As a pain specialist who manages cancer-related pain daily with both interventional and non-interventional approaches, I still encounter a frustrating reality: Too many patients suffer longer than necessary. Recent data show that roughly 44.5 percent of patients with cancer experience pain, and about 30 percent report moderate-to-severe intensity. While prevalence has declined modestly over the past decade, the absolute burden remains high, especially in advanced disease and among survivors living with treatment-related pain syndromes.
The good news is that cancer pain can be well controlled in the large majority of patients when we apply a systematic, multimodal strategy. The National Comprehensive Cancer Network (NCCN) Adult Cancer Pain Guidelines, version 2.2025, emphasize routine screening, mechanism-based assessment, and the integration of pharmacologic, non-pharmacologic, and interventional therapies. My practice philosophy follows that framework while adding a strong bias toward early specialist involvement and thoughtful use of procedures when they can reduce systemic medication burden.
Start with rigorous assessment and non-interventional foundations
Every patient needs a careful characterization of pain mechanisms as either nociceptive, neuropathic, nociplastic, or mixed, plus evaluation of breakthrough pain, psychological distress, and functional goals. Non-interventional care forms the foundation for most patients.
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Pharmacologically, we still rely on the principles of the World Health Organization (WHO) analgesic ladder, updated for modern practice. Opioids remain essential for moderate-to-severe pain, particularly in progressive disease, but they are rarely used in isolation. Adjuvants (gabapentinoids, SNRIs, TCAs, corticosteroids, NSAIDs when safe) target specific mechanisms and often allow lower opioid doses. The NCCN guidelines provide clear guidance on initiation, titration, rotation, and safe reduction of opioids when appropriate, including attention to risk stratification and urine drug testing in selected cases.
Non-pharmacologic interventions matter. Physical and occupational therapy, psychological approaches (cognitive behavioral strategies, pain education), and integrative therapies can meaningfully improve function and coping. In survivors with persistent centralized pain, selected patients may benefit from newer psychologically informed techniques that address amplification of pain signals. These modalities are complementary, not alternatives to medical management.
When and how interventional therapies change the trajectory
Interventional procedures are not last-resort options reserved for the imminently dying. Used earlier in appropriate candidates, they can improve analgesia, reduce opioid requirements, and enhance quality of life.
For upper abdominal malignancies, particularly pancreatic cancer, celiac plexus neurolysis (percutaneous or endoscopic ultrasound-guided) has been shown in multiple randomized trials and meta-analyses to provide meaningful pain reduction and decreased opioid consumption compared with systemic therapy alone. Benefits are often greatest when performed earlier rather than after prolonged high-dose opioid exposure. Superior hypogastric plexus and other sympathetic blocks serve similar roles in pelvic pain.
Intrathecal drug delivery systems represent one of the most powerful tools for refractory cancer pain. Systematic reviews and meta-analyses consistently demonstrate clinically significant reductions in pain intensity (often 3-4 points on a 0-10 scale) and substantial decreases in systemic opioid use. Patients with a reasonable life expectancy who have failed or cannot tolerate systemic therapy are candidates for trial and implantation. The Polyanalgesic Consensus Conference recommendations and multiple observational series support the use of morphine, ziconotide, local anesthetics, and combination regimens tailored to the individual.
Other valuable procedures include vertebral augmentation for pathologic fractures, peripheral nerve blocks or neurolysis for focal neuropathic pain, and, in carefully selected survivors, neuromodulation. These interventions require experienced operators, careful patient selection, and close coordination with oncology and palliative care teams.
Barriers we still need to overcome
Despite strong evidence and guideline support, several obstacles persist. Late referrals remain common, and patients often reach pain specialists only after months of escalating systemic opioids and declining function. Access to interventional expertise varies geographically. Lingering opioid stigma, even in the cancer setting, sometimes leads to undertreatment. Fragmented communication between oncology, palliative care, and pain medicine delays optimal care.
The solution is cultural and structural: Embed pain specialists earlier in the cancer care continuum, normalize discussion of interventional options alongside systemic therapy, and measure outcomes that matter to patients like pain intensity, function, sleep, and ability to continue disease-directed treatment.
A practical call to action
Cancer pain management is not a choice between “medical” and “interventional.” It is the skilled integration of both, guided by mechanism, prognosis, and patient goals. When we screen routinely, escalate thoughtfully, involve specialists early, and use the full range of available tools, the large majority of patients achieve meaningful relief.
If you care for patients with cancer, ask about pain at every visit. When pain is moderate or severe, or when side effects limit therapy, consider early referral. The evidence and the guidelines support an aggressive, multimodal approach. Our patients deserve nothing less.
Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.
Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.
Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.
