Decision-making in the cancer pain setting: Beyond the WHO ladder

The treatment of cancer-related pain is an area of great concern to patients and physicians alike. In the recent past, emotional reactions, societal pressure, and misinformation guided physicians in their choice of treatment modalities and often led to undertreated pain. The development of the World Health Organization ladder for guiding the treatment of cancer pain helped to not only guide physicians in the proper use of opioids, but also to break down social and legal barriers to their proper use. The World Health Organization ladder has also constrained physicians when used in a purely mechanistic manner. Despite the aggressive use of opioids and adjuvant medications, 10%-20% of patients with cancer pain suffer with severe pain. This underscores the need to move beyond the ladder concept and into a paradigm of multimodal care. The early inclusion of interventional pain management before patients have been maximized on opioids should be considered. Such procedures include percutaneous vertebroplasty, percutaneous kyphoplasty, and neurolytic celiac plexus block. Use of a multimodal pain management regimen should help to decrease suffering and side effects, and improve quality of life for cancer patients.