Breakthrough cancer pain: review and calls to action to improve its management

Definition and Assessment of Paediatric Breakthrough Pain: A Qualitative Interview Study

Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals' insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: 'the elusive nature of breakthrough pain', 'breakthrough pain assessment', 'positive attitudes towards', 'reservations towards' and 'features to include in' a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept.

The influence of ambient environmental factors on breakthrough Cancer pain: insights from remote health home monitoring and a proposed data analytic approach

BACKGROUND

Breakthrough cancer pain (BTCP) is primarily managed at home and can stem from physical exertion and emotional distress triggers. Beyond these triggers, the impact of ambient environment on pain occurrence and intensity has not been investigated. This study explores the impact of environmental factors on the frequency and severity of breakthrough cancer pain (BTCP) in the home context from the perspective of patients with advanced cancer and their primary family caregiver.

METHODS

A health monitoring system was deployed in the homes of patient and family caregiver dyads to collect self-reported pain events and contextual environmental data (light, temperature, humidity, barometric pressure, ambient noise.) Correlation analysis examined the relationship between environmental factors with: 1) individually reported pain episodes and 2) overall pain trends in a 24-hour time window. Machine learning models were developed to explore how environmental factors may predict BTCP episodes.

RESULTS

Variability in correlation strength between environmental variables and pain reports among dyads was found. Light and noise show moderate association (r = 0.50-0.70) in 66% of total deployments. The strongest correlation for individual pain events involved barometric pressure (r = 0.90); for pain trends over 24-hours the strongest correlations involved humidity (r = 0.84) and barometric pressure (r = 0.83). Machine learning achieved 70% BTCP prediction accuracy.

CONCLUSION

Our study provides insights into the role of ambient environmental factors in BTCP and offers novel opportunities to inform personalized pain management strategies, remotely support patients and their caregivers in self-symptom management. This research provides preliminary evidence of the impact of ambient environmental factors on BTCP in the home setting. We utilized real-world data and correlation analysis to provide an understanding of the relationship between environmental factors and cancer pain which may be helpful to others engaged in similar work.

Cancer Pain Management with Traditional Chinese Medicine: Current Status and Future Perspectives

Cancer pain, especially the moderate-to-severe pain experienced by patients with advanced cancer, is still one of the most challenging clinical problems. The current mainstream pharmacological treatment for cancer pain involves applying opioid medications and other pain-killing drugs. However, analgesic drugs have many adverse effects such as addiction, tolerance, and other formidable clinical and social issues. Thus, finding a new therapeutic approach to treat cancer pain is essential. Traditional Chinese medicine (TCM) has been increasingly applied in clinical practice because of its good efficacy and few side effects. However, its mechanisms of action in treating pain are still under investigation. The most important mechanism of cancer pain is that a large amount of pain-causing substances are secreted from cancer cells and promote their growth and invasion. The physical and chemical stimulations of these substances exist along with the cancer growth, leading to constantly increased pain sensation. Whether cancer pain can be alleviated by inhibiting cancer cells from releasing the substances and changing the microenvironment around the cancer mass, or even by eliminating pain-causing substances, is largely unknown. Based on TCM theory, this study reported that the aforementioned approach could effectively manage different cancer pains by tonifying qi, clearing and activating channels and meridians, and strengthening body resistance. The TCM therapies activate blood circulation, remove blood stasis, and nourish the heart. Commonly used Chinese herbal drugs include Corydalis yanhusuo, Angelica dahurica, and Ligusticum chuanxiong. Instead of using conventional analgesics to reduce pain, we should focus on using TCM modalities to alleviate cancer pain and increase the quality of life in patients suffering from cancer pain. TCM should provide us with a new strategy for managing cancer pain.

Breakthrough pain among cancer patients at oncology units in Northern Ethiopia; a multi-center study

Background

Breakthrough cancer pain (BTCP) is a transient exacerbation of pain that affects the length of hospitalization and quality of life of patients. The objective of this study was to determine the prevalence and factors associated with BTCP among cancer patients at oncology units in Northern Ethiopia in 2022.

Methods

A multi-center cross-sectional study was conducted from April to June 2022. After obtaining ethical approval, data were collected prospectively from 424 adult cancer patients admitted to oncology units. Breakthrough cancer pain was assessed by the numeric rating scale. Descriptive and binary logistic regression analyses were performed to determine the factors associated with BTCP. The strength of association was described in adjusted odds ratio (AOR) with 95% confidence intervals and variables with a P-value < 0.05 were considered to have a statistically significant association with BTCP.

Result

The prevalence of BTCP among cancer patients was 41.5%. The factors that were found to be associated with BTCP were colorectal cancer (AOR: 7.7, 95% CI: 1.8, 32.3), lung cancer (AOR: 6.9, 95% CI: 1.9, 26.0), metastasis (AOR: 9.3, 95% CI: 3.0, 29.1), mild background pain (AOR: 7.5, 95% CI: 2.5, 22.6), moderate background pain (AOR: 7.0, 95% CI: 2.2, 23.1), severe background pain (AOR: 7.1, 95% CI: 2.2, 22.8), no analgesics taken for background pain (AOR: 5.1, 95% CI: 2.8, 9.3) and uncontrolled background pain (AOR: 3.3, 95% CI: 1.8, 6.1).

Conclusion

The prevalence of BTCP was high. Colorectal cancer, lung cancer, the presence of metastasis, the presence of background pain, not taking analgesics for background pain, and uncontrolled background pain were significantly associated with BTCP.

Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits

Cancer pain is an important challenge in treatment and requires a rapid onset of action for its control. In particular, breakthrough cancer pain (BTcP) should be adequately controlled with a stable dose of a short-acting oral opioid. Fentanyl is a synthetic, highly selective opioid with many advantageous chemical properties, including high lipophilicity and distinct pharmacokinetic properties. It is recommended for pain management in a variety of settings, including acute pain, chronic pain and BTcP. To date, its variously designed formulations allow non-invasive administration; amongst others, sublingual fentanyl has proven useful in the management of BTcP and in improving the quality of life of patients with cancer. This review provides an update on the management of BTcP with fentanyl, with consideration of safety, as it remains an important tool in the treatment of cancer pain.

A systematic review of qualitative research exploring patient and health professional perspectives of breakthrough cancer pain

PURPOSE

Breakthrough cancer pain (BtCP) is a prevalent health issue which is difficult to manage. A plethora of quantitative research in this area exists. There is a paucity of research on the perspectives of health professionals and patients surrounding domains impacting effective treatment, including definitions of BtCP, treatment, and education opportunities. This review aims to identify and synthesize the extent of qualitative research exploring health professional and patient perspectives of BtCP.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach was undertaken. The approach was registered with Prospero. MEDLINE, EMBASE, and Web of Science were searched for peer-reviewed literature published any date prior to May 19, 2022. Eligible sources must have considered health professional and/or patient perspectives of BtCP. A narrative synthesis approach was utilized.

RESULTS

Three sources met the review criteria. One source explored nurse perspectives, while two sources explored patient perspectives. Study quality was moderate to high. Overlapping themes across the three studies included communication, defining BtCP, impact of BtCP, management of BtCP, perceptions of BtCP, analgesia and pain relief, and training and professional development.

CONCLUSION

Given limited research investigating clinician and patient perspectives of BtCP, a rich understanding informed by exploratory qualitative methods around identification, best management strategies, professional development, and factors promoting and inhibiting best practice remains unclear. Further qualitative inquiry is warranted, and it is expected such research will inform BtCP clinical guidelines.

Increased quality of life in patients with breakthrough cancer pain after individualized therapy: the CAVIDIOM study

Aim: To evaluate the quality of life (QoL) in patients with breakthrough cancer pain (BTcP) in Spanish medical oncology departments. Patients & methods: In a prospective, observational, multicenter study, we assessed QoL using the EQ-5D-5L instrument at baseline and after 15 and 30 days of individualized BTcP therapy, as well as BTcP characteristics and treatment. Results: Patients (n = 118) were mainly women, over 64 years old and with advanced cancer. QoL improved at 15 (p = 0.013) and 30 days (p = 0.011) versus baseline. Individualized BTcP therapy consisted mostly of rapid-onset opioids (transmucosal fentanyl at doses of 67-800 μg) according to the physician evaluation. BTcP improved, including statistically significant reductions in intensity, duration, number of episodes in the last 24 h and time to onset of BTcP relief. Conclusion: QoL increased after individualized pain therapy in patients with advanced cancer and BTcP in medical oncology departments.

Bibliometric Network Analysis on Rapid-Onset Opioids for Breakthrough Cancer Pain Treatment

BACKGROUND AND OBJECTIVES

Proper breakthrough cancer pain (BTcP) management is of pivotal importance. Although rapid-acting, oral and nasal transmucosal, fentanyl formulations (rapid-onset opioids, ROOs) are licensed for BTcP treatment, not all guidelines recommend their use. Presumably, some research gaps need to be bridged to produce solid evidence. We present a bibliometric network analysis on ROOs for BTcP treatment.

METHODS

Documents were retrieved from the Web of Science (WOS) online database. The string was "rapid onset opioids" or "transmucosal fentanyl" and "breakthrough cancer pain". Year of publication, journal metrics (impact factor and quartile), title, document type, topic, and clinical setting (in-patients, outpatients, and palliative care) were extracted. The software tool VOSviewer (version 1.6.17) was used to analyze the semantic network analyzes, bibliographic coupling, journals analysis, and research networks.

RESULTS

502 articles were found in WOS. A declining trend in published articles from 2014 to 2021 was observed. Approximately 50% of documents regard top quartile (Q1) journals. Most articles focused on ROOs efficacy, but abuse and misuse issues are poorly addressed. With respect to article type, we calculated 132 clinical investigations. The semantic network analysis found interconnections between the terms "breakthrough cancer pain," "opioids," and "cancers." The top co-cited article was published in 2000 and addressed pain assessment. The largest number of partnerships regarded the United States, Italy, and England.

CONCLUSION

In this research area, most articles are published in top-ranked journals. Nevertheless, paramount topics should be better addressed, and the implementation of research networks is needed.

Strengths and Weaknesses of Cancer Pain Management in Italy: Findings from a Nationwide SIAARTI Survey

Objectives: Despite guidelines, a large percentage of cancer patients continue to suffer from ineffectively treated pain. The authors undertook this survey to assess the strengths and weaknesses of cancer pain management in Italy. Design: This was a prospectively administered survey. Participants: The participants were anesthesiologists of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Intervention: A 58-item questionnaire covered the demographics and features of cancer pain management in the Italian context. Results: The authors received responses from 611 pain therapists of 279 centers. Only 22% of physicians are exclusively pain therapists. Seventy-five percent are specialists in anesthesiology, intensive care, and pain medicine. Most pain centers are hospital or university facilities (78%). The strengths of cancer pain management in Italy are the careful opioid prescriptions, the use of strategies for the treatment of neuropathic pain, patient/healthcare provider partnerships, and breakthrough cancer pain management. Weaknesses to be addressed include poor adherence to guidelines, inadequate attention toward the patient’s quality of life, insufficient use of minimally invasive techniques, lack of teamwork approaches, inappropriate timing of pain specialist engagement, and poor telemedicine use. Conclusions: Despite several strengths, further efforts are needed to improve the care of patients suffering from cancer pain in Italy.

A Systematic Review of Measures of Breakthrough Pain and Their Psychometric Properties

CONTEXT

Breakthrough pain (BTP) is common in cancer and other conditions yet there is a lack of validated BTP measurement tools.

OBJECTIVES

We aimed to identify all tools assessing or characterising BTP in patients of any age with any condition, and to critically appraise their psychometric properties.

METHODS

The Cochrane Library, PROSPERO, Embase, CINAHL, Medline, PsycINFO, Web of Science, Google Scholar, ProQuest, Evidence Search and OpenGrey were searched to identify all available tools used to assess BTP. A second search identified studies that had evaluated psychometric properties of tools identified in Search 1. Databases were searched from inception to November 2020. Studies were assessed using COSMIN criteria and GRADE guidelines.

RESULTS

Search 1 found 51 tools used to assess BTP. Search 2 found six tools that had a development study and/or a study evaluating a tool psychometric property. No tool had more than one study evaluating psychometric properties so a meta-analysis could not be conducted. Studies were of inadequate to very good quality. Only the Breakthrough Pain Assessment Tool (BAT) had sufficient content validity and at least low-quality evidence for sufficient internal consistency.

CONCLUSION

The BAT is recommended to characterise BTP in adults with cancer; its applicability to other conditions is unknown. The remaining tools need further evaluation. Only the Breakthrough Pain Questionnaire for Children was designed for children with cancer, but no psychometric properties were evaluated. There is a need for a tool to assess and characterise BTP in children with non-cancer diagnoses and those who cannot self-report.

Identifying the unmet supportive care needs of people affected by kidney cancer: a systematic review

PURPOSE

To synthesize existing evidence on the unmet supportive care needs of people affected by kidney cancer, across the cancer care continuum.

METHODS

A systematic review was conducted according to the PRISMA Statement Guidelines. Electronic databases (CINAHL, MEDLINE, and PsychINFO) were searched using key search terms. Articles were assessed according to pre-specified eligibility criteria. Data extraction and quality appraisal were conducted. The findings were integrated in a narrative synthesis.

RESULTS

One thousand sixty-three publications were screened, and 18 publications met the inclusion criteria. The following domains of unmet needs in order of frequency included psychological/emotional needs (17/18: 94%), physical needs (10/18: 56%), social needs (4/18: 22%), interpersonal/intimacy needs (4/18: 22%), patient-clinician communication needs (3/18: 17%), family-related needs (3/18: 17%), health system/information needs (3/18: 17%), spiritual needs (3/18: 17%), daily living needs (2/18: 11%), practical needs (1/18: 6%), and cognitive needs (1/18: 6%).

CONCLUSIONS

There was a wide range of unmet supportive care needs experienced by people diagnosed with kidney cancer. A prominent focus was on psychological and physical needs. Further research is needed to understand how clinical (stage/treatment) and demographic (age/socio-economic/ethnicity) variables may moderate or mediate the relationship with unmet needs over time. With many unmet needs identified, this review provides a starting place to inform future work to address the complex unmet supportive care needs of people affected by kidney cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Individuals living with kidney cancer have many unmet supportive care needs, and future research is needed to learn about what are the most pressing needs and how to best address these concerns to ensure holistic person-centered care is delivered.

Effect of a theory-driven educational intervention on the level of knowledge, attitudes, and assessment practices regarding breakthrough cancer pain (BTCP) management among medical nurses in Hong Kong

PURPOSE

To examine the effect of an educational intervention intended to improve medical nurses' adherence to breakthrough cancer pain (BTCP) assessment practices and their level of knowledge, attitudes and perceived assessment practices regarding BTCP management.

METHODS

Nurses working in a regional hospital were recruited to this quasi-experimental study. The intervention group received a 3-h educational workshop and one session of individual clinical instruction, whilst the control group did not receive any intervention. Chart audits were performed to examine adherence to BTCP assessment practices as the primary outcome. A self-developed questionnaire was used to measure nurses' knowledge, attitudes and perceived assessment practices regarding BTCP management as the secondary outcomes. The chi-square or Fisher's exact test was used to compare the rate of adherence to BTCP assessment practices between groups. A generalised estimating equation was used to compare changes in knowledge, attitudes, and perceived assessment practices between groups over time.

RESULTS

One hundred and five nurses completed the study. The chart audits revealed a significantly higher rate of adherence to BTCP assessment practices in the intervention group after the intervention (p < .05). The intervention group exhibited significant positive changes in scores for knowledge (β = 25.49, p < .001), attitude (β = 0.98 to 2.81, p < .01), and their perceived assessment practices (β = 1.33 to 3.14, p < .002) when compared with the control group.

CONCLUSIONS

This theory-driven educational intervention significantly improved the medical nurses' adherence to BTCP assessment practices and their level of knowledge attitudes and perceived assessment practices regarding BTCP management.

Laser-photobiomodulation on experimental cancer pain model in Walker Tumor-256

CONTEXT

Cancer Pain is considered a common and significant clinical problem in malignant neoplasms, comprising 20% to 50% of all patients with tumor progression. Laser photobiomodulation (L-PBM) has been used in a multitude of pain events, ranging from acute trauma to chronic articular. However, L-PBM has never been tested in cancer pain.

OBJECTIVES

Evaluate hyperalgesia, edema, COX-1, COX-2, IL-10, and Bdkrb1 mRNA in low-level laser irradiated Walker-256 tumor-bearing rats.

METHODS

Rat hind paw injected with Walker Tumor-256 (W-256) and divided into six groups of 6 rats: G1 (control) - W-256 injected, G2- W-256 + Nimesulide, G3- W-256 + 1 J, G4- W-256 + 3 Jand G5- W256 + 6 J. Laser parameters: λ = 660 nm, 3.57 W/cm², Ø = 0.028 cm². Mechanical hyperalgesia was evaluated by Randall-Selitto test. Plethysmography measured edema; mRNA levels of COX-1, COX-2, IL-10, and Bdkrb1were analyzed.

RESULTS

It was found that the W-256 + 1 J group showed a decrease in paw edema, a significant reduction in pain threshold. Higher levels of IL-10 and lower levels of COX-2 and Bdkrb1 were observed.

CONCLUSION

Results suggest that 1 J L-PBM reduced the expression of COX-2 and Bdkrb1 and increasing IL-10 gene expression, promoting analgesia to close levels to nimesulide.

Careful Breakthrough Cancer Pain Treatment through Rapid-Onset Transmucosal Fentanyl Improves the Quality of Life in Cancer Patients: Results from the BEST Multicenter Study

OBJECTIVES

To explore the effect of breakthrough cancer pain (BTcP) treatment on quality of sleep and other aspects of the health-related quality of life (HRQoL) in patients with cancer pain.

METHODS

In an observational, multicenter, cohort study, cancer patients from palliative care units, oncology departments, and pain clinics and affected by BTcP were included. Enrolled patients were assessed at the four visits: T0 (baseline), T7, T14, and T28. Stable chronic background pain (numeric rating scale, NRS ≤ 4) during the whole study period was mandatory. BTcP was treated through transmucosal fentanyl. Three questionnaires were used to measure the HRQoL: EORTC QLQ-C15-PAL, Pittsburgh Sleep Quality Index (PSQI), and the Edmonton Symptom Assessment System (ESAS).

RESULTS

In 154 patients, the HRQoL showed a significant improvement for all physical and emotional characteristics in the EORTC QLQ-C15-PAL, except for nausea and vomiting (linear p-value = 0.1) and dyspnea (Linear p-value = 0.05). The ESAS and PSQI questionnaires confirmed these positive results (p < 0.0001 and p = 0.002, respectively).

CONCLUSIONS

This prospective investigation by an Italian expert group, has confirmed that careful management of BTcP induces a paramount improvement on the HRQoL. Because in cancer patients there is a high prevalence of BTcP and this severe acute pain has deleterious consequences, this information can have an important clinical significance.

Using the revised Edmonton symptom assessment scale during neoadjuvant radiotherapy for retroperitoneal sarcoma

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Patent-reported outcomes guide managment for retroperitoneal sarcoma.

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All patients completed treatment uninterrupted with improvements in anxiety and pain.

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Symptom reporting helps personalize patient care in the era of precision medicine.

Background and purpose

Retroperitoneal sarcoma (RPS) is a rare, complex disease requiring multidisciplinary management. We have previously reported that use of the Revised Edmonton Symptom Assessment Scale (ESAS-r-CSS) allows for proactive symptom management, and we sought to report the results of ESAS-r-CSS screening during pre-operative radiotherapy (RT) for a cadre of patients with RPS.

Materials and methods

We reviewed records of 47 patients with RPS evaluated at our institution between 2015 and 2018. Of this group, 29 non-metastatic patients were treated with definitive intent neoadjuvant RT with at least 2 weekly ESAS-r-CSS reports. A generalized estimating equation model was used to compare 13 symptoms during weekly on-treatment visits compared to baseline scores at week 1 of RT. Additionally, covariate effects of age, gender, dose, tumor size and location were assessed.

Results

The population was predominantly male (66%) with median age of 65 years, KPS of 90, and tumor size of 12.8 cm. ESAS scores significantly decreased for anxiety at week 3 (P = 0.01), and pain at week 5 (P = 0.01). Worse constipation was reported at week 2 (P = 0.02). In an exploratory covariate analysis, female gender, age, high dose, and larger tumor size were associated with worse ESAS scores across all time points.

Conclusion

Patient reporting of symptoms during radiotherapy through weekly ESAS-r-CSS facilitates timely management in patients with this unique tumor type. Expectant care during RT offers the opportunity to minimize symptom progression or treatment interruptions in a population that generally has worsening side effects.