Pain As a Presenting Symptom in Patients with Newly Diagnosed Oral Squamous Cell Carcinoma

Background

Pain is the most common symptom experienced by newly diagnosed patients in a head and neck oncology practice. Despite recent advances in recognition, clinical assessment, diagnosis, and treatment, the problem of pain is one which requires further investigation. The purpose of this study is to examine newly diagnosed patients and to determine whether pain prevalence or severity relates to stage of cancer.

Methods

Our study period began in April 2014 at the start of our hospital service. We enrolled patients with new Oral Cavity Squamous Cell Carcinomas as they presented. A retrospective chart review identified 53 individuals, of whom, 45 met inclusion criteria. The records were searched for characteristics thought to be associated with increased pain: tumor location, size, pathologic staging, nodal disease, tobacco, and alcohol. Consecutive patients were all evaluated by the senior author. The patients were staged according to the AJCC Staging Manual, and divided into early (I-II) and advanced (III-IV). Records were used to provide a history, location, severity, and other associated symptoms. Future patients will be enrolled prospectively and data collection will continue in order to provide more desirable sample size.

Results

Early stage lesions (Stage I-2) comprised 58% of our patients, or twenty-six cases. Of those cases, 15 of 26 presented with pain, while 11 were asymptomatic. With early stage lesions, according to this data, approximately 58% experience pain as a presenting symptom, while 42% do not. This is thought to explain the well-established problem of head and neck cancers presenting in late stages. Those who are less symptomatic may wait until clear evidence of harm before seeking care. When more advanced lesions are considered as a group (Stage 3-4), 42% of our population, the percentages of pain dramatically increases . 79% of the Stage 3-4 lesions are painful on presentation, while 21% are not, in our subset of patients.

Conclusions

The prevalence of pain on initial diagnosis is between 40% and 81% (1). The initial results show our population is similar, although our study probably underestimates advanced stage pain. Olsen and Creagan showed 80-100% pain in Stage 3 or 4 (2). As our study continues to recruit patients, we hope to be able to learn more about the true incidence of pain in this population. We have initiated a patient questionnaire designed to elicit a spectrum of concerns at each visit, which includes a pain and symptom scale. The form will enable us to collect more data on many different quality of life concerns. With an increased sample size, we may have more evidence of tumor staging influencing pain. A larger and more prospective trial would also eliminate some of the difficulties with retrospective chart review that limited us here. It would also give us the opportunity to investigate the roles of cancer behavior and biology, such as perineural invasion (3) Pain is ubiquitous in cancer practices. We should focus more intently on this area in the future.

References

1. C Bianchini, F Maldotti, L Crème, M Malago, and A Ciorba. Pain in head and neck cancer: prevalence and possible predictive factors. Journal of Balkan Union of Oncology 2014; 19(3): 592-597.

2. KD Olsen, ET Creagan. Pain management in advanced carcinoma of the head and neck. Am J Otol 1991; 12: 154-160.

3. FK Keefe, G Manuel, A. Brantley, & J. Crisson, Pain in the head and neck cancer

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