A systematic review of the impact of pain on overall survival in patients with cancer

Serious Health-Related Suffering Impairs Treatments and Survival in Older Patients With Cancer

CONTEXT

More than half of new cancer cases occurred in older adults. Older patients with cancer are particularly at risk of physical, psycho-existential or socio-familial suffering as defined by the concept of Serious Health-related Suffering (SHS).

OBJECTIVES

To assess the direct and indirect effects of physical, psycho-existential and socio-familial dimensions of suffering on cancer treatability, supportive care needs and 12-month mortality in older patients with cancer.

METHODS

We included patients with cancer aged 70 years and over from the Elderly Cancer Patients cohort (ELCAPA, Ile-de-France), referred for geriatric assessment between 2007 and 2019 before cancer treatment. Structural equation modelling examined the direct and indirect relationships between SHS dimensions (latent variables), patients' characteristics (age, sex, tumor location and metastatic status, comorbidity, period of care), and outcomes.

RESULTS

The analysis included 4,824 patients (mean age: 82.2 ± 4 years; women: 56%; main cancer sites: breast [22.3%], colorectal [15.2%], prostate [8.5%], and lung [6.8%]; metastatic cancer: 46%). Physical suffering had direct pejorative effects on cancer treatability, and mortality (standardized coefficient [SC] = 0.12 [P < 0.001], SC = 0.27 [P < 0.001], respectively). Psycho-existential and socio-familial sufferings had indirect pejorative effects on survival through decreased cancer treatability (SC = 0.08 [P < 0.001], SC = 0.03 [P < 0.001], respectively). Psycho-existential dimension had the main direct effect size on supportive care needs (SC = 0.35 [P < 0.001]) and was interrelated with physical suffering.

CONCLUSION

Physical suffering has direct pejorative effect on survival. All dimensions indirectly decrease survival due to poorer cancer treatability. Our findings support concomitant management of physical and psycho-existential suffering.

Identification of 8 candidate microsatellite instability loci in colorectal cancer and validation of the ACVR2A mechanism in the tumor progression

This study probes the utility of biomarkers for microsatellite instability (MSI) detection and elucidates the molecular dynamics propelling colorectal cancer (CRC) progression. We synthesized a primer panel targeting 725 MSI loci, informed by The Cancer Genome Atlas (TCGA) and ancillary databases, to construct an amplicon library for next-generation sequencing (NGS). K-means clustering facilitated the distillation of 8 prime MSI loci, including activin A receptor type 2A (ACVR2A). Subsequently, we explored ACVR2A's influence on CRC advancement through in vivo tumor experiments and hematoxylin-eosin (HE) staining. Transwell assays gauged ACVR2A's role in CRC cell migration and invasion, while colony formation assays appraised cell proliferation. Western blotting illuminated the impact of ACVR2A suppression on CRC's PI3K/AKT/mTOR pathway protein expressions under hypoxia. Additionally, ACVR2A's influence on CRC-induced angiogenesis was quantified via angiogenesis assays. K-means clustering of NGS data pinpointed 32 MSI loci specific to tumor and DNA mismatch repair deficiency (dMMR) tissues. ACVR2A emerged as a pivotal biomarker, discerning MSI-H tissues with 90.97% sensitivity. A curated 8-loci set demonstrated 100% sensitivity and specificity for MSI-H detection in CRC. In vitro analyses corroborated ACVR2A's critical role, revealing its suppression of CRC proliferation, migration, and invasion. Moreover, ACVR2A inhibition under CRC-induced hypoxia markedly escalated MMP3, CyclinA, CyclinD1, and HIF1α protein expressions, alongside angiogenesis, by triggering the PI3K/AKT/mTOR cascade. The 8-loci ensemble stands as the optimal marker for MSI-H identification in CRC. ACVR2A, a central element within this group, deters CRC progression, while its suppression amplifies PI3K/AKT/mTOR signaling and angiogenesis under hypoxic stress.

Opioid Nonadherence Risk Prediction of Patients with Cancer-Related Pain Based on Five Machine Learning Algorithms

Objectives

Opioid nonadherence represents a significant barrier to cancer pain treatment efficacy. However, there is currently no effective prediction method for opioid adherence in patients with cancer pain. We aimed to develop and validate a machine learning (ML) model and evaluate its feasibility to predict opioid nonadherence in patients with cancer pain.

Methods

This was a secondary analysis from a cross-sectional study that included 1195 patients from March 1, 2018, to October 31, 2019. Five ML algorithms, such as logistic regression (LR), random forest, eXtreme Gradient Boosting, multilayer perceptron, and support vector machine, were used to predict opioid nonadherence in patients with cancer pain using 43 demographic and clinical factors as predictors. The predictive effects of the models were compared by the area under the receiver operating characteristic curve (AUC_ROC), accuracy, precision, sensitivity, specificity, and F1 scores. The value of the best model for clinical application was assessed using decision curve analysis (DCA).

Results

The best model obtained in this study, the LR model, had an AUC_ROC of 0.82, accuracy of 0.82, and specificity of 0.71. The DCA showed that clinical interventions for patients at high risk of opioid nonadherence based on the LR model can benefit patients. The strongest predictors for adherence were, in order of importance, beliefs about medicines questionnaire (BMQ)-harm, time since the start of opioid, and BMQ-necessity. Discussion. ML algorithms can be used as an effective means of predicting adherence to opioids in patients with cancer pain, which allows for proactive clinical intervention to optimize cancer pain management. This trial is registered with ChiCTR2000033576.

Patients' satisfaction with cancer pain treatment at adult oncologic centers in Northern Ethiopia; a multi-center cross-sectional study

BACKGROUND

Patient satisfaction is an important indicator of the quality of healthcare. Pain is one of the most common symptoms among cancer patients that needs optimal treatment; rather, it compromises the quality of life of patients.

OBJECTIVE

To assess the levels and associated factors of satisfaction with cancer pain treatment among adult patients at cancer centers found in Northern Ethiopia in 2023.

METHODS

After obtaining ethical approval, a multi-center cross-sectional study was conducted at four cancer care centers in northern Ethiopia. The data were collected using an interviewer-administered structured questionnaire that included the Lubeck Medication Satisfaction Questionnaire (LMSQ). The severity of pain was assessed by a numerical rating scale from 0 to 10 with a pain score of 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, and 7-10 = severe pain Binary logistic regression analysis was employed, and the strength of association was described in an adjusted odds ratio with a 95% confidence interval.

RESULT

A total of 397 cancer patients participated in this study, with a response rate of 98.3%. We found that 70.3% of patients were satisfied with their cancer pain treatment. Being married (AOR = 5.6, CI = 2.6-12, P < 0.001) and being single (never married) (AOR = 3.5, CI = 1.3-9.7, P = 0.017) as compared to divorced, receiving adequate pain management (AOR = 2.4, CI = 1.1-5.3, P = 0.03) as compared to those who didn't receive it, and having lower pain severity (AOR = 2.6, CI = 1.5-4.8, P < 0.001) as compared to those who had higher level of pain severity were found to be associated with satisfaction with cancer pain treatment.

CONCLUSION

The majority of cancer patients were satisfied with cancer pain treatment. Being married, being single (never married), lower pain severity, and receiving adequate pain management were found to be associated with satisfaction with cancer pain treatment. It would be better to enhance the use of multimodal analgesia in combination with strong opioids to ensure adequate pain management and lower pain severity scores.

From pain to tumor immunity: influence of peripheral sensory neurons in cancer

The nervous and immune systems are the primary sensory interfaces of the body, allowing it to recognize, process, and respond to various stimuli from both the external and internal environment. These systems work in concert through various mechanisms of neuro-immune crosstalk to detect threats, provide defense against pathogens, and maintain or restore homeostasis, but can also contribute to the development of diseases. Among peripheral sensory neurons (PSNs), nociceptive PSNs are of particular interest. They possess a remarkable capability to detect noxious stimuli in the periphery and transmit this information to the brain, resulting in the perception of pain and the activation of adaptive responses. Pain is an early symptom of cancer, often leading to its diagnosis, but it is also a major source of distress for patients as the disease progresses. In this review, we aim to provide an overview of the mechanisms within tumors that are likely to induce cancer pain, exploring a range of factors from etiological elements to cellular and molecular mediators. In addition to transmitting sensory information to the central nervous system, PSNs are also capable, when activated, to produce and release neuropeptides (e.g., CGRP and SP) from their peripheral terminals. These neuropeptides have been shown to modulate immunity in cases of inflammation, infection, and cancer. PSNs, often found within solid tumors, are likely to play a significant role in the tumor microenvironment, potentially influencing both tumor growth and anti-tumor immune responses. In this review, we discuss the current state of knowledge about the degree of sensory innervation in tumors. We also seek to understand whether and how PSNs may influence the tumor growth and associated anti-tumor immunity in different mouse models of cancer. Finally, we discuss the extent to which the tumor is able to influence the development and functions of the PSNs that innervate it.

Validation of the Danish version of the knowledge and attitudes survey regarding pain

OBJECTIVES

Pain management is critical for nurses; therefore, knowledge assessment is also critical. The Knowledge and Attitudes Survey Regarding Pain (KASRP), designed for testing pain management knowledge among nurses, finds widespread use internationally; yet, key validity evidence according to American Psychological Association standards is missing. Therefore, this study aimed to translate and test the psychometric traits of KASRP based on an item response theory model.

METHODS

Cronbach's α was included to assess internal consistency, and the Kolmogorov-Smirnov test was included to assess the total score normal distribution goodness of fit. KASRP was tested using the Kaiser-Meyer-Olkin (KMO) test for sphericity to examine its suitability for factor analysis and exploratory factor analysis to examine construct evidence. The Kruskal-Wallis H test was used to assess discriminant evidence. The correlation between KASRP and the Brockopp-Warden Pain Knowledge Questionnaire (BWPKQ) was included as a measure of convergent validity evidence, and correlation with self-assessed knowledge was tested as a divergent validity measure.

RESULTS

The questionnaire was translated using back-forth and parallel translation. The KMO test for sphericity was 0.49 for all items and 0.53 for the adjusted scale without items 30, 33, and 36, with factor analysis explaining 70.42% of the variation suggesting unacceptable construct validity evidence. Cronbach's α was 0.75, suggesting acceptable reliability evidence; the Kolmogorov-Smirnov test revealed an insignificant skewness of -0.195 and a kurtosis of 0.001, while the Kruskal-Wallis H test revealed a significance of p < 0.001. The correlation between KASRP and the BWPKQ was 0.69 (p = 0.0001), suggesting acceptable convergent validity evidence. A correlation between KASRP and self-assessed knowledge of -0.59 was also found, which suggests acceptable divergent validity evidence.

CONCLUSIONS

The translated KASRP passed six out of seven tests based on the given sample.

Anti-Algics in the Therapeutic Response of Breast and Urological Cancers

The effect of anti-algics on tumor progression and the overall survival of patients is controversial and remains unclear. Herein, we disclose the in vitro effects of the local anesthetics lidocaine, ropivacaine, and levobupivacaine on breast (MCF7), prostate (PC3, LNCaP), and bladder (TCCSUP, HT1376) cancer cell lines, both as monotherapy and in combination with standard-of-care therapeutics. Assays for cell proliferation, viability, death profile, and migration were performed. Additionally, we explored the clinical outcomes of opioid use through a cross-sectional study involving 200 metastatic prostate cancer patients. The main clinical data collected included the type of opioid therapy administered, dosage, treatment duration, disease progression, and overall survival. Results obtained demonstrate that treatment with local anesthetics has a promising selective anti-tumor effect on these types of cancer, with higher effects when associated with docetaxel. This points out the use of local anesthetics as an added value in the treatment of prostate carcinoma patients. Alternatively, chronic opioid use was correlated with reduced overall survival (p < 0.05) and progression-free survival (p < 0.05) at each treatment line in the observational study. While these results provide valuable insights, larger prospective studies are imperative to comprehensively evaluate the clinical impact of opioid analgesics in prostate cancer patients.

Battlefield acupuncture for chronic musculoskeletal pain in cancer survivors: a novel care delivery model for oncology acupuncture

Introduction

Battlefield Acupuncture (BFA), a standardized auricular acupuncture protocol, is widely used for pain in the military but is not well-studied in oncology. This study examined cancer survivors who received BFA for pain.

Methods

This is a secondary analysis of a randomized trial that compared the effectiveness of BFA and electroacupuncture vs. usual care for chronic musculoskeletal pain in cancer survivors. This study focused on participants randomized to BFA. Participants received 10 weekly treatments. Needles were placed until one of these stop conditions were satisfied: ten needles were administered; pain severity decreased to ≤1 out of 10; patient declined further needling, or vasovagal reaction was observed. Pain severity was assessed using Brief Pain Inventory. Responders were those with ≥30% pain severity reduction. We examined pain location, BFA stop reason, and pain reduction of participants during the first session. We also examined which factors predicted responder status after the first session (week 1) or the full treatment (week 12).

Results

Among 143 randomized to BFA, most common pain locations were lower back (30.8%) and knee/leg (18.2%). Of 138 who initiated treatment, 41 (30.0%) received ten needles; 81 (59.1%) achieved pain ≤1; 14 (10.2%) declined further needling; and 1 (0.7%) had vasovagal reaction. BFA reduced pain severity by 2.9 points (95% CI 2.6 to 3.2) after the first session (P < 0.001). After adjusting for baseline pain severity, responders at week 1 were 2.5 times more likely to be responders at week 12, compared to those who were non-responders at week 1 (AOR 2.5, 95% CI 1.02 to 6.11, P = 0.04). Among those who achieved pain ≤1, 74% were responders at week 12, a higher proportion compared to the proportion of responders among those who received ten needles (39.5%), those who declined further needling (50%), and those with vasovagal reaction (0.0%) (P = 0.001). Those with pain in proximal joints had a higher proportion of responders at week 12, compared to those with pain in distal joints (64.2% vs. 20%, P = 0.008).

Conclusion

Specific factors may predict the likelihood of achieving meaningful pain reduction from BFA. Understanding these predictors could inform precision pain management and acupuncture delivery models.

Risk factors for unresectable pancreatic cancer following high-intensity focused ultrasound treatment

PURPOSE

Pancreatic cancer is one of the most aggressive malignant tumors with poor prognosis. High-intensity focused ultrasound (HIFU) is an effective and safe treatment option for advanced pancreatic cancer, however, the survival time of patients after the treatment was different. So, the purpose of this study was to evaluate the relationship between the high-risk characteristics and prognosis of unresectable pancreatic cancer after HIFU treatment.

PATIENTS AND METHODS

This prospective study included 30 patients with unresectable pancreatic cancer who received HIFU at Beijing Friendship Hospital. Data on patients' tumor size, pain scores, peripheral blood lymphocyte subsets, CA19-9 and contrast enhanced ultrasound (CEUS) features were collected to assess the relationship with overall survival (OS) after HIFU.

RESULTS

The median OS from the start of HIFU treatment was 159 days, 95% confidence interval (95% CI): 108-210. The levels of pain were determined by visual analogue scale (VAS) score, and the quartile of the score decreased from 6 (2, 7) to 4 (2, 5) immediately after one session of the treatment (p = 0.001). The diagnostic model showed that high post VAS score and decreasing of peripheral CD4+ T cells were significantly correlated with poor prognosis (p < 0.05), and showed good discrimination ability (AUC = 0.848, 95% CI = 0.709-0.987).

CONCLUSION

HIFU can effectively relieve pain in patients with unresectable pancreatic cancer. Post treatment VAS and change of peripheral CD4+ T cells are independent risk factors affecting the prognosis in patients with unresectable pancreatic cancer after HIFU treatment.

Predictors and Consequences of Cancer and Non-Cancer-Related Pain in Those Diagnosed with Primary and Metastatic Cancers

OBJECTIVES

The aims of the study were to (1) describe types of pain in cancer patients, (2) examine the predictors and consequences of pain, (3) investigate the association between type of pain and survival, and (4) examine potential biological mediators of pain and survival.

METHODS

This was a secondary analysis of baseline data from patients diagnosed with cancer. Patients answered questionnaires that assessed sociodemographic characteristics, pain, depression, sleep, and fatigue. Blood was collected and cytokine assays were performed. Analysis of variance, Kaplan-Meier, and Cox regression survival analyses were used to test the aims.

RESULTS

Of the 779 patients diagnosed with cancer, the mean age was 63.5 years, 57.8% male, and 90.6% White. Of those who reported pain (total 70.3%), 46.5% stated their pain was cancer-related while 53.5% stated their pain was non-cancer-related. While both cancer and non-cancer-related pain was associated with depressive symptoms, fatigue, and sleep duration, those with cancer-related pain had significantly higher rates of depressive symptoms (F(1,516) = 21.217, p < 0.001) and fatigue (F(1,516) = 30.973, p < 0.001) but not poorer sleep (F(1,497) = 0.597, p = 0.440). After adjusting for sociodemographic, disease-related characteristics, depression, sleep duration, and morphine milligram equivalent, patient reports of cancer-related pain were significantly associated with poorer survival (HR = 0.646, 95% CI = 0.459-0.910, p = 0.012) compared to those with non-cancer-related pain, which was not associated with survival (HR = 1.022, 95% CI = 0.737-1.418, p = 0.896). Cytokines did not significantly mediate the link between pain and survival.

CONCLUSION

While nearly half of the pain reported was cancer-related, both types of pain resulted in greater symptom burden, but only cancer-related pain was associated with survival.

Thirty-day mortality in hospitalised patients with lung cancer: incidence and predictors

OBJECTIVES

Patients with lung cancer experience high rates of hospitalisation, mainly due to the high risk of complications that emerge during the natural history of the disease. We designed a retrospective, single-centre, observational study aimed at defining the clinical predictors of 30-day mortality in hospitalised patients with lung cancer.

METHODS

Clinical records from the first admission of patients with lung cancer to the oncology ward of the University Hospital of Parma from 1 January 2017 to 1 January 2022 were collected.

RESULTS

251 consecutive patients were enrolled at the time of data cut-off. In the univariate analysis, baseline clinical predictors of 30-day mortality were Eastern Cooperative Oncology Group performance status (ECOG PS) (≥2 vs 0-1: 27.5% vs 14.8%, p=0.028), high Blaylock Risk Assessment Screening Score (BRASS) (high vs intermediate-low: 34.3% vs 11.9%, p<0.001), presence of pain (yes vs no: 24.4% vs 11.7%, p=0.009), number of metastatic sites (≥3 vs <3: 26.5% vs 13.4%, p=0.017) and presence of bone metastases (yes vs no: 29.0% vs 10.8%, p=0.001). In the multivariate analysis, high BRASS remained significantly associated with increased 30-day mortality (high vs intermediate-low; OR 2.87, 95% CI 1.21 to 6.78, p=0.016).

CONCLUSION

Our results suggest that baseline poor ECOG PS, high BRASS, presence of pain, high tumour burden and presence of bone metastases could be used as clinical predictors of 30-day mortality in hospitalised patients with lung cancer. In particular, the BRASS scale should be used as a simple tool to predict 30-day mortality in hospitalised patients with lung cancer.

COMT Val158Met Affects the Analgesic Response to Acupuncture Among Cancer Survivors With Chronic Pain

Catechol-O-methyltransferase (COMT) is the major enzyme involved in the catabolism of dopamine, a neurotransmitter in the brain's reward system. The common COMT polymorphism Val158Met (rs4680 G>A) modulates pain response to opioids through a reward-motivated mechanism; however, its role in nonpharmacological pain medicine has not been clinically characterized. We genotyped 325 participants from a randomized controlled trial of cancer survivors with chronic musculoskeletal pain. We found that carrying methionine at position 158 (158Met) of COMT, encoded by the A allele, significantly increased the analgesic response to electroacupuncture (74% vs 50%; odds ratio [OR]: 2.79; 95% confidence interval [CI]: 1.31, 6.05; P < .01), but not to auricular acupuncture (68% vs 60%; OR: 1.43; 95% CI: .65, 3.12; P = .37) or usual care (24% vs 18%; OR: 1.46; 95% CI: .38, 7.24; P = .61) compared to Val/Val. These findings raise the possibility that COMT Val158Met might be an important predictor of analgesic response to electroacupuncture, providing novel insights into precision nonpharmacologic pain management tailored to individual genetic backgrounds. PERSPECTIVE: This work suggests the modulating effects of the polymorphism in COMT Val158Met on the response to acupuncture. Further research needs to validate these findings, increase the mechanistic understanding of acupuncture, and guide further development of acupuncture as a precision pain management strategy.

Effects of High-Intensity Interval Training and Combined High-Intensity Interval Training Programs on Cancer-Related Fatigue and Cancer Pain: A Systematic Review and Meta-analysis

PURPOSE

This systematic review and meta-analysis assessed the effectiveness of high-intensity interval training (HIIT) alone and combined HIIT programs compared with usual care on cancer-related fatigue (CRF) and pain related to cancer or cancer-related treatments.

METHODS

Articles published prior to January 2023 were searched in the following digital databases: PubMed, Cochrane Database of Systematic Reviews and Cochrane Controlled Clinical Trials (CENTRAL), Web of Science, Scopus and ScienceDirect. Randomized controlled trials were included that met the following criteria: (i) adult cancer patients and survivors (>18 yr old); (ii) HIIT or combined HIIT programs versus usual care; (iii) assessment of fatigue and pain. Cochrane tool was used for assessing Risk of Bias (RoB) and Review Manager (RevMan 5.2) was used for data analysis.

RESULTS

Based on limited number (12) of studies included, we found HIIT and combined HIIT interventions have significant effect sizes on reducing both CRF (standardized mean difference, 0.63; 95% confidence interval, 0.42-0.84; P < 0.001) and cancer-associated pain (standardized mean difference, 0.44; 95% confidence interval, 0.25-0.63; P < 0.001).

CONCLUSIONS

This systematic review and meta-analysis indicate that HIIT and combined HIIT programs can reduce CRF and pain.

The acid-sensing nociceptor TRPV1 controls breast cancer progression in bone via regulating HGF secretion from sensory neurons

Cancers showing excessive innervation of sensory neurons (SN) in their microenvironments are associated with poor outcomes due to promoted growth, increased tumor recurrence, metastasis, and cancer pain, suggesting SNs play a regulatory role in cancer aggressiveness. Using a preclinical model in which mouse 4T1 breast cancer (BC) cells were injected into the bone marrow of tibiae, we found 4T1 BC cells aggressively colonized bone with bone destruction and subsequently spread to the lung. Of note, 4T1 BC colonization induced the acidic tumor microenvironment in bone in which SNs showed increased innervation and excitation with elevated expression of the acid-sensing nociceptor transient receptor potential vanilloid-1 (TRPV1), eliciting bone pain (BP) assessed by mechanical hypersensitivity. Further, these excited SNs produced increased hepatocyte growth factor (HGF). Importantly, the administration of synthetic and natural TRPV1 antagonists and genetic deletion of TRPV1 decreased HGF production in SNs and inhibited 4T1 BC colonization in bone, pulmonary metastasis from bone, and BP induction. Our results suggest the TRPV1 of SNs promotes BC colonization in bone and lung metastasis via up-regulating HGF production in SNs. The SN TRPV1 may be a novel therapeutic target for BC growing in the acidic bone microenvironment and for BP.

SIO-ASCO guideline on integrative medicine for cancer pain management: implications for racial and ethnic pain disparities

Racial and ethnic disparities in pain management pose major challenges to equitable cancer care delivery. These disparities are driven by complex interactions between patient-, provider-, and system-related factors that resist reductionistic solutions and require innovative, holistic approaches. On September 19, 2022, the Society for Integrative Oncology and the American Society of Clinical Oncology published a joint guideline to provide evidence-based recommendations on integrative medicine for cancer pain management. Integrative medicine, which combines conventional treatments with complementary modalities from cultures and traditions around the world, are uniquely equipped to resonate with diverse cancer populations and fill existing gaps in pain management. Although some complementary modalities, such as music therapy and yoga, lack sufficient evidence to make a specific recommendation, other modalities, such as acupuncture, massage, and hypnosis, demonstrated an intermediate level of evidence, resulting in moderate strength recommendations for their use in cancer pain management. However, several factors may hinder real-world implementation of the Society for Integrative Oncology and the American Society of Clinical Oncology guideline and must be addressed to ensure equitable pain management for all communities. These barriers include, but are not limited to, the lack of insurance coverage for many complementary therapies, the limited diversity and availability of complementary therapy providers, the negative social norms surrounding complementary therapies, the underrepresentation of racial and ethnic subgroups in the clinical research of complementary therapies, and the paucity of culturally attuned interventions tailored to diverse individuals. This commentary examines both the challenges and the opportunities for addressing racial and ethnic disparities in cancer pain management through integrative medicine.

Effects of Opioids on Immune and Endocrine Function in Patients with Cancer Pain

OPINION STATEMENT

Opioids are an important treatment in managing cancer pain. Uncontrolled pain can be detrimental to function and quality of life. Common adverse effects of opioids such as sedation, constipation and nausea are well recognised, but opioid effects on the endocrine and immune systems are less apparent. The evidence for the immunomodulatory effects of opioids suggest that some opioids might be immunosuppressive and that their use might be associated with reduced survival and increased rates of infection in patients with cancer. However, the quality of this evidence is limited. Opioid-induced endocrinopathies, in particular opioid-induced hypogonadism, may also impact cancer survival and impair quality of life. But again, evidence in patients with cancer is limited, especially with regard to their management. There are some data that different opioids influence immune and endocrine function with varying outcomes. For example, some opioids, such as tramadol and buprenorphine, demonstrate immune-sparing qualities when compared to others. However, most of this data is preclinical and without adequate clinical correlation; thus, no opioid can currently be recommended over another in this context. Higher opioid doses might have more effect on immune and endocrine function. Ultimately, it is prudent to use the lowest effective dose to control the cancer pain. Clinical presentations of opioid-induced endocrinopathies should be considered in patients with cancer and assessed for, particularly in long-term opioid users. Hormone replacement therapies may be considered where appropriate with support from endocrinology specialists.

Mapping the Evidence for Opioid-Mediated Changes in Malignancy and Chemotherapeutic Efficacy: Protocol for a Scoping Review

BACKGROUND

Numerous reports contend opioids can augment or inhibit malignancy. At present, there is no consensus on the risk or benefit posed by opioids on malignancy or chemotherapeutic activity. Distinguishing the consequences of opioid use from pain and its management is challenging. Additionally, opioid concentration data is often lacking in clinical studies. A scoping review approach inclusive of preclinical and clinical data will improve our understanding of the risk-benefit relationship concerning commonly prescribed opioids and cancer and cancer treatment.

OBJECTIVE

The aim of the study is to map diverse studies spanning from preclinical to clinical regarding opioids with malignancy and its treatment.

METHODS

This scoping review will use the Arksey six stages framework to (1) identify the research question; (2) identify relevant studies; (3) select studies meeting criteria; (4) extract and chart data; (5) collate, summarize, and report results; and (6) conduct expert consultation. An initial pilot study was undertaken to (1) parameterize the extent and scale of existing data for an evidence review, (2) identify key factors to be extracted in systematic charting efforts, and (3) assess opioid concentration as a variable for its relevance to the central hypothesis. Six databases will be searched with no filters: MEDLINE, Embase, CINAHL Complete, Cochrane Library, Biological Sciences Collection, and International Pharmaceutical Abstracts. Trial registries will include ClinicalTrials.gov, Cochrane CENTRAL, International Standard Randomised Controlled Trial Number Registry, European Union Clinical Trials Register, and World Health Organization International Clinical Trials Registry. Eligibility criteria will include preclinical and clinical study data on opioids effects on tumor growth or survival, or alteration on the antineoplastic activity of chemotherapeutics. We will chart data on (1) opioid concentration from human subjects with cancer, yielding a "physiologic range" to better interpret available preclinical data; (2) patterns of opioid exposure with disease and treatment-related patient outcomes; and (3) the influence of opioids on cancer cell survival, as well as opioid-related changes to cancer cell susceptibility for chemotherapeutics.

RESULTS

This scoping review will present results in narrative forms as well as with the use of tables and diagrams. Initiated in February 2021 at the University of Utah, this protocol is anticipated to generate a scoping review by August 2023. The results of the scoping review will be disseminated through scientific conference proceedings and presentations, stakeholder meetings, and by publication in a peer-reviewed journal.

CONCLUSIONS

The findings of this scoping review will provide a comprehensive description of the consequences of prescription opioids on malignancy and its treatment. By incorporating preclinical and clinical data, this scoping review will invite novel comparisons across study types that could inform new basic, translational, and clinical studies regarding risks and benefits of opioid use among patients with cancer.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/38167.

Cancer-nerve interplay in cancer progression and cancer-induced bone pain

INTRODUCTION

Cancer-induced bone pain (CIBP) is one of the most common and debilitating complications associated with bone metastasis. Although our understanding of the precise mechanism is limited, it has been known that bone is densely innervated, and that CIBP is elicited as a consequence of increased neurogenesis, reprogramming, and axonogenesis in conjunction with sensitization and excitation of sensory nerves (SNs) in response to the noxious stimuli that are derived from the tumor microenvironment developed in bone. Recent studies have shown that the sensitized and excited nerves innervating the tumor establish intimate communications with cancer cells by releasing various tumor-stimulating factors for tumor progression.

APPROACHES

In this review, the role of the interactions of cancer cells and SNs in bone in the pathophysiology of CIBP will be discussed with a special focus on the role of the noxious acidic tumor microenvironment, considering that bone is in nature hypoxic, which facilitates the generation of acidic conditions by cancer. Subsequently, the role of SNs in the regulation of cancer progression in the bone will be discussed together with our recent experimental findings.

CONCLUSION

It is suggested that SNs may be a newly-recognized important component of the bone microenvironment that contribute to not only in the pathophysiology of CIBP but also cancer progression in bone and dissemination from bone. Suppression of the activity of bone-innervating SNs, thus, may provide unique opportunities in the treatment of cancer progression and dissemination, as well as CIBP.

Survival Outcomes Associated With the Size of Opioid Prescriptions in the Management of Chronic Pain Related to Advanced Nasopharyngeal Carcinoma

OBJECTIVE

Patients with advanced nasopharyngeal carcinoma (ANC) often experience chronic pain. Opioids are generally recommended to treat tumor-related pain, but increased opioid use may lead to detrimental aftereffects, particularly with respect to tumor progression, resulting in reduced quality of life and increased risk of death. Our objective was to investigate whether the high size of opioid prescriptions is associated with poor overall survival (OS) in patients with ANC.

METHODS

A consecutive cohort of patients with newly diagnosed ANC who underwent high or low opioid prescription size treatment during 2012-2019 was retrospectively identified from our medical institutions. Survival was estimated with the Kaplan-Meier method with a log-rank test. Multivariate binary logistic regression was used to assess the association between opioid use and OS, adjusting for age, sex, body mass index (BMI), Eastern Collaborative Oncology Group performance status (ECOG PS), and ANC histology. The criterion to distinguish between the high opioid prescription size group [HD] and the low opioid prescription size group [LD] was 5 mg of oral morphine equivalents (OME) per 24 hours.

RESULTS

The cohort consisted of 244 consecutive patients (HD: n = 120, median age = 66 years [range, 40-81 years]; LD: n = 124, median age = 65 years [40-82 years]. Patients who underwent treatment with a high opioid prescription size had a worse median OS than those who underwent treatment with a low opioid prescription size (5.1 vs 6.6 months), and the high opioid prescription size was associated with a remarkable 48% higher risk of death than the low opioid prescription size (HR 1.48, 95% CI 1.11-1.98; P = .005). The cumulative dose of opioids greater than or equal to 500 mg of OME was associated with a higher risk of death, adjusted for age, sex, BMI, ECOG PS, and ANC histology.

CONCLUSIONS

In patients with newly diagnosed ANC experiencing palliative care, a high opioid prescription size may be associated with shorter OS than a low opioid prescription size.

Effect of Opioids on Survival in Patients with Cancer

Opioids are commonly used for pain management in patients with cancer. They have a range of unwanted effects, including some that potentially influence cancer growth. This article reviews the data assessing the effects of opioids on survival in patients with cancer. Many studies assessing this show an association between opioids and decreased survival. This effect is present even at very low doses of opioids. These studies do not assess causality, so it is not known if it is a direct effect of opioids on survival. As the control groups are not matched to the opioid group it might be that opioids are being used to control pain and patients receiving opioids have more aggressive cancers and it is the underlying cancer which is causing the decreased survival. Furthermore, although some studies allude to different opioids having different effects on survival, often all opioids are pooled in analysis. Future work needs to try to ascertain causality and differentiate between different opioids, pain, and cancer-mediated effects on survival in specific cancer types. Until then, opioids should continue to be used in patients with cancer as part of measures to optimise comfort and quality of life.

Impact of opioid analgesics on the efficacy of immune checkpoint inhibitors in a lung cancer population

OBJECTIVE

A retrospective clinical study was conducted to compare the prognosis between the opioid analgesic (OA) treated and OA-untreated groups and to evaluate the effect of opioid analgesics on the efficacy of immune checkpoint inhibitors (ICIs) in the treatment of advanced lung cancer patients. In addition, a subgroup analysis of the clinical characteristics of the enrolled patients was performed to explore possible influencing factors.

METHODS

This study reviewed the medical records of eligible patients who received ICIs at our institution. The clinicopathological features and clinical outcomes were compared. Also, the use of OA was collected. Patient survival, the incidence of immune-related adverse events (irAEs), and other baseline variables were examined in both cohorts according to whether OA was used.

RESULTS

A total of 132 patients were included in the study. Of them, 39 (29.5%) were in the OA-treated group. No significant differences in baseline characteristics were observed between the OA-treated and untreated groups. The combined application of OA treatment significantly shortened progression-free survival (PFS) (P < 0.001) and overall survival (OS) (P = 0.002). However, both groups experienced similar incidences and gradations of irAEs. According to multivariate analysis, OA treatment resulted in significantly worse PFS (HR = 4.994, 95% CI 3.217-7.753, P < 0.001) and OS (HR = 3.618, 95% CI 2.030-6.240, P < 0.001).

CONCLUSIONS

Clinical outcomes of ICIs were significantly diminished in a cohort of Chinese patients with advanced lung cancer receiving OA therapy.

Prevalence and management of pain in lung cancer patients in northern China: A multicenter cross-sectional study

Background

Pain is a fearful yet common symptom among lung cancer patients. This multicenter, cross‐sectional study was conducted to examine the current status of pain prevalence and management in lung cancer patients in northern China.

Methods

A total of 18 hospitals across northern China were selected. Patients with primary lung cancer who visited the outpatient clinic or were admitted in the wards on a preplanned day were invited to complete a questionnaire. Meanwhile, physicians who had experience of treating primary lung cancer patients were also surveyed.

Results

A total of 533 patients and 197 physicians provided valid responses to the survey, of which 45.4% (242/533) of patients reported pain during the course of disease and 24.2% (129/533) of patients had experienced pain within the past 24 h. The mean average pain intensity by the brief pain inventory was 3.47 ± 1.55. The binary logistic regression analysis showed female gender and stage IV disease were significantly associated with the presence of pain. A total of 74.4% (96/129) of patients reporting pain within 24 h were taking analgesics. The most common reason for patients not using analgesics was that the pain was tolerable (48.2%), while the most common barriers to prescribing opioids as reported by physicians were fear of adverse reactions (43.7%) and fear of addiction (43.1%).

Conclusion

Despite recognition of the importance of pain control by most physicians and an improvement in cancer pain management, inadequate treatment of cancer pain still exists in lung cancer patients in northern China. High‐quality pain education for both patients and physicians is needed in the future.

Opioids in cancer: The κ‑opioid receptor (Review)

The κ‑opioid receptor (KOR) is one of the primary receptors of opioids and serves a vital role in the regulation of pain, anesthesia, addiction and other pathological and physiological processes. KOR is associated with several types of cancer and may influence cancer progression. It has been proposed that KOR may represent a new tumor molecular marker and provide a novel basis for molecular targeted therapies for cancer. However, the association between KOR and cancer remains to be explored comprehensively. The present review introduces KOR and its association with different types of cancer. Improved understanding of KOR may facilitate development of novel antitumor therapies.

Effect of Continuing Nursing Education on the Quality of Nursing Management of Cancer Pain in China

BACKGROUND

Limited knowledge and poor attitudes toward pain are major barriers to nursing management of cancer pain. This study investigated the effect of continuing nursing education (CNE) on the management of cancer pain.

METHOD

Annual CNE was provided from 2016 to 2019, and evaluation of nursing management of cancer pain was conducted every 2 years. The effect of CNE was determined based on the evaluation results.

RESULTS

After annual CNE, the participating hospitals showed significant improvement in nursing management of cancer pain. Annual CNE significantly increased subscores in all domains except the domain of initial pain assessment. In terms of hospital levels, nursing management of cancer pain was significantly improved only for tertiary A hospitals.

CONCLUSION

Annual CNE significantly improved nursing management of cancer pain. [J Contin Educ Nurs. 2021;52(11):535-540.].

Sensory nerves: A driver of the vicious cycle in bone metastasis?

Bone is one of the preferential target organs of cancer metastasis. Bone metastasis is associated with various complications, of which bone pain is most common and debilitating. The cancer-associated bone pain (CABP) is induced as a consequence of increased neurogenesis, reprogramming and axonogenesis of sensory nerves (SNs) in harmony with sensitization and excitation of SNs in response to the tumor microenvironment created in bone. Importantly, CABP is associated with increased mortality, of which precise cellular and molecular mechanism remains poorly understood. Bone is densely innervated by autonomic nerves (ANs) (sympathetic and parasympathetic nerves) and SNs. Recent studies have shown that the nerves innervating the tumor microenvironment establish intimate communications with tumors, producing various stimuli for tumors to progress and disseminate. In this review, our current understanding of the role of SNs innervating bone in the pathophysiology of CABP will be overviewed. Then the hypothesis that SNs facilitate cancer progression in bone will be discussed in conjunction with our recent findings that SNs play an important role not only in the induction of CABP but also the progression of bone metastasis using a preclinical model of CABP. It is suggested that SNs are a critical component of the bone microenvironment that drives the vicious cycle between bone and cancer to progress bone metastasis. Suppression of the activity of bone-innervating SNs may have potential therapeutic effects on the progression of bone metastasis and induction of CABP.

Prevalence and Severity of Pain in Cancer Patients in Germany

Pain is a common symptom in cancer patients, restricts daily life activities and reduces survival time. Identification of sociodemographic, medical and psychological correlates of pain among cancer patients in Germany could help identify subgroups most in need of pain management. In this multicenter, epidemiologic cross-sectional study, we assessed pain prevalence and severity, quality of life (QoL) and psychological distress in a sample of 3,745 cancer patients across all tumor entities. In total, 37.9% patients suffered from cancer-related pain and 56.1% suffered from non-specific pain. Younger, female, less educated and unemployed patients reported pain more frequently and more severe pain (p < 0.001). Pain was associated with distress, depression, anxiety, QoL, tumor stage (p < 0.001), and time since diagnosis (p = 0.012). Pain assessment and pain management should be a routine part of cancer treatment and cancer survivorship care plans.

Palliative Radiotherapy for Advanced Cancers: Indications and Outcomes

Palliative radiotherapy (PRT) is well-tolerated, effective treatment for pain, bleeding, obstruction, and other symptoms/complications of advanced cancer. It is an important component of multidisciplinary management. It should be considered even for patients with poor prognosis, because it can offer rapid symptomatic relief. Furthermore, expanding indications for treatment of noncurable disease have shown that PRT can extend survival for select patients. For those with good prognosis, advanced PRT techniques may improve the therapeutic ratio, maximizing tumor control while limiting toxicity. PRT referral should be considered for any patient with symptomatic or asymptomatic sites of disease where local control is desired.

Herbal Topical Analgesic for Pain Management: Perspectives from Cancer Patients

OBJECTIVE

Herbs and natural products are increasingly used by cancer patients for pain management, but few studies have examined their integration within conventional cancer care. This study describes the characteristics, experiences, and perspectives of cancer patients who were prescribed an herbal topical analgesic for pain management.

DESIGN AND SETTING

Program evaluation of a pilot herbal dispensary at a National Cancer Institute-designated comprehensive cancer center.

SUBJECTS

Cancer patients who were prescribed the Tibetree Pain-Relieving Plaster (PRP) by an integrative medicine physician.

METHODS

Sociodemographic and clinical characteristics of patients were abstracted from medical records. Semistructured phone interviews were conducted 1-2 weeks after PRP prescription to evaluate patient experiences with using PRP for pain. Interviews were analyzed through thematic content analysis.

RESULTS

From February 2019 to February 2020, 50 patients were prescribed PRP. Median age (range) was 63 years (21-86), 37 patients (74%) were female, 14 (28%) were non-White, and 38 (76%) were using oral analgesics. During interviews, the majority of patients reported that the PRP improved pain and health-related outcomes, was convenient to use, and addressed pain management needs that were not fulfilled by oral analgesics. However, a few patients described adverse experiences with PRP, including skin irritation.

CONCLUSIONS

Understanding patient experiences and perspectives is a critical step toward evidence-based integration of herbs and natural products into cancer pain management. Findings from this program evaluation will inform the design of a randomized clinical trial on the efficacy and safety of PRP for pain in patients with cancer.

Anesthesia Medications and Interaction with Chemotherapeutic Agents

Cancer is now a leading health concern worldwide. In an effort to provide these patients with adequate care, coordination between anesthesiologists and surgeons is crucial. In cancer-related treatment, it is very clear that radio-chemotherapy and medical procedures are important. There are some obstacles to anesthesia when dealing with cancer treatment, such as physiological disturbances, tumor-related symptoms, and toxicity in traditional chemotherapy treatment. Therefore, it is important that a multisystemic, multidisciplinary and patient-centered approach is used to preserve perioperative homeostasis and immune function integrity. Adding adjuvants can help increase patient safety and satisfaction and improve clinical efficacy. Correctly paired anesthetic procedures and medications will reduce perioperative inflammatory and immune changes that could potentially contribute to improved results for future cancer patients. Further research into best practice strategies is required which will help to enhance the acute and long-term effects of cancer care in clinical practice.

Clinical Predictors of Early Trial Discontinuation for Patients Participating in Phase I Clinical Trials in Oncology

Simple Summary

About 20% of patients with cancer who participate in a phase I clinical trial discontinue the trial early. Early trial discontinuation is undesirable both for the wellbeing of the patient as well as for the trial efficiency and the development of new anticancer drugs. We investigated which clinical predictors at baseline were significantly associated with early trial discontinuation of patients with cancer who participated in phase I clinical trials. The clinical predictors which were identified in this study were hyponatremia, elevated alkaline phosphatase level, performance score of 1 or higher and opioid use. Hyponatremia especially, which was the strongest predictor, should be considered to be used as an additional eligibility criterion in order to reduce the early trial discontinuation of patients with cancer who participate in phase I clinical trials.

Abstract

Despite stringent eligibility criteria for trial participation, early discontinuation often occurs in phase I trials. To better identify patients unlikely to benefit from phase I trials, we investigated predictors for early trial discontinuation. Data from 415 patients with solid tumors who participated in 66 trials were pooled for the current analysis. Early trial discontinuation was defined as (i) trial discontinuation within 28 days after start of treatment or (ii) discontinuation before administration of the first dosage in eligible patients. Multilevel logistic regression analyses were conducted to identify predictors for early trial discontinuation. Eighty-two participants (20%) demonstrated early trial discontinuation. Baseline sodium level below the lower limit of normal (OR = 2.95, 95%CI = 1.27–6.84), elevated alkaline phosphatase level > 2.5 times the upper limit of normal (OR = 2.72, 95%CI = 1.49–4.99), performance score ≥ 1 (OR = 2.07, 95%CI = 1.03–4.19) and opioid use (OR = 1.82, 95%CI = 1.07–3.08) were independent predictors for early trial discontinuation. Almost 50% of the patients with hyponatremia and all four patients in whom all four predictors were present together discontinued the trial early. Hyponatremia, elevated alkaline phosphatase level, performance score ≥ 1 and opioid use were identified as significant predictors for early trial discontinuation. Hyponatremia was the strongest predictor and deserves consideration for inclusion in eligibility criteria for future trials.

Effectiveness of Electroacupuncture or Auricular Acupuncture vs Usual Care for Chronic Musculoskeletal Pain Among Cancer Survivors: The PEACE Randomized Clinical Trial

Importance

The opioid crisis creates challenges for cancer pain management. Acupuncture confers clinical benefits for chronic nonmalignant pain, but its effectiveness in cancer survivors remains uncertain.

Objective

To determine the effectiveness of electroacupuncture or auricular acupuncture for chronic musculoskeletal pain in cancer survivors.

Design, Setting, and Participants

The Personalized Electroacupuncture vs Auricular Acupuncture Comparative Effectiveness (PEACE) trial is a randomized clinical trial that was conducted from March 2017 to October 2019 (follow-up completed April 2020) across an urban academic cancer center and 5 suburban sites in New York and New Jersey. Study statisticians were blinded to treatment assignments. The 360 adults included in the study had a prior cancer diagnosis but no current evidence of disease, reported musculoskeletal pain for at least 3 months, and self-reported pain intensity on the Brief Pain Inventory (BPI) ranging from 0 (no pain) to 10 (worst pain imaginable).

Interventions

Patients were randomized 2:2:1 to electroacupuncture (n = 145), auricular acupuncture (n = 143), or usual care (n = 72). Intervention groups received 10 weekly sessions of electroacupuncture or auricular acupuncture. Ten acupuncture sessions were offered to the usual care group from weeks 12 through 24.

Main Outcomes and Measures

The primary outcome was change in average pain severity score on the BPI from baseline to week 12. Using a gatekeeping multiple-comparison procedure, electroacupuncture and auricular acupuncture were compared with usual care using a linear mixed model. Noninferiority of auricular acupuncture to electroacupuncture was tested if both interventions were superior to usual care.

Results

Among 360 cancer survivors (mean [SD] age, 62.1 [12.7] years; mean [SD] baseline BPI score, 5.2 [1.7] points; 251 [69.7%] women; and 88 [24.4%] non-White), 340 (94.4%) completed the primary end point. Compared with usual care, electroacupuncture reduced pain severity by 1.9 points (97.5% CI, 1.4-2.4 points; P < .001) and auricular acupuncture reduced by 1.6 points (97.5% CI, 1.0-2.1 points; P < .001) from baseline to week 12. Noninferiority of auricular acupuncture to electroacupuncture was not demonstrated. Adverse events were mild; 15 of 143 (10.5%) patients receiving auricular acupuncture and 1 of 145 (0.7%) patients receiving electroacupuncture discontinued treatments due to adverse events (P < .001).

Conclusions and Relevance

In this randomized clinical trial among cancer survivors with chronic musculoskeletal pain, electroacupuncture and auricular acupuncture produced greater pain reduction than usual care. However, auricular acupuncture did not demonstrate noninferiority to electroacupuncture, and patients receiving it had more adverse events.

Trial Registration

ClinicalTrials.gov Identifier: NCT02979574.

Effects of Three Consecutive Days of Morphine or Methadone Administration on Analgesia and Open-Field Activity in Mice with Ehrlich Carcinoma

This study assessed the exploratory behavioral responses in BALB/c mice inoculated with Ehrlich ascitic carcinoma after 3 consecutive days of treatment with morphine or methadone. Fifty-three female mice, 60 ± 10 d old, were used. Seven days after intraperitoneal tumor inoculation (2 × 10⁶ cells), the animals were randomized into 7 groups: morphine 5 mg/kg (MO₅), morphine 7.5 mg/kg (MO_7.5), morphine 10 mg/kg (MO₁₀), methadone 2.85 mg/kg (ME_2.85), methadone 4.3 mg/kg (ME_4.3), methadone 5.7 mg/kg (ME_5.7), and 0.9% NaCl (Saline) (n = 7). Drug treatments were administered subcutaneously every 6 h for 3 d. The animals were evaluated for analgesia using the mouse grimace scale (MGS) and for general activity using the open field test. The MGS was performed before tumor inoculation (day 0), on day 7 at 40, 90, 150, 240, and 360 min after drug injection, and on days 8 and 9 at 40, 150, 240, and 360 min after drug injection. The open field test was performed before tumor inoculation (day 0), on day 7 after inoculation at 40, 90, 150, 240, and 360 min after drug injection, and on days 8 and 9 after inoculation at 40, 150, and 360 min after drug injection. MGS results indicated that administration of morphine promoted analgesia for up to 240 min. Conversely, methadone reduced MGS scores only at 40 min. All tested doses promoted a significant dose-dependent increase in the total distance traveled and the average speed, and increase that was markedly pronounced on days 8 and 9 as compared with day 7. The frequencies of rearing and self-grooming decreased significantly after morphine or methadone administration. Despite the difference in analgesia, both drugs increased locomotion and reduced the frequency of rearing and self-grooming as compared with the untreated control animals.

β-endorphin at the intersection of pain and cancer progression: Preclinical evidence

We examined the association between endogenous opioid β-endorphin, cancer progression and pain in a transgenic mouse model of breast cancer, with a rat C3(1) simian virus 40 large tumor antigen fusion gene (C3TAg). C3TAg mice develop ductal epithelial atypia at 8 weeks, progression to intra-epithelial neoplasia at 12 weeks, and invasive carcinoma with palpable tumors at 16 weeks. Consistent with invasive carcinoma at 4 months of age, C3TAg mice demonstrate a significant increase in hyperalgesia compared to younger C3TAg or control FVBN mice without tumors. Our data show that the growing tumor contributes to circulating β-endorphin. As an endogenous ligand of mu opioid receptor, β-endorphin has analgesic activity. Paradoxically, we observed an increase in pain in transgenic breast cancer mice with significantly high circulating and tumor-associated β-endorphin. Increased circulating β-endorphin correlates with increasing tumor burden. β-endorphin induced the activation of mitogenic and survival-promoting signaling pathways, MAPK/ERK 1/2, STAT3 and Akt, observed by us in human MDA-MB-231 cells suggesting a role for β-endorphin in breast cancer progression and associated pain.

Impact of Pain, Opioids, and the Mu-opioid Receptor on Progression and Survival in Patients With Newly Diagnosed Stage IV Pancreatic Cancer

OBJECTIVES

Pancreatic adenocarcinoma is frequently associated with pain requiring opioid therapy. Opioids, however, have been implicated in causing tumor progression, ultimately shortening survival. We examined the impact of pain, opioid use, and the mu-opioid receptor (MOP-R) expression in tumor tissue on progression-free survival and overall survival of patients with metastatic pancreatic cancer.

METHODS

We identified 103 patients with metastatic pancreatic adenocarcinoma receiving chemotherapy and abstracted data from Tumor Registry, in addition to pain, opioid exposure, carbohydrate antigen 19-9 values, survival, and imaging response. MOP-R expression was evaluated using an immunohistochemistry assay. The association of variables with progression-free survival and overall survival was analyzed in univariate and multivariate models.

RESULTS

Patients with low opioid use (<5 mg oral morphine equivalent/d) survived longer than patients with high opioid (HO) use (≥5 mg oral morphine equivalent/d) (median overall survival of 315 vs. 150 d; hazard ratio [HR]=1.79; 95% confidence interval [CI]: 1.13, 2.84). This effect persisted on multivariate models (adjusted HR=2.76; 95% CI: 1.39, 5.48). Low opioid patients tended to respond better to treatment than HO patients, based on carbohydrate antigen 19-9. Patients with low MOP-R expression had longer median survival (230 vs. 193 d), though the HR was not significant (1.15; 95% CI: 0.71, 1.88). Baseline pain was not associated with outcomes.

CONCLUSION

In patients with metastatic pancreatic adenocarcinoma, HO use is associated with decreased survival, but the severity of baseline pain and MOP-R expression score in tumor tissue does not correlate with clinical outcomes.

Prospective patient-reported symptom profiles associated with pediatric acute lymphoblastic leukemia relapse

PURPOSE

Despite improvements in frontline pediatric acute lymphoblastic leukemia (ALL) treatment, relapse remains a concern. Research in adult cancer patients suggests that patient-reported symptoms may predict survival, but the relationship between symptoms and relapse for pediatric ALL has received little attention.

METHODS

Pediatric patients with ALL (age 2-18 years) and/or their primary caregivers completed symptom surveys at the end of induction, start of delayed intensification (DI), start of maintenance cycle 1 (MC1), and start of maintenance cycle 2 (MC2). Symptom clusters for co-occurring fatigue, pain, sleep disruptions, and nausea were defined using latent profile analysis. Hazard ratios (HR) and 95% confidence intervals (CI) for the association between symptom clusters, individual symptoms, and subsequent relapse were calculated using multivariable Cox proportional hazards models, adjusting for clinical and demographic factors.

RESULTS

Eligible patients (n = 208) were followed an average of 2.6 years for the incidence of relapse (n = 22). Associations between relapse and symptoms were identified for fatigue at DI (HR = 1.83, 95%CI 1.23-2.73) and MC1 (HR = 2.14, 95%CI 1.62-2.84), pain at DI (HR = 1.80, 95%CI 1.19-2.72), nausea at the end of induction (HR = 1.19, 95%CI 1.01-1.39), and sleep disturbances at the end of induction (HR = 2.00, 95%CI 1.11-3.62), DI (HR = 1.73, 95%CI 1.01-2.96), and MC1 (HR = 2.19, 95%CI 1.10-4.35). Symptom clusters comprised of individuals with a higher average symptom burden at DI were significantly (p < 0.05) associated with relapse.

CONCLUSION

Patient-reported symptoms may provide prognostic information to aid in the identification of pediatric ALL patients at increased risk of relapse.

Associations between baseline symptom burden as assessed by patient-reported outcomes and overall survival of patients with metastatic cancer

BACKGROUND

Serial symptom assessments using patient-reported outcomes may be challenging to implement in routine clinical practices. We aimed to determine if a single measurement of symptom burden at the time of metastatic diagnosis is associated with survival.

METHODS

We examined baseline patient-reported outcomes (within 90 days of diagnosis) of patients newly diagnosed with metastatic breast, lung, colorectal, or prostate cancer using the revised Edmonton Symptom Assessment System (ESASr) questionnaire. The ESASr was categorized into physical, psychological, and total symptom domains whereby scores were classified as none to mild (0-3) or moderate to severe (4-10). Multivariable Cox proportional hazards models were constructed to evaluate the effect of baseline symptom scores on overall survival.

RESULTS

We identified 1316 patients eligible for analysis. There were 181, 601, 240, and 294 patients with breast, lung, colorectal, and prostate cancer, respectively. Approximately one-quarter of all patients reported moderate to severe physical, psychological, and total symptom subscores. On multivariable Cox regression analysis, older age (P < 0.001), male sex (P = 0.002), primary lung cancer (P < 0.001), and smoking in the previous month (P = 0.007) were predictive of inferior overall survival as were baseline moderate to severe physical (hazard ratio, 1.49; 95% confidence interval, 1.16-1.90; P = 0.002) and total symptom subscores (hazard ratio, 1.38; 95% confidence interval, 1.06-1.81; P = 0.017).

CONCLUSIONS

A single assessment of baseline symptom burden using the ESASr in patients with metastatic cancer has significant prognostic value. This may represent a feasible first step towards routine collection of patient-reported outcomes in real-world settings where serial symptom measurements can be challenging to implement.

Personalized electro-acupuncture versus auricular-acupuncture comparative effectiveness (PEACE): A protocol of a randomized controlled trial for chronic musculoskeletal pain in cancer survivors

INTRODUCTION

Chronic pain is a leading cause of disability and remains under-treated in nearly half of patients with cancer. The opioid crisis has highlighted an urgent public health need for effective nonpharmacological pain management. Electroacupuncture (EA) and Battlefield Acupuncture (BFA) represent nonpharmacological modalities used in clinical practice to manage pain; however, their effectiveness has not been rigorously evaluated in oncology settings.

METHODS

We describe the design of a 3-arm, parallel, single-center, multisite randomized controlled trial that investigates EA and BFA versus usual-care wait-list control (WLC) for chronic musculoskeletal pain among 360 patients with diverse cancer types across various stages. The primary aim is to compare effects of EA and BFA versus WLC on pain, physical function, and co-morbid symptoms. The secondary aim is to examine the interaction between patient outcome expectancy and acupuncture modality (EA vs BFA) on pain reduction. The tertiary aim is to evaluate the association between genetic polymorphisms and responses to acupuncture. Patients will be randomized in a 2:2:1 ratio to EA:BFA:WLC. Acupuncture groups will receive weekly treatments over 10 weeks. WLC will receive usual care over the same evaluation period as the acupuncture groups. The primary endpoint will be the change in average pain intensity score from baseline to week 12. We will collect validated patient-reported outcomes and blood/saliva samples at multiple timepoints over 24 weeks.

DISCUSSION

Our findings will advance nonpharmacological pain management in oncology and inform personalized treatment approaches that integrate individuals' expectations and genetic biomarkers to deliver "precision" acupuncture to cancer patients with chronic pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02979574.

Fear of analgesic side effects predicts preference for acupuncture: a cross-sectional study of cancer patients with pain in the USA

PURPOSE

Approximately one in two cancer patients globally are under-treated for pain. Opioids and other analgesics represent the mainstay of cancer pain management; however, barriers to their use are well-documented. We evaluated whether acupuncture would be a preferable treatment option among cancer patients with attitudinal barriers to pharmacological pain management.

METHODS

We conducted a cross-sectional survey of cancer patients at a tertiary urban cancer center and eleven suburban/rural hospitals in the Northeastern United States. We assessed attitudinal barriers to pharmacological pain management with the Barriers Questionnaire (BQ-13). The BQ-13 consists of two subscales: pain management beliefs and analgesic side effects. We also asked patients whether they prefer acupuncture, analgesics, or have no preference between these two modalities for pain management. Covariates included sociodemographics, clinical characteristics, and attitudes/beliefs about acupuncture. We used logistic regression to examine the association between attitudinal barriers and acupuncture preference.

RESULTS

Among 628 patients, 197 (31.4%) preferred acupuncture for pain management, 146 (23.3%) preferred analgesics, and 285 (45.4%) had no preference. The highest reported attitudinal barriers were fear of addiction and fear of analgesic-associated constipation and nausea. Adjusting for covariates, we found that attitudinal barriers related to fear of analgesic side effects were significantly associated with acupuncture preference (adjusted odds ratio [AOR] 1.45, 95% confidence interval [CI] 1.17-1.81), but barriers related to pain management beliefs were not (AOR 1.17, 95% CI 0.91-1.51). Attitudes/beliefs about acupuncture (i.e., greater expected benefits, fewer perceived barriers, and more positive social norms) and female gender also predicted acupuncture preference, whereas race and educational status did not.

CONCLUSION

Acupuncture may be a preferable treatment option among cancer patients at risk of inadequately controlled pain due to fear of analgesic side effects. Evidence-based integration of acupuncture and analgesics, guided by patient treatment preferences, represents an essential aspect of patient-centered care and has potential to address unmet cancer pain management needs.

Do Longitudinally Collected Symptom Scores Predict Time to Death in Advanced Breast Cancer: A Joint Modeling Analysis

CONTEXT

Patients with advanced breast cancer have low rates of survival that can be associated with symptom burden.

OBJECTIVES

This study seeks to characterize the effect of longitudinally collected symptom scores on predicting time to death for patients with advanced breast cancer.

METHODS

A cohort of 993 Stage IV breast cancer patients was constructed using linked population-level health administrative databases that captured longitudinally collected symptom data using the Edmonton Symptom Assessment System. Data were captured on individual symptom scores (20,371 assessments) for pain, tiredness, drowsiness, nausea, appetite, dyspnea, depression, anxiety, and wellbeing, as well as three summative scores of total symptom distress score, physical subscore, and psychological subscore. A joint modeling approach was undertaken to simultaneously model repeated-measures longitudinal data and time-to-event data.

RESULTS

Of patients who died in the study, 56.11% survived for a mean time of less than three years and had lower mean symptom scores for all symptoms except shortness of breath, in comparison with patients who lived for more than three years. Symptom burden was predictive of patient time to death for all symptoms, with risk of death increasing with worsening symptom scores. For total symptom distress score, age at diagnosis (0.009; P < 0.05), chemotherapy (-0.63; P < 0.001), and palliative care (3.15; P < 0.001) were significant predictors of patient time to death.

CONCLUSION

Patients with advanced breast cancer experience chronic ongoing low symptom burden, which predicts patient time to death. Future research should examine the mechanisms by which patient characteristics, treatment, and supportive and palliative care can have an impact on patient survival.

Opioids and Cancer Mortality

OPINION STATEMENT

Opioids are the gold standard for the treatment of cancer-related pain. Preclinical studies have associated opioids with cancer progression and overall survival. In mice models, opioids have been shown to possess pro-tumor activity secondary to immunosuppression, migration of tumor cells, increased activity of vascular endothelial growth factor receptors, and angiogenesis leading to tumor progression. In contrast, opioids have also been associated with having antitumor activity by activation of apoptosis and phagocytosis. However, high-quality randomized controlled trials in humans that are focused on the association between opioids and survival in cancer patients are lacking, which underscores the importance of being cautious when interpreting the results of the preclinical studies. Cancer-related pain is complex and multifactorial and may worsen as the disease progresses leading to higher opioid utilization. Moreover, cancer pain by itself has been associated with poor survival. The survival in these advanced cancer patients taking opioids may be more likely to be associated with cancer progression and not the opioid use. Adequate treatment of cancer pain has the potential to improve quality of life and performance status, highlighting the importance of continuing to use opioids to manage pain efficiently. More research is clearly needed.

The relationship between pain, analgesics and survival in patients with advanced cancer; a secondary data analysis of the international European palliative care Cancer symptom study

PURPOSE

Opioids reduce cancer-related pain but an association with shorter survival is variably reported.

AIM

To investigate the relationship between pain, analgesics, cancer and survival within the European Palliative Care Cancer Symptom (EPCCS) study to help inform clinical decision making.

METHODS

Secondary analysis of the international prospective, longitudinal EPCCS study which included 1739 adults with advanced, incurable cancer receiving palliative care. In this secondary analysis, for all participants with date of death or last follow up, a multilevel Weibull survival analysis examined whether pain, analgesics, and other relevant variables are associated with time to death.

RESULTS

Date of death or last follow-up was available for 1404 patients (mean age 65.7 [SD:12.3];men 50%). Secondary analysis of this group showed the mean survival from baseline was 46.5 (SD:1.5) weeks (95% CI:43.6-49.3). Pain was reported by 76%; 60% were taking opioids, 51% non-opioid analgesics and 24% co-analgesics. Opioid-use was associated with decreased survival in the multivariable model (HR = 1.59 (95% CI:1.38-1.84), p < 0.001). An exploratory subgroup analysis of those with C-reactive protein (CRP) measures (n = 219) indicated higher CRP was associated with poorer survival (p = 0.001). In this model, the strength of relationship between survival and opioid-use weakened (p = 0.029).

CONCLUSION

Opioid-use and survival were associated; this relationship weakened in a small sensitivity-testing subgroup analysis adjusting for CRP. Thus, the observed relationship between survival and opioid-use may partly be due to tumour-related inflammation. Larger studies, measuring disease activity, are needed to confirm this finding to more accurately judge the benefits and risks of opioids in advanced progressive disease.

EORTC Quality of Life Questionnaire Head and Neck (H&N)-35 scores from H&N squamous cell carcinoma patients obtained at diagnosis and at 6, 9 and 12 months following diagnosis predict 10-year overall survival

PURPOSE

To study the 10-year overall survival predictions, and mechanisms behind, of head and neck (HN) quality of life (QoL) scores obtained at diagnosis and 6, 9, and 12 months following diagnosis in a cohort of HN squamous cell carcinoma (HNSCC) patients.

METHODS

Consecutive HNSCC patients (N = 109) subjected to standard workup and treatment self-reported their QoL measured by the EORTC Quality of Life Questionnaire (QLQ) H&N-35 between November 2002 and June 2005. Each QoL index was calculated and additionally aggregated to one sum score. The included patients were at diagnosis younger than 78 years, judged adequately cognitive functioning, and scheduled for curative treatment. Self-reported smoking, alcohol consumption, and socio-demographic information were registered. Twenty-two patients were high-risk (hr)-HPV DNA tumor positive. If the treatment goal was changed to palliative, no new QoL information was collected. All living patients were followed until 10 years after diagnosis.

RESULTS

Median survival was 105 months. Significant overall survival predictions were found from the EORTC H&N-35 QLQ sum scores continuously measured at diagnosis (p = 0.006) and obtained at 6 (p = 0.02), 9 (p = 0.002) and 12 (p = 0.05) months. Lower QoL predicted lower overall survival. These sum score survival predictions were in part independent of TNM stage, hr-HPV status, gender, age, alcohol and smoking status. The indices "pain", "swallowing", "social eating", and "feeling ill" were predictive of survival at 3 out of 4 measuring points (diagnosis, 6, 9 and 12 months) in univariate analyses.

CONCLUSION

EORTC H&N-35 QLQ scores at diagnosis and throughout the first year thereafter harbor prognostic power.

Opioids in cancer-related pain: current situation and outlook

PURPOSE

Despite progress in treatments, cancer pain remains underestimated, poorly assessed and under-treated. Prescribing strong opioids, because of their specificities, requires precision in management considering their pharmacology but also a clear understanding of recommendations. Some clinicians highlight the risk of addiction, excessive sedation and respiratory depression and their need for information. Our objective in this review is to suggest some clinical guidance for the positioning and daily use of opioids within cancer pain management.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Strong opioids may be initiated as soon as pain diagnosis is defined. Factors to consider are pain aetiology, opioid pharmacokinetics and pharmacodynamics, genetic polymorphism, physiology (age, gender, weight and pregnancy), comorbidities (especially renal, hepatic, cardiovascular diseases), chronobiology, environmental factors, medication interference and treatment adherence. Achieving the best-balanced opioid treatment for background pain is complex, mainly due to the variable benefit/risk ratio between individuals and the experience of breakthrough cancer pain. Opioid initiation alongside a dynamic reassessment of pain should be fully integrated into the patient's management to optimise analgesia. The efficacy and safety of a strong opioid treatment need to be re-evaluated and adapted to individuals constantly as it varies over time.

CONCLUSIONS

Cancer pain is multimorphic and permanently changing due to disease evolution, curative treatments and disruptive events (concomitant treatments, pain from associated disease, comorbidities and complications, modifications of the environment). Well-managed opioids are the cornerstone of a complex environment requiring multidisciplinary dynamic assessments integrated into the patient's care pathway.

Strategies for interventional therapies in cancer-related pain-a crossroad in cancer pain management

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.

Assessing cancer pain-the first step toward improving patients' quality of life

PURPOSE

Numerous studies on cancer patients have shown that cancer pain still remains underestimated, poorly assessed, and under-treated. Pain relief should be considered as early as possible within personalized care and as an integral part of quality healthcare in many countries. Nevertheless, personalized care is still insufficiently taken into consideration, partly due to improper or incomplete assessment of cancer pain. The objective of this article is to propose a practical approach to this complex assessment, as the first step to improving patients' quality of life.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Assessment of cancer pain means evaluating the pain intensity over time, the dimensions of pain (sensory-discriminative, cognitive, emotional, and behavioral), the pathophysiological nature of pain (neuropathic, nociceptive, and nociplastic), the etiology, and the patient's perception (diffuse, localized, global). Cancer patients may have simple or multiple forms of pain (mixed, overlapped, combined, and associated). Furthermore, with the use of new specific therapies, the symptomatology of pain is also changing, and certain cancers are becoming chronic. Thus, cancer pain is an archetype of multimorphic pain, and its dynamic assessments (regular and repeated) require a multimodal and targeted approach in order to offer personalized pain management. Multimodal pain treatment must be adapted to the elements that disrupt cancer pain, to the patient's cancer and to the specific treatments.

CONCLUSIONS

The dynamic assessments of pain demand the simplest, and the most complete possible procedure, to avoid feasibility problems or self-/hetero-assessment excesses that might lead to less precise and less reliable results. Multimodal and interdisciplinary approaches are being developed, making it possible to optimize cancer pain management.

Optimizing Initial Intrathecal Drug Ratio for Refractory Cancer-Related Pain for Early Pain Relief. A Retrospective Monocentric Study

Objective

Intrathecal (IT) drug delivery has shown its efficiency in treating refractory cancer pain, but switching opioids from the systemic to the intrathecal route is a challenging phase. Moreover, associations are widely used and recommended. Few data deal with the initial dosage of each drug. Analyzing conversion factors and initial dosages used in intrathecal therapy seems essential to decreasing the length of titration and to delivering quick pain relief to patients.

Methods

We retrospectively analyzed data from consecutive adult patients implanted with an intrathecal device for cancer pain and treated at the Institut de Cancérologie de l’Ouest, in Angers, France, for four years. The main goal was to identify factors associated with early pain relief after intrathecal drug delivery system (IDDS) implantation.

Results

Of the 220 IDDS-treated patients, 70 (32%) experienced early pain relief (EaPR) and 150 (68%) delayed pain relief (DePR). Performance Status stage and initial IT ropivacaine:IT morphine ratio were the variables independently associated with EaPR. The best IT ropivacaine:IT morphine ratio to predict EaPR was 5:1, with a 73% (95% confidence interval [CI] = 64.8% to 79.6%) sensitivity and a 67.1% (95% CI = 54.9% to 77.9%) specificity. EaPR subjects experienced better pain relief (–84% vs –60% from baseline pain score, P < 0.0001), shorter length of hospitalization (7 vs 10 days, P < 0.0001), and longer survival (155 vs 82 days, P = 0.004).

Conclusions

Local anesthetic:morphine ratio should be considered when starting IDDS treatment. EaPR during the IT analgesia titration phase was associated with better pain relief and outcomes in patients with refractory cancer-related pain.