Interventional therapies for cancer pain management: important adjuvants to systemic analgesics

Optimized use of systemic analgesics fails to adequately control pain in some patients with cancer. Commonly used analgesics, including opioids, nonopioids (acetaminophen and non-steroidal anti-inflammatory drugs), and adjuvant analgesics (anticonvulsants and antidepressants), have limited analgesic efficacy, and their use is often associated with adverse effects. Without adequate pain control, patients with cancer not only experience the anguish of poorly controlled pain but also have greatly diminished quality of life and may even have reduced life expectancy. Interventional pain therapies are a diverse set of procedural techniques for controlling pain that may be useful when systemic analgesics fail to provide adequate control of cancer pain or when the adverse effects of systemic analgesics cannot be managed reasonably. Commonly used interventional therapies for cancer pain include neurolytic neural blockade, spinal administration of analgesics, and vertebroplasty. Compared with systemic analgesics, which generally have broad indications for control of pain, individual interventional therapies generally have specific, narrow indications. When appropriately selected and implemented, interventional pain therapies are important components of broad, multimodal cancer pain management that significantly increases the proportion of patients able to experience adequate pain control.     

Drug delivery for intractable cancer pain. Use of a new disposable parenteral infusion device for continuous outpatient epidural narcotic infusion

Administration of narcotic analgesics through the epidural route has proven useful for treating pain of acute and chronic nature. This route of narcotic administration is frequently chosen for cancer patients with intractable pain that may be refractory to treatment by conventional oral or parenteral therapy. Implantable constant infusion devices have been commonly described as an alternative drug delivery system for this type of patient. This case report describes the use of the Travenol Infusor (Travenol Laboratories Inc., Deerfield, Illinois) an external, lightweight, disposable, drug delivery device for delivering continuous epidural morphine infusion to a patient with severe cancer pain. The patient has achieved stable pain relief for greater than 8 months without hospital admission for pain control, or management of complications due to the drug delivery system. The Travenol Infusor may prove to be an alternative drug delivery system for patients requiring continuous epidural narcotic infusion.     

基于循证医学的临床常用癌痛微创介入技术

癌痛严重影响肿瘤患者的生命质量,临床上仍有一部分患者药物治疗后未能获得满意的疼痛缓解。微创介入在其中发挥了重要意义。根据循证医学证据,建议使用腹腔神经丛或内脏神经阻滞治疗上腹部癌痛、上腹下丛阻滞治疗骨盆肿瘤所致内脏痛、经皮椎体成形或椎体后凸成形术治疗肿瘤所致椎体疼痛。肋间神经阻滞治疗胸壁癌痛、奇神经节及鞍区阻滞治疗骨盆肿瘤所致会阴部癌痛只有在临床研究中或是无有效缓解手段时作为一种体恤性治疗使用。     

Interventional techniques for cancer pain management

Patients with cancer frequently experience pain, and even with increased modern knowledge and skills in drug and other therapy, this pain is poorly controlled in a significant proportion. For these patients, a range of interventional techniques can play a significant role in providing pain relief. These include neuraxial administration of opioids and other drugs, temporary or permanent blockade of nerve pathways and minimally invasive management of bony and other metastases. Those involved in the treatment of pain from cancer should be aware of the scope of these techniques and ready to call upon specialists in their use.     

The management of cancer pain

Any therapeutic strategy developed for patients experiencing cancer pain depends on the goals of care, which can be broadly categorized as prolonging survival, optimizing comfort, and optimizing function. The relative priority of these goals for any individual should direct therapeutic decision-making. By combining primary treatments, systemic analgesic agents, and other techniques, most cancer patients can achieve satisfactory relief of pain. In cases where pain appears refractory to these interventions, invasive anesthetic or neurosurgical maneuvers may be necessary, and sedation may be offered to those with unrelieved pain at the end of life. The principles of analgesic therapy are presented, as well as the practical issues involved in drug administration, ranging from calculating dosage to adverse effects, and, when necessary, how to switch and/or combine therapies. Adjuvant analgesics, which are drugs indicated for purposes other than relief of pain but which may have analgesic effects, are also listed and discussed in some detail. Surgical and neurodestructive techniques, such as rhizotomy or cordotomy, although not frequently required or performed, represent yet other options for patients with unremitting pain and diminished hope of relief. Although cancer pain can be a complex medical problem arising from multiple sources, patients should be assured that suffering is not inevitable and that relief is attainable.     

Internet-based survey evaluating use of pain medications and attitudes of radiation oncology patients toward pain intervention

PURPOSE: Pain is a common symptom among cancer patients, yet many patients do not receive adequate pain management. Few data exist quantifying analgesic use by radiation oncology patients. This study evaluated the causes of pain in cancer patients and investigated the reasons patients fail to receive optimal analgesic therapy. METHODS AND MATERIALS: An institutional review board-approved, Internet-based questionnaire assessing analgesic use and pain control was posted on the OncoLink (available at www.oncolink.org) Website. Between November 2005 and April 2006, 243 patients responded. They were predominantly women (73%), white (71%), and educated beyond high school (67%) and had breast (38%), lung (6%), or ovarian (6%) cancer. This analysis evaluated the 106 patients (44%) who underwent radiotherapy. RESULTS: Of the 106 patients, 58% reported pain from their cancer treatment, and 46% reported pain directly from their cancer. The pain was chronic in 51% and intermittent in 33%. Most (80%) did not use medication to manage their pain. Analgesic use was significantly less in patients with greater education levels (11% vs. 36%, p = 0.002), with a trend toward lower use by whites (16% vs. 32%, p = 0.082) and women (17% vs. 29%, p = 0.178). The reasons for not taking analgesics included healthcare provider not recommending medication (87%), fear of addiction or dependence (79%), and inability to pay (79%). Participants experiencing pain, but not taking analgesics, pursued alternative therapies for relief. CONCLUSIONS: Many radiation oncology patients experience pain from their disease and cancer treatment. Most study participants did not use analgesics because of concerns of addiction, cost, or failure of the radiation oncologist to recommend medication. Healthcare providers should have open discussions with their patients regarding pain symptoms and treatment.     

Interventional procedures for cancer pain management: when are they indicated?

Non-invasive pharmacological management of patients with cancer related pain has resulted in pain control in 90-95% of the patients. Thus, 5-10% of patients still experience inadequate pain control despite aggressive combined pharmacological therapy. Moreover, patients may not tolerate an aggressive program of titration of medications and fail this approach because of side effects. In these patients interventional techniques have been very useful. This article discusses the alternative therapies, as well as the pitfalls in implementing these therapies, to achieve the highest possible success while minimizing potential complications and side effects.     

An alternative algorithm for dosing transdermal fentanyl for cancer-related pain

Many cancer patients are undermedicated and inappropriately managed for pain, leading to a diminished quality of life. Patients with moderate to severe pain often require opioid analgesics. Recently published guidelines emphasize individualization of opioid treatment to provide the drug and route of administration that meet the needs of the particular patient. Intolerable side effects, ineffective pain relief, or a change in the patient's clinical status can dictate the need for a new pain management regimen. Physicians must be able to readily quantify relative analgesic potency when converting from one opioid to another or from one route of administration to another. Transdermal fentanyl (Duragesic) is an opioid agonist that has been shown to be safe and effective for the treatment of cancer pain. However, clinicians should realize that the manufacturer's recommendations for equianalgesic dosing of transdermal fentanyl may result in initial doses that are too low in some patients, and in a titration period that is too long. Under these circumstances, the patient is likely to experience unrelieved pain. An alternative dosing algorithm that considers both a review of the literature and our combined clinical experience with transdermal fentanyl should help clinicians individualize the treatment of pain.     

Minimally Invasive Interventional Procedures for Metastatic Bone Disease: A Comprehensive Review

Metastases are the main type of malignancy involving bone, which is the third most frequent site of metastatic carcinoma, after lung and liver. Skeletal-related events such as intractable pain, spinal cord compression, and pathologic fractures pose a serious burden on patients’ quality of life. For this reason, mini-invasive treatments for the management of bone metastases were developed with the goal of pain relief and functional status improvement. These techniques include embolization, thermal ablation, electrochemotherapy, cementoplasty, and MRI-guided high-intensity focused ultrasound. In order to achieve durable pain palliation and disease control, mini-invasive procedures are combined with chemotherapy, radiation therapy, surgery, or analgesics. The purpose of this review is to summarize the recently published literature regarding interventional radiology procedures in the treatment of cancer patients with bone metastases, focusing on the efficacy, complications, local disease control and recurrence rate.     

Road map for pain management in pancreatic cancer: A review

Beside its poor prognosis and its late diagnosis, pancreatic cancer remains one of the most painful malignancies. Optimal management of pain in this cancer represents a real challenge for the oncologist whose objective is to ensure a better quality of life to his patients. We aimed in this paper to review all the treatment modalities incriminated in the management of pain in pancreatic cancer going from painkillers, chemotherapy, radiation therapy and interventional techniques to agents under investigation and alternative medicine. Although specific guidelines and recommendations for pain management in pancreatic cancer are still absent, we present all the possible pain treatments, with a progression from medical multimodal treatment to radiotherapy and chemotherapy then interventional techniques in case of resistance. In addition, alternative methods such as acupuncture and hypnosis can be added at any stage and seems to contribute to pain relief.     

Interventional cancer pain therapies

Interventional pain therapies play a critical role in palliation of severe cancer pain. Anesthesiologists specializing in cancer pain management have developed minimally invasive techniques to: (1) optimize pain control; (2) minimize side effects, adverse outcomes, and costs; (3) enhance functional abilities and physical and psychological well-being; and (4) enhance the quality of life for cancer patients. A thorough understanding of the pathophysiology of the cancer pain is needed to implement interventional therapies. It is also important to understand the prognosis of the patient, associated comorbidities, and expectations of the patient and family. Interventional pain therapies are minimally invasive techniques that can be divided into direct drug delivery, neuroablation and neural blockade, and neurostimulation.     

Barriers to pain assessment and management in cancer survivorship

Introduction Healthcare providers frequently lack the knowledge and skills to provide optimal pain management for cancer survivors. Scientific evidence and clinical guidelines are lacking in the management of chronic, persistent pain in survivors. The purpose of this article is to describe pain-related issues of cancer survivors using case presentations of selected patients enrolled in a randomized trial to eliminate barriers to pain management. Materials and methods Case presentations were selected from a National Cancer Institute-funded study that utilizes patient and professional educational content derived from the clinical guidelines of the National Comprehensive Cancer Network. Case presentation criteria included a pain rating of ≥6 and diagnosis of Stage I, II, or III of the following cancers: breast, colon, lung, or prostate cancer. Cases are presented based on the study’s framework of patient, professional, and system-related barriers to optimal pain relief. Results Across all three case presentations, barriers such as fear of side effects from pain medications, fear of addiction, lack of professional knowledge of the basic principles of pain management, and lack of timely access to pain medications due to reimbursement issues are prevalent in cancer survivorship. Conclusions Chronic pain syndromes related to cancer treatments are common in cancer survivors. Patient, professional, and system-related barriers that are seen during active treatment continue to hinder optimal pain relief during survivorship. Implications for cancer survivors Healthcare providers must acknowledge the impact of chronic, persistent pain on the quality of cancer survivorship. Clinical as well as scientific efforts to increase knowledge in chronic pain management will improve the symptom management of cancer survivors. Supported by a grant from the National Cancer Institute R-01 CA115323.     

背根神经节射频联合芬太尼贴剂治疗胸椎骨转移神经痛

  目的  观察背根神经节射频热凝联合芬太尼透皮贴剂治疗胸椎肿瘤骨转移所致癌性神经痛的临床效果、生存质量、镇痛药用量变化。  方法  选取86例胸椎肿瘤骨转移神经痛患者。术前将镇痛药更替为芬太尼透皮贴剂。疼痛评分（Numerical Rating Scale,NRS）>4或不良反应严重,在CT引导下行胸部背根神经节射频热凝术。观察术后疼痛缓解情况、镇痛药物用量变化等。  结果  治疗后患者疼痛明显缓解,中度以上缓解例数术后1 d为83例（96.5%）、术后7 d为79例（91.9%）、术后30 d为77例（89.5%）,芬太尼用量显著减少（P < 0.05）。患者生存质量改善,无严重并发症。  结论  背根神经节射频热凝术联合芬太尼透皮贴剂可以明显缓解胸椎肿瘤骨转移所致的癌性神经痛,改善患者的生存质量,安全易行,疗效确切。      

The management of neuropathic pain in cancer: clinical guidelines for the use of adjuvant analgesics

Neuropathic pain is seen in a third of cancer patients and is not always responsive to traditional analgesics. We describe practical guidelines for the use antidepressants and anticonvulsants as adjuvant analgesics in such situations. Newer adjuvant analgesics, interventional procedures and options for the management of pain emergencies, are also briefly outlined.     

Supportive care in oncology

Pain management, nutritional support, and psychosocial support are fundamental services that enhance patients' ability to cope with their cancer and its therapy. The common goal of symptom prevention mandates that each of these supportive services be provided to all patients throughout their cancer experience. Comprehensive cancer pain management begins with identifying the origin of all of the patient's pains and treating each one specifically. Pain prevention can be achieved through around-the-clock opioid administration with as-needed supplements for breakthrough pain and dose titration. Common narcotic side effects such as constipation and nausea also must be prevented. Successful opioid analgesia requires that patient and family concerns regarding addiction and tolerance be dispelled at the outset. Cancer pain prevention can be further optimized with the use of appropriate coanalgesics in response to the pathophysiology of the patient's pains. Cognitive and behavioral therapies may also be useful adjuncts to reduce both pain and suffering. Procedure-oriented pain control should be considered when systemic pharmacologic therapy does not provide adequate pain relief or is associated with intolerable side effects. The only absolute contraindications for pain-relieving procedures are untreatable coagulopathy and a decrease in mental status not related to medical pain management. Useful neurodestructive techniques include radiofrequency lesioning, cryoanalgesia, and chemical neurolysis with agents such as phenol, alcohol, and hypertonic saline. The most beneficial pain-relieving procedures and percutaneous cordotomy, spinal narcotics, celiac and hypogastric plexus ablation, spinal neurolysis, and epidural injection of steroids and hypertonic saline. Procedure selection depends on the cause of the pain and the patient's prognosis. Common indications for pain-relieving procedures include unilateral pain below the shoulder, upper abdominal visceral pains, pelvic visceral pain, perineal pain, vertebral body metastasis, discogenic pain, and spinal stenosis. As results of well-conducted scientific trials begin to appear in the literature, the indications for these procedures will be better understood, resulting in their more appropriate use. Principles of nutritional support in patients with cancer include an awareness of the problem of malnutrition and its impact on performance status, quality of life, prognosis, and treatment; identification of those patients at risk; prophylactic versus therapeutic intervention; and analysis and management of the specific impediment(s) to adequate nutrient intake and absorption. The primary goals for nutritional support in cancer patients are prevention of weight loss and maintenance of adequate protein status. Appreciation of practical issues of nutritional support will enable the practicing physician to achieve these goals using primarily oral nutrition options.(ABSTRACT TRUNCATED AT 400 WORDS)     

盐酸羟考酮控释片阴道给药治疗癌性疼痛的临床研究

背景与目的：盐酸羟考酮控释片是治疗中重度癌性疼痛的强阿片类口服镇痛药,部分患者由于持续的恶心、呕吐、意识障碍或吞咽困难等,常使其口服应用受到限制。本研究目的是观察盐酸羟考酮控释片阴道给药方式治疗中重度癌性疼痛的疗效及不良反应,为口服药物困难的女性患者提供新选择。方法：36例不能口服药物中重度癌痛女性患者采用盐酸羟考酮控释片阴道给药方式治疗,以往未使用阿片类止痛药物者,初始盐酸羟考酮控释片剂量为10mg,每12h用药一次,剂量滴定参考口服给药方法：对凶不能继续口服盐酸羟考酮控释片而改用阴道给药方式者,继续原来剂量阴道给药。结果：36例患者中完全缓解6例,明显缓解20例,中度缓解和轻度缓解各4例,未缓解2例;中度以上疼痛缓解率为83．3％。中位起效时间为49min;中位镇痛时间为13．8h。主要不良反应为阴道烧灼感（9例,25．0％）,无因不良反应而中止治疗者。结论：盐酸羟考酮控释片阴道给药方式安全、有效、方便,在口服药物困难的女性患者是一种可选择的给药方式。     

Management of cancer pain: basic principles and neuropathic cancer pain

Pain is one of the commonest symptoms in patients with cancer occurring in as many as 90% of patients during their illness. Pain is a complex phenomenon, which can be exacerbated by numerous other factors. This paper discusses the common strategies for the management of cancer pain in general and also neuropathic cancer pain. Using the World Health Organisation (WHO) analgesic ladder for cancer pain relief, 80% of cancer pain can usually be controlled. It follows therefore that 20% of cancer pain can be difficult to control. Neuropathic cancer pain is often in this category and the use of adjuvant analgesics such as amitriptyline and gabapentin is important. Optimum cancer pain control is achieved by integrating standard analgesic approaches during tumouricidal therapy or any other active cancer treatment.     

Patient barriers to optimal cancer pain control

Poorly controlled pain is a significant problem for cancer patients. Contributing factors may include concerns about analgesics and fears about the implications of pain, which may hinder open communication. We surveyed the prevalence of these concerns in Australian oncology patients and investigated associations with inadequate pain control. Ninety-three adult patients with cancer, undergoing treatment at a teaching hospital, completed the patient barriers questionnaire (BQ) and a self-report questionnaire to determine pain severity, interference with daily activities, use of analgesics and alternative therapies, and hesitation to report pain. Overall, there was a high prevalence of agreement with the BQ scales assessing concerns about communication and analgesic use. One-third of patients had clinically significant pain, which interfered with daily activities, despite use of analgesics. They were more likely to use alternative therapies for pain control, to hesitate to discuss their pain, and had significantly greater concerns about side effects of analgesics and injections. Our study confirms that patient barriers exist in this Australian population and are associated with inadequate pain control. Oncology staff need to actively screen for pain, particularly targeting patients using alternative therapies and experiencing side effects, develop communication and prescribing skills, and diversify pain management approaches beyond analgesics.     

Management of central airway obstruction

The efficacy of interventional pulmonology for palliation of patients with central airway obstruction has been established, and its curative potential for early cancer has raised great interest in current screening programs. The success of endoscopic strategies for palliation and treatment with curative intent strongly depends on the diligent identification of the various factors in lung cancer management, including full comprehension of the limits and potential of each particular technique. In the palliative setting of alleviating central airway obstruction, laser resection, electrocautery, argon plasma coagulation, and stenting are techniques that can provide immediate relief, in contrast with cryotherapy, brachytherapy, and photodynamic therapy, which have delayed effects. With curative intent, intraluminal techniques that easily coagulate early-stage cancer lesions will increase the implementation of interventional pulmonology for benign and relatively benign diseases, as well as early cancer lesions and its precursors at their earliest stage of disease.     

大剂量阿片类药物治疗癌性疼痛回顾性分析

目的：观察大剂量阿片类止痛药物控制国人癌性疼痛的疗效及安全性。方法：八一医院肿瘤内科２００５年１月～２００９年２月住院治疗晚期恶性肿瘤患者中,有２１例因重度疼痛而需要大剂量阿片类（口服吗啡等效剂量为≥３００ｍｇ／ｄ）治疗,回顾性分析其临床诊断,阿片类滴定时间、剂量、使用持续时间以及毒副反应。结果：２１例中,１６例为胃肠道肿瘤;１４例存在骨骼转移,８例有腹膜后淋巴结转移;躯体痛１４例,神经性疼痛和内脏痛各９例。治疗过程中１７例患者经历阿片类转换。滴定至最大剂量的时间为４～３７８ｄ（中位时间９２ｄ）。最大剂量范围为３３０ｄ～１２００ｍｇ／ｄ（中位数４５０ｍｇ／ｄ）。大剂量阿片类持续时间为１２～２５５ｄ（中位时间６１ｄ）。出现疼痛后生存期为２～４５个月（中位数１１个月）。未出现威胁生命的毒副反应。结论：大剂量阿片类止痛药对具有重度疼痛的国人晚期肿瘤患者是安全有效的。