ACADEMIA AND CLINIC Management of Pain and Spinal Cord Compression in Patients with Advanced Cancer

General internists often care for patients with advanced cancer. These patients have substantial morbidity caused by moderate to severe pain and by spinal cord compres-sion. With appropriate multidisciplinary care, pain can be controlled in 90 % of patients who have advanced malig-nant conditions, and 90 % of ambulatory patients with spinal cord compression can remain ambulatory. Guide-lines have been developed for assessing and managing patients with these problems, but implementing the guidelines can be problematic for physicians who infre-quently need to use them. This paper traces the last year of life of Mr. Simmons, a hypothetical patient who is dying of refractory prostate cancer. Mr. Simmons and his family interact with professionals from various disciplines during this year. Advance care planning is completed and acti-vated. Practical suggestions are offered for assessment and treatment of all aspects of his pain, including its physical, psychological, social, and spiritual dimensions. The meth-ods of pain relief used or discussed include nonpharmaco-logic techniques, nonopioid analgesics, opioids, adjuvant medications, radiation therapy, and radiopharmaceutical agents. Overcoming resistance to taking opioids; initiat-ing, titrating, and changing opioid routes and agents; and preventing or relieving the side effects they induce are also covered. Data on assessment and treatment of spinal cord compression are reviewed. Physicians can use the tech-niques described to more readily implement existing guidelines and provide comfort and optimize quality of life for patients with advanced cancer