Surveys indicate 10-30% cancer patients have pain that is difficult-to-control with the usual pharmacologic approaches. In this talk, I will discuss pain management challenges that can occur at five key time points across the cancer trajectory, with special reference to lung cancer and other thoracic malignancies. 1. At presentation: patients with thoracic malignancies can present with severe pain e.g. Pancoast’s syndrome. The pharmacological management of neuropathic pain will be reviewed; 2. Perioperative: Surgery is an important part of treating thoracic malignancies. There is increasing concern about the long term-consequences of acute pain management in the peri-operative period, including the importance of acute pain management ot prevent chronic pain, and the potential of some modalities (volatile anaestehtcis, opioids) to cause immunosuppression. This has given rise to the concept of “oncoanaesthesia”; 3. Disease recurrence/progression: malignant chest pain can be refractory to pharmacologic management. The 4th rung of the WHO ladder proposes using interventional techniques in these situations, e.g. percutaneous and/or operative cordotomy; 4. At the end of life, patients dying of advanced thoracic malignancies often have concomitant pain, dyspnea and anxiety which are very distressing. Occasionally terminal sedation is justified; 5. Survivorship. As the prognosis of all cancers — including thoracic malignancies — improves, the principles of chronic non-malignant pain management becomes relevant in cancer survivors. Some patient have persistent post-treatment pain, e.g. post thoracotomy, RT plexopathy or CIPN. Others have pre-existing chronic pain that has become exacerbated by the deconditioning associated with cancer and/or its treatment. In the light of the ‘opioid crisis’, it is increasingly being recommended that these patients should be managed like chronic pain patients rather than cancer patients.