Transcript Cancer What, Why, Who,When….

Management of Cancer Pain
Prof. Dr. Başak Oyan-Uluç
Yeditepe Üniversitesi Hastanesi
Medikal Onkoloji Bölümü
Cancer pain
At diagnosis
During treatment
Advanced stage
% 20-50
% 30-40
%75-90
Physiological effects of Pain
• Decreased limb movement: increased risk of DVT/PE
• Respiratory effects: shallow breathing, tachypnea, cough
suppression resulting increased risk of pneumonia and
atelectasis
• Tachycardia and elevated blood pressure
• Increased catabolic demands: poor wound healing, weakness,
muscle breakdown
• Increased sodium and water retention (renal)
• Decreased gastrointestinal mobility
Psychological effects of Pain
• Negative emotions: anxiety, depression
• Sleep deprivation
• Existential suffering
• Patient questions the very foundations of their life:
whether their life has any meaning, purpose or value
Immunological effects of Pain
Decrease natural killer cell counts
Tolerance to chemotherapy decrease. infection
Cancer pain
Physiological effects
Psychological effects
Immunological effects
Decreased quality of life
Shorter survival
What Does Pain Mean to Patients?
• Poor prognosis or impending death
• Particularly when pain worsens
• Decreased autonomy
• Impaired physical and social function
• Decreased enjoyment and quality of life
• Challenges to dignity
• Threat of increased physical suffering
Causes of Cancer-Related Pain
• Tumor / Mass effect (70%)
• Bone metastases, soft tissue infiltration, nerve infiltration
• Treatment related (20%)
• Post-chemotherapy
• Post-radiation (mucositis, enteritis , etc)
• Post-surgical (mucositis, neuropathy, G-CSF related bone
pain, etc)
• Other (10%)
– Decubitis ulcers, constipation
– Postherpetikc neuralgia
Types of pain
• Somatic pain
• Visceral pain
• Neuropathic pain
Somatic Pain
• Generally described as musculoskeletal pain
• Dull, sometimes sharp
• Intermittent or continuous
• Well-localized: Because many nerves supply the
muscles, bones and other soft tissues, somatic pain
is usually easier to locate than visceral pain.
• Related to tumor / mass effect
• Example: Soft tissue infiltration, bone metastases
Patient with head and neck cancer:
Large right sided mass causing somatic pain
Visceral Pain
• Infiltration, compression, extension, or
stretching of the thoracic, abdominal, or pelvic
viscera
• Pressure, deep, squeezing, cramps
• Not well-localized or referred pain
• Intermittent or continuous
• Example: Intraabdominal metastases
Colorectal cancer with liver metastases:
Visceral pain
Neuropathic Pain
• Causes:
• Cancer compressing or infiltrating nerves/nerve
roots/blood supply to nerve
• Nerve damage from treatments
• Types:
• Dysestetic: Burning, “pins & needles”
• Ex: Postherpetic neuralgia
• Neuralgic: Sharp, shooting and paroxysmal pain along
the course of a nerve
• Ex: Trigeminal neuralgia
Neuropathic Pain
• Chemotherapy-induced neuropathies: symmetrical
polyneuropathy – localized in hands and feet
• Cisplatin, Oxaliplatin
• Paclitaxel, Thalidomide
• Vincristine, Vinblastine
• Surgical Neuropathies
• Phantom limb pain
• Post-mastectomy syndrome
• Post-thoracotomy syndrome
Most cancer pts have some sort of combination
of somatic, visceral pain and neuropathic pain
Patient with cervival
cancer
• Visceral pain due to
peritoneal carcinomatosis
• Somatic pain: Due to
vertebral metastasis
• Neuropathic pain from
nerve root involvement
Assessment of cancer pain
Assessment of Pain
• Pain history
•
Onset / duration
•
Severity of paiN
•
Site(s) of pain/radiation
•
Type of pain
• What aggravates or relieves pain?
• Impact on sleep, mood, activity
• Effectiveness of medication
Non-verbal signs of pain
• Autonomic changes
– Hypertension, tachycardia, sweating
• Patients with organic brain syndrome: Agitation or
confusion
• Patients with cognitive dysfunction: Apathy,
inactivity, irritability
– Refuse eating
– Avoidance of painful site
– Painful expression on face
Principles of Assessment
• A (Ask) Assess and REASSESS
• B (Believe) the patient and care-givers
• C (Choose) Use methods appropriate to cognitive status and
context
• D (Deliver)
• E (Empower) Include the family
Assessment of severity of pain
• Pain scales
– Numeric
– categoric
– Facial expression pictures
• Body maps
• Pain queries
MUST BE FİLLED BY THE PATIENT
TREATMENT
Aims of Cancer Pain treatment
MAXIMUM PAIN CONTROL
MINIMUM SIDE EFFECT
No pain at rest
No pain with activity
No interrruption of sleep due to pain
INCREASED QUALITY OF LIFE
Modalities of treatment
•
Pharmacological Management
•
Radiation / Nuclear Medicine
•
Non-Pharmacologic Management
•
Interventions
– Blocks
– Epidural or intratecal pain pumps
– Palliative surgery (ablative neurosurgery)
– Nerve Blocks
Pharmacological Treatment
Pharmacologic Management
• WHO Ladder
• Non-opioid therapy / Co-analgesics
• Opioids
Oral
By the clock
Step by step
(7-10)
(4-6)
(1-3)
WHO Ladder
4. Basamak:
Invasive modalities
Non-Opioids
 NSAIDS
 Acetaminophen (Paracetamol)
 Topicals
 Lidocaine, Capsaicin
 For mild pain
 Ceiling effect: increasing doses of a given medication to
have progressively smaller incremental effect
 Can be combined with opioids-> Opioid dose lower
 No tolerance and no addiction risk
 NSAID: Gastointestinal, renal and hematological side effects
Adjuvants
• Primary indication other than pain, but have some analgesic
properties in some painful conditions
• Usually coadministered with other analgesics
 Antidepressants
 Anticonvulsants
 Corticosteroids
 Neuroleptics
 Alpha2 – agonists
 Benzodiazepines
 Antispasmodics
 Muscle relaxants
 NMDA-blockers
 Systemic local
anesthetics
Adjuvants for special pain types
• Neuropathic pain: Antidepresants, Anticonvulsants,
GABA agonists, etc
• Bone pain: Osteoclast inhibitors (bisfosfonates),
radiopharmaceuticals, corticosteroids
• Musculoskeletal pain: Muscle relaxants
Opioids
Step 2 opioids
Codeine, Oxycodone, tramadol
Step 3 opioids
Oxycodone, morphine, fentanyl
 AVOID: Meperidine
 If pain constant/chronic – use long-acting opioids
with short-acting for breakthrough pain
Principles of analgesic treatment
• Patient –specifc treatment: Dose, route
• By clock: Analgesics should be administered at regular
intervals, not as needed
• Appropriate dose
• Consider renal and liver functions
• When changing to and other opioid or the route of adbministration, use “equal analgesic conversions” guides
• Avoid placebo
Principles of analgesic treatment
• Be aware of drug side effects and prevent side effects
• Monitor development of tolerance
• DO NOT USE MEPERİDİNE (Dolantin) for cancer pain
– Toxic metabolite is normeperidine –> highserum levels can cause
seizures
– Short-acting
Side effects of opioids
Physiological side effects
Toxic side effects
Sedation
Lethagy
Constipation
Hallusination
Nausea-vomiting
Myoclonik jerks
Urinary retention
Supression of respiration
Supression of cough
Tolerance to Nausea-vomitingand sedation: Early
Tolerance to constipation: Late
Success rate of Cancer pain Treatment
• Appropriate
•
•
•
•
Oral /Transdermal
Administer by clock
Step by step
Patient-specific
– Dose
– Route
– Dose interval
• Treatment of breakthrough
pain
• Treatment od side effects
Success rate>%80
Reasons for failure to relieve cancer pain
• Inadequate dose of opioids
– No ceiling dose for agonist opioids like morphine
– Only dose-limiting factor: Side effects
• In young patients, dose should be higher
Seminars in Oncology, Vol 27. No.1 February 2000: pp 45-63
Torkey
Mean: 0.0872
World: Rank number 44
EURO zone Rank number 33
Torkey
Mean: 0.1763
World: Rank number 106
EURO zone Rank number 42
Reason for inadequate doing of opioids?
• Physicians’ lack of information about opioids
• Patients’/Relatives’ lack of information about opioids
• Exaggeration of risks
• Side effects
• Risk of addiction
• Legal factors
Non-Pharmacologic Management
 Acupuncture
 Yoga
 Guided imagery
 Cold/heat
 Massage
 Vibration
 TENS units
 Exercise programs
 Hypnosis
 Music
 Pet therapy
Intervensions
Palliative surgery
Nerve Blocks
Kyphoplasty/Vertebroplasty
Epidural
Intrathecal pain pumps
Celiac Plexus Block
Kyphoplasty/Vertebroplasty
Intrathecal Pain Pumps
Conclusion
 Cancer pain can effect quality of life and mortality
 Ask the patient about pain and REASSESS!
 Choose non-opioid / adjuvants carefully paying close
attention to side effect profile
 Use WHO ladder guidelines when titrating pain medications
 Use long-acting opioids for chronic cancer pain
 Recognize “4th step” in WHO ladder and utilize your
multidisciplinary resources