**2.1 Pain**

Pain is one of the most pressing concerns for children with cancer, as it has a significant impact on their quality of life [18]. It is one of the most concerning and widespread symptoms, with prevalence rates ranging from 24–60% of patients during chemotherapy and 62–86% in advanced-stage cancer, indicating that the problem has yet to be solved [13, 19]. Furthermore, according to a recent meta-analysis, more than one-third of patients with pain describe it as moderate to severe (VAS >4), and while many authors distinguish between cancers with a high risk of pain (bone, pancreas, and esophagus) and cancers with a low risk of pain (lymphoma, leukemia, and soft tissue), no significant correlation has been found between pain prevalence and cancer type. There were no changes in the prevalence of pain between senior and younger patients [20].

Aside from physical concerns, a variety of variables might influence how you feel. Pain management is important in palliative care because cancer pain is multifactorial and can present with a variety of other symptoms. It should include pharmacological, medical, biopsychosocial, and even surgical approaches (such as debulking procedures to reduce tumoral compression/stimulation of nerves or ganglions). To study each clinical case and establish a customized "pain-relieving" strategy, a multidisciplinary surgical team (e.g. surgeons, anesthesiologists, radiologist, interventionist, and nursing staff) is required [21].

WHO developed a "Three-Step Analgesic Ladder" to demonstrate proper analgesic use in adult patients [22], with three levels:


In pediatrics, however, it is recommended to use analgesics in two steps, depending on the degree of the pain: paracetamol and ibuprofen should be used first for children with light pain; in patients with moderate to severe pain, an opioid may be considered [23].

Analgesics from the following step up should be added or substituted as the pain intensity increases and the current analgesics are no longer sufficient. Adjuvant therapies, such as anticonvulsant medication for neuropathic pain, should be added at all stages.

The authors of a recent multicenter study based in the United Kingdom found that patients dying of solid tumors are more likely to receive high doses of opioids; this circumstance could be related to the biology of these neoplasms, which can compress nerves or metastasize to bone in the late stages, causing pain: in fact, pain was more common in children with solid tumors (98.4%) than in others (87%) [24].

Other instruments that can aid in the pain management of cancer patients include:

• *Intrathecal therapy*: individuals with refractory cancer pain or unbearable side effects may benefit from intrathecal morphine sulfate delivery via an implanted patient-activated delivery system [25–27];

*Perspective Chapter: Palliative Surgery in Pediatric Cancer DOI: http://dx.doi.org/10.5772/intechopen.104290*


Despite all of the various therapies to oncological pain, a number of studies have found that 40–70% of patients had insufficient pain control [42, 43]. The Agency for Health Care Policy and Research's "First Barriers National Clinical Practice Guidelines on Cancer Pain" [44] clearly describes and categorizes the barriers to proper cancer pain treatment into three groups:


Based on WHO standards, two metrics for evaluating analgesic adequacy have been created:


The analgesic drug prescribed is similarly classified at one of four levels:


The PMI is calculated by subtracting the pain level from the analgesic level. Scores will range from −3 to 3: negative scores are an indicator of undertreatment, while a score of 0 is considered acceptable as a minimal level of treatment.
