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Lee YC, Brake T, Zhao E, Dumitrescu A, Lee W, Tassie B, Khor KE, Wang AYY. The use of interventional procedures for cancer pain. A brief review. Support Care Cancer 2024; 32:285. [PMID: 38607568 PMCID: PMC11009760 DOI: 10.1007/s00520-024-08467-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/27/2024] [Indexed: 04/13/2024]
Abstract
CONTEXT Pain is a common experience in people living with cancer. Concerns around opioid prescribing have seen a move toward a multi-modality management approach, which includes interventional pain procedures. PURPOSE In this paper we discuss the interventional pain procedures used to treat cancer pain at two major tertiary centers in Australia. METHODS AND RESULTS This expert review provides practical insights on cancer pain management from healthcare providers in different specialties. These insights can be used to guide the management of a wide range of cancer pain types. CONCLUSIONS Furthermore, this review identifies the need for a systematic and comprehensive approach to the management of cancer pain that is broader than that of a single specialty. With recent advances in pain management procedures, an interdisciplinary approach is essential in order to provide an up to date, patient tailored approach to pain management. This review will help inform the development of a cancer pain intervention registry.
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Affiliation(s)
- Yi-Ching Lee
- Department of Anaesthetics and Pain Management Centre, Royal Prince Alfred Hospital, Level 4, QEII, Missenden Rd, Camperdown, Sydney, NSW, 2050, Australia.
- Department of Anaesthetics and Pain Service, Chris O'Brien Lifehouse, Sydney, NSW, Australia.
- School of Medicine, Faculty of Medicine & Health, University of Sydney, Sydney, NSW, Australia.
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Timothy Brake
- Department of Anaesthetics and Pain Management Centre, Royal Prince Alfred Hospital, Level 4, QEII, Missenden Rd, Camperdown, Sydney, NSW, 2050, Australia
- School of Medicine, Faculty of Medicine & Health, University of Sydney, Sydney, NSW, Australia
| | - Emma Zhao
- Department of Anaesthetics and Pain Management Centre, Royal Prince Alfred Hospital, Level 4, QEII, Missenden Rd, Camperdown, Sydney, NSW, 2050, Australia
- Department of Anaesthetics and Pain Service, Chris O'Brien Lifehouse, Sydney, NSW, Australia
- Sydney Nursing School, Faculty of Medicine & Health, University of Sydney, Sydney, NSW, Australia
| | - Alix Dumitrescu
- Department of Anaesthetics and Pain Management Centre, Royal Prince Alfred Hospital, Level 4, QEII, Missenden Rd, Camperdown, Sydney, NSW, 2050, Australia
- School of Medicine, Faculty of Medicine & Health, University of Sydney, Sydney, NSW, Australia
- Department of Palliative Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Wei Lee
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- HammondCare, Royal North Shore Hospital, Sydney, NSW, Australia
- Northern Clinical School, University of Sydney, St Leonards, Australia
| | - Benjamin Tassie
- Department of Anaesthetics and Pain Management Centre, Royal Prince Alfred Hospital, Level 4, QEII, Missenden Rd, Camperdown, Sydney, NSW, 2050, Australia
| | - Kok-Eng Khor
- Pain Management Department, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Andy Yi-Yang Wang
- Department of Anaesthetics and Pain Management Centre, Royal Prince Alfred Hospital, Level 4, QEII, Missenden Rd, Camperdown, Sydney, NSW, 2050, Australia.
- Department of Anaesthetics and Pain Service, Chris O'Brien Lifehouse, Sydney, NSW, Australia.
- School of Medicine, Faculty of Medicine & Health, University of Sydney, Sydney, NSW, Australia.
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Taghlabi KM, Hassan T, Somawardana IA, Rajendran S, Doomi A, Bhenderu LS, Cruz-Garza JG, Faraji AH. Spinal cord stimulation for chronic pain treatment following sacral chordoma resection: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 6:CASE23540. [PMID: 38145561 PMCID: PMC10751222 DOI: 10.3171/case23540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/10/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Cancer-related or postoperative pain can occur following sacral chordoma resection. Despite a lack of current recommendations for cancer pain treatment, spinal cord stimulation (SCS) has demonstrated effectiveness in addressing cancer-related pain. OBSERVATIONS A 76-year-old female with a sacral chordoma underwent anterior osteotomies and partial en bloc sacrectomy. She subsequently presented with chronic pain affecting both buttocks and posterior thighs and legs, significantly impeding her daily activities. She underwent a staged epidural SCS paddle trial and permanent system placement using intraoperative neuromonitoring. The utilization of percutaneous leads was not viable because of her history of spinal fluid leakage, multiple lumbosacral surgeries, and previous complex plastic surgery closure. The patient reported a 62.5% improvement in her lower-extremity pain per the modified Quadruple Visual Analog Scale and a 50% improvement in the modified Pain and Sleep Questionnaire 3-item index during the SCS trial. Following permanent SCS system placement and removal of her externalized lead extenders, she had an uncomplicated postoperative course and reported notable improvements in her pain symptoms. LESSONS This case provides a compelling illustration of the successful treatment of chronic pain using SCS following radical sacral chordoma resection. Surgeons may consider this treatment approach in patients presenting with refractory pain following spinal tumor resection.
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Affiliation(s)
- Khaled M Taghlabi
- 1Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; and
- 2Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas
| | - Taimur Hassan
- 1Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; and
- 2Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas
| | - Isuru A Somawardana
- 1Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; and
- 2Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas
| | - Sibi Rajendran
- 1Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; and
- 2Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas
| | - Ahmed Doomi
- 1Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; and
| | - Lokeshwar S Bhenderu
- 1Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; and
- 2Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas
| | - Jesus G Cruz-Garza
- 1Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; and
- 2Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas
| | - Amir H Faraji
- 1Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; and
- 2Clinical Innovations Laboratory, Houston Methodist Research Institute, Houston, Texas
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Adams JL, Goble G, Johnson A. Multidisciplinary Approaches: Cingulotomy in an Adult With Refractory Neuropathic Cancer-Related Pain. J Palliat Med 2023; 26:1297-1301. [PMID: 37192484 DOI: 10.1089/jpm.2022.0444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Background: Oral medications, intravenous medications, and invasive interventions are effective means of neuropathic pain control. In patients with pain refractory to more conventional approaches, cingulum bundle ablation is an alternative treatment modality not routinely considered by providers. Case Description: A 42-year-old woman with history of cervical cancer in remission presented with intractable left lower extremity pain. Workup revealed radiation-induced left iliopsoas osteosarcoma complicated by deep venous occlusion and thrombosis. Her pain remained intractable to pharmacologic therapies and more invasive pain control interventions. A multidisciplinary decision was made to pursue bilateral subcortical cingulum bundle radiofrequency ablation. After a technically successful surgery, the patient exhibited improved pain control as evidenced by a decline in her numerical rating scale of pain and analgesic medication requirements. Conclusion: Cancer-related neuropathic pain often requires treatment with multiple modalities involving multidisciplinary teams. In select refractory cases, cingulum bundle ablation may be an effective alternative treatment modality.
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Affiliation(s)
- Jessica L Adams
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gretchen Goble
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amy Johnson
- Department of Palliative Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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4
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ESTRO ACROP guidelines for external beam radiotherapy of patients with complicated bone metastases. Radiother Oncol 2022; 173:240-253. [DOI: 10.1016/j.radonc.2022.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 12/19/2022]
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Abstract
Recent decades have demonstrated significant strides in cancer screening, diagnostics and therapeutics. As such there have been dramatic changes in survival following a diagnosis of cancer.
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Affiliation(s)
- Matthew R D Brown
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | | | - David J Magee
- The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK.
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Yang A, Nadav D, Legler A, Chen GH, Hingula L, Puttanniah V, Gulati A. An Interventional Pain Algorithm for the Treatment of Postmastectomy Pain Syndrome: A Single-Center Retrospective Review. PAIN MEDICINE 2021; 22:677-686. [PMID: 33155049 DOI: 10.1093/pm/pnaa343] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Breast cancer is the most common female malignancy worldwide. Breast surgery and adjuvant oncological therapies are often required to increase survival. Treatment-related pain may persist and evolve into postmastectomy pain syndrome (PMPS) in a significant subset of breast cancer survivors. In this retrospective investigation, we will present our experience in applying an interventional algorithmic approach to treat PMPS. DESIGN A retrospective study. SETTING An academic cancer hospital. SUBJECTS Adult females with PMPS diagnosis. METHODS We reviewed 169 records with the diagnosis of PMPS from 2015 to 2019 within our health system. Pre- and post-injection pain scores, relief duration, and medication usage changes were collected. The decision to perform each procedure was based on the anatomic location of the painful area with the corresponding peripheral sensory innervation. Decision-making flow diagrams were created to present our experience in managing PMPS beyond peripheral nerve blocks. RESULTS Ultrasound-guided peripheral nerve block results (n=350) were analyzed. The mean baseline pain score was 7, compared with the post-treatment mean score of 3 (95% confidence interval: 3.58 to 3.98, P = 0.0001). Among the responders, the mean pain relief duration was 45 days, with a median of 84 days. Opioid medication consumption was reduced by 11% (t = 0.72, P = 0.47). CONCLUSIONS Ultrasound-guided nerve blocks of this area could be performed safely and effectively after breast surgeries. We also present our proposed algorithm to provide a stepwise application for selecting the appropriate therapies in the management of more complex PMPS.
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Affiliation(s)
- Ajax Yang
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.,The Spine and Pain Institute of New York, New York, USA
| | - Danielle Nadav
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Aron Legler
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Grant H Chen
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lee Hingula
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay Puttanniah
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Hagedorn JM, Pittelkow TP, Hunt CL, D'Souza RS, Lamer TJ. Current Perspectives on Spinal Cord Stimulation for the Treatment of Cancer Pain. J Pain Res 2020; 13:3295-3305. [PMID: 33324090 PMCID: PMC7732175 DOI: 10.2147/jpr.s263857] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022] Open
Abstract
Cancer and cancer treatment-related chronic pain affect a significant number of patients. The etiology of this pain is diverse and may include nociceptive and/or neuropathic characteristics. Treatment is often multifactorial and may require advanced interventional techniques, such as spinal cord stimulation (SCS). This narrative review provides a thorough overview of cancer-related pain mechanisms and the use of SCS for cancer-related pain. Additionally, a review of the precautions that should be considered when caring for this patient population is provided with recommendations for safe care when utilizing these techniques.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas P Pittelkow
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christine L Hunt
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tim J Lamer
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
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Steinberger JM, Yuk F, Doshi AH, Green S, Germano IM. Multidisciplinary management of metastatic spine disease: initial symptom-directed management. Neurooncol Pract 2020; 7:i33-i44. [PMID: 33299572 PMCID: PMC7705525 DOI: 10.1093/nop/npaa048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
In the past 2 decades, a deeper understanding of the cancer molecular signature has resulted in longer longevity of cancer patients, hence a greater population, who potentially can develop metastatic disease. Spine metastases (SM) occur in up to 70% of cancer patients. Familiarizing ourselves with the key aspects of initial symptom-directed management is important to provide SM patients with the best patient-specific options. We will review key components of initial symptoms assessment such as pain, neurological symptoms, and spine stability. Radiographic evaluation of SM and its role in management will be reviewed. Nonsurgical treatment options are also presented and discussed, including percutaneous procedures, radiation, radiosurgery, and spine stereotactic body radiotherapy. The efforts of a multidisciplinary team will continue to ensure the best patient care as the landscape of cancer is constantly changing.
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Affiliation(s)
- Jeremy M Steinberger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Frank Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amish H Doshi
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sheryl Green
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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9
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Comlek S. Pain Control with Splanchnic Neurolysis in Pancreatic Cancer Patients Unresponsive to Celiac Plexus Neurolysis. J Pain Res 2020; 13:2023-2031. [PMID: 32848449 PMCID: PMC7429208 DOI: 10.2147/jpr.s266689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS In most instances of abdominal pain associated with pancreatic cancer, pain may become refractory to increasing doses of narcotics. Celiac plexus neurolysis represents an option; however, altered celiac plexus anatomy may render this treatment infeasible or ineffective, where splanchnic nerve neurolysis may represent another option. This study aimed to investigate the outcomes of splanchnic neurolysis in pancreatic cancer patients not responsive to celiac plexus neurolysis. PATIENTS AND METHODS Among all 84 patients who underwent celiac plexus neurolysis for pancreatic cancer pain during the study period, 34 patients did not respond and underwent splanchnic nerve neurolysis under fluoroscopic guidance and thus included in this retrospective study. Stage IV, III, and II disease was present in 38.2%, 47.1%, and 14.7% of the patients. During the study, 88.2% were receiving chemotherapy, whereas none were on radiotherapy. Data for daily narcotic dose equivalents and Visual Analogue Scale (VAS) scores during outpatient visits at baseline, 2 weeks, 2 months, and 3 months were extracted. RESULTS Pain response rates were 76.5%, 84.4%, and 71.0%, at 2 weeks, 2 months, and 3 months, respectively. A significant and dramatic reduction was seen in VAS scores at 2 weeks (2.8±1.2 versus 6.3±1.1, p<0.001), and this significant decline was maintained for 3 months. Similarly, a significant and dramatic reduction was seen in daily narcotic need at 2 weeks (20.8±32.9 versus 93.4±86.2 mg, p<0.001), which was also maintained during the 3-month follow-up. The procedure was generally well tolerated. CONCLUSION Findings of this study suggest that splanchnic neurolysis represents a durable and effective option for pain control in pancreatic cancer patients in whom the neurolysis of the celiac plexus is ineffective. However, these conclusions refer to only preliminary single-center results in a selected patient group; thus, further large studies are warranted.
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Affiliation(s)
- Savas Comlek
- Gayrettepe Florence Nightingale Hospital, Department of Anesthesiology and Reanimation, Istanbul, Besiktas 34349, Turkey
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10
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Lau J, Flamer D, Murphy-Kane P. Interventional anesthesia and palliative care collaboration to manage cancer pain: a narrative review. Can J Anaesth 2020; 67:235-246. [PMID: 31571119 DOI: 10.1007/s12630-019-01482-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022] Open
Abstract
Pain is a common symptom associated with advanced cancer. An estimated 66.4% of people with advanced cancer experience pain from their disease or treatment. Pain management is an essential component of palliative care. Opioids and adjuvant therapies are the mainstay of cancer pain management. Nevertheless, a proportion of patients may experience complex pain that is not responsive to conventional analgesia. Interventional analgesia procedures may be appropriate and necessary to manage complex, cancer-related pain. This narrative review uses a theoretical case to highlight core principles of palliative care and interventional anesthesia, and the importance of collaborative, interdisciplinary care. An overview and discussion of pragmatic considerations of peripheral nervous system interventional analgesic procedures and neuraxial analgesia infusions are provided.
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Affiliation(s)
- Jenny Lau
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada.
- Division of Palliative Care, Department of Family and Community Medicine, Toronto, ON, Canada.
| | - David Flamer
- Department of Anesthesia and Pain Medicine, University Health Network, Toronto, ON, Canada
- Toronto Western Hospital, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Patricia Murphy-Kane
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada
- Department of Nursing, Princess Margaret Cancer Center, Toronto, ON, Canada
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Abstract
PURPOSE OF REVIEW This paper aims to give the specialist and non-specialist alike an overview of the considerations involved in the management of cancer-related pain in the older population. RECENT FINDINGS Comprehensive guidelines on cancer pain management have been published recently by expert bodies. Cancer pain differs in many respects to other pain conditions and we are likely to encounter it more frequently in older patients in the future. The elderly are more sensitive to the effects of many analgesic medications. The elderly patient with cancer pain presents a unique challenge to the treating physician. The biological effects of ageing impact on the efficacy of many pain management strategies as well as its diagnosis and assessment. Treatment options can be broadly divided into pharmacological, non-pharmacological and interventional. A multidisciplinary approach and frequent re-assessment are essential in achieving favourable outcomes in this patient group.
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Affiliation(s)
- Dylan Finnerty
- Department of Anaesthesia, Mater Misericordiae University Hospital, Level 4, Whitty Building, Eccles Street, Dublin, D07 R2WY, Ireland.
| | - Áine O'Gara
- Department of Anaesthesia, Mater Misericordiae University Hospital, Level 4, Whitty Building, Eccles Street, Dublin, D07 R2WY, Ireland
| | - Donal J Buggy
- Department of Anaesthesia, Mater Misericordiae University Hospital, Level 4, Whitty Building, Eccles Street, Dublin, D07 R2WY, Ireland
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Strategies for interventional therapies in cancer-related pain-a crossroad in cancer pain management. Support Care Cancer 2019; 27:3133-3145. [PMID: 31093769 DOI: 10.1007/s00520-019-04827-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 04/23/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Interventional therapies are important to consider when facing cancer pain refractory to conventional therapies. The objective of the current review is to introduce these effective strategies into dynamic interdisciplinary pain management, leading to an exhaustive approach to supportive oncology. METHODS Critical reflection based on literature analysis and clinical practice. RESULTS Interventional therapies act on the nervous system via neuromodulation or surgical approaches, or on primitive or metastatic lesions via interventional radiotherapy, percutaneous ablation, or surgery. Interventional therapies such as neuromodulations are constantly evolving with new technical works still in development. Nowadays, their usage is better defined, depending on clinical situations, and their impact on quality of life is proven. Nevertheless their availability and acceptability still need to be improved. To start with, a patient's interdisciplinary evaluation should cover a wide range of items such as patient's performance and psychological status, ethical considerations, and physiochemical and pharmacological properties of the cerebrospinal fluid for intrathecal neuromodulation. This will help to define the most appropriate strategy. In addition to determining the pros and cons of highly specialized interventional therapies, their relevance should be debated within interdisciplinary teams in order to select the best strategy for the right patient, at the right time. CONCLUSIONS Ultimately, the use of the interventional therapies can be limited by the requirement of specific trained healthcare teams and technical support, or the lack of health policies. However, these interventional strategies need to be proposed as soon as possible to each patient requiring them, as they can greatly improve quality of life.
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13
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Shteamer JW, Harvey RD, Spektor B, Curseen K, Egan K, Chen Z, Gillespie TW, Sniecinski RM, Singh V. Safety of Intranasal Ketamine for Reducing Uncontrolled Cancer-Related Pain: Protocol of a Phase I/II Clinical Trial. JMIR Res Protoc 2019; 8:e12125. [PMID: 31038469 PMCID: PMC6658277 DOI: 10.2196/12125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/27/2018] [Accepted: 12/31/2018] [Indexed: 11/27/2022] Open
Abstract
Background Approximately 12 million Americans are affected with cancer. Of these, 53% experience pain at all stages of cancer. Pain may remain uncontrolled despite high-dose opioid therapy, and opioids have many well-documented harmful side effects. Intranasal ketamine has been shown to be effective in controlling breakthrough noncancer pain in a double-blind randomized control trial (DBRCT) by Carr et al in 2003 as well as to help with depression in a DBRCT by Lapidus et al in 2014. We seek to obtain preliminary data on the safety, feasibility, and utility of this novel technique for the treatment of uncontrolled cancer pain. Objective This study aimed to obtain preliminary data via a clinical trial addressing the safety, feasibility, pharmacokinetics, and pharmacodynamics of intranasal ketamine. These initial findings will be applied to a subsequent trial to determine the effectiveness and associated toxicities of ketamine in a larger sample of cancer patients and to address the compelling need to identify new, successful management therapies for cancer pain. Methods This is an institutional review board– and investigational new drug–approved, prospective phase I/II trial to investigate the safety and use of intranasal ketamine in patients with uncontrolled pain related to cancer or cancer treatment. Informed consent will be obtained prior to all study procedures. All patients will be assigned to the same investigational treatment arm. After patient selection via inclusion/exclusion criteria, patients will be seen over 5 visits, with each visit conducted 2-7 days apart. Patients will be administered ketamine on visits 1-4 and monitored for 240 minutes with continuous pulse oximetry and regular blood pressure checks. Blood samples as well as patient-reported outcomes will be collected at set time points at baseline and after drug delivery. Patients will receive 10 mg intranasal ketamine on visit 1, 10 mg intravenous ketamine on visit 2, 30 mg intranasal ketamine on visit 3, and 50 mg intranasal ketamine on visit 4. On visit 5, an addition blood sample will be drawn. Results As of March 2019, enrollment is in progress, and a total of 7 subjects have completed the study. Enrollment is expected to be completed by April 2019. Final data analysis will commence soon after, and the results are expected to be submitted for publication in 2019. Conclusions If intranasal ketamine can be utilized for pain control in cancer patients, it could provide superior analgesia and better quality of life, without the risk of significant respiratory depression and constipation associated with opioid medications. These findings will be an important initial step toward testing the effectiveness of intranasal ketamine as a nonopioid medication for cancer pain and as potential maintenance outpatient therapy. Trial Registration ClinicalTrials.gov NCT03146806; https://clinicaltrials.gov/ct2/show/NCT03146806. International Registered Report Identifier (IRRID) DERR1-10.2196/12125
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Affiliation(s)
- Jack W Shteamer
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - R Donald Harvey
- Department of Pharmacology, Emory University, Atlanta, GA, United States.,Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, United States
| | - Boris Spektor
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - Kimberly Curseen
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Katherine Egan
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - Zhengjia Chen
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, United States.,Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | | | - Roman M Sniecinski
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - Vinita Singh
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
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Hacker KE, Reynolds RK, Uppal S. Ongoing strategies and updates on pain management in gynecologic oncology patients. Gynecol Oncol 2018; 149:410-419. [DOI: 10.1016/j.ygyno.2018.01.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/24/2018] [Accepted: 01/30/2018] [Indexed: 12/23/2022]
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15
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He Y, Liu Y, May BH, Zhang AL, Zhang H, Lu C, Yang L, Guo X, Xue CC. Effectiveness of acupuncture for cancer pain: protocol for an umbrella review and meta-analyses of controlled trials. BMJ Open 2017; 7:e018494. [PMID: 29229658 PMCID: PMC5778333 DOI: 10.1136/bmjopen-2017-018494] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The National Comprehensive Cancer Network guidelines for adult cancer pain indicate that acupuncture and related therapies may be valuable additions to pharmacological interventions for pain management. Of the systematic reviews related to this topic, some concluded that acupuncture was promising for alleviating cancer pain, while others argued that the evidence was insufficient to support its effectiveness. METHODS AND ANALYSIS This review will consist of three components: (1) synthesis of findings from existing systematic reviews; (2) updated meta-analyses of randomised clinical trials and (3) analyses of results of other types of clinical studies. We will search six English and four Chinese biomedical databases, dissertations and grey literature to identify systematic reviews and primary clinical studies. Two reviewers will screen results of the literature searches independently to identify included reviews and studies. Data from included articles will be abstracted for assessment, analysis and summary. Two assessors will appraise the quality of systematic reviews using Assessment of Multiple Systematic Reviews; assess the randomised controlled trials using the Cochrane Collaboration's risk of bias tool and other types of studies according to the Newcastle-Ottawa Scale. We will use 'summary of evidence' tables to present evidence from existing systematic reviews and meta-analyses. Using the primary clinical studies, we will conduct meta-analysis for each outcome, by grouping studies based on the type of acupuncture, the comparator and the specific type of pain. Sensitivity analyses are planned according to clinical factors, acupuncture method, methodological characteristics and presence of statistical heterogeneity as applicable. For the non-randomised studies, we will tabulate the characteristics, outcome measures and the reported results of each study. Consistencies and inconsistencies in evidence will be investigated and discussed. Finally, we will use the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of the overall evidence. ETHICS AND DISSEMINATION There are no ethical considerations associated with this review. The findings will be disseminated in peer-reviewed journals or conference presentations. PROSPERO REGISTRATION NUMBER CRD42017064113.
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Affiliation(s)
- Yihan He
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
- Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yihong Liu
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
- Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Brian H May
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
| | - Anthony Lin Zhang
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
| | - Haibo Zhang
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
- Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - ChuanJian Lu
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
- Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Lihong Yang
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
- Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Xinfeng Guo
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
- Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Charlie Changli Xue
- China-Australia International Research Center for Chinese Medicine, RMIT University, Melbourne, Victoria, Australia
- Guangdong Provincial Academy of Chinese Medical Sciences, Guangdong Provincial Hospital of Chinese Medicine and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Chakravarthy K, Richter H, Christo PJ, Williams K, Guan Y. Spinal Cord Stimulation for Treating Chronic Pain: Reviewing Preclinical and Clinical Data on Paresthesia-Free High-Frequency Therapy. Neuromodulation 2017; 21:10-18. [PMID: 29105244 DOI: 10.1111/ner.12721] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/17/2017] [Accepted: 09/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traditional spinal cord stimulation (SCS) requires that paresthesia overlaps chronic painful areas. However, the new paradigm high-frequency SCS (HF-SCS) does not rely on paresthesia. STUDY DESIGN A review of preclinical and clinical studies regarding the use of paresthesia-free HF-SCS for various chronic pain states. METHODS We reviewed available literatures on HF-SCS, including Nevro's paresthesia-free ultra high-frequency 10 kHz therapy (HF10-SCS). Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, and SCOPUS, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES The primary goal is to describe the present developing conceptions of preclinical mechanisms of HF-SCS and to review clinical efficacy on paresthesia-free HF10-SCS for various chronic pain states. RESULTS HF10-SCS offers a novel pain reduction tool without paresthesia for failed back surgery syndrome and chronic axial back pain. Preclinical findings indicate that potential mechanisms of action for paresthesia-free HF-SCS differ from those of traditional SCS. CONCLUSIONS To fully understand and utilize paresthesia-free HF-SCS, mechanistic study and translational research will be very important, with increasing collaboration between basic science and clinical communities to design better trials and optimize the therapy based on mechanistic findings from effective preclinical models and approaches. Future research in these vital areas may include preclinical and clinical components conducted in parallel to optimize the potential of this technology.
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Affiliation(s)
- Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health System, San Diego, CA, USA
| | - Hira Richter
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kayode Williams
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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17
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Abstract
Cancer pain remains a significant clinical problem worldwide. Causes of cancer pain are multifactorial and complex and are likely to vary with an array of tumor-related and host-related factors and processes. Pathophysiology is poorly understood; however, new laboratory research points to cross-talk between cancer cells and host’s immune and neural systems as an important potential mechanism that may be broadly relevant to many cancer pain syndromes. Opioids remain the most effective pharmaceuticals used in the treatment of cancer pain. However, their role has been evolving due to emerging awareness of risks of chronic opioid therapy. Despite extensive research efforts, no new class of analgesics has been developed. However, many potential therapeutic targets that may lead to the establishment of new pharmaceuticals have been identified in recent years. It is also expected that the role of non-pharmacological modalities of treatment will grow in prominence. Specifically, neuromodulation, a rapidly expanding field, may play a major role in the treatment of neuropathic cancer pain provided that further technological progress permits the development of non-invasive and inexpensive neuromodulation techniques.
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Affiliation(s)
- Marcin Chwistek
- Department of Hematology and Medical Oncology, Fox Chase Cancer Center/Temple Health, Philadelphia, PA, USA
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18
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Hochberg U, Elgueta MF, Perez J. Interventional Analgesic Management of Lung Cancer Pain. Front Oncol 2017; 7:17. [PMID: 28261561 PMCID: PMC5306685 DOI: 10.3389/fonc.2017.00017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/25/2017] [Indexed: 12/31/2022] Open
Abstract
Lung cancer is one of the four most prevalent cancers worldwide. Comprehensive patient care includes not only adherence to clinical guidelines to control and when possible cure the disease but also appropriate symptom control. Pain is one of the most prevalent symptoms in patients diagnosed with lung cancer; it can arise from local invasion of chest structures or metastatic disease invading bones, nerves, or other anatomical structures potentially painful. Pain can also be a consequence of therapeutic approaches like surgery, chemotherapy, or radiotherapy. Conventional medical management of cancer pain includes prescription of opioids and coadjuvants at doses sufficient to control the symptoms without causing severe drug effects. When an adequate pharmacological medical management fails to provide satisfactory analgesia or when it causes limiting side effects, interventional cancer pain techniques may be considered. Interventional pain management is devoted to the use of invasive techniques such as joint injections, nerve blocks and/or neurolysis, neuromodulation, and cement augmentation techniques to provide diagnosis and treatment of pain syndromes resistant to conventional medical management. Advantages of interventional approaches include better analgesic outcomes without experiencing drug-related side effects and potential for opioid reduction thus avoiding central side effects. This review will describe various pain syndromes frequently described in lung cancer patients and those interventional techniques potentially indicated for those cases.
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Affiliation(s)
- Uri Hochberg
- Cancer Pain Program, McGill University Health Centre , Montreal, QC , Canada
| | | | - Jordi Perez
- Cancer Pain Program, McGill University Health Centre, Montreal, QC, Canada; Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, QC, Canada
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