Comparison between the traditional WHO analgesic ladder and the invasive treatments suggested as the fourth step in the management of cancer pain

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The aim of this Systematic review is to do, through a review of the literature, a comparison between the effectiveness of the current World Health Organization analgesic ladder and the effectiveness of the same ladder adding a further step about invasive analgesic treatments. Methods: Screening through databases (PubMed, Cochrane Library) of the clinical trials concerning the effectiveness of the analyzed treatments, Free Full Text available, published in english during the ten years preceding the research and without limitation about the age of the investigated population (except for the adulthood) or the cancer type related to the symptoms. Results: 6 studies have been selected. The 2 RCT about the WHO analgesic ladder suggest a variable effectiveness from 36,6% to 82,7%. Instead the remaining 4 studies (an RCT and 3 clinical trials), about the invasive treatments, show an effectiveness close to 100% for the difficult pain management. Conclusions: Despite the obvious limitations of the study, cordotomy, intrathecal pump and spinal cord stimulation represent a valid solution, albeit expensive, for the patients who don’t respond to the traditional analgesic therapy and without whom, they will be forced to face the neoplastic pathology without an adequate control of the most disabling symtomp. Is therefore desiderable, if not necessary, their insertion in the World Health Organization guidelines; more exactly at the peak of the analgesic ladder.

Key words: WHO analgesic ladder, opioids, cancer pain, fourth step.
DOI: 10.19190/PNM2018.1_ra32