Prise en charge des douleurs cancéreuses rebelles : stratégies pratiques

Despite recommendations currently available on the management of cancer pain, 10 to 15% of patients with cancer-related pain have inadequate pain relief or experience severe opioid-related side effects, limiting the increase in opioid doses. With intractable pain, an interdisciplinary pain management team is strongly recommended. In the presence of persistent intractable pain after opioid rotation, a switching route of systemic administration, or patient-controlled analgesia, we resort to non-invasive therapies, such as NMDA-antagonists (ketamine, methadone), then invasive alternatives, such as locoregional analgesia (intrathecal morphine possibly associated with local anesthetics and ziconotide), interventional radiology, and more rarely, neurosurgery. Best practice guidelines for the treatment of intractable pain in an advanced palliative state (published in June 2010) are available on the website of the ANSM (Agence nationale de sécurité du médicament et des produits de santé): these guidelines specify the modalities of use of certain drugs, including off-label. Recommendations from an expert panel, published in 2013, address the issue of locoregional analgesia in cancer pain, but further randomized controlled trials are needed and review articles are useful, as well as the development of concerted multidisciplinary network to determine the respective roles of these invasive techniques in the therapeutic arsenal and to establish a validated decision-making tree.