In 1986, the World Health Organization (WHO) launched the WHO Analgesic Ladder. 1 It was suggested, at that time, that opioids may be able to help between 80% and 95% of patients with cancer-related pain. This WHO ladder has been modified a number of times since then with the addition of adjuvant agents to manage neuropathic pain and a fourth step to include the management of more complex or resistant pain that could be treated by interventional techniques.

I had anticipated from the title that this publication would address in detail this fourth step of the WHO ladder—and to a certain extent, it does. It is a multi-editor and multi-author, North American focused book with 5 editors and 105 contributors to its 55 chapters. It is presented in IX sections covering 530 pages and is not written to be read cover to cover. There is a significant overlap between many of the chapters with some not addressing any interventional cancer pain management techniques. Neuropathic pain syndromes have considerable overlap. The chapters provide references as evidence for the efficacy of the interventional techniques recommended. However, many of the references are> 10 years old. A large number of the techniques described and referenced are utilized in the noncancer arena with very little evidence in managing cancer pain. There are some abbreviations (eg,“HTM” and “BRC”) which are not defined, but I guessed they meant “hematological malignancies” and “blood-related cancers,” respectively, although I wasn’t clear what the difference between these 2 terms was. The chapter on dermatological cancer pain syndromes has a list of abbreviations at the beginning, which was very helpful. Chapter 14 introduces the reader to bone pain from pegfilgrastim with the interesting prophylactic role for loratadine to decrease its risk of development. I was surprised that there wasn’ta chapter discussing the role of palliative or hospice care and their value when providing an interdisciplinary approach which includes interventional techniques. There are good chapters on general pain management concepts and a whole section called “Interventional Physiatry”(which includes rehabilitation and bracing and exercise therapy and fatigue along with osteopathy) together with a section on “Complimentary and Psycho-Behavioural Therapies”(psychosocial assessment, relaxation, mood and anxiety, acupuncture, and mind-body health systems) but no integrated approach that I could identify. Under the chapter entitled “Sympathetic Nervous System Blocks for the Treatment of Cancer Pain,” there is an excellent schematic diagram of the peripheral sympathetic nervous system and then a description of every possible block that is available. The discussion on celiac plexus and splanchnic nerve block is superficial considering that it is one of the few interventions for pancreatic cancer pain that has a good level of evidence for efficacy. There are some good radiographs and computed tomographic (CT) scans throughout the text but no images on how to position the image intensifier part of the x-ray machine.