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Gray NA, Horton JR, Dionne-Odom JN, Smith CB, Johnson KS. Update in Hospice and Palliative Care. J Palliat Med 2016; 19:559-65. [PMID: 27046735 DOI: 10.1089/jpm.2016.0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND/OBJECTIVE The goal of this update in hospice and palliative care is to summarize and critique research published between January 1 and December 31, 2014 that has a high potential for impact on clinical practice. DESIGN To identify articles we hand searched 22 leading journals, the Cochrane Database of Systematic Reviews, and Fast Article Critical Summaries for Clinicians in Palliative Care. We also performed a PubMed keyword search using the terms "hospice" and "palliative care." MEASUREMENTS We ranked candidate articles based on study quality, appeal to a breadth of palliative care clinicians, and potential for impact on clinical practice. RESULTS In this manuscript we have summarized the findings of eight articles with the highest ratings and make recommendations for clinical practice based on the strength of the resulting evidence.
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Affiliation(s)
- Nathan A Gray
- 1 Duke Palliative Care, Division of General Internal Medicine, Duke University School of Medicine , Durham, North Carolina
| | - Jay R Horton
- 2 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | | | - Cardinale B Smith
- 2 Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.,4 Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Kimberly S Johnson
- 1 Duke Palliative Care, Division of General Internal Medicine, Duke University School of Medicine , Durham, North Carolina.,5 Division of Geriatrics, Department of Medicine, Duke University School of Medicine , Durham, North Carolina.,6 Duke University Center for the Study of Aging and Human Development, Duke University , Durham, North Carolina.,7 Geriatrics Research, Education and Clinical Center, Veterans Affairs Medical Center , Durham, North Carolina
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Vayne-Bossert P, Afsharimani B, Good P, Gray P, Hardy J. Interventional options for the management of refractory cancer pain--what is the evidence? Support Care Cancer 2015; 24:1429-38. [PMID: 26660344 DOI: 10.1007/s00520-015-3047-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 11/29/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Pain is the most common symptom in cancer patients. Standard pain treatment according to the WHO three-step analgesic ladder provides effective pain management in approximately 70-90% of cancer patients. Refractory pain is defined as not responding to "standard" treatments. Interventional analgesic techniques can be used in an attempt to control refractory pain in patients in whom conventional analgesic strategies fail to provide effective pain relief or are intolerable due to severe adverse effects. This systematic review aims to provide the latest evidence on interventional refractory pain management in cancer patients. METHODS Systematic literature search in Cochrane, EMBASE and PubMed including reviews and randomised controlled trials (RCTs) and non-randomised controlled trials in the absence of reviews. RESULTS Neuraxial analgesia may play a role in refractory cancer pain management. Paravertebral blocks decrease the incidence of persistent post-surgical pain after breast cancer. Coeliac plexus blocks improve pain scores in refractory pancreatic cancer pain for up to 4 weeks after the intervention with fewer burdensome side effects as compared to opioids. Cordotomy has mainly been studied in mesothelioma, and the case series suggest possible benefit for pain at the expense of a relatively high risk of side effects. CONCLUSIONS Overall, very few RCTs have been conducted on interventional pain techniques. In reality, it is very difficult to undertake large controlled trials for a number of reasons. Therefore, today's best evidence for practice may be from large case series of comparable patients with careful response and toxicity evaluation and follow-up.
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Affiliation(s)
- Petra Vayne-Bossert
- Readaptation and Palliative Care, University Hospital of Geneva, Geneva, Switzerland.,Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia
| | - Banafsheh Afsharimani
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia
| | - Phillip Good
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia.,Palliative Care Services, St Vincent's Private Hospital Brisbane, Kangaroo Point, Australia
| | - Paul Gray
- School of Medicine, University of Queensland, St Lucia, Australia.,Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Australia
| | - Janet Hardy
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia. .,School of Medicine, University of Queensland, St Lucia, Australia.
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Affiliation(s)
- Eric E. Prommer
- Division of Hematology/Oncology, Veterans Integrated Palliative Care Program, Veterans Integrated Palliative Care, David Geffen School of Medicine, University of California, Los Angeles, California
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Pimentel CB, Briesacher BA, Gurwitz JH, Rosen AB, Pimentel MT, Lapane KL. Pain management in nursing home residents with cancer. J Am Geriatr Soc 2015; 63:633-41. [PMID: 25900481 DOI: 10.1111/jgs.13345] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess improvements in pain management of nursing home (NH) residents with cancer since the implementation of pain management quality indicators. DESIGN Cross-sectional. SETTING One thousand three hundred eighty-two U.S. NHs (N = 1,382). PARTICIPANTS Newly admitted, Medicare-eligible NH residents with cancer (N = 8,094). MEASUREMENTS Nationwide data on NH resident health from Minimum Data Set 2.0 linked to all-payer pharmacy dispensing records (February 2006-June 2007) were used to determine prevalence of pain, including frequency and intensity, and receipt of nonopioid and opioid analgesics. Multinomial logistic regression was used to evaluate resident-level correlates of pain and binomial logistic regression to identify correlates of untreated pain. RESULTS More than 65% of NH residents with cancer had any pain (28.3% daily, 37.3% <daily), 13.5% of whom had severe and 61.3% had moderate pain. Women; residents admitted from acute care or who were bedfast; and those with compromised activities of daily living, depressed mood, an indwelling catheter, or a terminal prognosis were more likely to have pain. More than 17% of residents in daily pain (95% confidence interval (CI) = 16.0-19.1%) received no analgesics, including 11.7% with daily severe pain (95% CI = 8.9-14.5%) and 16.9% with daily moderate pain (95% CI = 15.1-18.8%). Treatment was negatively associated with age of 85 and older (adjusted OR (aOR) = 0.67, 95% CI = 0.55-0.81 vs aged 65-74), cognitive impairment (aOR = 0.71, 95% CI = 0.61-0.82), presence of feeding tube (aOR = 0.77, 95% CI = 0.60-0.99), and restraints (aOR = 0.50, 95% CI = 0.31-0.82). CONCLUSION Untreated pain is still common in NH residents with cancer and persists despite pain management quality indicators.
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Affiliation(s)
- Camilla B Pimentel
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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Abstract
BACKGROUND This is an update of a review first published in The Cochrane Library in Issue 3, 2013. Cancer-related pain places a heavy burden on public health with related high expenditure. Severe pain is associated with a decreased quality of life in patients with cancer. A significant proportion of patients with cancer-related pain are under-treated. There is a need for more effective control of cancer-related pain. Spinal cord stimulation (SCS) may have a role in pain management. The effectiveness and safety of SCS for patients with cancer-related pain is currently unknown. OBJECTIVES This systematic review evaluated the effectiveness of SCS for cancer-related pain compared with standard care using conventional analgesic medication. We also appraised risk and potential adverse events associated with the use of SCS. SEARCH METHODS This is an update of a review first published in The Cochrane Library in Issue 3, 2013. The search strategy for the update was the same as in the original review. We searched the following bibliographic databases in order to identify relevant studies: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library; MEDLINE; EMBASE; and CBM (Chinese Biomedical Database) in October 2014. We also handsearched relevant journals. There were no language restrictions. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs) that directly compared SCS with other interventions with regards to the effectiveness of pain management. We also planned to include cross-over trials that compared SCS with another treatment. We planned to identify non-randomised controlled trials but these would only be included if no RCTs could be found. DATA COLLECTION AND ANALYSIS The literature search for the update of this review found 121 potentially eligible articles. The initial search strategy yielded 430 articles. By scrutinising titles and abstracts, we found 412 articles irrelevant to the analytical purpose of this systematic review due to different scopes of diseases or different methods of intervention (intrathecal infusion system; oral medication) or aims other than pain control (spinal cord function monitoring, bladder function restoration or amelioration of organ metabolism). The remaining 18 trials were reviewed as full manuscripts. No RCTs were identified. Fourteen sporadic case reports and review articles were excluded and four before-and-after case series studies (92 participants) were included. Two review authors independently selected the studies to be included in the review according to the prespecified eligibility criteria. A checklist for methodological quality of non-randomised controlled trials was used (STROBE checklist) and all review authors discussed and agreed on the inclusion of trials and the results of the quality assessment. MAIN RESULTS No new studies were identified for inclusion in this update of the review. Four before-and-after case series studies (a total of 92 participants) met our criteria for inclusion in the previous version of the review. All included trials adopted a visual analogue scale (VAS) to evaluate pain relief. Heterogeneity existed in terms of baseline characteristics, electrode and stimulator parameters, level of implantation and route of implantation; each trial reported data differently. In two trials, pain relief was achieved in 76% (48/63) of participants at the end of the follow-up period. In the third trial, pre-procedure VAS was 6 to 9 (mean 7.43 ); the one-month post-implant VAS was 2 to 4 (mean 3.07); the 12-month post-implant VAS was 1 to 3 (mean 2.67). In the fourth trial, the pre-procedure VAS was 6 to 9 (mean 7.07); 1 to 4 (mean 2.67) at one-month; 1 to 4 (mean 1.87) at 12 months. Analgesic use was largely reduced. The main adverse events were infection of sites of implantation, cerebrospinal fluid (CSF) leakage, pain at the sites of electrodes, dislodgement of the electrodes, and system failure; however, the incidence in participants with cancer could not be calculated. Since all trials were small, non-randomised controlled trials, they carried high or unclear risk of all types of bias. AUTHORS' CONCLUSIONS Since the first publication of this review, no new studies were identified. Current evidence is insufficient to establish the role of SCS in treating refractory cancer-related pain. Future randomised studies should focus on the implantation of SCS in participants with cancer-related pain.
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Affiliation(s)
- Lihua Peng
- The First Affiliated Hospital, Chongqing Medical UniversityThe Department of Anaesthesia and Pain MedicineNo 1 Youyi Road, Yuan‐jia‐gangYu‐zhong DistrictChongqingChina40016
| | - Su Min
- The First Affiliated Hospital, Chongqing Medical UniversityThe Department of Anaesthesia and Pain MedicineNo 1 Youyi Road, Yuan‐jia‐gangYu‐zhong DistrictChongqingChina40016
| | - Zhou Zejun
- The First Affiliated Hospital, Chongqing Medical UniversityThe Department of Anaesthesia and Pain MedicineNo 1 Youyi Road, Yuan‐jia‐gangYu‐zhong DistrictChongqingChina40016
| | - Ke Wei
- The First Affiliated Hospital, Chongqing Medical UniversityDepartment of Anaesthesia and Pain Medicine1# Youyi Road, Yuanjiangang CommunityYuzhong DistrictChongqingChina400016
| | - Michael I Bennett
- University of LeedsLeeds Institute of Health SciencesCharles Thackrah Building101 Clarendon RoadLeedsUKLS2 9LJ
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Kamdar MM, Doyle KP, Sequist LV, Rinehart TJ, Maytal G, Flores EJ, Mino-Kenudson M. Case records of the Massachusetts General Hospital. Case 17-2015. A 44-year-old woman with intractable pain due to metastatic lung cancer. N Engl J Med 2015; 372:2137-47. [PMID: 26017825 DOI: 10.1056/nejmcpc1404141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Minimally invasive palliative procedures in oncology: a review of a multidisciplinary collaboration. Support Care Cancer 2014; 23:1589-96. [PMID: 25412726 DOI: 10.1007/s00520-014-2509-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 11/10/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Minimally invasive palliative procedures (MIPPs) are sometimes considered step 4 of the World Health Organization's three-step ladder. A case conference has been created at the BC Cancer Agency to facilitate access to MIPPs for advanced cancer patients with severe pain not responding to conventional analgesics. The twice monthly conference discusses referrals for pain control procedures and reviews imaging, with palliative care, musculoskeletal interventional radiology, radiation oncology, medical oncology, and anesthesia experts in attendance. STUDY OBJECTIVES The aims of this study are: first, to determine the benefit to patients from the procedures recommended by the case conference, and second, to explore the impact of the case conference on clinical decision-making. METHODS A retrospective review of electronic charts of all cancer patients referred to the MIPP case conference between December 20, 2011 and June 25, 2013. RESULTS There were 103 referrals, resulting in 69 procedures performed among 63 patients. Over 80 % of procedures provided analgesic benefit. Pain scores fell across all categories post-procedure. Mean worst pain scores fell from 8.1 ± 1.4 to 4.6 ± 2.8 (P < 0.001). Patient function, mobility, and symptoms measured by the Edmonton Symptom Assessment System also improved post-procedure. At time of abstract submission, 37/63 (58.7 %) patients had died, and the mean survival post-procedure was 200 days. The documented rate of major adverse events attributable to MIPPs was 2/69 (2.9 %). CONCLUSIONS MIPPs are valuable treatment options in patients with severe cancer pain despite use of appropriate step 3 WHO ladder medications. The case conference facilitates excellent communication and sharing of expertise, ensuring optimal patient care.
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Honey CR, Yeomans W, Isaacs A, Honey CM. The Dying Art of Percutaneous Cordotomy in Canada. J Palliat Med 2014; 17:624-8. [DOI: 10.1089/jpm.2013.0664] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Gulati A, Joshi J, Baqai A. An overview of treatment strategies for cancer pain with a focus on interventional strategies and techniques. Pain Manag 2014; 2:569-80. [PMID: 24645889 DOI: 10.2217/pmt.12.61] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY As the incidence of cancer increases, considerations for pain treatments become more important and varied. While traditional views on pain therapy are successful in treating the majority of cancer-related pain, a continuum has developed to include interventional strategies in addition to pharmacologic management. Further improvements in understanding anatomy in the context of imaging and pathophysiology of cancer-pain syndromes direct our current interventional pain management options. We discuss the current interventional treatment options regularly used in the cancer-pain population.
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Affiliation(s)
- Amitabh Gulati
- Department of Anesthesiology & Critical Care, Board Certified in Anesthesiology & Pain Management, Memorial Sloan Kettering Cancer Center, M308, New York, NY, 10065, USA.
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Smyth CE, Jarvis V, Poulin P. Brief review: Neuraxial analgesia in refractory malignant pain. Can J Anaesth 2014; 61:141-53. [PMID: 24233771 DOI: 10.1007/s12630-013-0075-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/31/2013] [Indexed: 11/30/2022] Open
Abstract
PURPOSE This narrative review aims to inform health care practitioners of the current literature surrounding the use of intrathecal (IT) and epidural analgesia in cancer patients with refractory pain at end of life. Topics discussed and reviewed include: patient selection, treatment planning, procedure, equipment, medications, complications, policies and procedures, as well as directions for future research. PRINCIPAL FINDINGS Cancer pain is inadequately treated in an estimated 10% of patients with malignant pain despite the implementation of the World Health Organization three-step analgesic ladder. This has prompted some to advocate for the addition of a fourth step that would include neuraxial interventions. There is moderate evidence supporting the safety and efficacy of IT drug therapy in cancer patients with refractory pain. A detailed assessment and interdisciplinary team approach is necessary to develop and implement care plans for patients requiring neuraxial analgesia. Neuraxial analgesia can significantly improve pain and reduce side effects, but this must be balanced against the increased complexity of care and the risk of uncommon but serious complications. CONCLUSION Neuraxial drug delivery gives clinicians more options to manage refractory pain at end of life and should be offered to patients with intractable cancer pain. Teams should be interprofessional with clear delineation of roles and responsibilities. They should discuss advanced discharge planning with the patient prior to implantation as well as provide on-call support.
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61
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Burton AW, Hamid B. Current challenges in cancer pain management: does the WHO ladder approach still have relevance? Expert Rev Anticancer Ther 2014; 7:1501-2. [DOI: 10.1586/14737140.7.11.1501] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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62
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Fielding F, Sanford TM, Davis MP. Achieving effective control in cancer pain: a review of current guidelines. Int J Palliat Nurs 2013; 19:584-91. [DOI: 10.12968/ijpn.2013.19.12.584] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Flannery Fielding
- Cleveland Clinic, Taussig Cancer Institute, and Cleveland Clinic, The Harry R. Horvitz Center for Palliative Medicine, and Case Western Reserve University, School of Nursing, Cleveland, Ohio, USA
| | - Tanya M Sanford
- Cleveland Clinic, Taussig Cancer Institute, and Cleveland Clinic, Harry R. Horvitz Center for Palliative Medicine
| | - Mellar P Davis
- Cleveland Clinic, Taussig Cancer Institute, Cleveland Clinic, Harry R. Horvitz Center for Palliative Medicine, and Cleveland Clinic, Lerner School of Medicine, Case Western Reserve University
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Abstract
BACKGROUND Cancer-related pain places a heavy burden on public health with related high expenditure. Severe pain is associated with a decreased quality of life in patients with cancer. A significant proportion of patients with cancer-related pain are under-treated.There is a need for more effective control of cancer-related pain. Spinal cord stimulation (SCS) may have a role in pain management. The effectiveness and safety of SCS for patients with cancer-related pain is currently unknown. OBJECTIVES This systematic review evaluated the effectiveness of SCS for cancer-related pain compared with standard care using conventional analgesic medication. We also appraised risk and potential adverse events associated with the use of SCS. SEARCH METHODS We searched the following bibliographic databases in order to identify relevant studies: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Libary (from inception to 2012, Issue 6); MEDLINE; EMBASE; and CBM (Chinese Biomedical Database) (from inception to July, 2012). We also handsearched relevant journals. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs) that directly compared SCS with other interventions with regards to the effectiveness of pain management. We also planned to include cross-over trials that compared SCS with another treatment. We planned to identify non-randomised controlled trials but these would only be included if no RCTs could be found. DATA COLLECTION AND ANALYSIS The initial search strategy yielded 430 articles. By scrutinising titles and abstracts, we found 412 articles irrelevant to the analytical purpose of this systematic review due to different scopes of diseases or different methods of intervention (intrathecal infusion system; oral medication) or aims other than pain control (spinal cord function monitoring, bladder function restoration or amelioration of organ metabolism). The remaining 18 trials were reviewed as full manuscripts. No RCTs were identified. Fourteen sporadic case reports and review articles were excluded and four before-and-after case series studies (92 participants) were included. Two review authors independently selected the studies to be included in the review according to the pre-specified eligibility criteria. A checklist for methodological quality of non-randomised controlled trials was used (STROBE checklist) and all review authors discussed and agreed on the inclusion of trials and the results of the quality assessment. MAIN RESULTS Four before-and-after case series studies (a total of 92 participants) met our criteria for inclusion. All included trials adopted a visual analogue scale (VAS) to evaluate pain relief. Heterogeneity existed in terms of baseline characteristics, electrode and stimulator parameters, level of implantation and route of implantation; data reporting was different among all trials. In two trials, pain relief was achieved in 76% (48/63) of patients at the end of the follow-up period. In the third trial, pre-procedure VAS was 6 to 9 (mean 7.43 ); the one-month post-implant VAS was 2 to 4 (mean 3.07); the 12-month post-implant VAS was 1 to 3 (mean 2.67). In the fourth trial, the pre-procedure VAS was 6 to 9 (mean 7.07); 1 to 4 (mean 2.67) at one-month; 1 to 4 (mean 1.87) at 12 months. Analgesic use was largely reduced. The main adverse events were infection of sites of implantation, cerebrospinal fluid (CSF) leakage, pain at the sites of electrodes, dislodgement of the electrodes and system failure, however, the incidence in patients with cancer could not be calculated. Since all trials were non-randomised controlled trials, they carried risk of all types of bias. AUTHORS' CONCLUSIONS Current evidence is insufficient to establish the role of SCS in treating refractory cancer-related pain. Future randomised studies should focus on the implantation of SCS in patients with cancer-related pain.
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Affiliation(s)
- Peng Lihua
- The First Affiliated Hospital, Chongqing Medical University, Chongqing Municipanity, China.
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Abstract
BACKGROUND Metastatic bone disease is a common cause of pain in cancer patients. A multidisciplinary approach to treatment is often necessary because simplified analgesic regimens may fail in the face of complex pain generators, especially those involved in the genesis of neuropathic pain. From the origins of formalized guidelines by the World Health Organization (WHO) to recent developments in implantable therapies, great strides have been made to meet the needs of these patients. METHODS The authors review the existing literature on the pathophysiology and treatment options for pain generated by metastatic bone disease and summarize classic and new approaches. RESULTS Relatively recent animal models of malignant bone disease have allowed a better understanding of the intimate mechanisms involved in the genesis of pain, resulting in a mechanistic approach to its treatment. Analgesic strategies can be developed with specific targets in mind to complement the classic, opioid-centered WHO analgesic ladder obtaining improved outcomes and quality of life. Unfortunately, high-quality evidence is difficult to produce in pain medicine, and these concepts are evolving slowly. CONCLUSIONS Treatment options are expanding for the challenging clinical problem of painful metastatic bone disease. Efforts are concentrated on developing alternative nonopioid approaches that appear to increase the success rate and improve patients' quality of life.
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Affiliation(s)
- S Buga
- Psychosocial and Palliative Care Program (BS) and the Anesthesiology Program (JES) at the H. Lee Moffi tt Cancer Center and Research Institute, Tampa, Florida, USA
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Burgoyne LL, Pereiras LA, Bertani LA, Kaddoum RN, Neel M, Faughnan LG, Anghelescu DL. Long-term use of nerve block catheters in paediatric patients with cancer related pathologic fractures. Anaesth Intensive Care 2012; 40:710-3. [PMID: 22813501 DOI: 10.1177/0310057x1204000419] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report three cases of children with osteosarcoma and pathologic fractures treated with long-term continuous nerve blocks for preoperative pain control. One patient with a left distal femoral diaphysis fracture had a femoral continuous nerve block catheter for 41 days without complications. Another with a fractured left proximal femoral shaft had three femoral continuous nerve block catheters for 33, 26 and 22 days respectively. The third patient, whose right proximal humerus was fractured, had a brachial plexus continuous nerve block catheter for 36 days without complication. In our experience, prolonged use of continuous nerve block is safe and effective in children with pathologic fractures for preoperative pain control.
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Affiliation(s)
- L L Burgoyne
- Division of Anesthesia and Pain Management Service, St Jude Children's Research Hospital, Memphis, TN, USA
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66
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Take an individualized approach when managing pain in the elderly at the end of life. DRUGS & THERAPY PERSPECTIVES 2012. [DOI: 10.1007/bf03262120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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McHugh ME, Miller-Saultz D, Wuhrman E, Kosharskyy B. Interventional pain management in the palliative care patient. Int J Palliat Nurs 2012; 18:426-8, 430-3. [DOI: 10.12968/ijpn.2012.18.9.426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marlene E McHugh
- Palliative Care Service, Montefiore Medical Center, and Assistant Professor of Clinical Nursing, Columbia University Medical Center (CUMC), New York, NY 10032, USA
| | - Debbie Miller-Saultz
- Beth Israel Medical Center, Adjunct Professor of Nursing, City University of New York, and Assistant Clinical Professor of Nursing, CUMC
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&NA;. Take an individualized approach when managing pain in the elderly at the end of life. DRUGS & THERAPY PERSPECTIVES 2012. [DOI: 10.2165/11209790-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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70
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Hurlow A, Bennett MI, Robb KA, Johnson MI, Simpson KH, Oxberry SG. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database Syst Rev 2012; 2012:CD006276. [PMID: 22419313 PMCID: PMC6669272 DOI: 10.1002/14651858.cd006276.pub3] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cancer-related pain is complex and multi-dimensional but the mainstay of cancer pain management has predominantly used a biomedical approach. There is a need for non-pharmacological and innovative approaches. Transcutaneous Electric Nerve Stimulation (TENS) may have a role in pain management but the effectiveness of TENS is currently unknown. This is an update of the original review published in Issue 3, 2008. OBJECTIVES The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. SEARCH METHODS The initial review searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED and PEDRO databases in April 2008. We performed an updated search of CENTRAL, MEDLINE, EMBASE, CINAHL and PEDRO databases in November 2011. SELECTION CRITERIA We included only randomised controlled trials (RCTS) investigating the use of TENS for the management of cancer-related pain in adults. DATA COLLECTION AND ANALYSIS The search strategy identified a further two studies for possible inclusion. One of the review authors screened each abstract using a study eligibility tool. Where eligibility could not be determined, a second author assessed the full paper. One author used a standardised data extraction sheet to collect information on the studies and independently assess the quality of the studies using the validated five-point Oxford Quality Scale. The small sample sizes and differences in patient study populations of the three included studies (two from the original review and a third included in this update) prevented meta-analysis. For the original review the search strategy identified 37 possible published studies; we divided these between two pairs of review authors who decided on study selection; all four review authors discussed and agreed final scores. MAIN RESULTS Only one additional RCT met the eligibility criteria (24 participants) for this updated review. Although this was a feasibility study, not designed to investigate intervention effect, it suggested that TENS may improve bone pain on movement in a cancer population. The initial review identified two RCTs (64 participants) therefore this review now includes a total of three RCTs (88 participants). These studies were heterogenous with respect to study population, sample size, study design, methodological quality, mode of TENS, treatment duration, method of administration and outcome measures used. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-type TENS and sham in palliative care patients; this study was underpowered. AUTHORS' CONCLUSIONS Despite the one additional RCT, the results of this updated systematic review remain inconclusive due to a lack of suitable RCTs. Large multi-centre RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.
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Affiliation(s)
- Adam Hurlow
- Palliative Care Team, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Hurlow A, Bennett MI, Robb KA, Johnson MI, Simpson KH, Oxberry SG. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [PMID: 22419313 DOI: 10.1002/14651858.cd006276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cancer-related pain is complex and multi-dimensional but the mainstay of cancer pain management has predominantly used a biomedical approach. There is a need for non-pharmacological and innovative approaches. Transcutaneous Electric Nerve Stimulation (TENS) may have a role in pain management but the effectiveness of TENS is currently unknown. This is an update of the original review published in Issue 3, 2008. OBJECTIVES The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. SEARCH METHODS The initial review searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED and PEDRO databases in April 2008. We performed an updated search of CENTRAL, MEDLINE, EMBASE, CINAHL and PEDRO databases in November 2011. SELECTION CRITERIA We included only randomised controlled trials (RCTS) investigating the use of TENS for the management of cancer-related pain in adults. DATA COLLECTION AND ANALYSIS The search strategy identified a further two studies for possible inclusion. One of the review authors screened each abstract using a study eligibility tool. Where eligibility could not be determined, a second author assessed the full paper. One author used a standardised data extraction sheet to collect information on the studies and independently assess the quality of the studies using the validated five-point Oxford Quality Scale. The small sample sizes and differences in patient study populations of the three included studies (two from the original review and a third included in this update) prevented meta-analysis. For the original review the search strategy identified 37 possible published studies; we divided these between two pairs of review authors who decided on study selection; all four review authors discussed and agreed final scores. MAIN RESULTS Only one additional RCT met the eligibility criteria (24 participants) for this updated review. Although this was a feasibility study, not designed to investigate intervention effect, it suggested that TENS may improve bone pain on movement in a cancer population. The initial review identified two RCTs (64 participants) therefore this review now includes a total of three RCTs (88 participants). These studies were heterogenous with respect to study population, sample size, study design, methodological quality, mode of TENS, treatment duration, method of administration and outcome measures used. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-type TENS and sham in palliative care patients; this study was underpowered. AUTHORS' CONCLUSIONS Despite the one additional RCT, the results of this updated systematic review remain inconclusive due to a lack of suitable RCTs. Large multi-centre RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.
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Affiliation(s)
- Adam Hurlow
- Palliative Care Team, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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72
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Prostate cancer pain management: EAU guidelines on pain management. World J Urol 2012; 30:677-86. [PMID: 22318612 DOI: 10.1007/s00345-012-0825-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Accepted: 01/04/2012] [Indexed: 12/16/2022] Open
Abstract
CONTEXT The first publication of the European Association of Urology (EAU) guidelines on Pain Management in Urology dates back to 2003. Since then, these guidelines have been revised several times with the most recent update achieved in 2010. OBJECTIVE Given the scope of the full text guidelines, condensing the entire document was no option in this context. This paper presents a summary of the section of pain management in prostate cancer, a topic considered of direct relevance for the practicing urologist. EVIDENCE ACQUISITION A multidisciplinary expert panel (urologists, anaesthesiologists, radio-oncologists) compiled this document based on a comprehensive consultation of the literature. Data were identified through a structured search, covering the time frame 2000 through 2010, using Medline and Embase as well as the Cochrane Library of systematic reviews. The scientific papers were weighed by the expert panel and a level of evidence (LE) assigned. Recommendations have been graded as a means to provide transparency between the underlying evidence and the guidance provided. Pain can occur in each stage of prostate cancer. It could be caused by the cancer itself (77%), be related to the cancer treatment (19%) or be unrelated to either (3%). The incidence of pain rises to 90% as patients enter the terminal phase of their illness. The physician's task is to discover and treat the cause of pain and the pain itself, to determine whether or not the underlying cause is treatable, to provide pain relief and palliative care. These tasks more often than not require a multidisciplinary team. Pain management involves mainly pharmacotherapy, including direct anticancer therapy such as androgen deprivation and chemotherapy, as well as analgetics, for instance non-steroidal anti-inflammatory drugs (NSAIDs) or opioids. In case of local impairment due to the cancer or its metastases, primary treatments like surgery, radiotherapy or radionuclides can provide adequate pain relief. In addition, in palliative care, functional, psychosocial and spiritual support are essential components. The EAU guidelines on Pain Management in Urology are available in a number of different formats through the EAU Central Office and the EAU website ( http://www.uroweb.org/guidelines/online-guidelines/ ). CONCLUSION The mainstay of pain management in prostate cancer is involvement of and collaboration between experts from a number of disciplines to be able to achieve a complete pain evaluation and to offer the full range of treatment options. Prostate cancer-related pain can, in most cases, be managed effectively, but it requires careful monitoring where a balance should be found between pain relief and potential side effects of treatment and quality of life (QoL).
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Rana S, Gupta R, Chaudhary P, Khurana D, Mishra S, Bhatnagar S. Cancer pain management: basic information for the young pain physicians. Indian J Palliat Care 2011; 17:127-30. [PMID: 21976852 PMCID: PMC3183601 DOI: 10.4103/0973-1075.84533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cancer pain is multifactorial and complex. The impact of cancer pain is devastating, with increased morbidity and poor quality of life, if not treated adequately. Cancer pain management is a challenging task both due to disease process as well as a consequence of treatment-related side-effects. Optimization of analgesia with oral opioids, adjuvant analgesics, and advanced pain management techniques is the key to success for cancer pain. Early access of oral opioid and interventional pain management techniques can overcome the barriers of cancer pain, with improved quality of life. With timely and proper anticancer therapy, opioids, nerve blocks, and other non-invasive techniques like psychosocial care, satisfactory pain relief can be achieved in most of the patients. Although the WHO Analgesic Ladder is effective for more than 80% cancer pain, addition of appropriate adjuvant drugs along with early intervention is needed for improved Quality of Life. Effective cancer pain treatment requires a holistic approach with timely assessment, measurement of pain, pathophysiology involved in causing particular type of pain, and understanding of drugs to relieve pain with timely inclusion of intervention. Careful evaluation of psychosocial and mental components with good communication is necessary. Barriers to cancer pain management should be overcome with an interdisciplinary approach aiming to provide adequate analgesia with minimal side-effects. Management of cancer pain should comprise not only a physical component but also psychosocial and mental components and social need of the patient. With risk–benefit analysis, interventional techniques should be included in an early stage of pain treatment. This article summarizes the need for early and effective pain management strategies, awareness regarding pain control, and barriers of cancer pain.
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Affiliation(s)
- Sps Rana
- Department of Unit of Anaesthesiology (IRCH), Dr. BRA IRCH, AIIMS, New Delhi, India
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75
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Dixmérias F, Palussière J. [Management of painful bone metastases]. ACTA ACUST UNITED AC 2011; 92:796-800. [PMID: 21944238 DOI: 10.1016/j.jradio.2011.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 11/30/2022]
Abstract
Bone metastases are frequently symptomatic. The pain is specific due to its pathophysiology, characteristics and treatment. Conventional antalgic pain management may be insufficient and management should be multifacetted, global and multidisciplinary. Interventional radiology procedures widen the range of possible antalgic therapies. Their role in the management of patients should be defined by a multidisciplinary team on a case-by-case review, based on the patient's symptoms and fracture risk. Additional scientific validation of the effectiveness of such therapies is needed. Recommendations on the role of interventional radiology procedures in the management of patients with symptomatic bone metastases are needed to standardize the different practices and increase the role of interventional radiology in the management of symptomatic bone metastases at the national level. Implementation of the cancer 2009-2012 project could facilitate the availability of these therapies to patients with cancer pain.
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Affiliation(s)
- F Dixmérias
- Unité de traitement des douleurs en cancérologie, département d'anesthésie-réanimation, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
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Gogia V, Chaudhary P, Ahmed A, Khurana D, Mishra S, Bhatnagar S. Intrathecal morphine pump for neuropathic cancer pain: a case report. Am J Hosp Palliat Care 2011; 29:409-11. [PMID: 21868426 DOI: 10.1177/1049909111419650] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The WHO ladder has been the most widely used approach for management of Cancer Pain. However, oral medications alone may be inadequate, particularly in difficult to treat cancer pain syndromes. Neuropathic pain is one of these refractory syndromes. The role of opioids has always been controversial in pain of neuropathic origin. We report a case of a 61 year old female patient with endometrial carcinoma suffering from severe neuropathic pain in her left lower limb. The pain was refractory to highest tolerable doses of oral morphine and neuromodulator drugs, viz. gabapentin and pregabalin. We managed the patient successfully with intrathecal morphine pump reducing the total morphine dose and improving patient comfort and satisfaction. Intrathecal delivery of Morphine ensured better efficacy with fewer side effects.
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Affiliation(s)
- Vikas Gogia
- Department of Anaesthesia, Pain and Palliative Care, IRCH, AIIMS, New Delhi, India
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77
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de Courcy J. Interventional Techniques for Cancer Pain Management. Clin Oncol (R Coll Radiol) 2011; 23:407-17. [DOI: 10.1016/j.clon.2011.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 12/13/2010] [Accepted: 04/05/2011] [Indexed: 12/11/2022]
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Bhatnagar S. Interventional pain management: need of the hour for cancer pain patients. Indian J Palliat Care 2011; 15:93-4. [PMID: 20668584 PMCID: PMC2902122 DOI: 10.4103/0973-1075.58451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sushma Bhatnagar
- Editor, IJPC, Associate Prof. and Head Anesthesiology, Department of Anesthesiology, Pain and Palliative Care, Dr. B.R. Ambedkar, IRCH, AIIMS, New Delhi, India E-mail:
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Dupoiron D, Lefebvre-kuntz D, Brenet O, de Bourmont S, Grelon F, Dixmeria F, Buisset N, Lebrec N, Bore F, Monnin D. Douleur chronique cancéreuse et analgésie intrathécale : expérience de trois centres de lutte contre le cancer. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.douler.2011.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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80
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Watanabe A, Yamakage M. Intrathecal neurolytic block in a patient with refractory cancer pain. J Anesth 2011; 25:603-5. [PMID: 21479833 DOI: 10.1007/s00540-011-1141-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 03/24/2011] [Indexed: 11/26/2022]
Abstract
We report the successful treatment of refractory cancer pain by bilateral intrathecal neurolysis using phenol-glycerol. A 60-year-old man had recurrent sigmoid cancer and metastases to the lumbar (L4-5) and sacral bones. He complained of refractory pain in the lower back and lower extremities despite high-dose opioid treatment based on the WHO ladder. On admission to our hospital, he received continuous intravenous infusion of morphine (7,000 mg/day) with ketamine (300 mg/day) and lidocaine (700 mg/day). Intravenous midazolam was required to treat extreme anxiety. Because of inadequate pain relief and severe drowsiness, intrathecal phenol-glycerol neurolytic block was performed twice at the L2/3 intervertebral space. His analgesia was greatly improved and high-dose intravenous opioid was retitrated and ceased. He remained comfortable and lucid at home for 2 months, until 2 days before his death at hospital. Intrathecal neurolytic block may be appropriate for some patients suffering from refractory pain that is resistant to conventional opioid analgesic treatment.
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Affiliation(s)
- Akihiko Watanabe
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan.
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81
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Lovrincevic M, Lema MJ, Hsu BH. Postmastectomy Pain. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00081-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Tay W, Ho KY. The Role of Interventional Therapies in Cancer Pain Management. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n11p989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.
Key words: Intractable pain, Intrathecal analgesia, Neurolysis
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85
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Robb K, Oxberry SG, Bennett MI, Johnson MI, Simpson KH, Searle RD. A cochrane systematic review of transcutaneous electrical nerve stimulation for cancer pain. J Pain Symptom Manage 2009; 37:746-53. [PMID: 18790600 DOI: 10.1016/j.jpainsymman.2008.03.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 03/13/2008] [Accepted: 04/03/2008] [Indexed: 11/30/2022]
Abstract
Cancer-related pain is complex and multi-dimensional; yet, the mainstay of cancer pain management has been the biomedical approach. There is a need for nonpharmacological and innovative pain management strategies. Transcutaneous electrical nerve stimulation (TENS) may have a role. The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, and PEDro databases were searched for randomized controlled trials (RCTs) investigating the use of TENS for the management of cancer-related pain in adults. Once relevant studies were identified, two pairs of reviewers assessed eligibility for inclusion in the review based on a study eligibility form and using the 5-point Oxford Quality Scale. Two RCTs met the study eligibility criteria (these involved 64 patients). These studies were heterogeneous with respect to study population, methodology, and outcome measures. This prevented meta-analysis. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-like TENS (AL-TENS) and sham in palliative care patients; this study was significantly underpowered. There is insufficient available evidence to determine the effectiveness of TENS in treating cancer-related pain. Further research is needed to help guide clinical practice, and large multi-center RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.
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Affiliation(s)
- Karen Robb
- St. Bartholomew's Hospital, London, United Kingdom
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86
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O S, Ha SM, Cheong YK. Spinal cord stimulation in a patient with pain in both legs due to spinal metastasis of lung cancer - A case report -. Korean J Anesthesiol 2009; 56:349-352. [DOI: 10.4097/kjae.2009.56.3.349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Seri O
- Department of Oral and Maxillofacial Surgery, Daejeon Dental Hospital, College of Dentistry, Wonkwang University, Daejeon, Korea
| | - Soo Mi Ha
- Department of Anesthesiology and Pain Medicine, School of Medicine, Wonkwang University, Iksan, Korea
| | - Yong Kwan Cheong
- Department of Anesthesiology and Pain Medicine, School of Medicine, Wonkwang University, Iksan, Korea
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Abstract
Cancer pain is prevalent and often multifactorial. For a segment of the cancer pain population, pain control remains inadequate despite full compliance with the WHO analgesic guidelines including use of co-analgesics. The failure to obtain acceptable pain or symptom relief prompted the inclusion of a fourth step to the WHO analgesic ladder, which includes advanced interventional approaches. Interventional pain-relieving therapies can be indispensable allies in the quest for pain reduction among cancer patients suffering from refractory pain. There are a variety of techniques used by interventional pain physicians, which may be grossly divided into modalities affecting the spinal canal (e.g., intrathecal or epidural space), called neuraxial techniques and those that target individual nerves or nerve bundles, termed neurolytic techniques. An array of intrathecal medications are infused into the cerebrospinal fluid in an attempt to relieve refractory cancer pain, reduce disabling adverse effects of systemic analgesics, and promote a higher quality of life. These intrathecal medications include opioids, local anesthetics, clonidine, and ziconotide. Intrathecal and epidural infusions can serve as useful methods of delivering analgesics quickly and safely. Spinal delivery of drugs for the treatment of chronic pain by means of an implantable drug delivery system (IDDS) began in the 1980s. Both intrathecal and epidural neurolysis can be effective in managing intractable cancer-related pain. There are several sites for neurolytic blockade of the sympathetic nervous system for the treatment of cancer pain. The more common sites include the celiac plexus, superior hypogastric plexus, and ganglion impar. Today, interventional pain-relieving approaches should be considered a critical component of a multifaceted therapeutic program of cancer pain relief.
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Affiliation(s)
- Paul J Christo
- Department of Anesthesiology & Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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88
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Halpert D, Erdek MA. Pain Management for Hepatobiliary Cancer. Curr Treat Options Oncol 2008; 9:234-41. [DOI: 10.1007/s11864-008-0069-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 07/28/2008] [Indexed: 01/29/2023]
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89
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Anselmetti GC, Manca A, Ortega C, Grignani G, DeBernardi F, Regge D. Treatment of Extraspinal Painful Bone Metastases with Percutaneous Cementoplasty: A Prospective Study of 50 Patients. Cardiovasc Intervent Radiol 2008; 31:1165-73. [DOI: 10.1007/s00270-008-9396-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2007] [Revised: 04/05/2008] [Accepted: 06/24/2008] [Indexed: 10/21/2022]
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90
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Robb KA, Bennett MI, Johnson MI, Simpson KJ, Oxberry SG. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database Syst Rev 2008:CD006276. [PMID: 18646140 DOI: 10.1002/14651858.cd006276.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cancer-related pain is complex and multi-dimensional but the mainstay of cancer pain management has predominately used a biomedical approach. There is a need for non-pharmacological and innovative approaches. Transcutaneous Electric Nerve Stimulation (TENS) may have a role for a significant number of patients but the effectiveness of TENS is currently unknown. OBJECTIVES The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. SEARCH STRATEGY We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED and PEDRO databases (11/04/08). SELECTION CRITERIA Only randomised controlled trials (RCTS) investigating the use of TENS for the management of cancer-related pain in adults were included. DATA COLLECTION AND ANALYSIS The search strategy identified 37 possible published studies which were divided between two pairs of review authors that decided on study selection. A study eligibility form was used to screen each abstract and where study eligibility could not be determined from the abstract, the full paper was obtained and assessed by one pair of review authors. A standardised data extraction sheet was used to collect information on the studies and the quality of the studies was assessed independently by two review authors using the validated five-point Oxford Quality Scale. Final scores were discussed and agreed between all four review authors. The small sample sizes and differences in patient study populations of the two included studies prevented meta-analysis. MAIN RESULTS Only two RCTs met the eligibility criteria (64 participants). These studies were heterogenous with respect to study population, sample size, study design, methodological quality, mode of TENS, treatment duration, method of administration and outcome measures used. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-type TENS and sham in palliative care patients; this study was underpowered. AUTHORS' CONCLUSIONS The results of this systematic review are inconclusive due to a lack of suitable RCTs. Large multi-centre RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.
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Affiliation(s)
- Karen A Robb
- Physiotherapy Department, Bart's Hospital, Kenton and Lucas Block, West Smithfield, London, UK, EC1A 7BE.
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91
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Postmastectomy Pain. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50080-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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92
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Azevedo São Leão Ferreira K, Kimura M, Jacobsen Teixeira M. The WHO analgesic ladder for cancer pain control, twenty years of use. How much pain relief does one get from using it? Support Care Cancer 2006; 14:1086-93. [PMID: 16761128 DOI: 10.1007/s00520-006-0086-x] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Accepted: 05/02/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Pain is a major problem in the treatment of patients with cancer. This article reviews studies concerning evaluation of patients with cancer pain treated according to The World Health Organization (WHO) analgesic ladder. MATERIALS AND METHODS Systematic search of PUBMED, MEDLINE, EMBASE, LILACS, BDENF, and OVID and a hand search of reference lists and textbooks from 1982 to 2004 were performed. RESULT Analgesia was considered adequate in 45 to 100% of patients analyzed in the studies. CONCLUSION However, the evidence that they provide is insufficient to grant the effectiveness of the WHO guidelines because a controlled clinical trial of this intervention has never been published.
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Waara-Wolleat KL, Hildebrand KR, Stewart GR. A Review of Intrathecal Fentanyl and Sufentanil for the Treatment of Chronic Pain. PAIN MEDICINE 2006; 7:251-9. [PMID: 16712626 DOI: 10.1111/j.1526-4637.2006.00155.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Intrathecal infusion of morphine using implantable pumps is an accepted practice for long-term management of chronic pain. Despite clinical benefit, development of tolerance and side-effects associated with intrathecal morphine has prompted investigators to explore alternative opioids such as the potent anilinopiperidine analogs, fentanyl, and sufentanil. Relevant preclinical and clinical literature from the MEDLINE database was used primarily for this review. In vitro, both compounds are stable in solution, but studies have not been conducted using implantable pumps under simulated use conditions (e.g., long-term stability at body temperature). Preclinical studies of limited duration have demonstrated efficacy, but safety-toxicology studies have been limited to intermittent boluses of sufentanil only. Few clinical reports on the use of intrathecal sufentanil or fentanyl for chronic pain are available. Although results confirm potency and efficacy with intrathecal administration, further studies are needed to support the long-term use of either opioid in chronic pain management.
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94
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Abstract
Since the establishment of the WHO three-step ladder for management of cancer pain, several controversies have arisen, which are partly due to new drug development, reformulations of older analgesics, and technological advancements. As a result, clinicians need clarification of several questions. Is morphine the opioid of choice for moderate to severe pain in cancer? Should combinations of opioids be used? When should spinal opioids be used to treat pain in cancer? What are the appropriate opioid doses for breakthrough pain? Should selective cyclo-oxygenase (COX) 2 inhibitors be used? What is the best tactic to treat neuropathic pain, and what first-line adjuvant analgesic should be used? And do bisphosphonates relieve bone pain in cancers other than breast cancer and myeloma? This review addresses these questions.
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Affiliation(s)
- Mellar P Davis
- Harry R Horvitz Center for Palliative Medicine, Cleveland Clinic Taussig Cancer Center, 9500 Euclid Avenue, R35, Cleveland, OH 44195, USA.
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de Oliveira R, dos Reis MP, Prado WA. The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain. Pain 2004; 110:400-8. [PMID: 15275792 DOI: 10.1016/j.pain.2004.04.023] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2004] [Revised: 04/06/2004] [Accepted: 04/12/2004] [Indexed: 12/19/2022]
Abstract
Neurolytic sympathetic plexus block (NSPB) has been proposed to prevent the development of pain and improve the quality of life of patients with cancer, thus questioning the WHO protocol that proposes the use of invasive methods only as a final resort. This study evaluates the pain relief, opioid consumption and quality of life provided by the use of NSPB in two different phases of cancer pain and compares them with that provided by pharmacological therapy only. Sixty patients with abdominal or pelvic cancer pain were divided into three groups and observed for 8 weeks. In group I, neurolytic celiac (NCPB) or superior hypogastric plexus block (SHPB), or lumbar sympathetic ganglion chain block (LSGCB) was performed with alcohol in patients using NSAID and a weak oral opioid or morphine (dose</=90 mg/day) and reporting VAS>/=4. In group II, NCPB, SHPB or LSGCB were performed on patients using NSAID and morphine (dose>/=90 mg/day) and reporting VAS>/=4. The patients of group III received pharmacological therapy only. The patients of groups I and II had a significant reduction of pain (P < 0.004), opioid consumption (P < 0.02) and a better quality of life (P < 0.006) than those of group III, but no significant differences between groups I and II were seen in these aspects. Opioid-related adverse effects were significantly greater in group III (P < 0.05). The occasional neurolysis-related complications were transitory. The results suggest NSPB for the management of cancer pain should be considered earlier in the disease.
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Affiliation(s)
- Raquel de Oliveira
- Department of Biomechanic, Medicine and Rehabilitation of the Locomotor Apparatus, Faculty of Medicine of Ribeirão Preto, Av. Bandeirantes 3900, 14049-900, Ribeirão Preto, SP, Brazil
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Affiliation(s)
- D M Cain
- Department of Preventive Sciences, University of Minnesota, Minneapolis, MN 55455, USA
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