to medication [39] . Besides,
patients consider the use of buprenorphine
patches easy and convenient [43] and 81% of
patients with cancer pain achieve good or
very good pain relief with transdermal
buprenorphine [44] .
●● The treatment drug options that should be
considered for each patient:
-- The cornerstone of cancer pain treatment is
the major opioids, especially pure agonists.
Morphine is the historical standard because
of its wide use and low price but there are
several other drugs, varying between coun-
tries: buprenorphine, tapentadol, fentanyl,
oxycodone, hydromorphone and methadone;
-- Titration has been successfully done with
the lowest dose producing analgesia and no
or minimum adverse events;
future science group
-- In case of renal impairment some opioids
that do not require dose adjustment can be
used (buprenorphine, fentanyl, methadone);
-- Pure agonist opioids do not have a ceiling
effect and in the case of buprenorphine it is
higher than the commonly used analgesic
doses;
-- For neuropathic pain the opioids with the
most evidence are oxycodone and buprenor-
phine. Buprenorphine is often given by the
transdermal route in cancer patients who
have severe neuropathic pain. The analgesic
efficacy of buprenorphine in neuropathic
pain is probably due to its suggested antihy-
peralgesic action [45];
-- Studies in patients with cancer with stable
pain control support the use of a relative
analgesic power of 75:1 to interchange
between oral morphine and transdermal
buprenorphine [46];
-- Transmucosal fentanyl should always be
used in lower doses for breakthrough cancer
pain to avoid toxicity although the opioid
already used for basal pain had been admin-
istered in high doses;
-- Methadone is not frequently used (at least
in the oncology services in Spain) because
its titration is complex, requires very close
monitoring and it requires expertise;
-- In case of economic or any other restric-
tions, it is important to optimize the use of
those treatments available and it is always
better to use something well than to use
everything badly;
-- Corticosteroids as analgesics in oncology
have little evidence and although they seem
to be useful in pain from spinal compression
and other nerve compressions and in symp-
tomatic brain metastases, caution should be
taken due to its adverse effects in the short
and long term;
-- Other drugs used for cancer pain treat-
ment are muscular relaxants, bisphospho-
nates, radioactive isotopes or nonpharma-
cological treatments such as radiation
therapy, surgery, rehabilitation and
­psychotherapy;
-- Neuropathic cancer pain is also treated with
opioids but the cornerstone of the treatment
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Special Report Escobar Alvarez, Agamez Insignares, Ahumada Olea et al.
includes so-called adjuvant drugs (gabapen-
tin, pregabalin and antidepressants).
The drugs and treatments which the experts
panel agreed to be recommended are in the fol-
lowing table (Table 5, Table 6 & Box 9) .
●● The pain control should be included in the
patient follow-up:
--  It is important to re-evaluate the patient
24–48 h after the first oral/transdermal opi-
oid treatment;
-- Once symptoms are managed and doses
established, the patient is re-evaluated with
tumor treatment checks every 1, 2 or 3 weeks;
-- The adverse events that patients treated with
opioids develop (constipation, nausea, vom-
iting, urinary retention, drowsiness, confu-
sion) may sometimes be reduced by lower-
ing the dose or switching to another opioid;
-- Throughout the treatment it may be neces-
sary to change the route of administration
or switch opioids, so we must know the con-
version doses between the different drugs.
The most frequent reasons for the opioid
switch are no efficacy and toxicity;
-- Taking the time to explain potential toxicity
is very important so that the patient can
cope with it and communicate it to the
oncologist at the next visit;
-- It should always be emphasized that consti-
pation will be a permanent side effect and
will require prevention. Transdermal
buprenorphine and fentanyl has lower rates
of constipation and sedation than oral opi-
oids and offer a convenient dosing regimen
that improves patient compliance [46];
-- Other adverse effects such as nausea and
vomiting will usually disappear within 48
h and prevention should be done consider-
ing this fact. Therefore, the patient with
cancer pain with an opioid prescription
should also be prescribed an antiemetic and
a laxative treatment;
-- Respiratory depression is very uncommon
in patients with cancer pain whose titration
is done correctly and with periodic reevalu-
ation but some factors such as dehydration
or renal insufficiency may facilitate the
occurrence;
10.2217/fon-2017-0288 Future Oncol. (Epub ahead of print)
-- The most serious opioid toxicity is neuro-
toxicity in its manifold manifestations: from
fasciculations to delirium. It is always neces-
sary to monitor its appearance and the fac-
tors that can trigger it;
-- It should be remembered that opioids can
be stopped in cancer patients if pain disap-
pears by elimination of its cause but this
suspension must be gradual to avoid absti-
nence syndrome;
-- It is important not to confuse tolerance with
dependence or addiction. In cancer patients
addiction is very rare and is often related to
previous substance abuse behaviors;
-- Buprenorphine, unlike morphine, has no
immunosuppressive effect and may be con-
sidered as an option in patients with low
immune defenses, as is often the case of
patients with cancer [7,47] .
Table 7 shows the comparison of opioids
adverse events.
Future perspective
Cancer pain has a strong impact on the patient’s
quality of life and thus the correct pain man-
agement should be as important as the tumor
treatment with an early diagnose of the pain in
order to initiate the pain treatment at any stage.
One of the challenges to better relieving cancer
pain in Latin-America is implementing effective
opioid use by improving its access by the country
authorities and through educating oncologists
on its management.
Pain is probably the main but not the only
symptom that a palliative patient faces. That
is why the creation and development of pallia-
tive care as a new specialty in Latin-America is
almost a fact within the next 10 years, due to this
increasing and unsatisfied demand for quality
and holistic palliative care services, including
domiciliary attention. This is an urgent need
that is being partially fulfilled by many special-
ties but cannot be totally covered by any of them.
Supplementary data
To view the supplementary data that accompany this paper
please visit the journal website at: www.futuremedicine.
com/doi/full/10.2217/fon-2017-0288
Financial & competing interests disclosure
Expert’s meeting was supported by an educational grant
from Grünenthal. The authors have no other relevant
future science group
 Cancer pain management: recommendations from a Latin-American experts panel  Special Report

affiliations or financial involvement with any organization Writing and editorial assistance was provided by Irene
or entity with a financial interest in or financial conflict Perucho and Content Ed Net (Madrid, Spain) with fund-
with the subject matter or materials discussed in the manu- ing from Grünenthal Services, Inc.
script apart from those disclosed.

Executive summary
●● The oncologist should manage and be responsible for the cancer patient at all stages.
●● Cancer pain should be diagnosed and managed early.
●● Opioid drugs are approved and recommended for the cancer pain.
●● Barriers to opioid use should be eased.
●● There is no age limit for opioid treatment, only dose adjustment is required.
●● The oncologist is responsible for the integral management of the patient.
●● The Medical Oncology Societies of each country must lead the way.
●● Coordination between the multidisciplinary team taking care of cancer patients is crucial.
●● E ducation and training for the oncologists on pain management is essential and should be mandatory and guaranteed
by the National Education Authorities. This education should be on-going and included in the Medical degree
(undergraduate), Oncology studies (degree) and even postgraduate studies; it should also involve treatment options,
opioid treatment switch, breakthrough pain management and supportive care.
●● Palliative care, as a nationwide policy, should be included in every Latin-American government’s health agenda.

5 Uso de opioides en tratamiento del dolor. of prevalence, treatment, and patient

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Título y publicación originales: “Cancer pain management: recommendations from a Latin-American experts panel”
Yolanda Escobar Alvarez et al. - Future Oncology (2017) 1-18

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