1
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
2
|
Abstract
Breakthrough cancer pain (BTcP) is a complex and variegate phenomenon that may change its presentation during the course of patients' disease in the same individual. An appropriate assessment is fundamental for depicting the pattern of BTcP. This information is determinant for a personalized 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. The most controversial point regards the opioid dose to be used. The presence of opioid tolerance suggests to use a dose proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested to use the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never ended question.
Collapse
Affiliation(s)
- Sebastiano Mercadante
- Anesthetics, Main Regional Center for Pain Relief & Palliative Care Unit, La Maddalena Cancer Center, Acute Supportive/Palliative Care Unit & Hospice, 90146, Palermo, Italy.
| |
Collapse
|
3
|
Cuomo A, Boutis A, Colonese F, Nocerino D. High-rate breakthrough cancer pain and tumour characteristics - literature review and case series. Drugs Context 2023; 12:dic-2022-11-1. [PMID: 36926050 PMCID: PMC10012833 DOI: 10.7573/dic.2022-11-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/08/2023] [Indexed: 03/18/2023] Open
Abstract
Cancer pain requires careful comprehensive patient evaluation and an appropriate and personalized clinical approach by a trained multidisciplinary team. The proper assessment of breakthrough cancer pain (BTcP) is part of an all-inclusive multidimensional evaluation of the patient. The aim of this narrative review is to explore the relationship between high-rate BTcP, which strongly impacts health- related quality of life and tumour characteristics, in the face of novel approaches that should provide guidance for future clinical practice. The presentation of short, emblematic clinical reports also promotes knowledge of BTcP, which, despite the availability of numerous therapeutic approaches, remains underdiagnosed and undertreated. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.
Collapse
Affiliation(s)
- Arturo Cuomo
- IRCCS Istituto Nazionale Tumori Fondazione G Pascale, Napoli, Italy
| | - Anastasios Boutis
- First Department of Clinical Oncology, Theagenio Hospital, Thessaloniki, Greece
| | - Francesca Colonese
- Department Medical Oncology-ASST-Monza Ospedale San Gerardo, Monza, Italy
| | - Davide Nocerino
- IRCCS Istituto Nazionale Tumori Fondazione G Pascale, Napoli, Italy
| |
Collapse
|
4
|
Neuwersch-Sommeregger S, Köstenberger M, Stettner H, Pipam W, Breschan C, Feigl G, Likar R, Egger M. CT-Guided Coeliac Plexus Neurolysis in Patients with Intra-Abdominal Malignancy: A Retrospective Evaluation of 52 Palliative In-Patients. Pain Ther 2021; 10:1593-1603. [PMID: 34546553 PMCID: PMC8586091 DOI: 10.1007/s40122-021-00317-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/02/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Prevalence rates of chronic abdominal pain (CAP) and breakthrough cancer pain (BTcP) are high in patients with intra-abdominal malignancies. As part of a multimodal approach, CT-guided coeliac plexus blockade (CPB) and CT-guided coeliac plexus neurolysis (CPN) are commonly used pain management strategies. The aim of this study was to evaluate pain outcomes among patients with intra-abdominal malignancies who underwent CPB and/or CPN. METHODS Patients with intra-abdominal malignancies who underwent CPB and/or CPN for pain control at the general hospital Klagenfurt am Wörthersee from 2010 to 2019 were enrolled. RESULTS A total of 84 procedures (24 CPB and 60 CPN) were performed on 52 patients; 62% of these patients had pancreatic cancer. CPN led to significant pain reduction and decreased BTcP intensity. Patients receiving repeated CPN showed higher individual pain reduction. Higher pre-procedural pain intensity was correlated with higher pain reduction. No difference in pain reduction in patients receiving a diagnostic CPB prior to CPN compared to patients without a diagnostic CPB was found. Higher pain reduction after CPN led to longer-lasting pain relief. The time frame from diagnosis to CPN was 472 (± 416) days. Patients experienced a mean duration of pain prior to CPN of 330 (± 53) days. The time frame from diagnosis to CPN was shorter in patients with pancreatic cancer compared to other intra-abdominal malignancies. In 58% of patients pain medication was stable or was reduced after CPN; 16% of patients complained about pain during the procedure; no major complications occurred. There was no correlation between median survival after CPN and pain outcomes. CONCLUSIONS In patients with intra-abdominal malignancy-related CAP, CPN is a safe and effective procedure which can provide long-lasting significant relief of background pain and BTcP. As part of a multimodal approach, CPN should be considered as an earlier option for pain management in these patients.
Collapse
Affiliation(s)
- Stefan Neuwersch-Sommeregger
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria.
- Medical University of Graz, Graz, Austria.
| | - Markus Köstenberger
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
- Medical University of Graz, Graz, Austria
| | - Haro Stettner
- Department of Statistics, Alpen-Adria University Klagenfurt, Klagenfurt am Wörthersee, Austria
| | - Wofgang Pipam
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
| | - Christian Breschan
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
- Medical University of Graz, Graz, Austria
| | - Georg Feigl
- Institute for Anatomy and Clinical Morphology, Witten/Herdecke University, Witten, Germany
| | - Rudolf Likar
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
| | - Markus Egger
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt am Wörthersee, Feschnigstrasse 11, 9020, Klagenfurt am Wörthersee, Austria
| |
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW An overview on breakthrough cancer pain (BTCP), including inherent limitations of the terminology, assessment, clinical presentation, and treatment options. RECENT FINDINGS The estimated prevalence of BTCP is dependent on the defined cutoffs for controlled background pain and the magnitude of the pain flare. In addition, pain flares outside the definition of BTCP are prevalent. In the 11th Revision of the International Classification of Diseases, the temporal characteristics of cancer pain are described as continuous background pain and intermittent episodic pain. BTCP should be assessed by validated methods, and the patient perspective should be included. The pain may be related to neoplastic destruction of bone, viscera, or nerve tissue and is characterized by rapid onset, high intensity, and short duration. Treatment directed towards painful metastases must be considered. Due to pharmacological properties mirroring the pain characteristics, transmucosal fentanyl formulations are important for the treatment of BTCP. Oral immediate release opioids can be used for slow-onset or predictable BTCP. For more difficult pain conditions, parenteral, or even intrathecal pain medication, may be indicated. SUMMARY All clinically relevant episodic pains must be adequately treated in accordance with the patient's preferences. Transmucosal fentanyl formulations are effective for BTCP.
Collapse
|
6
|
Wang J, Yuan X, Guo W, Xiang X, Wu Q, Fang M, Zhang W, Ding Z, Xie K, Fang J, Zhou H, Fu S. Sedation and Analgesia for Liver Cancer Percutaneous Radiofrequency Ablation: Fentanyl and Oxycodone Comparison. Int J Med Sci 2020; 17:2194-2199. [PMID: 32922181 PMCID: PMC7484665 DOI: 10.7150/ijms.47067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/31/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Sedation and analgesia use in percutaneous radiofrequency ablation (RFPA) for liver cancer is a necessary part of the procedure; however, the optimal medicine for sedation and analgesia for PRFA remains controversial. The aim of this study was to compare the perioperative pain management, haemodynamic stability and side effects between oxycodone (OXY) and fentanyl (FEN) use in patients under dexmedetomidine sedation. Methods: Two hundred and five adults with an American Society of Anaesthesiologists physical status score of I to II were included in this study. Patients were assigned to the OXY (n=101) or FEN (n=104) group. Radiofrequency ablation was performed under spontaneous breathing and with painless anaesthesia administered intravenously. The outcomes included fluctuations in mean arterial pressure, heart rate, side effects and the perioperative numerical rating scale (NRS). Results: Radiofrequency ablation was successfully performed in 205 patients. No significant differences were observed in mean blood pressure fluctuations between the two groups despite the longer durations of ablation and total sedation time in the OXY group. The highest NRS score during the surgery and 1 hour and 2 hours after the surgery were significantly lower in the OXY group than in the FEN group. Heart rate fluctuations were significantly lower in the OXY group than in FEN group throughout the surgery. More patients in the FEN group displayed unwanted body movement and respiratory depression. Conclusions: Both oxycodone and fentanyl can be applied for liver cancer percutaneous radiofrequency ablation; however, oxycodone provides a better patient experience, lower postoperative pain, less respiratory depression and stable haemodynamic fluctuations.
Collapse
Affiliation(s)
- Jiangling Wang
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Xiaohong Yuan
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Wenjing Guo
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Xiaobin Xiang
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Qicheng Wu
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Man Fang
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Wen Zhang
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Zewu Ding
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Kangjie Xie
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Jun Fang
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Huidan Zhou
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| | - Shuang Fu
- Department of Anaesthesiology, Cancer Hospital of the University of Chinese Academy and Sciences. Zhejiang, Hangzhou, 310022, China
| |
Collapse
|