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Tekie Y, Nigatu YA, Mekonnen W, Berhe YW. Breakthrough pain among cancer patients at oncology units in Northern Ethiopia; a multi-center study. Front Oncol 2024; 13:1248921. [PMID: 38264754 PMCID: PMC10805268 DOI: 10.3389/fonc.2023.1248921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024] Open
Abstract
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.
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Affiliation(s)
- Yohanes Tekie
- Department of Anesthesia, Aksum University, Aksum, Ethiopia
| | | | - Wudie Mekonnen
- Department of Anesthesia, University of Gondar, Gondar, Ethiopia
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Cuomo A. Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits. Drugs Context 2023; 12:2023-10-2. [PMID: 38148830 PMCID: PMC10751104 DOI: 10.7573/dic.2023-10-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/14/2023] [Indexed: 12/28/2023] Open
Abstract
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.
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Affiliation(s)
- Arturo Cuomo
- Istituto Nazionale dei Tumori, IRCCS Fondazione G. Pascale, Naples,
Italy
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Løhre ET, Jakobsen G, Solheim TS, Klepstad P, Thronæs M. Breakthrough and Episodic Cancer Pain from a Palliative Care Perspective. Curr Oncol 2023; 30:10249-10259. [PMID: 38132380 PMCID: PMC10742182 DOI: 10.3390/curroncol30120746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/23/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023] Open
Abstract
Cancer pain intensity (PI) fluctuates, but the relationship between pain flares and background pain with respect to pain management is not settled. We studied how flare and background PIs corresponded with treatment results for background cancer pain. Patients admitted to an acute palliative care unit with average and/or worst PI ≥ 1 on the 11-point numeric rating scale were included. Average and worst PI at admission and average PI at discharge were collected. We examined how the difference and ratio between worst and average PI and average PI at admission, were associated with average PI development during hospitalization. Positive differences between worst and average PI at admission were defined as pain flares. Ninety out of 131 patients had pain flares. The reduction in average PI for patients with flares was 0.9 and for those without, 1.9 (p = 0.02). Patients with large worst minus average PI differences reported the least improvement, as did those with large worst/average PI ratios. Patients with pain flares and average PI ≤ 4 at admission had unchanged average PI during hospitalization, while those with pain flares and average PI > 4 experienced pain reduction (2.1, p < 0.001). Large pain flares, in absolute values and compared to background PI, were associated with inferior pain relief.
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Affiliation(s)
- Erik Torbjørn Løhre
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
| | - Gunnhild Jakobsen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Tora Skeidsvoll Solheim
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Morten Thronæs
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
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Porzio G, Capela A, Giusti R, Lo Bianco F, Moro M, Ravoni G, Zułtak-Baczkowska K. Multidisciplinary approach, continuous care and opioid management in cancer pain: case series and review of the literature. Drugs Context 2023; 12:dic-2022-11-7. [PMID: 37077766 PMCID: PMC10108666 DOI: 10.7573/dic.2022-11-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/10/2023] [Indexed: 04/21/2023] Open
Abstract
Underlying cancer pain has heterogenous aetiologies and mechanisms. It requires detailed and comprehensive pain assessment, combined with personalized treatment. A multidisciplinary team is essential to providing the best management of cancer pain at every disease stage, improving the quality of life and outcomes in patients with cancer. This narrative literature review emphasizes the value of providing all patients with multidisciplinary pain management in their preferred care setting. Real-life experiences are also reported to witness the efforts of physicians to properly manage cancer pain. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.
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Affiliation(s)
| | - Andreia Capela
- Centro Hospitalar Vila Nova de Gaia, Espinho; Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Arcozelo – Vila Nova de Gaia, Portugal
| | - Raffaele Giusti
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Francesca Lo Bianco
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Mirella Moro
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Giulio Ravoni
- Tuscany Tumor Association, Home Care Service, Florence, Italy
| | - Katarzyna Zułtak-Baczkowska
- Zakład Zdrowia Publicznego, Wydział Nauk o Zdrowiu, Pomorski Uniwersytet Medyczny w Szczecinie, Stettin, Poland
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Batistaki C, Graczyk M, Janecki M, Lewandowska AA, Moutinho R, Vagdatli K. Relationship between breakthrough cancer pain, background cancer pain and analgesic treatment - case series and review of the literature. Drugs Context 2022; 11:dic-2022-9-4. [PMID: 36660261 PMCID: PMC9828877 DOI: 10.7573/dic.2022-9-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/17/2022] [Indexed: 12/30/2022] Open
Abstract
The assessment and treatment of breakthrough cancer pain (BTcP) remain a major challenge in medicine due to its high impact on several aspects of health-related quality of life. BTcP should be carefully monitored in all cancer care settings by a multidisciplinary team to provide an appropriate and personalized clinical approach. The aim of this paper is to provide healthcare professionals involved in cancer pain management with a review of the relevant literature on the relationship between background cancer pain and BTcP which, by definition, occurs despite adequately controlled background cancer pain. The clinical cases presented contribute to a better understanding of this issue and underline its impact in daily clinical practice. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.
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Affiliation(s)
| | - Michal Graczyk
- Department of Palliative Care, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Marcin Janecki
- Department of Palliative Care and Palliative Medicine, Medical University of Silesia, Katowice, Poland
| | | | - Rita Moutinho
- Multidisciplinary Pain Unit, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Porto, Portugal
| | - Kiriaki Vagdatli
- Anaesthesia Department General Hospital of Athens “G. Gennimatas”, Athens, Greece
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Retrospective Observational Study on the Characteristics of Pain and Associated Factors of Breakthrough Pain in Advanced Cancer Patients. Pain Res Manag 2022; 2022:8943292. [PMID: 35463627 PMCID: PMC9023204 DOI: 10.1155/2022/8943292] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/08/2022] [Accepted: 03/29/2022] [Indexed: 12/25/2022]
Abstract
Objective This study aimed to conduct a retrospective observational study to understand the status of characteristics of pain and identify potential variables influencing the clinical presentation of breakthrough cancer pain (BTP) in advanced cancer patients. Methods Advanced cancer patients over 18 years of age; diagnosed with cancer of any type and stage III or IV in the palliative care ward with available data were enrolled between 2018 and 2020. Demographic data and pain-related information were collected by using structured electronic extraction form from Hospital Information System (HIS). Patients who had well-controlled background pain with an intensity ≤4 on a 0–10 numerical scale for >12 hours/day, the presence of transient exacerbations of pain with moderate-severe intensity (≧5), and clearly distinguish from background pain were regarded to have suffered BTP. Spearman correlation was conducted to explore the relationship between pain score and demographics characteristics. Factors significant in univariate analysis were included in the multiple regression model to explore independent predictive factors associated with the BTP. Results Of 798 advanced cancer patients, the mean age was 56.7 (SD = 11.84) years. Lung cancer (29.95%) was the most common cancer, and pain (93%) was the most common symptom. More than half (n = 428, 53.6%) of the patients experienced BTP. The median number of BTP episodes was 4 (IQR = 2, 7, range: 1–42). The median intensity of BTP was 6 (IQR = 6, 7, range 5–10). Patients with severe background pain or BTP had longer hospital stay and more symptoms. Besides, more severe background pain was related to higher activity of daily living. Intramuscular injection of hydromorphone hydrochloride was the main medication for BTP onset. Younger age, background pain, anorexia, and constipation were independently associated with the presentation of BTP. BTP pain intensity was independently associated with bloating. Symptom numbers were an independent factor and positively associated with BTP episodes. Conclusions BTP resulted in poor prognosis, which has a variable presentation depending on interdependent relationships among different characteristics. Good controlling of background pain and assessment of pain-related symptoms are essential for BTP management. BTP should be managed individually, especially the invisible pain among aged patients. Furthermore, BTP-related education and training were still needed.
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A Longitudinal Study of Breakthrough Cancer Pain: An Extension of IOPS-MS Study. J Clin Med 2021; 10:jcm10112273. [PMID: 34073907 PMCID: PMC8197313 DOI: 10.3390/jcm10112273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022] Open
Abstract
The aim of this study was to longitudinally assess the characteristics of background pain and breakthrough pain (BTcP), analgesic treatment, and satisfaction with treatment four weeks after the first assessment. METHODS Adult cancer patients with a diagnosis of BTcP were included. At T0, age, gender, visit setting, cancer diagnosis, the extent of the disease, ongoing anticancer treatments, and Karnofsky level were recorded. The background pain intensity in the last 24 h (on a numerical scale 0-10), opioids used for background pain, and their doses, expressed as oral morphine equivalents (OME), as well as other analgesic drugs, were recorded. The number of BTcP episodes, their intensity, predictability and precipitating factors, onset duration of untreated episodes, and interference with daily activities were collected. Analgesics and doses used for BTcP, and the mean time to meaningful pain relief after taking medication, were assessed. The level of satisfaction with BTcP medication was also assessed. Adverse effects to be attributed to these medications were also recorded. At T4, the same data were evaluated. RESULTS After one-month follow-up, patients had a lower number of BTcP episodes and peak intensity, possibly due to the optimization of background analgesia. The principal characteristics of BTcP did not change significantly. CONCLUSION A careful and continuous assessment should be guaranteed to all patients to limit the burden induced by BTcP, other than treating BTcP episodes with short-onset opioids.
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Mercadante S, Maltoni M, Russo D, Adile C, Ferrera P, Rossi R, Rosati M, Casuccio A. The Prevalence and Characteristics of Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain. Cancers (Basel) 2021; 13:cancers13051058. [PMID: 33801478 PMCID: PMC7958843 DOI: 10.3390/cancers13051058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. This prospective study showed that in this population, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes. Abstract The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. A consecutive sample of advanced cancer patients receiving less than 60 mg/day of oral morphine equivalent (OME) was selected. Epidemiological data, background pain intensity, and current analgesic therapy were recorded. The presence of BTcP was diagnosed according to a standard algorithm. The number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, satisfaction with BTcP medication, and time to meaningful pain relief were collected. A total of 126 patients were screened. The mean intensity of background pain was 2.71 (1.57), and the mean OME was 28.5 mg/day (SD15.8). BTP episodes were recorded in 88 patients (69.8%). The mean number/day of BTP episodes was 4.1 (SD 7.1, range 1–30). In a significant percentage of patients, BTcP was both predictable and unpredictable (23%). The BTcP onset was less than 20 min in the majority of patients. The mean duration of untreated episodes was 47.5 (SD 47.6) minutes. The mean time to meaningful pain relief after taking a BTcP medication was >20 min in 44.5% of patients. The efficacy of BTcP medication was not considered good in more than 63% of patients. Gender (females) (OR = 4.16) and lower Karnofsky (OR = 0.92) were independently associated with BTcP. A higher number of BTcP episodes/day was associated with gender (females) (p = 0.036), short duration of BTcP (p = 0.005), poorer efficacy of BTcP medication (none or mild) (p = 0.001), and late meaningful pain relief (p = 0.024). The poor efficacy of BTcP medication was independently associated with a higher number of episodes/day (OR = 0.22). In patients who were receiving low doses of opioids, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
- Correspondence:
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Domenico Russo
- Hospice and the Palliative Care Service, Clinica San Marco, 04100 Latina, Italy;
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Marta Rosati
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy;
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Mercadante S, Portenoy RK. Understanding the Chameleonic Breakthrough Cancer Pain. Drugs 2021; 81:411-418. [PMID: 33515376 DOI: 10.1007/s40265-021-01466-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Abstract
Breakthrough cancer pain (BTcP) is a variegated phenomenon, that often presents in different ways in each individual, and may change its presentation in the same individual during the course of disease. An appropriate assessment is fundamental for depicting the pattern of BTcP in individuals. This information is determinant for a personalised management of BTcP. The use of opioids as needed, is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective, providing analgesia in 5-15 min. The most controversial point regards the opioid dose to be used. The presence of tolerance suggests using a dose that is proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested using the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never-ending question.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative Care Unit, La Maddalena Cancer Centre, Via San Lorenzo 312, 90146, Palermo, Italy. .,Regional Home Care Programme, SAMOT, Palermo, Italia.
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, 39 Broadway, 3rd Floor, New York, NY, 10006, USA. .,Neurology and Family and Social Medicine, Albert Einstein College of Medicine, New York, USA.
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Mercadante S, Adile C, Masedu F, Valenti M, Aielli F. Breakthrough Cancer Pain in Patients With Abdominal Visceral Cancer Pain. J Pain Symptom Manage 2019; 57:966-970. [PMID: 30822530 DOI: 10.1016/j.jpainsymman.2019.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this study was to assess the characteristics of breakthrough cancer pain (BTcP) in patients with abdominal cancer pain, and the eventual factors associated with its presentation. METHODS Patients with abdominal visceral cancer presenting BTcP were included in the analysis. Pain intensity, current analgesic therapy, number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset (≤10 minutes or >10 minutes), duration, interference with daily activities, medications and doses currently used for BTcP, and time to meaningful pain relief were collected. Adverse effects imputable to a BTcP medication were recorded. RESULTS Four hundred fourteen patients were included in the study. The mean background pain was 2.7 (SD 1.19) and most patients (97.6%) were receiving opioids. The mean number of BTcP episodes/day was 2.2 (SD 1.51). The mean intensity of BTcP was 7.3 (SD 1.32). BTcP onset was ≤10 minutes and >10 minutes in 271 (65.5%) and 143 patients (35.5%), respectively, and the mean duration was 52.6 minutes (SD 38.1). Interference of BTcP with daily activity was relevant for 340 patients (82%). In 122 patients (29.5%), BTcP was predictable and ingestion of food (n = 63, 51.6%) was the most frequent trigger. In comparison with unpredictable BTcP, postprandial BTcP had a lower intensity (P = 0.039), had a faster onset (P = 0.042), and was associated with the use of oxycodone/naloxone (P = 0.003), and less use of nonsteroidal anti-inflammatory drugs (P = 0.006). CONCLUSION Patients with abdominal visceral BTcP represent a subgroup with specific features of BTcP, particularly those with predictable BTcP. Ingestion of food was the prominent trigger for BTcP, having a faster onset and a lower intensity. This group of patients more frequently used oxycodone/naloxone or no anti-inflammatory drugs. These findings suggest consequential therapeutic decisions.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Marco Valenti
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Federica Aielli
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
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Campagna S, Sperlinga R, Milo A, Sannuto S, Acquafredda F, Saini A, Gonella S, Berruti A, Scagliotti GV, Tampellini M. The Circadian Rhythm of Breakthrough Pain Episodes in Terminally-ill Cancer Patients. Cancers (Basel) 2018; 11:cancers11010018. [PMID: 30586878 PMCID: PMC6356835 DOI: 10.3390/cancers11010018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 12/22/2022] Open
Abstract
Opioid therapy must be adjusted to the rhythm of a cancer patient’s pain to ensure adequate symptom control at the end of life (EOL). However, to-date no study has explored the rhythm of breakthrough pain (BTP) episodes in terminally-ill cancer patients. This prospective longitudinal study was aimed at verifying the existence of a circadian rhythm of BTP episodes in terminally-ill cancer patients. Consecutive adult cancer patients at their EOL treated with long-acting major opioids to control background pain (Numeric Rating Scale ≤ 3/10) were recruited from two Italian palliative care services. Using a personal diary, patients recorded the frequency and onset of BTP episodes and the analgesic rescue therapy taken for each episode over a 7-day period. Rhythms identified in BTP episodes were validated by Cosinor analysis. Overall, 101 patients were enrolled; nine died during the study period. A total of 665 BTP episodes were recorded (average of 7.2 episodes, mean square error 0.8) per patient, with 80.6% of episodes recorded between 8:00 a.m. and 12:00 a.m. At Cosinor analysis, a circadian rhythm of BTP episodes was observed, with a Midline Estimating Statistics of the Rhythm (MESOR) of 1.5, a double amplitude of 1.8, and an acrophase at 12:30 p.m. (p < 0.001). Oral morphine was the most frequent analgesic rescue therapy employed. In terminally-ill cancer patients, BTP episodes follow a circadian rhythm; thus, tailoring the timing of opioid administration to this rhythm may prevent such episodes. This circadian rhythm of BTP episodes in terminally-ill cancer patients should be confirmed in larger samples.
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Affiliation(s)
- Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, 10126 Torino, Italy.
| | - Riccardo Sperlinga
- School of Nursing, Catholic University of the Sacred Heart, Cottolengo Hospital, 10152 Torino, Italy.
| | - Antonella Milo
- FARO Foundation-Hospice Sergio Sugliano, 10121 Torino, Italy.
| | - Simona Sannuto
- School of Nursing, Catholic University of the Sacred Heart, Cottolengo Hospital, 10152 Torino, Italy.
| | - Fabio Acquafredda
- School of Nursing, Catholic University of the Sacred Heart, Cottolengo Hospital, 10152 Torino, Italy.
| | - Andrea Saini
- Medical Oncology, University of Torino; Department of Oncology, San Luigi Gonzaga Hospital, 10043 Orbassano, Italy.
| | - Silvia Gonella
- Department of Public Health and Pediatrics, University of Torino, 10126 Torino, Italy.
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia, ASST-Spedali Civili, 25123 Brescia, Italy.
| | - Giorgio Vittorio Scagliotti
- Medical Oncology, University of Torino; Department of Oncology, San Luigi Gonzaga Hospital, 10043 Orbassano, Italy.
| | - Marco Tampellini
- Medical Oncology, University of Torino; Department of Oncology, San Luigi Gonzaga Hospital, 10043 Orbassano, Italy.
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Tagami K, Okizaki A, Miura T, Watanabe YS, Matsumoto Y, Morita T, Fujimori M, Kinoshita H. Breakthrough Cancer Pain Influences General Activities and Pain Management: A Comparison of Patients with and without Breakthrough Cancer Pain. J Palliat Med 2018; 21:1636-1640. [PMID: 29975582 DOI: 10.1089/jpm.2017.0675] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Breakthrough cancer pain (BTcP) is a predictor of interference with general activities and poor pain management. The extent of this influence has not yet been determined. OBJECTIVE This study aimed to investigate the influence of BTcP on general activities, and pain management in patients with controlled background pain. DESIGN Single-center prospective observational study. SETTING/SUBJECTS The study cohort comprised 258 consecutive patients (female, 40.0%; mean age, 64.5 years) who had received opioid medication for cancer pain for over 2 weeks. MEASUREMENTS A recommended diagnostic algorithm was used to quantitate and compare interference with general activities, average background pain intensity over the previous 24 hours (24h-PI), and achievement of personalized pain goals (PPGs) (24h-PI≤PPG) of 119 patients with and 139 patients without BTcP. RESULTS Interference with general activities, 24h-PI, and PPG scores [mean (standard deviation)] in patients with BTcP were 2.8 (2.2), 3.0 (1.7), and 1.8 (1.4), respectively, which are all significantly higher than for those without BTcP [1.3 (2.0), p < 0.01; 1.7 (1.6), p < 0.01; 1.5 (1.3), p = 0.03], respectively. A significantly smaller percentage of patients with BTcP than without BTcP achieved their PPGs (36.1% vs. 67.6%, p < 0.01). CONCLUSIONS BTcP has a negative impact on general activities and pain management. Healthcare providers should recognize that management of BTcP is important in improving general activities and management of cancer pain.
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Affiliation(s)
- Keita Tagami
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan .,2 Department of Palliative Medicine, Tohoku University School of Medicine , Sendai, Japan
| | - Ayumi Okizaki
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan
| | - Tomofumi Miura
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan .,3 Division of Biomarker Discovery, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center Hospital East , Kashiwa, Japan
| | - Yuki Sumazaki Watanabe
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan
| | - Yoshihisa Matsumoto
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan
| | - Tatsuya Morita
- 4 Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital , Hamamatsu, Japan
| | - Maiko Fujimori
- 5 Division of Cohort Consortium Research, Center for Public Health Sciences, National Cancer Center , Tokyo, Japan .,6 Division of Health Care Research, Center for Public Health Sciences, National Cancer Center , Tokyo, Japan
| | - Hiroya Kinoshita
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan .,7 Department of Palliative Care, Tokatsu Hospital , Nagareyama, Japan
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Factors Influencing the Clinical Presentation of Breakthrough Pain in Cancer Patients. Cancers (Basel) 2018; 10:cancers10060175. [PMID: 29865170 PMCID: PMC6025469 DOI: 10.3390/cancers10060175] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 11/17/2022] Open
Abstract
Background: The aim of this study was to identify potential variables influencing the clinical presentation of breakthrough cancer pain (BTP). Methods: Cancer patients with a diagnosis of BTP were enrolled. Demographic and clinical characteristics, as well as background pain and BTP characteristics were collected. Multivariate analyses were conducted to assess the correlation between BTP characteristics and the variables examined. Results: Data of 4016 patients were analysed. Average daily number of BTP episodes was 2.4, mean intensity was 7.5, and a mean duration was 43.3 min. A short onset BTP was observed in 68.9% of patients. In 30.5% of patients BTP was predictable. There were 86.0% of participants who reported a marked interference of BTP with their daily activities. Furthermore, 86.8% of patients were receiving opioids for the management of BTP. The average time to meaningful pain relief was 16.5 min and 70.9% of patients were satisfied with their BTP medications. Age, head and neck cancer, Karnofsky, background pain intensity, predictable and fast onset BTP were independently associated with the number of BTP episodes. BTP pain intensity was independently associated with background pain intensity, fast onset BTP, and Karnofsky. Neuropathic pain mechanism was independently associated with unpredictable BTP. Variables independently associated with a longer duration of BTP were age, place of visit, cancer diagnosis, disease-oriented therapy, background pain intensity and mechanism, and unpredictable BTP. Age, Karnofsky, background pain intensity, fast onset, and long duration of BTP were independently associated with interference with daily activity. Conclusions: BTP has a variable presentation depending on interdependent relationships among its different characteristics.
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Mercadante S, Marchetti P, Cuomo A, Caraceni A, Mediati RD, Mammucari M, Natoli S, Lazzari M, Dauri M, Airoldi M, Azzarello G, Bandera M, Blasi L, Cartenì G, Chiurazzi B, Costanzo BVP, Degiovanni D, Fusco F, Guardamagna V, Iaffaioli V, Liguori S, Lorusso V, Mameli S, Mattioli R, Mazzei T, Melotti RM, Menardo V, Miotti D, Moroso S, De Santis S, Orsetti R, Papa A, Ricci S, Sabato AF, Scelzi E, Sofia M, Tonini G, Aielli F, Valle A. Breakthrough Cancer Pain: Preliminary Data of The Italian Oncologic Pain Multisetting Multicentric Survey (IOPS-MS). Adv Ther 2017; 34:120-135. [PMID: 27873235 PMCID: PMC5216057 DOI: 10.1007/s12325-016-0440-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Indexed: 11/29/2022]
Abstract
Introduction An ongoing national multicenter survey [Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS)] is evaluating the characteristics of breakthrough cancer pain (BTP) in different clinical settings. Preliminary data from the first 1500 cancer patients with BTP enrolled in this study are presented here. Methods Thirty-two clinical centers are involved in the survey. A diagnosis of BTP was performed by a standard algorithm. Epidemiological data, Karnofsky index, stage of disease, presence and sites of metastases, ongoing oncologic treatment, and characteristics of background pain and BTP and their treatments were recorded. Background pain and BTP intensity were measured. Patients were also questioned about BTP predictability, BTP onset (≤10 or >10 min), BTP duration, background and BTP medications and their doses, time to meaningful pain relief after BTP medication, and satisfaction with BTP medication. The occurrence of adverse reactions was also assessed, as well as mucosal toxicity. Results Background pain was well controlled with opioid treatment (numerical rating scale 3.0 ± 1.1). Patients reported 2.5 ± 1.6 BTP episodes/day with a mean intensity of 7.5 ± 1.4 and duration of 43 ± 40 min; 977 patients (65.1%) reported non-predictable BTP, and 1076 patients (71.7%) reported a rapid onset of BTP (≤10 min). Higher patient satisfaction was reported by patients treated with fast onset opioids. Conclusions These preliminary data underline that the standard algorithm used is a valid tool for a proper diagnosis of BTP in cancer patients. Moreover, rapid relief of pain is crucial for patients’ satisfaction. The final IOPS-MS data are necessary to understand relationships between BTP characteristics and other clinical variables in oncologic patients. Funding Molteni Farmaceutici, Italy.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Supportive Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| | - Paolo Marchetti
- Molecular and Clinical Medicine, Medical Oncology, La Sapienza University of Rome, Rome, Italy
| | - Arturo Cuomo
- Anesthesiology, Resuscitation, and Pain Therapy Department, National Cancer Institute, IRCCS Foundation Pascale, Naples, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, National Cancer Institute IRCCS Foundation, Milan, Italy
| | | | | | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Marzia Lazzari
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Mario Airoldi
- 2nd Medical Oncology Division, Città della Salute e della Scienza Hospital of Turin, Turin, Italy
| | - Giuseppe Azzarello
- Medical Specialties Department, Oncology and Oncologic Hematology, ASL 13 Mirano, Venice, Italy
| | - Mauro Bandera
- Medical Oncology Unit, Ospedale di Circolo e Fondazione Macchi Hospital, Varese, Italy
| | - Livio Blasi
- Medical Oncology Unit, ARNAS Ospedale Civico, Di Cristina, Benfratelli, Palermo, Italy
| | | | | | | | | | - Flavio Fusco
- Palliative Care Unit, Department of Primary and Community Care, ASL3 Genovese, Genoa, Italy
| | - Vittorio Guardamagna
- Palliative Care and Pain Therapy Unit, European Oncology Institute IRCCS, Milan, Italy
| | - Vincenzo Iaffaioli
- Abdominal Medical Oncology, National Cancer Institute, IRCCS Foundation Pascale, Naples, Italy
| | - Simeone Liguori
- Palliative Care and Pain Therapy Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Vito Lorusso
- Medical Oncology Unit, National Cancer Research Centre "Giovanni Paolo II", Bari, Italy
| | - Sergio Mameli
- Pain Therapy Unit, "A. Businco" Hospital, ASL 8, Cagliari, Italy
| | | | - Teresita Mazzei
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Rita Maria Melotti
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
| | | | - Danilo Miotti
- Palliative Care Unit, Salvatore Maugeri-IRCCS Foundation, Pavia, Italy
| | - Stefano Moroso
- Medical Oncology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Stefano De Santis
- Palliative Care and Oncologic Pain Service, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Remo Orsetti
- Pain Medicine Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Alfonso Papa
- Pain Relief, A.O. Dei Colli, Monaldi Hospital, Naples, Italy
| | - Sergio Ricci
- Division of Medical Oncology, Department of Oncology, S. Chiara University Hospital, Pisa, Italy
| | - Alessandro Fabrizio Sabato
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Elvira Scelzi
- Medical Oncology, Castelfranco Veneto Hospital, Treviso, Italy
| | - Michele Sofia
- Department of Palliative Care with Hospice and Pain Therapy Unit, "G.Salvini" Hospital, Garbagnate Milanese, Milan, Italy
| | - Giuseppe Tonini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Mercadante S, Cuomo A. Breakthrough Cancer Pain: Ten Commandments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:531-536. [PMID: 27565269 DOI: 10.1016/j.jval.2016.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/03/2016] [Accepted: 03/05/2016] [Indexed: 06/06/2023]
Abstract
The term "breakthrough cancer pain" (BTcP) was introduced about 25 years ago. Peaks of pain intensity reported in patients with cancer had been invariably examined in the past years, providing relevant information for a better knowledge of this phenomenon and its treatment. The aim of this critical review was to provide the golden rules, namely, the 10 commandments, for a correct diagnostic pathway of BTcP and a consequent personalized pharmacological treatment. These are as follows: 1) assessment of background analgesia, 2) drugs used for background analgesia, 3) BTcP is a frequent phenomenon, 4) characteristics of BTcP, 5) diagnosis of BTcP, 6) continuous assessment, 7) tailored pharmacological treatment of BTcP, 8) selection of BTcP medication, 9) dosing BTcP medications, and 10) education. These steps may help clinicians to recognize and treat BTcP adequately.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Arturo Cuomo
- Anesthesia, Intensive care and Pain Therapy, National Cancer Institute, "Pascale", Naples, Italy
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Mercadante S, Aielli F, Adile C, Costanzi A, Casuccio A. Fentanyl Pectin Nasal Spray Versus Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Comparative Study. J Pain Symptom Manage 2016; 52:27-34. [PMID: 27208863 DOI: 10.1016/j.jpainsymman.2016.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/14/2016] [Accepted: 02/13/2016] [Indexed: 11/21/2022]
Abstract
CONTEXT Fentanyl products have shown superiority over oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use an appropriate patient selection, and drugs have been compared using a different rationale. OBJECTIVES The aim of this randomized, crossover, controlled study was to compare the efficacy and safety of fentanyl pectin nasal spray (FPNS) and oral morphine (OM), given in doses proportional to opioid daily doses. METHODS Cancer patients with pain receiving ≥60 mg of OM equivalents/day and presenting with ≤3 episodes of BTcP/day were included. Patients received, in a randomized, crossover manner, FPNS or OM at doses proportional to the daily opioid regimen in four consecutive episodes of BTcP. Pain intensity was measured before (T0), 15 (T15), and 30 minutes (T30) after study drugs. RESULTS A total of 167 episodes were treated, 82 with FNPS and 85 with OM. A statistical difference in pain intensity between the two groups was observed at T15, but not at T30 (P = 0.018 and P = 0.204, respectively). In a greater number of episodes treated with FPNS, there was a pain decrease of ≥33% in comparison with OM after 15 and 30 minutes (76.5% vs. 32.8%, and 89% vs. 54.9%, respectively). Similar differences were found in the decrease in pain intensity of ≥50% after 15 and 30 minutes (52.3% vs. 11.4%, and 75% vs. 45.8%, respectively). The difference was highly significant at T15 (P < 0.0005). The mean (SD) pain difference at T15 of FPNS and OM were 3.24 (1.7) and 2.70 (1.2), respectively, whereas the mean (SD) SPIDs30 of FPNS and OM were 4.87 (1.7) and 4.54 (1.5), respectively. The difference was highly significant at T15 (P = 0.019). No severe adverse effects after study drug administration were observed. CONCLUSION When used in doses proportional to the basal opioid regimen, FPNS showed a superior analgesic effect over OM for the management of BTcP. Only minor adverse effects were found with both medications.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Andrea Costanzi
- Department of Oncology, Hospital Sant'Andrea, University of Rome, Rome, Italy
| | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
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Breakthrough pain in cancer patients: prevalence, mechanisms and treatment options. Curr Opin Anaesthesiol 2016; 28:559-64. [PMID: 26263120 DOI: 10.1097/aco.0000000000000224] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The aim of this article was to examine the definition, the characteristics, and the management of breakthrough cancer pain (BTP) in cancer patients by a critical review of recent literature. RECENT FINDINGS BTP should be more correctly defined as an episode of severe intensity in patients receiving an adequate treatment with opioids able to provide at least mild analgesia. BTP is a heterogeneous condition as episodes vary between individuals. BTP can be classified into two big distinct pictures: spontaneous-type and incident-type pain. The principal pharmacological treatment of BTP is represented by the administration of opioids as needed. Recent reviews revealed that transmucosal preparation of fentanyl provided superior and more rapid pain relief as compared with placebo in the first 30 min after dosing. Few comparison studies among fentanyl products have been performed.Finally, although dose titration was recommended for years, a meaningful dosing according to the level of opioid tolerance may enhance the advantages of such products. SUMMARY BTP represents a serious problem reported by many cancer patients despite receiving regular use of opioids. Subgroups of breakthrough pain have been identified. Different modalities of pharmacological interventions are available. Further studies are warranted to assess the net benefit of these drugs to assist decision-making by patients, clinicians, and payers according to individual clinical conditions.
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Italian Oncological Pain Survey (IOPS): a multicentre Italian study of breakthrough pain performed in different settings. Clin J Pain 2015; 31:214-21. [PMID: 25654429 DOI: 10.1097/ajp.0000000000000161] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A survey of breakthrough pain (BTP) was performed in five palliative care units (PCU), seven oncology departments (ONC), and nine pain clinics (OPC). METHODS A standard algorithm was used to confirm the diagnosis of BTP of patients refereed to different settings. RESULTS 1,412 evaluable cancer patients were enrolled. 53.9% were males and the mean age was 63.7±13.1 years. The mean intensity of background pain was 2.8±0.73. Patients reported 2.4±1.1 BTP episodes/day with a mean intensity of 7.37±1.28. 80.6% patients reported that the BTP had a significant negative impact in everyday life. The majority of patients reported a fast onset of BTP, which was predictable in 50.7% of cases, while BTP with a gradual onset (>10 min) was less predictable (29%) (P=0.001). PCU patients were older, had lower Karnofsky levels, a lower number of BTP episodes/day, a slow onset of BTP onset, and a less predictable BTP. Cancer diagnosis was performed a mean of 23.5 months (SD±32.8) before the assessment. The mean duration of background pain was 3.5 months (SD±3.5), and the mean duration of any analgesic treatment was 2.5 months (SD±3). BTP started a mean of 2.2 months (SD±1.9) before the assessment. Characteristics of BTP were influenced by the course of disease, as well as the duration of background pain and initiation of BTP. Most patients took rapid onset opioids and were satisfied with the treatment. BTP diagnosis was prevalently made by ONC and OPC physicians, and rarely by GPs. CONCLUSION This survey performed by an Italian observatory expert review group, has confirmed that the BTP represents a clinically relevant condition with a negative impact on the patient's quality of life. BTP was detected in all settings involved. A number of factors are associated with the BTP. Also factors regarding the course of disease and setting of care have been assessed. This information may help in stratifying patients or predicting the risk of development of BTP with specific characteristics.
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Mercadante S, Adile C, Cuomo A, Aielli F, Cortegiani A, Casuccio A, Porzio G. Fentanyl Buccal Tablet vs. Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Randomized, Crossover, Comparison Study. J Pain Symptom Manage 2015; 50:579-86. [PMID: 26303188 DOI: 10.1016/j.jpainsymman.2015.05.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/28/2015] [Accepted: 05/31/2015] [Indexed: 11/16/2022]
Abstract
CONTEXT Fentanyl products have shown superiority to oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use appropriate patient selection, and drugs have been compared by using different rationales. OBJECTIVES The aim of this randomized, crossover, controlled study was to compare efficacy and safety of fentanyl buccal tablets (FBTs) and oral morphine (OM), given in doses proportional to opioid daily doses. METHODS Cancer patients with pain receiving ≥60 mg or more of oral morphine equivalents per day and presenting with ≤3 episodes of BTcP per day were included. In a randomized, crossover manner, patients received FBT or OM at doses proportional to the daily opioid regimen in four consecutive episodes of BTcP. Pain intensity was measured before (T0) and 15 (T15) and 30 minutes (T30), after study drugs. RESULTS In total, 263 episodes of BTcP were treated. A statistical difference in changes in pain intensity-decrease of ≥33% and ≥50%-between the two groups was observed at T15 and T30 (P < 0.0005). No severe adverse effects after study drug administration were observed. CONCLUSION When used in doses proportional to the basal opioid regimen, FBT showed a clear superiority and was well tolerated when compared with OM during the first 30 minutes, which is the approximate target for a timely intervention required for a BTcP medication.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Arturo Cuomo
- Anesthesia and Pain Therapy, National Cancer Institute Pascale, Naples, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Andrea Cortegiani
- Section of Anesthesia, Analgesia, Intensive Care and Emergency, Department of Biopathology, Medical and Forensic Biotechnologies, Policlinico P. Giaccone, University of Palermo, Palermo, Italy
| | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
| | - Giampiero Porzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Breakthrough pain and its treatment: critical review and recommendations of IOPS (Italian Oncologic Pain Survey) expert group. Support Care Cancer 2015; 24:961-968. [PMID: 26438145 DOI: 10.1007/s00520-015-2951-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/14/2015] [Indexed: 10/23/2022]
Abstract
Controversies exist about the definition and epidemiology of breakthrough cancer pain (BTcP), the pharmacological treatment options, drug dosing, and how to select the medications for BTcP among the new fentanyl products. Existing data were critically evaluated to provide recommendations by an expert group. An algorithm to diagnose BTcP should be used followed by a careful assessment. Fentanyl products provide efficacy and rapidity of action to counteract the temporal pattern of BTcP. The doses of opioids used for background pain should guide the choice of the doses of fentanyl products. The choice of fentanyl products should be based on individual clinical conditions.
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Cabezón-Gutiérrez L, Gómez-Pavón J, Pérez-Cajaraville J, Viloria-Jiménez MA, Álamo-González C, Gil-Gregorio P. [Update on oncological pain in the elderly]. Rev Esp Geriatr Gerontol 2015; 50:289-97. [PMID: 25777946 DOI: 10.1016/j.regg.2015.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 02/04/2015] [Indexed: 01/05/2023]
Abstract
Pain is a prevalent symptom in cancer geriatric patients, appearing in up to 90% of patients with terminal cancer. This requires a multidimensional approach, as there is a high percentage of inappropriate assessments and treatments. Unrecognized or poorly treated pain in the geriatric population, especially in cancer patients, leads to the development of disabling symptoms such as depression, anxiety, isolation, sleep disturbances, and appetite, and very especially, loss of functional capacity and quality of life. In this review an analysis is made on the most relevant studies on the diagnosis and management of cancer pain in the geriatric population.
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Affiliation(s)
- Luis Cabezón-Gutiérrez
- Servicio de Oncología Médica, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España.
| | | | | | | | | | - Pedro Gil-Gregorio
- Servicio de Geriatría, Unidad de Cuidados Paliativos, Hospital Clínico Universitario San Carlos, Madrid, España; Coordinador del Comité de Expertos del Dolor de la Sociedad Española de Geriatría y Gerontología, España
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Sperlinga R, Campagna S, Berruti A, Laciura P, Ginosa I, Paoletti S, Giuliano P, Tucci M, Rosato R, Scagliotti G, Saini A. Alberta Breakthrough Pain Assessment Tool: A validation multicentre study in cancer patients with breakthrough pain. Eur J Pain 2014; 19:881-8. [DOI: 10.1002/ejp.612] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 11/09/2022]
Affiliation(s)
- R. Sperlinga
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - S. Campagna
- School of Nursing; ‘San Luigi Gonzaga’; University of Torino; Italy
| | - A. Berruti
- Medical Oncology; Department of Medical and Surgical Specialties; Radiological Sciences and Public Health; ‘Spedali Civili’ Hospital; University of Brescia; Italy
| | | | - I. Ginosa
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - S. Paoletti
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - P.L. Giuliano
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - M. Tucci
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - R. Rosato
- Cancer Epidemiology Unit; ‘Città della Salute e della Scienza’ Hospital; Turin Italy
| | - G.V. Scagliotti
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - A. Saini
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
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Mercadante S. Fentanyl buccal tablet for the treatment of cancer-related breakthrough pain. Expert Rev Clin Pharmacol 2014; 8:9-13. [DOI: 10.1586/17512433.2015.977254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mercadante S. The pain, the oncologist. Support Care Cancer 2014; 22:2021-2. [DOI: 10.1007/s00520-014-2302-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/26/2014] [Indexed: 10/25/2022]
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Breakthrough pain in patients with controlled or uncontrolled basal pain: an observational study. Pain Res Manag 2014; 19:e168-71. [PMID: 24945289 PMCID: PMC4273716 DOI: 10.1155/2014/646312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recently, there has been debate regarding the definition of ‘breakthrough pain’ and the patients to whom the term applies, with suggestions made to broaden the definition to include both patients with uncontrolled and controlled baseline pain, rather than only patients with controlled pain. To contribute to this discussion, the authors assessed the occurrence and characteristics of breakthrough pain among patients with controlled and uncontrolled baseline pain. BACKGROUND: Breakthrough pain (BTP) is traditionally defined as a pain exacerbation in patients with chronic controlled pain. However, this definition has recently been challenged. OBJECTIVES: To evaluate the prevalence of unsatisfactory control in patients with chronic cancer pain, and investigate the frequency and intensity of BTP episodes. METHODS: A total of 665 patients with chronic cancer pain attending 21 pain therapy units in Italy were evaluated for baseline pain intensity and number of BTP episodes over a 30-day period. All patients started, continued or modified treatment for BTP at enrollment, according to medical judgment. RESULTS: The number of BTP events was higher in patients with uncontrolled baseline pain, although the intensity and duration of episodes were similar. In patients with uncontrolled baseline pain, the number of events decreased with time and reached values comparable with those reported in patients with controlled pain. Both the intensity of the pain and the duration of the BTP events exhibited similar values in the two groups at all time points, following increased monitoring and the prescription of analgesic medication. CONCLUSION: Patients with uncontrolled baseline pain experienced BTP flares with higher frequency, but similar intensity and duration with respect to patients with controlled pain at baseline. Notably, a close follow-up and adequate management of the BTP episodes led to an improvement of BTP in the observed patients.
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Mercadante S, Prestia G, Casuccio A. The use of sublingual fentanyl for breakthrough pain by using doses proportional to opioid basal regimen. Curr Med Res Opin 2013; 29:1527-32. [PMID: 23869428 DOI: 10.1185/03007995.2013.826640] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to prospectively assess the efficacy and safety of sublingual fentanyl (SLF) in doses proportional to opioid doses used for background analgesia for the treatment of BTP of cancer patients. METHODS A sample of patients admitted to an acute palliative care unit, presenting breakthrough pain (BTP) episodes and receiving stable doses of opioids for background pain was selected to assess the efficacy and safety of SLF used in doses proportional to the basal opioid regimen used for the management of BTP. For each patient, data from four consecutive episodes were collected. For each episode, nurses collected changes in pain intensity and adverse effects when pain got severe (T0), and 5, 10, and 15 minutes after SLF was given (T15). RESULTS Seventy patients were recruited for the study. The mean age was 61.7 (±11.5). Forty-one patients were males. A total of 173 episodes of BTP were recorded (mean 2.5 episodes/patient). In 19 events, documentation regarding changes in pain intensity was incomplete. Of the 154 evaluable episodes, 143 were successfully treated (92%). Mean doses of SLF were 637 µg (SD 786), and 51 patients (72.8%) received SLF doses ≥800 µg. When compared to younger adult patients, older patients received significantly lower doses of SLF (p < 0.0005) [DOSAGE ERROR CORRECTED], similarly to their lower basal opioid regimen. Pain intensity significantly decreased at T5, 10 and T15 (p < 0.0005). The number of patients with a pain reduction of more than 33% at T5, T10, and T15 were 11, 79, and 137, respectively, and the number of patients with a reduction in pain intensity of more than 50% were 1, 21, 114 at the same intervals, respectively. No differences in changes in pain intensity for gender (p < 0.9) or age (p < 0.85) were observed. No significant changes in the number of patients reporting adverse effects of mild-moderate intensity were reported after SLF administration in comparison with baseline, and no adverse effects severe enough in intensity to require medical intervention were observed. Limitations of this study are represented by the uncontrolled design. CONCLUSION This study suggests that SLF given in doses proportional to the basal opioid regimen for the management of BTP is safe and effective in clinical practice.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center , Palermo , Italy
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