The McGill University Health Centre Cancer Pain Clinic: A Retrospective Analysis of an Interdisciplinary Approach to Cancer Pain Management

Top Ten Tips Palliative Care Clinicians Should Know About Total Pain

"Total pain" is a fundamental concept in palliative care. It emphasizes the multidimensional nature of pain and suffering in patients with advanced illnesses. Originally introduced by Dame Cicely Saunders, the spectrum of total pain extends beyond pure physical pain to further encompass psychological, social, and spiritual distress. By focusing on the above four components of total pain, clinicians can provide better care for their patients with advanced illnesses and ultimately improve their overall quality of life. Compiled by a multidisciplinary team of experts in the field, this article provides ten key strategies (tips) for palliative care clinicians to enhance their understanding and management of total pain in clinical settings.

A nationwide neurosurgical inter-disciplinary service for cancer-related refractory pain

PURPOSE

Neurosurgical ablative procedures, such as cordotomy and cingulotomy, are often considered irreversible and destructive but can provide an effective and individualized solution for cancer-related refractory pain, when all other approaches have been unsuccessful. This paper provides an in-depth exploration of a novel approach to managing refractory cancer pain. It involves an interdisciplinary team led by a neurosurgeon at a renowned national referral center.

METHODS

a retrospective analysis of the medical records of all sequential patients who underwent their initial evaluation at our interdisciplinary refractory cancer pain clinic from February 2017 to January 2023.

RESULTS

A total of 207 patients were examined in the clinic for a first visit during the study period. All patients were referred to the clinic due to severe pain that was deemed refractory by the referring physician. The mean age was 61 ± 12.3 years, with no significant sex difference (P = 0.58). The mean ECOG Performance Status score was 2.35. Conservative measures had not yet been exhausted in 28 patients (14%) and 9 patients were well controlled (4%). Neurosurgical ablative procedures were recommended for 151 (73%) of the patients. Sixty-six patients (32%) eventually underwent the procedure. 91 patients (44%) received a negative recommendation for surgery. Thirty-five patients (17%) were referred for further invasive procedures at the pain clinic.

CONCLUSION

An Interdisciplinary cooperation between palliative care specialists, pain specialists, and neurosurgeons ensures optimal patient selection and provides safe and effective neurosurgery for the treatment of refractory cancer-related pain.

Good practice recommendations to better coordinate the management of oncological pain: a Delphi survey

Treatment of oncological pain is complex and requires a multidisciplinary management approach between oncology services and pain units. Although significant improvements have been achieved in the treatment and overall survival of cancer patients, the management of oncological pain has not followed the same directions. Many patients are not referred to pain units even though they could benefit from it. The purpose of this Delphi survey was to map the current situation in the management of cancer pain, identify barriers and propose recommendations to improve its management by emphasizing the importance of collaboration and coordination between oncology services and pain units. A survey among members with recognized experience in the management of oncology patients and oncological pain was held based on the Delphi method principles. The experts were asked to vote preselected statements on cancer pain management in two rounds and conclusions and recommendations were formulated based on the consensus reached for each statement. Barriers and areas for improvement were identified: need of multidisciplinary management approach, effective communication between oncology services and pain units, timely referral of cancer patients to pain units, training of health care professionals dealing with cancer aspects and identification of those patients that could benefit from a multidisciplinary management of their oncological disease. The experts issued recommendations targeting the identified barriers and areas for improvement by defining the service requirements of hospital and units treating cancer pain patients, establishing referral pathways necessities and adopted measures to improve the care of cancer patients.

Is the Erector Spinae Plane Block Effective for More than Perioperative Pain? A Retrospective Analysis

Introduction: The thoracic Erector Spinae Plane Block (ESPB) is an ultrasound-guided block that has gained popularity and is widely used in acute pain setups. However, data regarding its role in chronic and cancer-related pain are anecdotal. Material and Methods: The study is a retrospective analysis of patients who underwent ESPB. The cohort was divided into subgroups based on three determinants: etiology, pain type, and chronicity. Results: One hundred and ten patients were included, and genders were affected equally. The average age was 61.2 ± 16.1 years. The whole group had a statistically significant reduction in a numerical rating scale (NRS) (7.4 ± 1.4 vs. 5.0 ± 2.6, p-value > 0.001). NRS reduction for 45 patients (41%) exceeded 50% of the pre-procedural NRS. The mean follow-up was 7.9 ± 4.6 weeks. Baseline and post-procedure NRS were comparable between all subgroups. The post-procedural NRS was significantly lower than the pre-procedural score within each group. The proportion of patients with over 50% improvement in NRS was lower for those with symptom duration above 12 months (p-value = 0.02). Conclusions: Thoracic ESPB is a simple and safe technique. The results support the possible role of ESPB for chronic as well as cancer-related pain.

Knowledge, Practices, and Perceived Barriers in Cancer Pain Management at Oncology Units: A Cross-Sectional Survey of Medical Staff in China

Background

Patients and Methods

Results

Conclusion

A New Solution to an Old Problem: Ultrasound-guided Cervical Retrolaminar Injection for Acute Cervical Radicular Pain: Prospective Clinical Pilot Study and Cadaveric Study

STUDY DESIGN

Prospective clinical pilot study and cadaveric study.

OBJECTIVE

The aim of this study was to evaluate the spread of an ultrasound-guided interfascial plane blocks (UGIPBs) and its potential efficacy for cervical radiculopathy.

SUMMARY OF BACKGROUND DATA

Cervical radiculopathy is a common disorder, potentially leading to severe pain and disability. Conservative treatment with cervical epidural steroid injections (ESI) is limited by concerns regarding their safety. UGIPBs are used in cervical surgical procedures as part of the multimodal postoperative analgesia regimen however, were not described for cervical radiculopathy.

METHODS

Twelve patients with acute cervical radicular pain who failed conservative treatment and were candidates for surgery were offered a cervical retrolaminar injection. A solution of 4 mL lidocaine 0.5% and 10 mg dexamethasone was injected, assisted by ultrasound guidance, at the posterior aspect of the cervical lamina corresponding to the compressed nerve root level. Additionally, a cadaver study was carried to evaluate the contrast spread and infiltration into near structures, both anatomically and radiographically.

RESULTS

Twelve patients underwent the procedure, with a mean follow-up time of 14.5 weeks. Average numerical rating scale improved from 7.25 at baseline to 2.83 following the injection (P < 0.001). Three patients received 2 to 3 injections without significant improvement and were eventually operated. No adverse events were reported.In the cadaver study, fluoroscopy demonstrated contrast spread between T1 and T3 caudally, C2 to C5 cranially and facet joints laterally. Anatomically, the dye spread was demonstrated up to C2 cranially, T1 caudally, the articular pillars of C4 to C7, and the neural foramen of C6 laterally.

CONCLUSION

A solution injected into the cervical retrolaminar plane can diffuse in the cranial-caudal axis to C2-T3 and laterally to the facet joints and the cervical neural foramen. Our pilot study confirmed the feasibility of our study protocol. Future studies are needed to support our early results.Level of Evidence: 4.

The Effectiveness of Cancer Pain Management in a Tertiary Hospital Outpatient Pain Clinic in Thailand: A Prospective Observational Study

Objectives

The objective was to examine the effectiveness of the updated approach.

Methods

With IRB approval, outpatients with cancer were enrolled from January to December 2018. Assessments were recorded at baseline and three consecutive visits (BL, FU1, FU2, and FU3), including Numerical Rating Scale (NRS), the Brief Pain Inventory (BPI), the Edmonton Symptom Assessment System (ESAS), side effects, and analgesic use. The primary outcome was a favorable response, defined as an NRS decrease more than 30% or NRS <4. Secondary outcomes included trends over time in BPI, ESAS, side effects, and analgesic use. Pain response predictors at FU3 were analyzed using logistic regression.

Results

Among 150 patients, 72 (48%) completed follow-ups. Of these, 61% achieved a favorable response at FU3. Pain interference diminished at all visits relative to baseline (p < 0.05). Median morphine equivalent daily dosage (MEDD) at BL was 20 mg/day, with a statistically significant, but clinically modest increase to 26.4 mg/day at FU3. Radiation therapy during pain care was a predictor of pain responders.

Conclusion

The current Siriraj multidisciplinary approach provided effective relief of pain and stabilization of other cancer-related symptoms. Radiation therapy during pain care can be used to predict pain outcomes. Ongoing improvement domains were identified and considered in the context of cultural, economic, and geographic factors.

Patterns and predictors of outpatient opioid use after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Background: Long-term opioid use is a well-known complication after surgery. In this retrospective study of adults who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), we sought to determine the rates and factors associated with outpatient opioid use within the sixth and twelfth postoperative months. Methods: Records of 288 opioid-naïve patients were included. Logistic regression models were used to determine factors prognostic of outpatient opioid use. Results: The median patient age was 54 years, and 63% were female. Rates of outpatient opioid use within the sixth and twelfth postoperative months were 21 and 13%, respectively. In the multivariate analysis, every doubling in the amount of in-hospital postoperative opioid consumption was associated with a 44% increase in odds of opioid use within the sixth postoperative month (OR 1.44, 95% CI 1.11-1.87, p = .006) and a 70% increase within the twelfth postoperative month (OR 1.70, 95% CI 1.70-2.37, p = .001). Other factors associated with opioid use within the sixth postoperative month included physical status (OR 5.26, 95% CI 1.08-25.55, p = .039) and recent additional surgery (OR 23.02, 95% CI 2.03-261.30, p = .011). Age (OR 4.39, 95% CI 1.77-10.89, p = .001) and tumor grade (OR 3.31, 95% CI 1.31-8.41, p = .012) were associated with opioid use within the twelfth postoperative month. Conclusion: In this study, the amount of in-hospital postoperative opioid consumption was an important contributory factor to outpatient opioid use in the sixth and twelfth postoperative months. Synopsis In this study of adults who had undergone CRS-HIPEC, higher postoperative opioid consumption during hospitalization was associated with higher odds of opioid use within the sixth and twelfth postoperative months.

Analysis of Unscheduled Telephone Calls Received by a Specialized Cancer Pain Nurse

BACKGROUND

A key to successful symptom management in patients with cancer is to adapt the treatment to patient needs and complexities in an individual and dynamic manner. Rapid access to a clinician via telephone consultation supports treatment compliance, safety, and effectiveness and reduces the number of patients unnecessarily consulting emergency departments.

AIMS

To define the role of a cancer pain nurse in the management of unscheduled phone calls to the clinic.

DESIGN

The study is a retrospective analysis of unscheduled phone calls received at an outpatient cancer pain clinic. Details collected included caller identification, reasons for the call, and interventions provided. Actions taken after analysis of the nature of calls are discussed.

SETTINGS

Retrospective chart analysis.

PARTICIPANTS/SUBJECTS

Medical charts of patients seen at the cancer pain clinic.

METHODS

During three consecutive months, 102 unscheduled telephone calls fulfilling research criteria were analyzed. Seventy-four percent were initiated by patients or carers. In 46% and 45% of the calls, respectively, the reason for the call was to report a symptom or concern about the treatment.

RESULTS

Pain was the most common reported symptom (59.6%) followed by side effects (23.4%). The most frequent inquiry about medications concerned renewal of prescriptions (47.8%). The most common intervention was related to patients' treatments (74.5%), and it included an element of teaching in 51.3% of calls. In one third of cases, a prescription was changed after the call. The nurse was able to provide the intervention without involving a doctor in 87.3% of calls. Several changes were initiated after the analysis to decrease unnecessary calls to the nurse.

CONCLUSIONS

A telephone call service available for patients and other clinicians is an efficient way to enhance continuity of care for ambulatory patients. Continued efforts to make such a service cost effective must be implemented.

New frontier: cancer pain management clinical fellowship

Cancer pain is a multi-dimensional experience, varies from person to person both physically and psycho-socially, and impacts all aspects of the patients' quality of life. Majority of patients with an advanced or metastatic cancer will experience pain. It is estimated that as many as half of cancer patients are under-treated and as many as 20% experience pain refractory to the conventional WHO ladder of pain management. The McGill University Health Centre (MUHC) Cancer Pain Clinic (CPC) was created to meet the needs of those patients with a diagnosis of cancer whose pain had become a main symptom and those who failed to respond to conventional treatment. The clinic offers a unique interdisciplinary approach with a core team that includes an anesthesiologist, a palliative care physician, a radiation oncologist, a nurse clinician specialist in oncology and palliative care, and, recently, also an interventional radiologist. A cancer pain clinical fellowship was offered for the first time in July 2016. It provides intense training in the classification, epidemiology, pathophysiology, and treatment of cancer pain. Through our education program, the fellow learns to appreciate, weigh, and respond to the full spectrum of factors influencing a specific patient's condition and to develop a tailor-made care plan. To our knowledge, it is the only fellowship program in existence that focuses exclusively on cancer pain. We see it as a beacon and hope that our graduate fellows become professional leaders with a quest not only to provide the best possible care but also to raise awareness of the humanitarian need to control cancer pain.

Interventional Analgesic Management of Lung Cancer Pain

Lung cancer is one of the four most prevalent cancers worldwide. Comprehensive patient care includes not only adherence to clinical guidelines to control and when possible cure the disease but also appropriate symptom control. Pain is one of the most prevalent symptoms in patients diagnosed with lung cancer; it can arise from local invasion of chest structures or metastatic disease invading bones, nerves, or other anatomical structures potentially painful. Pain can also be a consequence of therapeutic approaches like surgery, chemotherapy, or radiotherapy. Conventional medical management of cancer pain includes prescription of opioids and coadjuvants at doses sufficient to control the symptoms without causing severe drug effects. When an adequate pharmacological medical management fails to provide satisfactory analgesia or when it causes limiting side effects, interventional cancer pain techniques may be considered. Interventional pain management is devoted to the use of invasive techniques such as joint injections, nerve blocks and/or neurolysis, neuromodulation, and cement augmentation techniques to provide diagnosis and treatment of pain syndromes resistant to conventional medical management. Advantages of interventional approaches include better analgesic outcomes without experiencing drug-related side effects and potential for opioid reduction thus avoiding central side effects. This review will describe various pain syndromes frequently described in lung cancer patients and those interventional techniques potentially indicated for those cases.