Transcription

Cancer Pain:A Clinical OverviewLinda A. King, MDSection of Palliative Care andMedical Ethics

Objectives Define Palliative CareReview prevalence of cancer painKnow barriers to cancer pain managementUnderstand how to assess pain in cancerpatientsDiscuss multimodal approach to cancerpain managementReview common cancer pain syndromes

Palliative Care: DefinitionComprehensive management of physical,psychological, social, spiritual needs ofpatients with serious, life-threatening illnessand their families.

Palliative Care Interdisciplinary approachAt any point in disease trajectoryMaximize QOL, mitigate sufferingOptimize coping, reduce illness burdenSupport communication, autonomy andchoice

Evolving Model of Palliative Care

Cancer Pain Any pain symptom in patient with cancerPrevalent across all cancer types 30-60% during treatment65-90% in advanced disease40% after treatment completed70-90% cancer pain can be controlled

Cancer Pain: Categories andCauses Nociceptive: Somatic: bone or soft tissue massesVisceral: pancreatic mass, liver metastases,peritoneal metastasesNeuropathic: epidural tumor, CIPN,Mixed nociceptive and neuropathic: Pelvicpain, head and neck cancer pain

Cancer Pain: Categories Cancer Itself – 75% Cancer Treatments – 25 % CIPN, definitive chemoXRT for head/neckcancerExacerbation of Chronic Non-cancer Pain Solid tumors, primary and metastaticMigraines, chronic LBPPain in Cancer Survivors: Post-mastectomy, post-amputation

Barriers to Cancer PainManagement Patient: Reluctance to report pain or takemeds, concern re: side effects andaddiction, tolerance, costProviders: Poor assessment, reluctance toprescribe opioids, lack of knowledge, timeSystem: Lack of easy access to resources,lack of care coordination, regulatorybarriers

Cancer Pain Assessment: General HistoryPhysical ExaminationLaboratory and Imaging StudiesGoal:Clarify cancer extentMake a diagnosisDesign a treatment plan

Pain Assessment: Principles More than one pain issue is common.Assess each pain at each visit.Pain is a subjective phenomenon. Patientreport guides the assessment.Make a diagnosis. Specific pains respondto specific treatments.Assess effects on function and QOL.

Assessment: History QualityLocationSeverityTemporal patternAlleviating/exacerbating factorsAssociated symptomsPrevious treatmentsImpact on functionRisk factors for aberrant use of pain meds

Pain Assessment “Tell me about your pain.”“How severe is the pain (0-10 scale)?”“Where is the pain?“Does it travel anywhere else?”“What does it feel like?”“Is it there all the time or does it come and go?”“Does it bother you at night?”

Assessment What makes it come on or makes it worse?”“What makes it better?”“Are there other symptoms that go along withthe pain?”“What have you tried that has helped the pain?”“Does the pain interfere with your ?”“What do you think is causing the pain?”“Do you have any worries about the pain?”

Cancer Pain: Treatment For each pain, develop a multimodaltreatment plan.Design a 4-step intervention Opioid regimenCo-analgesics and adjuvant analgesicsInterventional modalitiesComplementary and alternative modalities

Cancer Pain: Treatment For each pain, develop a multimodaltreatment plan.Design a 4-step intervention Opioid regimenCo-analgesics and adjuvant analgesicsInterventional modalitiesComplementary and alternative modalities

Basic Principles of OpioidPrescribing Make it simple: oral route, one drugPrescribe an adequate doseUse a correct dosing intervalPrescribe around-the-clock (long-acting opioid)Provide a breakthrough dose (short-actingopioid)Use equianalgesic conversion tableTreat common opioid side effects

Basic Principles of OpioidPrescribing Precautions for aberrant drug use Assess for risk factors, PDMP, substance useagreement, UDS, pill countsCaution when combining with othersedating meds

Principles of Opioid dosing Start immediate-release, short-actingopioids first in opioid naïve patientTransition to long-acting opioid based onfrequency of use and pain responseContinue to adjust dose based on use andeffect

Long-acting opioids For opioid-tolerant patients: Oral sustained-release formulationsOxycontin, MSContin, Opana XR 8 or 12 hour dosing Most abuse-resistant Transdermal Fentanyl 72 hr duration

Long-Acting Opioid: Methadone Effective, inexpensive, neuropathic paingiven NMDA activityComplicated pharmacokinetics make ittricky to dose Significant drug-drug interactions. Not linear: equivalent dose depends onprevious opioid useAnalgesic effects prompt; side effects delayedProlonged QTc interval, arrhythmiasGet help if prescribing

Opioid Rotation Consider when escalating doses ineffectiveor dose-limiting side effectsUse equianalgesic dosing tablesConsider incomplete cross-tolerance whendosing

Equianalgesic morphone(Dilaudid)FentanylHydrocodoneORAL (mg)3020-301.57.50.130

Cancer Pain: Different Routes ofOpioid Administration Parenteral: IV or SQ Patient-controlled: PCSublingual concentrateRectalEpidural/intrathecalTopical (wound, mucosa)

Anticipate and Treat Opioid Side Effects ConstipationNausea and vomitingSedation and mental slowingPruritusMyoclonusDry mouthUrinary retentionRespiratory depression

Cancer Pain: Treatment For each pain, develop a multimodaltreatment plan.Design a 4-step intervention Opioid regimenCo-analgesics and adjuvant analgesicsInterventional modalitiesComplementary and alternative modalities

Co-Analgesics Is there an inflammatory component? Bone metastases, epidural spinal diseaseLiver capsule distentionTreat with AcetaminophenNSAIDs: Ibuprofen, naprosyn, celexicob, etc.Corticosteroids: Prednisone, Decadron

Co-analgesics: Challenges Ceiling effectSide effect profile: GI, bleedingRenal or hepatic dysfunctionAnti-pyretic effects

Adjuvant Analgesics Is there a neuropathic component? Burning, stabbing, shootingNerve-rich location: head and neck, pelvis, spineDrugs for neuropathic pain Tricyclic anti-depressants: Amitriptyline, desipramineAnti-epileptics: Gabapentin, Pregabalin, Depakote,LamotrigineSNRIs: Venlaxafine, DuloxetineTopical agents: lidocaine, capsaicin

Cancer Pain: Treatment For each pain, develop a multimodaltreatment plan.Design a 4-step intervention Opioid regimenCo-analgesics and adjuvant analgesicsInterventional modalitiesComplementary and alternative modalities

Interventional Modalities Radiation therapy: bone, soft tissue metCeliac plexus block: pancreatic cancerIntercostal nerve block: chest wall/ribHypogastric plexus block: pelvic painEpidural steroid injection: spinal nervecompressionImplanted intrathecal catheter: refractorypain; side effects of opioid therapyKyphoplasty

Celiac plexus block: Visceralpain due to pancreatic cancer

Cancer Pain: Treatment For each pain, develop a multimodaltreatment plan.Design a 4-step intervention Opioid regimenCo-analgesics and adjuvant analgesicsInterventional modalitiesComplementary and alternative modalities

Complementary Modalities Heat and/or icePhysical therapyTENSAssistive devicesAcupunctureMassageBehavioral therapies: Imagery, hypnosis,mindfulness

Case 1. Bone Pain70 y/o woman with 1 month h/olateral thigh pain presents to ED,imaging shows large lytic lesionin femur.

Case 1. Bone Pain Further imaging reveals additional bonylytic lesions in bilateral humeri, multiplevertebra, pelvis, scapula, ribsChest CT scan shows spiculated L lowerlobe mass as likely primary as well as livermetastases

Case 1 (continued) Pt undergoes prophylactic operativepinning of L femur with intramedullary nailOxycodone 5-10 mg used for postoperative painNSAIDs contraindicated due to patientanti-coagulated for prior DVTPt undergoes 5 fractions of external beamXRT 2 weeks after surgery

Case 1 (continued) Patient has persistent leg pain as well asposterior shoulder painLong-acting opioid added (Oxycontin 20 BID)Develops significant constipation, sedation, drymouth and stops taking opioidsRotation to Fentanyl patch effective with lessside effects overallPathology confirms adenoca, lung primary, PDL1 expression. Pt started on immunotherapy

Case 2. Pancreatic cancer 46 y/o man with 3 month h/o mid-lowerback pain as well as 20 pound weight loss,anorexia.Patient initially treated symptomatically formusculoskeletal low back pain.Pain persists and imaging shows 4 cmhead of pancreas mass

Case 2. Pancreatic cancer

Case 2. Pancreatic cancer Later pt is hospitalized for refractory nausea,vomiting and jaundice.Pain controlled with Hydromorphone PCA 0.2mg IV q10 min prn patient bolusFentanyl 25 uq patch q72 hrs added based onPCA usePt undergoes endoscopy for biliary stentplacement with simultaneous celiac plexusblock

Case 2. Pancreatic cancer Jaundice and N/V resolve with stenting.Patient undergoes systemic chemotherapy withGemcitabine and AbraxaneDevelops painful numbness, tingling, burning ofbilateral feet and fingertips after 2 cycles ofchemoGabapentin initiated with titration of dose over 2weeks with some improvement

Case 2. Pancreatic cancer Pt referred to Integrative Oncologyprogram and initiates acupuncture forongoing management of anorexia andneuropathy painAlso, sees meditation coach formindfulness training to assist with anxietyand insomnia

Case 3. Spinal CordCompression 52 y/o woman with h/o breast cancer s/pprior mastectomy, chemo and XRTpresents with several week h/o mid-backpain worse with coughing, standing, oftenawakens patient at night.Imaging shows evidence of thoracic spinalmetastatic disease with epiduralinvolvement and early SCC

Case 3. SCC Oncologic emergencyGoal: to prevent loss of neurologicfunction, paralysisUrgent neurosurgical and radiationoncology consultation. Immediate XRT vs.surgical decompressionSteroids, analgesicsSerial neurological examinations

Cancer Pain: Summary Complete a thorough assessment todiagnose the cause of pain and to developa treatment plan.Individualize each patient’s pain regimen.Re-assess frequently.Use a multimodal approach to treatingcancer pain.