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neuropathic pain when they directly invade local nerves or when they cause local
edema that affects the nerves in the vicinity. Tumor infiltrating an organ may cause
ill-defined pain as the organ capsule becomes stretched. Bone pain may signify a
pathologic fracture from a tumor weakening the bone, as can occur with Ewing
sarcoma or osteosarcoma. The bones may also hurt due to tumor invading the bone
marrow space. Pain in the head and neck may result from increased ICP or tumor
involvement of the meninges/cerebrospinal fluid (most common in hematologic
malignancies).
On the other hand, pain may be related to cancer treatment. In these cases, the
patient or family may report that this particular pain has been historically linked to a
specific therapy. A particularly challenging problem is the phantom pain that can
occur after limb amputation. In addition, oncology patients may experience pain of
the mouth, GI tract, or even urethra as part of mucositis. Pain could also represent a
focal infection, complicating the patient’s compromised immune system. Bone pain
may reflect recent therapy with hematopoietic growth factors to stimulate neutrophil
recovery after chemotherapy. Radiation therapy can induce local tissue injury, which
may be very painful.
Abdominal pain is a common complaint in cancer patients and can arise from
several sources. The differential diagnosis may be very wide including pancreatitis,
hepatitis, cholecystitis, constipation, mucosal injury, intra-abdominal infection, and
bowel obstruction (see “Hepatic and Gastrointestinal Complications of Cancer
Treatment” section).

Clinical Considerations
Clinical Assessment
An important first step in management is to explicitly address pain when taking the
patient’s history. Even patients who come to the ED for other reasons may have pain
complicating their presentation. Upon determining that a patient is in pain,
according to the patient’s report as opposed to the clinician’s assessment, the
emergency clinician must initiate immediate pain treatment. The remainder of the
history and physical examination should be used to identify the cause of the pain

and to explore specific treatment for that cause.
Management
Acetaminophen is a useful analgesic with minimal side effects for most patients,
remembering to avoid the rectal route if the patient is neutropenic. NSAIDs and
aspirin may be effective as pain relievers but are generally avoided in this patient
population due to their antiplatelet effect in the setting of frequent