Pain management in MPM remains complex due to its multifactorial etiology. Despite progress in the options for treatment in MPM prognosis remains poor. Focus on symptom control is therefore paramount. While effective pain control can be gained through pharmacological treatment, many patients require multiple modalities to achieve symptomatic relief.

Current guidance reinforces the greatest evidence in support of the role of radiotherapy for pain control in MPM. Despite its use, the optimal radiotherapy dose and fraction remains unknown. The SYSTEMS study was key in demonstrating a significant pain response with minimal toxicity with radiotherapy. Now with advances in technology solutions, practical challenges of increasing radiotherapy doses have been achieved. It is hoped that IMRT will allow higher doses of radiation predicted to provide an improvement in analgesic effect and duration. The outcome of the SYSTEMS-2 trial will provide clarity as to this predicted effect of greater doses of radiotherapy on pain control.

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At present, both surgical and SACT require further research to focus not only on survival outcomes but also to address the symptomatic impact of treatment. While surgery and SACT may prolong patients’ survival, the consequences of toxicities and complications to patients’ quality of life and pain control requires further investigation. Does undergoing such treatments outweigh the benefit of active symptom control alone? Research to answer this question will continue to allow open communication between patients and clinicians as to the most effective palliative treatment. While interventional procedures, such as cordotomy, demonstrate an exciting opportunity for complex pain control, its availability remains a barrier to widespread use. Guidance highlights cordotomy as playing an important role in MPM for pain management but it remains to be perceived as an option of last resort. Further experience in this field may overcome the challenges to its access and change its role to become an adjuvant at any stage to common analgesic regimens.

Pain is an emotive subject for both patients and their families due to its impact physically and emotionally. MPM is sadly often an aggressive disease with complex pain pathophysiology. Medical professionals strive to achieve the best quality of life for patients through multiple treatment modalities. While pain control in MPM remains to have challenges, it is hoped that research continues to identify solutions to alleviate pain in patients with MPM.


The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

J. Saunders,1 M. Ashton,1,2 C. Hall,3,4 B. Laird,3,4 N. MacLeod1

1Beatson West of Scotland Cancer Centre, Glasgow G12 0YN, UK; 2Institute of Cancer Sciences, University of Glasgow, UK; 3Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh EH4 2XR, UK; 4St Columba’s Hospice, Edinburgh EH5 3RW, UK


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Source: Lung Cancer: Targets and Therapy
Originally published April 2, 2019.

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