Preliminary assessment of a neuropathic pain treatment and referral algorithm for patients with cancer

A qualitative analysis of algorithm-based decision support usability testing for symptom management across the trajectory of cancer care: one size does not fit all

BACKGROUND

Adults with cancer experience symptoms that change across the disease trajectory. Due to the distress and cost associated with uncontrolled symptoms, improving symptom management is an important component of quality cancer care. Clinical decision support (CDS) is a promising strategy to integrate clinical practice guideline (CPG)-based symptom management recommendations at the point of care.

METHODS

The objectives of this project were to develop and evaluate the usability of two symptom management algorithms (constipation and fatigue) across the trajectory of cancer care in patients with active disease treated in comprehensive or community cancer care settings to surveillance of cancer survivors in primary care practices. A modified ADAPTE process was used to develop algorithms based on national CPGs. Usability testing involved semi-structured interviews with clinicians from varied care settings, including comprehensive and community cancer centers, and primary care. The transcripts were analyzed with MAXQDA using Braun and Clarke's thematic analysis method. A cross tabs analysis was also performed to assess the prevalence of themes and subthemes by cancer care setting.

RESULTS

A total of 17 clinicians (physicians, nurse practitioners, and physician assistants) were interviewed for usability testing. Three main themes emerged: (1) Algorithms as useful, (2) Symptom management differences, and (3) Different target end-users. The cross-tabs analysis demonstrated differences among care trajectories and settings that originated in the Symptom management differences theme. The sub-themes of "Differences between diseases" and "Differences between care trajectories" originated from participants working in a comprehensive cancer center, which tends to be disease-specific locations for patients on active treatment. Meanwhile, participants from primary care identified the sub-theme of "Differences in settings," indicating that symptom management strategies are care setting specific.

CONCLUSIONS

While CDS can help promote evidence-based symptom management, systems providing care recommendations need to be specifically developed to fit patient characteristics and clinical context. Findings suggest that one set of algorithms will not be applicable throughout the entire cancer trajectory. Unique CDS for symptom management will be needed for patients who are cancer survivors being followed in primary care settings.

Clinical Decision Support for Symptom Management in Lung Cancer Patients: A Group RCT

CONTEXT

Clinical guidelines are available to enhance symptom management during cancer treatment but often are not used in the practice setting. Clinical decision support can facilitate the implementation and adherence to clinical guidelines. and improve the quality of cancer care.

OBJECTIVES

Clinical decision support offers an innovative approach to integrate guideline-based symptom management into oncology care. This study evaluated the effect of clinical decision support-based recommendations on clinical management of symptoms and health-related quality of life (HR-QOL) among outpatients with lung cancer.

METHODS

Twenty providers and 179 patients were allotted in group randomization to attention control (AC) or Symptom Assessment and Management Intervention (SAMI) arms. SAMI entailed patient-report of symptoms and delivery of recommendations to manage pain, fatigue, dyspnea, depression, and anxiety; AC entailed symptom reporting prior to the visit. Outcomes were collected at baseline, two, four and six-months. Adherence to recommendations was assessed through masked chart review. HR-QOL was measured by the Functional Assessment of Cancer Therapy-Lung questionnaire. Descriptive statistics with linear and logistic regression accounting for the clustering structure of the design and a modified chi-square test were used for analyses.

RESULTS

Median age of patients was 63 years, 58% female, 88% white, and 32% ≤high school education. Significant differences in clinical management were evident in SAMI vs. AC for all target symptoms that passed threshold. Patients in SAMI were more likely to receive sustained-release opioids for constant pain, adjuvant medications for neuropathic pain, opioids for dyspnea, stimulants for fatigue and mental health referrals for anxiety. However, there were no statistically significant differences in HR-QOL at any time point.

CONCLUSION

SAMI improved clinical management for all target symptoms but did not improve patient outcomes. A larger study is warranted to evaluate effectiveness.

Tetrodotoxin for Chemotherapy-Induced Neuropathic Pain: A Randomized, Double-Blind, Placebo-Controlled, Parallel-Dose Finding Trial

Tetrodotoxin (TTX) has emerged as a potentially efficacious agent for chemotherapy-induced neuropathic pain (CINP), a prevalent, debilitating condition often resistant to analgesics. This randomized, double-blind, dose-finding study was undertaken to explore safety and trends in efficacy of four TTX doses and to identify a dose for further study. One hundred and twenty-five patients with taxane- or platinum-related CINP received subcutaneous placebo or TTX (7.5 µg twice daily (BID), 15 µg BID, 30 µg once daily (QD), 30 µg BID) for four consecutive days. Primary outcome measure was average patient-reported Numeric Pain Rating Scale (NPRS) score during Days 21–28 post-treatment. Changes in mean NPRS score were not statistically different between cohorts, due to small trial size and influence of a few robust placebo responders. Cumulative responder analysis showed significant difference from placebo with 30 µg BID cohort using the maximum response at any timepoint (p = 0.072), 5-day (p = 0.059), 10-day (p = 0.027), and 20-day (p = 0.071) rolling averages. In secondary quality of life (QOL) outcomes, 30 µg BID cohort also differed significantly from placebo in a number of SF-36 and CIPN20 subscales. Most adverse events (AE) were mild or moderate with oral paresthesia (29.6%) and oral hypoesthesia (24.8%) as most common.

Psychometric Testing of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Chemotherapy-Induced Peripheral Neuropathy 20-Item Scale Using Pooled Chemotherapy-Induced Peripheral Neuropathy Outcome Measures Standardization and Alliance for Clinical Trials in Oncology A151408 Study Data

BACKGROUND

No criterion-standard patient-reported outcome measure of chemotherapy-induced peripheral neuropathy (CIPN) exists.

OBJECTIVES

The aims of this study were to reevaluate the sensitivity, reliability, and validity of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-CIPN (QLQ-CIPN20) measure and suggest possible revisions that could strengthen it.

METHODS

Cross-sectional QLQ-CIPN20 data from 8 European countries (n = 271) were pooled with data from 4 North American multisite CIPN intervention trials (n = 884). The combined sample (N = 1155) included patients with varied cancer diagnoses who had received neurotoxic chemotherapy. Item score ranges, Cronbach's α, and exploratory factor analysis were used to evaluate sensitivity, internal consistency, and structural validity.

RESULTS

Individual item mean scores ranged from 1.21 to 2.34 (SD range, 0.55-1.17). All item scores encompassed the entire 1 to 4 range. We recommend that 4 items be removed because of low item-item score correlations (r < 0.30). On the basis of the remaining 16 items, 88% of the variance was explained by 2 factors whose Cronbach's α coefficients were .90 and .85. However, items lacked conceptual alignment with previously published factor structures.

CONCLUSION

Using a large, diverse sample of European and North American participants, the reduced 16-item QLQ-CIPN20 is sensitive and internally consistent. However, factor analysis results revealed an unstable factor structure.

IMPLICATIONS FOR PRACTICE

The use of a reliable, valid, and sensitive criterion-standard QLQ-CIPN20 variant in clinical practice settings could improve function, quality of life, and CIPN symptom control by facilitating patient reporting and thereby clinician awareness of this underrecognized consequence of cancer therapy.

On the Road Less Traveled: Journey of an Oncology Palliative Care Researcher

In 2001, as the Trish Greene Quality of Life lecturer, I described coming to a career crossroads and cited a metaphor from Robert Frost's poem "The Road Not Taken," realizing that, as I chose to leave the path of bone marrow transplantation clinician and go to that of palliative care nurse, there was no turning back. In this article based on my 2016 Oncology Nursing Society Congress Distinguished Nurse Researcher Award lecture, I would like to continue the Frost metaphor as I describe what has transpired since taking "the one less traveled by"-that of palliative care nurse scientist.

The effect of intraperitoneal chemotherapy on early pain hyperalgesia in patients following elective laparoscopic transabdominal resection of rectal cancer

Background

Chemotherapy has been associated with hyperalgesia. This prospective study was designed to investigate the effect of intraperitoneal chemotherapy with lobaplatin on post-operative pain intensity and sufentanil requirements after laparoscopic transabdominal resection of rectal cancer.

Methods

Eighty subjects (40 subjects treated with intraperitoneal chemotherapy and 40 subjects without chemotherapy treatment) scheduled for laparoscopic transabdominal resection of rectal cancer were included in this study. All subjects received standardized anesthetic and patient-controlled analgesia using sufentanil for 72 h post-surgery, as the only analgesics. Pain intensity scores, cumulative sufentanil requirements and side effects were recorded until 72 h post-surgery.

Results

Following intraperitoneal chemotherapy, patients had a significantly higher total post-operative sufentanil requirement (193 μg vs. 142 μg; P = 0.008), significantly higher verbal rating scale post-surgery pain intensity scores at rest and with coughing (P < 0.05), and a significantly worse functional activity score (P < 0.05) over 72 h, compared with those without intraperitoneal chemotherapy. There were no post-operative differences in the incidence of side-effects (post-operative nausea [P = 0.189], vomiting [P = 0.311], pruritus [P = 0.263], respiratory depression [P = 1.000], and dizziness [P = 0.712]) between the two groups.

Conclusion

Intraperitoneal chemotherapy is associated with significantly increased post-operative sufentanil requirements and pain intensity, suggesting chemotherapy-associated hyperalgesia.

Emotional Responses to Persistent Chemotherapy-induced Peripheral Neuropathy Experienced by Patients with Colorectal Cancer in Japan

Objective:

For patients who wish to continue treatment for persistent chemotherapy-induced peripheral neuropathy (PCIPN) while maintaining the quality of life (QOL), the only effective way appears to be the stop-and-go strategy. The objective of the present study was to analyze emotional responses of Japanese patients with colorectal cancer (CRC) experiencing PCIPN for the first time and to consider effective ways of providing supportive nursing care.

Methods:

In all, 25 patients with metastatic CRC who had completed more than six courses receiving first-line therapy with modified FOLFOX6 were included. Data were collected through semi-structured interviews.

Results:

Emotional responses to PCIPN experienced by patients with CRC fell into the following categories: (1) suffering from an inability to cope with the previously unknown sensation of numbness, (2) inability to perform daily living activities activities of daily living [ADL]/instrumental activities of daily living [IADL] independently and feeling fear for physical safety, (3) feeling a sense of relief at being able to live the same life as before, and (4) facing the threat of cancer and tolerating the numbness caused by the life-supporting treatment. Fear, helplessness, dismay and other uncomfortable feelings represented 72.5% of all emotional responses, probably reflecting the lack of effective intervention for PCIPN.

Conclusions:

These results suggest that both subjective and objective assessments of PCIPN and proper use of a stop-and-go strategy are essential for treatment continuation and maintenance of patient's QOL; therefore, an integrated approach is desirable.

Assessment of Multiple Co-Occurring Cancer Symptoms in the Clinical Setting

OBJECTIVES

To discuss multiple co-occurring cancer symptoms, review symptom assessment instruments, identify innovative methods to integrate symptom assessment and management in the clinical setting, and examine barriers and facilitators for implementation of symptom assessment and use of clinical practice guidelines.

DATA SOURCES

Peer-reviewed articles, guidelines, systematic reviews, and web-based resources.

CONCLUSION

Despite the availability of brief, reliable, and valid instruments, symptom assessment has not been integrated as a routine aspect of clinical care. New technologies and changes in health policy provide an optimal environment to integrate electronic symptom assessment and management into cancer care.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses play a key role in early identification and management of distressing symptoms.

Antineuropathic profile of N-palmitoylethanolamine in a rat model of oxaliplatin-induced neurotoxicity

Neurotoxicity is a main side effect of the anticancer drug oxaliplatin. The development of a neuropathic syndrome impairs quality of life and potentially results in chemotherapy dose reductions and/or early discontinuation. In the complex pattern of molecular and morphological alterations induced by oxaliplatin in the nervous system, an important activation of glia has been preclinically evidenced. N-Palmitoylethanolamine (PEA) modulates glial cells and exerts antinociceptive effects in several animal models. In order to improve the therapeutic chances for chemotherapy-dependent neuropathy management, the role of PEA was investigated in a rat model of oxaliplatin-induced neuropathy (2.4 mg kg^-1 daily, intraperitoneally). On day 21, a single administration of PEA (30 mg kg^-1 i.p.) was able to reduce oxaliplatin-dependent pain induced by mechanical and thermal stimuli. The repeated treatment with PEA (30 mg kg^-1 daily i.p. for 21 days, from the first oxaliplatin injection) prevented lowering of pain threshold as well as increased pain on suprathreshold stimulation. Ex vivo histological and molecular analysis of dorsal root ganglia, peripheral nerves and spinal cord highlighted neuroprotective effects and glia-activation prevention induced by PEA repeated administration. The protective effect of PEA resulted in the normalization of the electrophysiological activity of the spinal nociceptive neurons. Finally, PEA did not alter the oxaliplatin-induced mortality of the human colon cancer cell line HT-29. The efficacy of PEA in neuropathic pain control and in preventing nervous tissue alteration candidates this endogenous compound as disease modifying agent. These characteristics, joined to the safety profile, suggest the usefulness of PEA in chemotherapy-induced neuropathy.

Symptom management in the older adult: 2015 update

This article updates the 2002 Jamie von Roenn article about "the palliation of commonly observed symptoms in older patients, including pain, neuropsychiatric, gastrointestinal, and respiratory symptoms." When palliative care was last covered in Clinics in Geriatric Medicine, President George W. Bush had just signed the No Child Left Behind Act, Homeland Security was being established, Michael Jackson won the Artist of the Century Award at the American Music Awards, and gas cost $1.61 a gallon. What has changed in the last decade and a half?

Chemotherapy-induced peripheral neuropathy: an algorithm to guide nursing management

Oncology nurses play a critical role in the assessment and management of chemotherapy-induced peripheral neuropathy (CIPN). Baseline and ongoing evaluation of physical function is a critical but often overlooked aspect of assessment of CIPN. The diversity of symptoms and the complexity associated with neuromuscular assessment lead to challenges in evaluation and management of CIPN. To meet this challenge, the authors devised a feasible algorithm to guide oncology nurses in the assessment and management of CIPN using techniques that can easily be implemented in a variety of clinical settings. Managing pain, maintaining safety, and maximizing physical function are the primary goals for nursing management of CIPN.

Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial

IMPORTANCE

There are no known effective treatments for painful chemotherapy-induced peripheral neuropathy.

OBJECTIVE

To determine the effect of duloxetine, 60 mg daily, on average pain severity.

DESIGN, SETTING, AND PATIENTS

Randomized, double-blind, placebo-controlled crossover trial at 8 National Cancer Institute (NCI)-funded cooperative research networks that enrolled 231 patients who were 25 years or older being treated at community and academic settings between April 2008 and March 2011. Study follow-up was completed July 2012. Stratified by chemotherapeutic drug and comorbid pain risk, patients were randomized to receive either duloxetine followed by placebo or placebo followed by duloxetine. Eligibility required that patients have grade 1 or higher sensory neuropathy according to the NCI Common Terminology Criteria for Adverse Events and at least 4 on a scale of 0 to 10, representing average chemotherapy-induced pain, after paclitaxel, other taxane, or oxaliplatin treatment.

INTERVENTIONS

The initial treatment consisted of taking 1 capsule daily of either 30 mg of duloxetine or placebo for the first week and 2 capsules of either 30 mg of duloxetine or placebo daily for 4 additional weeks.

MAIN OUTCOME MEASURES

The primary hypothesis was that duloxetine would be more effective than placebo in decreasing chemotherapy-induced peripheral neuropathic pain. Pain severity was assessed using the Brief Pain Inventory-Short Form "average pain" item with 0 representing no pain and 10 representing as bad as can be imagined.

RESULTS

Individuals receiving duloxetine as their initial 5-week treatment reported a mean decrease in average pain of 1.06 (95% CI, 0.72-1.40) vs 0.34 (95% CI, 0.01-0.66) among those who received placebo (P = .003; effect size, 0.513). The observed mean difference in the average pain score between duloxetine and placebo was 0.73 (95% CI, 0.26-1.20). Fifty-nine percent of those initially receiving duloxetine vs 38% of those initially receiving placebo reported decreased pain of any amount.

CONCLUSION AND RELEVANCE

Among patients with painful chemotherapy-induced peripheral neuropathy, the use of duloxetine compared with placebo for 5 weeks resulted in a greater reduction in pain.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00489411.

Assessing patient-reported peripheral neuropathy: the reliability and validity of the European Organization for Research and Treatment of Cancer QLQ-CIPN20 Questionnaire

PURPOSE

This clinimetric analysis was conducted to evaluate the reliability, validity, and responsiveness to changeover time of the QLQ-CIPN20 when used to quantify patient-reported chemotherapy-induced peripheral neuropathy (CIPN).

METHODS

Participants recruited to four cooperative group trials were pooled to create two groups (n = 376, 575): those who did versus did not receive neurotoxic chemotherapy. QLQ-CIPN20 internal consistency reliability was assessed using Cronbach's alpha coefficients. Instrument validity was assessed using factor analysis, by evaluating score correlations with other CIPN and pain measures, and by comparing scores between contrasting groups. Cohen's d was used to assess responsiveness to change.

RESULTS

Alpha coefficients for the sensory, motor, and autonomic scales were 0.88, 0.88, and 0.78, respectively. However, autonomic scale and hearing loss items exhibited low item-item correlations (r ≤ 0.30) and thus were deleted. Moderate correlations were found between QLQ-CIPN20 and Brief Pain Inventory pain severity items (r 0.30-0.57, p ≤ .0001). Correlation between the QLQ-CIPN20 sensory and toxicity grading scale scores was low (r = .20; p ≤ .01). Mean scores were higher (worse) (p ≤ 0.0001) in individuals who did versus did not receive neurotoxic chemotherapy. The sensory and motor scales exhibited moderate-high responsiveness to change (Cohen's d = 0.82 and 0.48, respectively). Factor analysis indicated that the 16-item version formed distinct factors for lower and upper extremity CIPN, delineating typical distal to proximal CIPN progression.

CONCLUSIONS

Results provide support for QLQ-CIPN20 sensory and motor scale reliability and validity. The more parsimonious and clinically relevant 16-item version merits further consideration.

Chemotherapy-induced peripheral neuropathy. Part II. Prevention

The incidence of chemotherapy-induced peripheral neuropathy (CIPN) in the population of cancer patients is estimated at 3-7% in cytostatic monotherapy and as high as 38% in the case of polytherapy. While testing drugs that may reduce the damage to the peripheral nervous system, particular attention should be paid to their protective action against the severe and painful complication in the patient. Another aspect, perhaps a more important one, is the confidence that application of preventive drugs will not exert a significant impact on progression of the neoplastic disease or the effectiveness of the causal treatment. Many drugs have been tested for prevention of CIPN; however, none of them have thus far been irrefutably proven to possess preventive properties. No guidelines on chemotherapy-induced peripheral neuropathy preventive action have been established, either. This article is an attempt to present reports from the available literature about the possibilities of prevention of CIPN.