Cancer pain in America: missing the target of relieving suffering.

This is not my usual issue specific and highly researched editorial piece, and for that I apologize in advance. In the next issue of Neuromodulation, I will discuss the significant issues with respect to quality control, patient outcomes and cost effectiveness facing both device manufacturers and physician practitioners of neuromodulation. During the production time of the current issue, however, my beloved wife and the mother of my young son has been diagnosed with lung cancer. While a horrific experience for anyone forced to see their family member suffer, these past few months have personally involved me in the cancer care and pain management system more intimately than I would ever have imagined. It has given me tremendous insight into the terrible fear and suffering that our patients endure and just how poorly we as health care professionals may sometimes address these issues. Pain management in general and neuromodulation for pain in specific are highly technical specialties; unfortunately, technology alone is not the answer to the problems that face our patients. I am afraid that many of us have lost our way with respect to our roles as healers; as technicians we provide only a small amount of what our patients require. My wife’s saga began in late June, when she began with an irritating cough. Despite anti-tussives and time, the cough did not resolve. Not one, but two courses of antibiotics for presumed bronchitis failed to alleviate her symptoms and on August 9th, 2013, a chest x-ray was obtained. With no radiologist readily available, I reviewed the films myself. Even a neurosurgeon could clearly identify the 4 cm right upper lobe lesion; I don’t know whether having to tell my wife the devastating news or holding back my fears was the harder task. Alas, I am a selfish man, and the concept of a life without my wife was unfathomable. Just viewing the x-ray, I felt an emptiness that I had never felt before. My wife had never smoked, had never been hospitalized, had no preexisting medical conditions and took no medications and yet we were faced with the possibility of her having lung cancer and I immediately feared her death. I could not imagine how devastating this fear would be to her. I was amazed to find that our head of neuroradiology was the most empathic and caring physician that we encountered. He immediately invited me to bring my wife to the medical center, took care of all of the difficult insurance issues with obtaining a scan that had not yet been approved by our insurance company, and performed a chest CT scan. He was genuinely concerned, conveyed an air of warmth and competence; while the news was grave, his manner helped us to be comfortable that we were in the right place. The CT scan showed a large, enhancing lung lesion. He arranged for a PET scan to be performed the next working day and again dealt with the difficult insurance issues; unfortunately that scan again revealed that the lesion was hyper-metabolic and almost certainly a malignant tumor. We met the next day with a pulmonologist, underwent pulmonary function testing, and the following day met with the cardiothoracic surgeon. Video assisted thoracoscopic surgery was performed six days after the chest x-ray. A 4 cm adenocarcinoma was completely resected and no lymphatic spread was identified; my wife was diagnosed with Stage IB lung cancer. As a physician intimately involved with pain management, I had now entered my comfort zone, or at least I thought. My wife was unarousable for nearly 12 hours after surgery and incoherent for several hours after that; she had been given large doses of sedatives and narcotics, despite being opioid naïve, to help minimize postoperative pain. She had terrible pruritus following opioid administration which was only mildly controlled with diphenhydramine. Most Figure 1. My wife, Dr. Amity Ruth, and I on our anniversary, September 30, 2013. Neuromodulation: Technology at the Neural Interface