Document Title: ISNCC Cancer Pain Position Statement
Date Drafted: January 2017
Date Approved by Board of Directors: January 2017

PurposeTo optimize cancer pain screening, assessment and management practices by cancer nurses’
globally.
Background
Pain is one of the major distressing symptoms associated with cancer. Most people diagnosed with cancer
experience unrelieved cancer pain at some stage during their illness trajectory. Cancer survivors may also live withpersistent pain due to effects of the disease or treatment. The WHO estimates approximately 5.5 million cancerpatients annually experience unrelieved pain due to lack of access to opioids(13). Clinicians’ lack of knowledge andskills; patients, families and clinicians’ misconceptions; inadequate health care systems, legislation and policy alcontribute to the burden of unrelieved cancer pain(12,14,15).
In 2012, approximately 14.1 million people were newly diagnosed with cancer and 8.2 million deaths were due tocancer(1-4). More than half (56%) of all people newly diagnosed with cancers and two thirds (64%) of cancer-related
deaths occur in low income countries(3). Cancer related deaths are anticipated to continue to rise, particularly in lowincome countries, and by 2030, the incidence of cancer is expected to rise to 22 million(3,4), with 13.2 million people
dying annually of cancer(4). Increasingly, people diagnosed with cancer are also living with other non-communicablediseases such as diabetes, chronic respiratory or cardiovascular disease, which add to the complexity of managing
their symptoms, including pain and breathlessness(3).
Unrelieved pain contributes to unnecessary distress and suffering, which reduces the quality of life of patients andtheir families. The adverse impact of pain makes unrelieved pain a human rights issue and thus an issue that must
be addressed(5-7). Suffering related to unrelieved pain is unnecessary because up to 90% of cancer pain can beeffectively controlled with currently available medications and treatments(8), however access to thesepharmacological interventions is often more challenging in low and middle income countries(9-11). In many of thesecountries, there is limited access to opioids and other analgesics and/or restrictive regulations governing their use(12),which impacts significantly on nurses’ abilities to effectively manage pain and the burden of unrelieved pain.
Whilst cancer pain management is complex, adhering to the key principles of routine pain screening, comprehensive
assessment, evidence based management and reassessment would do much to minimize the global burden ofunrelieved cancer pain. Nurses play a key role in helping to minimize pain(16). Better pain outcomes are within ourreach today if nurses enhance routine screening and assessments, and provide patients with the best available
evidenced based treatments.

Undertaking a comprehensive, multidimensional pain assessment (i.e. bio-psycho-socio-spiritual assessments) ismade easier with the use of validated tools such as the Brief Pain Inventory(17,18) or the hand scale (commonly usedin low-income settings)(19,20). Assessment findings ought to guide the interdisciplinary team’s development of anindividualized and timely cancer pain management plan that includes effective evidence-based pharmacological andnon-pharmacological interventions.
Recognizing and managing the cancer pain management needs of a wide variety of populations is an importantpriority and requires additional considerations, such as children, adolescents and young adults(20-22), older people,
those with dementia or special needs, people living with other non-communicable diseases and cancer survivors(23).
Each of these populations may have unique and complex needs with regards to pain screening, assessment andmanagement, alongside cancer-related needs.
Position
The International Society of Nurses in Cancer Care (ISNCC) is committed to supporting strategies that will
improve the reduction of cancer pain in keeping with the patient’s wishes and goals of care. The Society
supports strategies that promote and ensure access to analgesic medications and other effective strategies toimprove the management of cancer pain. Nurses play a pivotal role in screening, assessment and pain control
interventions for all cancer patients.
Even in countries where laws restrict the use of opioids, nurses have opportunities to help reduce the burdenof unrelieved pain through the administration of simple analgesics and evidence based non-pharmacologicalinterventions in line with local, regional and national policies governing nursing practice. This should be done
alongside ongoing advocacy for increased access to medications such as opioids. Nurses also need to be
mindful of the responsible use of opioids and to advocate and educate patients, caregivers and healthprofessionals to prevent misuse. Pain is holistic in nature, therefore spiritual counselling and discussion about
the meaning of pain may help reduce patients' and families' feeling of helplessness and isolation(20). Inclusionof other inter-professional team members to provide non-pharmacological interventions is recommended.
The ISNCC is committed to providing ongoing support, networking, consultation with peers and educational
opportunities to access and advance the knowledge and skills of cancer nurses in improving the managementof cancer pain.

ISNCC Recommends
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Cancer pain relief should be a priority for all cancer nurses, utilizing evidence based practice andfollowing WHO guidelines and principles (such as giving medication by the clock, by the ladder(three-step analgesic ladder for adults(8) and two-step for children(21)) and by the individual(24). In
doing this, they should work to reduce or minimize barriers in order to provide effective painmanagement.
Public, patient, family and professional education related to the right for pain relief is a primary
responsibility of nurses who should be aware of the options and resources available for theassessment and management of pain.
Nurses are ideally placed to provide comprehensive care of cancer patients and their families.

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Nurses need to keep abreast of advances in cancer pain management along with current guidelines
and recommendations within their scope of practice in the administration of medications andmanagement of side effects, aiming for an optimal balance of pain relief while minimizing sideeffects.
The development and implementation of institutional policies and guidelines for the effective
management of cancer pain should be undertaken by nurses in collaboration with the interdisciplinary team.
Access to, and availability of, pain medications and treatments for pain relief should be a national
health priority for Ministries of Health and relevant country/state governing bodies and nurses
should advocate for changes to restrictive legislations that hinder access to adequate analgesia.
Cancer nurses should have adequate access to practical (e.g., supplies) and emotional support toenable them to provide optimal cancer pain relief
Cancer pain relief should be an education priority for all institutions that employ or educate cancernurses.
Increasing the evidence base for pain screening, assessment and management should be an
ongoing priority and nurses should support and undertake independent and collaborative cancer
pain research, and utilize applicable findings in education and practice.

Acknowledgements
The ISNCC Board of Directors would like to specifically acknowledge the contributions of Julia Downing, RN, PhDand Jane Phillips, RN, PhD for their role in the leading the development of this document.

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