Management of pain and spinal cord compression in patients with advanced cancer

General internists often care for patients with advanced cancer. These pati ents have substantial morbidity caused by moderate to severe pain and by sp inal cord compression. With appropriate multidisciplinary care, pain can be controlled in 90% of patients who have advanced malignant conditions, and 90% of ambulatory patients with spinal cord compression can remain ambulato ry. Guidelines have been developed for assessing and managing patients with these problems, but implementing the guidelines can be problematic for phy sicians who infrequently need to use them. This paper traces the last year of life of Mr. Simmons, a hypothetical patient who is dying of refractory p rostate cancer. Mr. Simmons and his family interact with professionals from various disciplines during this year. Advance care planning is completed a nd activated. Practical suggestions are offered for assessment and treatmen t of all aspects of his pain, including its physical, psychological, social , and spiritual dimensions. The methods of pain relief used or discussed in clude nonpharmacologic techniques, nonopioid analgesics, opioids, adjuvant medications, radiation therapy, and radiopharmaceutical agents. Overcoming resistance to taking opioids; initiating, titrating, and changing opioid ro utes and agents; and preventing or relieving the side effects they induce a re also covered. Data on assessment and treatment of spinal cord compressio n are reviewed. Physicians can use the techniques described to more readily implement existing guidelines and provide comfort and optimize quality of life for patients with advanced cancer.