Cancer-Associated Pain Clinical Practice Guidelines (ASPN, 2021)

American Society of Pain and Neuroscience

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 03, 2021

Guidelines on the interventional management of cancer-associated pain were published in July 2021 by the American Society of Pain and Neuroscience in the Journal of Pain Research.[1]


Consider using opioids for patients with moderate-to-severe cancer-related pain.

Individualize the opioid agent selection in order to address the variability in pain presentations and the presence of any coexisting medical comorbidities.


Consider using methadone if opioids are ineffective or if the situation calls for additional serotonin receptor or NMDA modulation.

Base the initial dosing on the patient’s opioid tolerance and use low introductory doses for opioid-naïve patients.

Exercise a conservative approach for opioid-tolerant patients; the recommendation is for 75-90% less than the calculated equianalgesic dose using a 1:15 to 1:20 conversion factor.


Consider using ketamine for cancer pain on an individualized, case-by-case basis to treat refractory neuropathic pain, mucositis-related pain, and bone pain.

Radiotherapy, Radioisotopes, and Bone-Modifying Agents for Metastasis

For painful metastatic bone disease, external-beam radiation therapy with short, fractionated regimens is preferred over conventional, protracted schedules.

For radiotherapy-resistant cancers or oligometastatic disease, it may be preferable to use stereotactic body radiation therapy.

While osteoclast inhibitors have been ineffective in some cancers (eg, metastatic non–small cell lung cancer), evidence exists for their use. Thus, use osteoclast inhibitors only as adjuvant treatment and on a case-by-case basis.

Blocks and Neurolysis

For patients with abdominal pain related to pancreatic cancer, perform celiac plexus neurolysis.

For patients with intractable abdominal pain related to advanced pancreatic cancer located in the body and tail, consider performing splanchnic nerve neurolysis.

If neurolysis is performed early, better outcomes are expected.

For patients with intractable pain related to pelvic cancer, consider performing superior hypogastric plexus neurolysis.

For patients with intractable pain related to perineal cancer, consider performing ganglion impar neurolysis.

Targeted Drug Delivery

Strongly consider implementing intrathecal drug delivery using an implantable pump in patients with cancer-related pain not responding to conventional medical management.

Trialing prior to implanting an intrathecal pump for cancer-related pain is considered optional and discretionary, based on physician and patient decision-making.

Spinal Cord Stimulation

In patients who have refractory cancer-related pain, consider spinal cord stimulation.

It should be considered on a case-by-case basis for pain related to cancer treatments (eg, chemotherapy-induced neuropathy).

Vertebral Augmentation and Radiofrequency Ablation

Strongly consider using vertebral augmentation in patients with symptomatic vertebral compression fractures due to spinal metastases.

The recommended treatment for severe back pain from spinal tumors is percutaneous radiofrequency ablation, with or without cement augmentation. It has been proven to be safe and effective palliative therapy for painful spinal metastasis.

Radiofrequency Lesioning and Nerve Blocks

Radiofrequency lesioning of the dorsal root ganglion should be considered for axial thoracic back pain due to vertebral malignant metastases.

If the cancer pain is not responsive to medical management, consider applying nerve blocks with corticosteroids or radiofrequency lesioning to a peripheral nerve or brachial plexus.

Surgical Options

In patients with uncontrolled unilateral nociceptive pain in whom more conservative options have failed, consider performing a cordotomy.

For infradiaphragmatic visceral pain, myelotomy is recommended for pain control and to decrease opioid use.

For focal limb pain and in patients with Pancoast tumors, the indicated surgical procedure is dorsal root entry zone (DREZ)–otomy.

For late-stage and uncontrolled pain that is refractory to other therapies, cingulotomy is indicated.


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