Beyond pain relief: Rethinking palliative cancer care

September 5, 2026

Total pain is a holistic concept recognizing that suffering in a person with advanced or terminal illness is multidimensional and extends beyond physical discomfort caused by the underlying disease.

Pain is one of the major factors affecting individuals receiving palliative care, particularly those living with active or progressive cancer. In cancer care, pain is fundamentally a subjective experience: pain is what the person experiencing it says it is, and it exists whenever the person says it does.

Importantly, pain is a symptom, not a diagnosis. Effective palliative care therefore requires pain to be assessed carefully and managed as effectively as possible, while identifying and addressing the underlying causes and contributing factors.

Understanding the mechanism of pain
Pain begins as a protective mechanism designed to prevent harm to the body. When tissue is damaged, signals are transmitted to the spinal cord and brain, where the stimulus is interpreted. Depending on the nature of the stimulus, the brain may trigger a reflex that causes a person to withdraw from danger, or recognize the experience as unpleasant and generate a response that prompts action.

For example, touching something sharp or getting too close to something hard should prompt the body to move away from the potential source of injury.

The challenge becomes considerably more complex when inflammation is persistent or progressive, particularly in patients whose underlying disease cannot be cured but can be controlled through treatment.

In progressive cancer, inflammation and other disease-related processes may continue to generate pain over time. This makes appropriate management of chronic and progressive pain particularly important for patients receiving disease-modifying treatments.  

Why pain management matters in cancer care
Speaking on ‘Cancer pain: Mechanisms, assessment and evidence-based treatment’ at Sunway Medical Center, Sunway City’s 'Mastering pain in palliative medicine' symposium, Dr Saiful Adni Abdul Latif (picture below), Head of Palliative Care, National Cancer Institute (IKN), highlighted the significant prevalence of pain among patients with cancer.

​​An estimated 50–90% of oncology inpatients report some form of breakthrough pain. Among patients in community settings, approximately 35% report breakthrough pain.

In addition, one in three patients with active cancer will report some form of pain, while three out of four patients with advanced cancer report pain.

Addressing pain and other symptoms is important not only for comfort but also for maintaining functional ability. Effective symptom management can improve the quality of life of patients, their families and caregivers. It can also strengthen relationships and communication between patients, family members, caregivers and healthcare professionals, while potentially improving patients’ tolerance of treatments and other interventions.

Assessing cancer pain
A systematic pain assessment helps healthcare professionals understand the nature and impact of pain before determining an appropriate treatment strategy.

Dr Saiful uses the acronym SQITARRS to guide pain assessment:

S – Site(s): Whether pain occurs at a single or multiple sites
Q – Quality: Whether the pain is sharp, dull, throbbing or colicky
I – Intensity: The patient's pain score
T – Timing: Whether pain is persistent, episodic, associated with movement or spontaneous
A – Aggravating and relieving factors: What makes the pain worse or better
R – Radiation: Whether the pain radiates to another area

Associated symptoms should also be assessed, including numbness and abnormal sensations.

A detailed assessment is particularly important because not all pain experienced by a person with cancer is necessarily caused directly by the cancer.

Cancer, treatment and other causes of pain
Cancer itself can cause pain through inflammation and other disease-related mechanisms. The nature of the pain may also depend on whether the cancer is progressing, responding to treatment or has spread to other parts of the body.

Metastatic lesions may produce localized pain, while treatment itself can also be a source of significant discomfort.

“Treatment itself can cause pain. Have you seen how patients who have to undergo brachytherapy feel before and after the session? Not the nicest session. But of course, it helps. But you still need to manage the pain caused by the treatment as much as you need to manage the pain that is also caused by the disease. And patients might have concurrent diseases as well,” says Dr Saiful.

As people live longer, age-related conditions can contribute to their overall pain burden. Osteoarthritis, for example, becomes increasingly common with age. Mechanical pain may also arise from the cumulative effects of physical strain and musculoskeletal wear and tear.

Consequently, it is important to establish whether the pain being treated is cancer-related or arises from a concurrent condition associated with aging or other causes. The distinction may influence the most appropriate treatment approach.

Understanding ‘total pain’
The concept of total pain was first coined by Dame Cicely Saunders, founder of the modern hospice movement, and introduced in the 1960s.

Total pain is a holistic concept recognizing that suffering in a person with advanced or terminal illness is multidimensional and extends beyond physical discomfort caused by the underlying disease.

The concept became a foundational principle in modern palliative and hospice care by demonstrating that emotional and spiritual distress can manifest or contribute to the experience of physical pain.

Total pain comprises four interconnected dimensions:

• Physical pain - This includes disease symptoms, treatment effects, fatigue and the physical sensation of pain.
• Psychological pain - This encompasses anxiety and fear, depression, anger and mental stress.
• Social pain - Family concerns, loss of roles, financial worries and social isolation can contribute significantly to a person's overall suffering.
• Spiritual pain - Spiritual distress may involve existential questions, a search for meaning, loss of faith and the desire to find peace.

Recognizing these dimensions is essential because treating physical pain alone may not adequately address the person's overall suffering.

Five basic principles of analgesia
Several basic principles should be considered when initiating analgesic medication.

By the mouth
Ideally, the oral route should be used as the first-line route of administration when appropriate.

By the clock
Regular analgesia helps maintain medication levels and reduces the need for PRN, or as-needed, medication.

For patients experiencing continuous pain, analgesia may need to be administered regularly rather than relying solely on intermittent medication.

“When we say that someone has progressive cancer, do you think that at any point in time the inflammation will say, alright, I'm taking a rest now. I'm not going to cause much more pain to this person who's experiencing the disease?

“Unfortunately, that's not how cancer works. So telling them to take morphine just like taking paracetamol as per the disease may not work.

“If you have a person who has pain that is affecting them all the time, then you need to think about the pharmacological way of the medication that you're giving them. It's also around the clock to help them with the pain that they're experiencing 24-7 before getting the right dose and titrating them upwards later on when the disease continues to progress.”

Understanding how long a medication remains in the body is therefore important when determining the appropriate dosing interval for a patient experiencing continuous pain.

By the WHO analgesic ladder
Analgesia should be optimized according to the severity of pain.

For the individual
The objective is to achieve optimal pain relief with the fewest possible side effects.

With attention to detail
Analgesia should be reviewed regularly and adjusted according to the patient's response, disease trajectory and changing needs.

For a patient with severe cancer pain who remains highly functional, administering medication on a four-hourly basis may not always be practical. A demanding dosing schedule can interfere with daily activities and adherence.

The appropriate approach may involve establishing the correct dose promptly and subsequently transitioning to slower- or longer-acting preparations where suitable. This can help patients maintain as much functional independence as possible.

The WHO analgesic ladder
The WHO analgesic ladder provides a framework for selecting analgesic treatment according to pain severity.

Step 1: Non-opioids
For patients with mild pain, non-opioid analgesics such as paracetamol may be considered, together with adjuvant analgesics where appropriate.

Step 2: Weak opioids
For moderate pain, weak opioids such as tramadol, codeine and dihydrocodeine may be considered. Adjuvant analgesia may also be appropriate when neuropathic pain or other components of pain are present.

Step 3: Strong opioids
For severe pain, stronger opioids may be required, including morphine, oxycodone and fentanyl.

If a weak opioid used regularly at its maximum dose for mild to moderate pain does not provide adequate relief, treatment may progress to Step 3.

Morphine remains the gold-standard oral opioid.

Individualizing opioid treatment
Patients may sometimes be diagnosed with cancer at a late stage or referred to palliative care late in the disease trajectory. At that point, pain may still be moderate, while the prognosis may be too short to allow sufficient time for a patient to develop tolerance to a weak opioid.

In such circumstances, Step 3 may be initiated at a much lower dose, allowing the patient to reach tolerance more quickly while enabling careful titration according to response.

Cancer treatment has also evolved substantially. Historically, chemotherapy and radiotherapy were among the principal treatment options available. Today, patients may receive immunotherapy, targeted therapy and hormonal therapy, potentially resulting in considerably longer prognoses.

Some patients with longer prognoses may also experience highly localized areas of pain that can be targeted using interventional pain strategies. Such approaches may provide effective pain control without relying solely on continuous medication titration as the disease progresses.

Why does cancer pain worsen?
Pain may worsen because the underlying cancer is advanced and progressive. However, disease progression is not the only possible explanation.

Other contributing factors include:

• Inadequate treatment
• Constipation
• Acute infection
• Abscess
• Bleeding or hemorrhage
• Treatment-related factors
• Adherence issues
• Other concurrent medical conditions

Constipation is particularly relevant in patients receiving opioids. Opioid-induced constipation can occur when opioid medication slows bowel movement. Changes in bowel function may subsequently affect the absorption of medication.

Acute events such as infection, abscess, bleeding and hemorrhage may also exacerbate pain.

When an acute event occurs, its reversibility should be assessed. This helps determine whether the existing analgesic dose should be maintained or whether titration is required, particularly if the acute event is contributing to further disease progression.

Adherence and functional ability
Although many patients experiencing significant pain are already compliant with their medication, adherence should still be assessed when pain worsens.

Patients who remain highly functional and active may find tightly scheduled medication regimens difficult to maintain. The practical demands of medication administration should therefore be considered as part of an individualized pain-management plan.

Changes in pain following periods such as festive seasons may also provide useful information when assessing medication adherence and changes in routine.

Pain and disease progression
An increase in analgesic dosage does not necessarily mean that morphine or another medication has stopped working.

Patients and families may become concerned when doses are increased, questioning whether the medication is becoming ineffective.

Dr Saiful explains that analgesic doses are titrated according to the degree of pain. When the disease progresses, pain may also progress. An increasing dose therefore does not necessarily indicate that the medication is no longer effective.

“For patients who have very advanced diseases, we usually tell them from the beginning that we're going to start this medication and then titrate it according to how your disease trajectory is over time.”

Explaining this principle early can help patients and caregivers understand why medication requirements may change as cancer progresses.

Looking beyond physical pain
Pain management should not stop at physical assessment.

A psychosocial and spiritual assessment is an important component of palliative care. Healthcare professionals should ask patients what is happening in their lives, how pain is affecting them and what type of support they require.

There can be a tendency to focus heavily on physical symptoms and pharmacological treatment. However, patients, families and caregivers are human beings whose experiences of illness, pain and other symptoms can vary considerably.

Understanding what pain means to the individual is therefore important before treatment decisions are made.

Patients should be asked what they expect from treatment. Their social circumstances, available support and welfare needs should also be explored.

The importance of social and welfare support
Dr Saiful shared the case of a patient who presented to hospital with a headache caused by renal metastasis.

The patient had recently been diagnosed with stage 4 cancer. He had been independent throughout his life, living alone and not requiring assistance from others.

His immediate concern was whether he was eligible for financial assistance or a payout. Having worked for many years and being in his late 40s, he was concerned about whether arrangements could be made for someone to care for him.

Dr Saiful referred him to the hospital's welfare services and the social security organization (SOCSO). The patient subsequently managed to have his report processed, obtained a pension from SOCSO and arranged for a distant family member to become a paid caregiver.

Despite not requiring an increase in his medication dose, the patient felt considerably more reassured knowing that he was being cared for by people around him.

The case illustrates how addressing social and welfare concerns can influence a patient's overall experience of illness and suffering, even when the pharmacological management of pain remains unchanged.

Previous experiences and coping mechanisms matter
A patient's previous experiences with pain and individual coping mechanisms should also be explored before treatment is initiated or adjusted.

Advanced disease can bring significant emotional distress, including fear that the disease is worsening, depression, anxiety and hopelessness. These experiences can influence how pain is perceived and how patients respond to treatment.

Understanding the individual experience is therefore an essential part of comprehensive palliative care.

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