Robot-Assisted 6D Digital Pain Score Slashes Refractory Cancer Pain From 8 to 1 in Gallbladder Cancer Case

When a 70-year-old man with advanced gallbladder carcinoma arrived at a Chinese cancer hospital, his chest and back pain registered 8 out of 10 on the standard numeric rating scale, his sleep was nearly destroyed, and he was suffering six episodes of sudden breakthrough pain every day despite escalating doses of oxycodone, pregabalin, celecoxib, and morphine suppositories. Within ten days of a robot-assisted digital assessment and a personalized analgesic plan built on its output, his pain score had fallen to 1, his breakthrough pain episodes had dropped to zero, and his sleep and mood scores had collapsed from 9 and 10 to 0 and 1. The case, published in Frontiers in Pain Research, marks the first clinical application of a novel six-dimensional digital pain assessment tool known as the 6D BTS, or Botong score, integrated with a robotic bedside device, and it offers a glimpse of how artificial intelligence and robotics may reshape the management of one of medicine’s most stubborn problems: refractory cancer pain.

Cancer pain is extraordinarily common. According to a 2023 systematic review and meta-analysis cited in the report, the overall prevalence of pain among cancer patients is 44.5 percent, with roughly 30.6 percent experiencing moderate to severe pain. Among patients with advanced, metastatic, or end-stage disease, the prevalence climbs to 54.6 percent. Most of these patients achieve reasonable relief through oral or topical medications organized along the World Health Organization analgesic ladder. But an estimated 10 to 20 percent of those with moderate-to-severe cancer pain never obtain effective relief, or they abandon treatment because of intolerable side effects. These cases are defined as refractory cancer pain, and they represent a vicious physiological cycle in which persistent severe pain triggers central sensitization, placing the nervous system in a state of abnormally heightened and sustained sensitivity. Pain not only causes direct suffering but also amplifies its own signals through emotional and physiological mechanisms, elevating stress hormones, increasing cardiovascular demand, and impairing immune function, which may in turn accelerate disease progression.

The central technical argument of the new report is that traditional assessment tools are simply too narrow to capture this complexity. Clinicians have long relied on unidimensional instruments such as the numeric rating scale and the visual analogue scale, which reduce the entire pain experience to a single number, as well as on multidimensional questionnaires like the Brief Pain Inventory and neuropathic pain screening scales. All of these depend on patient subjectivity, which inherently biases the scores and can push treatment regimens away from optimal protocols. Neurophysiological testing offers objective data, but high equipment costs and technical complexity have limited its widespread clinical utility. The 6D BTS system was designed to fill this gap by combining multidimensional depth with objectivity and ease of use through a digital interface.

The Botong score comprises six dimensions. The first is the numeric rating scale itself, ranging from 0 for no pain to 10 for the worst pain imaginable, with scores of 1 to 3 reflecting mild pain, 4 to 6 moderate pain, and 7 to 10 severe pain. The second dimension assesses the impact of pain on physical function, with separate regional queries covering cervical spine, upper limb, lower back, and lower limb function, each scored from 0 for no impact to 10 for the most serious impact. The third and fourth dimensions measure the impact of pain on emotions and on sleep, using the same 0 to 10 range. The fifth dimension screens for neuropathic pain using the LANSS scale, in which affirmative responses to questions about needling stabbing pain, burning pain, tingling sensations, electric-shock-like pain, and pain exacerbated by touching clothes or sheets each add one point, while an affirmative response to a sixth question subtracts one point; scores of 2 to 3 suggest neuropathic pain and scores of 4 to 5 strongly suggest it. The sixth dimension assesses breakthrough pain, asking whether sudden, brief, unbearable severe pain occurs even when analgesics are otherwise controlling the baseline pain, including when body position changes.

Psychometric testing supports the instrument. Reliability analysis yielded a Cronbach’s alpha coefficient of 0.78 for the BTS, and validity analysis produced a KMO value of 0.80, indicating good reliability and construct validity. A randomized crossover trial published in Pain Therapeutics in 2023 compared the digital multidimensional Botong score with the Brief Pain Inventory for evaluating cancer-related pain and found the BTS could compensate for some of the BPI’s deficiencies. Notably, the BPI requires complex color-coding on body maps, a task frequently too difficult for elderly patients, whereas the BTS system employs voice-activated control and simplified queries to ensure accessibility. In the new case report, a robot equipped with the BTS 6D system visited the patient’s bedside, administered the questionnaire, and organized the results, remaining unaffected by healthcare staff and delivering standardized, objective scoring with a high detection rate.

The patient’s history illustrates why such comprehensive assessment matters. He had undergone laparoscopic cholecystectomy with extended radical resection and partial hepatectomy for gallbladder carcinoma in February 2022 at another hospital, where histopathology revealed moderately to well-differentiated adenocarcinoma invading the serosal layer with perineural invasion and metastases in both lymph nodes at the porta hepatis, staged T3N1Mx. Four cycles of oral capecitabine followed. In October 2022, clavicular metastasis was detected and treated with 25 sessions of localized radiotherapy. In May 2023, chest pain prompted imaging that suggested sternal metastasis, leading to another 25 radiotherapy sessions targeting the sternum plus two cycles of a GP chemotherapy regimen. Severe myelosuppression after each cycle forced discontinuation of further chemotherapy. Over the preceding year, his intermittent stabbing chest pain had escalated from self-managed codeine and ibuprofen to oxycodone extended-release tablets at 50 mg every 12 hours combined with pregabalin and celecoxib, with morphine suppositories for breakthrough episodes. In the five days before presentation, pain intensity surged, destroying his sleep and appetite.

On admission, the patient was cachectic with a Karnofsky Performance Status score of 60, confined to a forced supine position, with post-radiation hyperpigmentation across his chest, two firm palpable subcutaneous nodules roughly 2 cm in diameter, an enlarged tender lymph node in the right supraclavicular fossa, fine crackles in the right lung fields, and pitting edema in the lower extremities. His diagnoses included gallbladder carcinoma at stage IVB with multiple secondary bone, hepatic, pulmonary, and left adrenal malignancies, plus chronic refractory chest and back pain. The robot-assisted BTS evaluation localized his primary pain to the chest and back, characterized by stabbing and burning sensations, and quantified regional impact scores of 4 for the cervical spine, 3 for the upper limbs, 6 for the lumbar and dorsal regions, and 7 for the lower limbs. Sleep impact registered 9 and emotional impact 10. Screening identified a neuropathic pain component with a score of 3, and he reported six daily breakthrough episodes, significantly exacerbated by postural changes. In accordance with the 2017 Expert Consensus on Refractory Cancer Pain, the team designed a tailored multimodal analgesic regimen addressing this complex profile.

On January 3, 2024, the team initiated intravenous hydromorphone patient-controlled analgesia at a concentration of 0.6 mg/mL, with a basal rate of 1.3 mL/h, a 3.2 mL bolus, a 15-minute lockout interval, and an hourly limit of 10.9 mL. Baseline control was initially adequate, but three breakthrough episodes occurred within the first 12 hours. Titration on January 5 to a 1.5 mL/h basal rate and 3.6 mL bolus brought the NRS to 3 with three daily breakthrough episodes. By January 7, pain had rebounded to NRS 6 with six daily episodes occurring predominantly at night. The team added pregabalin and olanzapine and adjusted the PCA to a 2.5 mL/h basal rate and 4.5 mL bolus, achieving stable control at NRS 3 with only one daily episode. Critically, the BTS data identified the pain as classic incident pain triggered by movement or postural changes, so the patient was instructed to self-administer pre-emptive PCA boluses before physical activity. Laxatives and dietary modifications prevented opioid-induced constipation. By January 13, when he transferred to a local hospital continuing intravenous PCA, his NRS was 1 with no breakthrough episodes, and remote monitoring through the BTS digital health system confirmed stable analgesia at NRS 2 by January 20, with regional impact scores collapsing toward zero and the neuropathic component down to 1.

The patient’s own words capture what the numbers mean. Before treatment, he reported that his pain destroyed his will to live, and stated that his greatest fear was not death but dying in agony. After achieving adequate analgesia, he told the nursing staff that he could now say goodbye to his children without screaming in pain. The authors emphasize that the real harm of cancer pain lies not only in physical suffering but in the erosion of dignity and meaningful connection at the end of life. They also acknowledge important limitations: as the BTS is an assessment instrument, the observed analgesic benefit is attributable to the therapeutic regimen it informed rather than to the tool itself, and this single case cannot isolate the incremental contribution of multidimensional assessment over standard titration. The patient succumbed to disease progression one month after discharge, precluding long-term follow-up data.

Even so, the case demonstrates that multidimensional digital assessment proved feasible and provided clinically relevant information that may offer a foundation for hypothesis testing in subsequent controlled trials. The authors argue that investigations should now focus on full-cycle management and real-time surveillance of refractory pain, maximizing quality of life for cancer patients. If the 6D BTS system and its robotic interface can be validated at scale, the integration of artificial intelligence, standardized digital scoring, and remote dynamic monitoring could transform refractory cancer pain from an unmeasurable ordeal into a precisely quantified, continuously tracked, and effectively treated condition, offering patients the chance to spend their final months in comfort and connection rather than in agony.

Subject of Research: Digital pain assessment technology for refractory cancer pain management

Article Title: Case Report: Application of the 6D BTS digital assessment system in the comprehensive management of refractory cancer pain in a patient with gallbladder carcinoma

Article References: Ren, J., Li, Y., Zhou, K., Wang, Y., Wang, Q., Hu, D., Song, T., Dong, H., Cheng, Z., Hu, C., Huang, K., Zhang, Y., & Zhuang, L. (2026). Case Report: Application of the 6D BTS digital assessment system in the comprehensive management of refractory cancer pain in a patient with gallbladder carcinoma. Frontiers in Pain Research, 7, Article 1808441. https://doi.org/10.3389/fpain.2026.1808441

Image Credits: AI Generated

DOI: 10.3389/fpain.2026.1808441

Keywords: cancer pain, refractory cancer pain, digital health, pain assessment, gallbladder carcinoma, robotics, patient-controlled analgesia, palliative care, artificial intelligence, oncology, Case, Report