Cancer Pain Management-New Therapies

Effectiveness of epidural morphine for the treatment of cancer pain in patients with gastrointestinal neoplasm-a systematic review

One-third of cancer pain patients do not experience adequate pain relief using analgesic ladder by the World Health Organization. Interventional procedures, such as epidural morphine, have been considered. This study aimed to review the literature comparing the effects of epidural administration of morphine with the oral route. This systematic review included randomized controlled trials (RCTs) conducted with patients with gastrointestinal neoplasm. A search was conducted on PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and CINAHL databases to identify studies published up to May 2023. The retrieved study was evaluated using the Risk of Bias 2 (RoB 2) tool and qualitatively synthesized. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Prospero: CRD42021264728). Only one RCT, a crossover trial, was included in this systematic review. The study was conducted with ten participants (one withdrawal) and reported a statistically significant difference between both subcutaneous and epidural morphine solutions and oral morphine. The adverse events were not described. The included study presents some concerns of bias and low certainty of evidence on the effectiveness and security of epidural morphine administration. The available literature does not suffice to elucidate whether morphine administration via the epidural route is more effective than other routes. Further RCTs are necessary to improve the level of evidence on the effectiveness and risk-benefit of epidural morphine in the management of cancer pain in gastrointestinal neoplasm patients.

Knowledge, attitudes, and current practices toward lung cancer palliative care management in China: a national survey

Scope

The present investigation seeks to illuminate the current state and disparities in the knowledge, attitudes, and practices (KAP) among healthcare professionals regarding the management of lung cancer palliative care (LCPC) in China, while simultaneously assessing the prevalence and context of patient-controlled analgesia (PCA) usage in the management of cancer-related pain.

Methods

A total of 2093 healthcare practitioners from 706 hospitals across China completed a structured questionnaire that probed various facets of LCPC management. The questionnaire consisted of seven thematic sections, incorporating chi-square tests and Fisher's exact probabilities to statistically assess the discrepancies in KAP among healthcare professionals across different hospital grades. Ordered data distributions among hospital grades were compared using non-parametric Kruskal-Wallis H and Mann-Whitney U tests. Multiple-choice items were subjected to multiple-response cross-tabulation analysis, while the Spearman rank-order correlation coefficient was employed to gauge potential associations among variables.

Results

Around 84.2% of the respondents perceived anti-tumor therapy to be of equal importance to palliative care. Statistically significant differences (χ² = 27.402, P = 0.002) in satisfaction levels were observed, with participants from Tertiary hospitals demonstrating higher satisfaction compared to those from Secondary and Primary hospitals. Pain emerged as the most prevalent symptom necessitating LCPC. Major impediments to LCPC adoption included patients' and families' concerns about the safety of long-term palliative care-related drug use. 31.1% of the respondents cited the most frequent rationale for PCA use as cases involving patients who required systemic administration of large opioid doses or exhibited intolerable adverse reactions to opioids. The principal deterrents against the use of PCA for cancer pain management were (1): apprehension about adverse drug reactions due to overdose (2), concern about the potential for opioid addiction, and (3) the anticipated increase in patients' economic burdens. Over the preceding 24-month period, 33.9% of the surveyed healthcare practitioners reported no engagement in either online or offline LCPC-related training initiatives.

Conclusion

This study emphasizes the pressing need for comprehensive training in LCPC among Chinese health personnels, particularly focusing on the effective management of cancer pain symptoms.

Targeting TRPV4 Channels for Cancer Pain Relief

Despite the unique and complex nature of cancer pain, the activation of different ion channels can be related to the initiation and maintenance of pain. The transient receptor potential vanilloid 4 (TRPV4) is a cation channel broadly expressed in sensory afferent neurons. This channel is activated by multiple stimuli to mediate pain perception associated with inflammatory and neuropathic pain. Here, we focused on summarizing the role of TRPV4 in cancer etiology and cancer-induced pain mechanisms. Many studies revealed that the administration of a TRPV4 antagonist and TRPV4 knockdown diminishes nociception in chemotherapy-induced peripheral neuropathy (CIPN). Although the evidence on TRPV4 channels' involvement in cancer pain is scarce, the expression of these receptors was reportedly enhanced in cancer-induced bone pain (CIBP), perineural, and orofacial cancer models following the inoculation of tumor cells to the bone marrow cavity, sciatic nerve, and tongue, respectively. Effective pain management is a continuous problem for patients diagnosed with cancer, and current guidelines fail to address a mechanism-based treatment. Therefore, examining new molecules with potential antinociceptive properties targeting TRPV4 modulation would be interesting. Identifying such agents could lead to the development of treatment strategies with improved pain-relieving effects and fewer adverse effects than the currently available analgesics.

External treatment of traditional Chinese medicine for cancer pain: A systematic review and network meta-analysis

BACKGROUND

Cancer pain is one of the most intolerable and frightening symptoms of cancer patients. However, the clinical effect of the three-step analgesic ladder method (TSAL) is not satisfactory. The combination of external treatment of traditional Chinese medicine (TCM) can improve the clinical effect.

OBJECTIVE

This study used network meta-analysis to compare the effects of different external treatment methods of TCM combined with TSAL on cancer pain.

METHODS

Databases searched by our team included Google Scholar, Web of Science, Scopus, Embase, PubMed, and Cochrane Library. Randomized controlled trials related to the external treatment of TCM combined with TSAL for cancer pain were screened from the establishment of the database till now. The above literature extracted clinical efficacy, NRS score, KPS score, analgesic onset time, and duration as the main results after the screening. The 95% confidence interval (95% CI) of OR value and SMD value was used as the effect index to compare the difference in efficacy of different interventions, and the ranking was conducted. STATA 17.0 software was used for the statistical analysis of the above data.

RESULTS

A total of 78 studies were included, including 8 interventions and 5742 participants. Based on ranking probability, the clinical effective rate of manual acupuncture combined with TSAL was the best when the intervention time was set at 4 weeks [OR = 5.42, 95% CI (1.99,14.81)], and the improvement effect on KPS score was also the best [SMD = 0.97, 95% CI (0.61, 1.33)]. Acupoint external application was the best intervention in reducing NRS score [SMD = -1.14, 95% CI (-1.90, -0.93)]. Acupoint moxibustion combined with TSAL was considered to be the most effective intervention to prolong the duration of analgesia [SMD = 1.69, 95% CI (0.84, 2.54)] and shortening the onset time of analgesia [SMD = -3.00, 95% CI (-4.54, -1.47)].

CONCLUSIONS

TSAL combined with manual acupuncture is the best in terms of clinical efficacy and improvement of patients' functional activity status. With the extension of treatment time, the intervention of this kind of treatment on the clinical effect is more pronounced. Acupoint external application also has a unique advantage in reducing the pain level of patients. From the point of view of analgesic duration and duration of analgesia, combined acupoint moxibustion has the best effect.

Microglia Promote Inhibitory Synapse Phagocytosis in the Spinal Cord Dorsal Horn and Modulate Pain-Like Behaviors in a Murine Cancer-Induced Bone Pain Model

BACKGROUND

The microglial activation has been implicated in cancer-induced bone pain. Recent studies have revealed that microglia mediate synaptic pruning in the central nervous system, where the cluster of differentiation 47-signal regulatory protein α (CD47-SIRPα) axis creates a "don't eat me" signal and elicits an antiphagocytic effect to protect synapses against elimination. To date, the synaptic phagocytosis in microglia has never been investigated in the murine cancer-induced bone pain model. The present experiments sought to explore whether microglia phagocytize synapses in mice with bone cancer pain as well as the possible mechanisms.

METHODS

Male C3H/HeN mice were used to induce bone cancer pain. Minocycline and S-ketamine were injected into D14. The number of spontaneous flinches (NSF) and paw withdrawal mechanical thresholds (PWMT) were measured on D0, D4, D7, D10, D14, D21, and D28. Hematoxylin and eosin staining presented bone lesions. Western blotting examined the Gephyrin, CD47, and SIRPα expression. Flow cytometry evaluated the proportion of SIRPα+ cells in the spine. Immunofluorescence and 3-dimensional reconstruction showed the Gephyrin puncta inside microglial lysosomes.

RESULTS

Mice embedded with tumor cells induced persistent spontaneous pain and mechanical hyperalgesia. Hematoxylin and eosin staining revealed bone destruction and tumor infiltration in marrow cavities. Microglia underwent a responsive and proliferative burst (t = -16.831, P < .001). Western blotting manifested lowered Gephyrin expression in the tumor group (D4, D7, D10, D14, D21, and D28: P < .001). Immunofluorescence and 3-dimensional reconstruction showed larger volumes of Gephyrin puncta inside microglial lysosomes (t = -23.273, P < .001; t = -27.997, P < .001). Treatment with minocycline or S-ketamine exhibited pain relief and antiphagocytic effects (t = -6.191, P < .001, t = -7.083, P < .001; t = -20.767, P < .001, t = -17.080, P < .001; t = 11.789, P < .001, t = 16.777, P < .001; t = 8.868, P < .001, t = 21.319, P < .001). Last but not least, the levels of CD47 and SIRPα proteins were downregulated (D10: P = .004, D14, D21, and D28: P < .001; D10, D14, D21, and D28: P < .001). Flow cytometry and immunofluorescence substantiated reduced microglial SIRPα (t = 11.311, P < .001; t = 12.189, P < .001).

CONCLUSIONS

Microglia-mediated GABAergic synapse pruning in the spinal cord dorsal horn in bone cancer pain mice, which might be associated with the declined CD47-SIRPα signal. Our research uncovered an innovative mechanism that highlighted microglia-mediated synaptic phagocytosis in a murine cancer-induced bone pain model.

Clinical Significance of Mean Platelet Volume Combined with Neutrophil-Lymphocyte Ratio in Predicting the Therapeutic Effect of Splanchnic Neurolysis

Introduction

In most cases of pain related to abdominal tumors, increasing the dosage of analgesics still makes the pain difficult to alleviate. Splanchnic neurolysis is a new treatment option. However, not all patients receiving splanchnic neurolysis treatment will achieve satisfactory results. The aim of this study is to retrospectively analyze the predictive value of preoperative serum immune indicators (white blood cells, neutrophils, lymphocytes, and platelets) for the efficacy of splanchnic neurolysis.

Methods

The abdominal cancer patients (pancreatic cancer, liver cancer, gastric cancer, colorectal cancer, cholangiocarcinoma, and renal cancer) admitted to the Department of Pain Medicine, Harbin Medical University Cancer Hospital from January 2017 to October 2020 were collected. We evaluate the efficacy of splanchnic neurolysis by assessing the dosage of opioids and Numerical Rating Scale (NRS) scores of patients 24 to 48 hr before and after splanchnic neurolysis. The predictive value of preoperative serum immune indicators on the efficacy of splanchnic neurolysis was analyzed using Receiver Operating Characteristic (ROC). Contract the Nomogram prediction model by R software.

Results

We found that Mean Platelet Volume (MPV) has statistical significance for predicting splanchnic neurolysis efficacy in digestive system tumors. MPV and Neutrophil-Lymphocyte Ratio (NLR) are independent predictors and have statistical significance in predicting splanchnic neurolysis efficacy in pancreatic cancer. The combination of MPV and NLR had satisfactory predictive value in pancreatic cancer (AUC = 0.715) and the nomogram model was constructed. Furthermore, there was a negative correlation between lymphocyte count and NRS score, and a positive correlation between Platelet-Lymphocyte Ratio (PLR) and NRS score.

Discussion

The combined detection of MPV and NLR has important clinical predictive value for the postoperative efficacy of splanchnic neurolysis in pancreatic cancer.

The Role of Ultrasound in Cancer and Cancer-Related Pain-A Bibliometric Analysis and Future Perspectives

Ultrasound has a deep penetrating ability with minimal or no tissue injury, while cancer-mediated complications during diagnosis, therapy, and surgery have become a serious challenge for clinicians and lead to the severity of the primary condition (cancer). The current study highlights the importance of ultrasound imaging and focused ultrasound therapy during cancer diagnosis, pain reduction, guidance for surgical resection of cancer, and the effectiveness of chemotherapy. We performed the bibliometric analysis on research domains involving ultrasound, cancer management, pain, and other challenges (chemotherapy, surgical guidance, and postoperative care), to observe the trend by which the research field has grown over the years and propose a possible future trend. The data was obtained from the Web of Science, processed, and exported as plain text files for analysis in the Bibliometrix R web interface using the Biblioshiny package. A total of 3248 documents were identified from 1100 journal sources. A total of 390 articles were published in 2022, with almost a 100% growth rate from previous years. Based on the various network analysis, we conclude that the outcome of the constant research in this domain will result in better patient care during the management of various diseases, including cancer and other co-morbidities.

Cancer Patients with Chronic Pain and Their Caregivers during COVID-19: A Descriptive Study

BACKGROUND

The sanitary measures imposed by COVID-19 intensified challenges in the pain management of cancer patients.

METHODS

A descriptive study was conducted in a chronic pain unit of an oncological hospital aiming to explore the experiences of cancer patients with chronic pain and their caregivers during the pandemic period, as well as identify strategies to improve care in chronic pain management. An electronic questionnaire was developed containing sociodemographic variables, the Depression, Anxiety and Stress Scale-21, and open-ended questions exploring the experiences and circumstances of pain management.

RESULTS

A total of 30 patients and 13 caregivers filled in the questionnaire. Patients revealed a higher level of depression, anxiety, and stress than caregivers, without statistically significant differences. Both groups mentioned having experienced difficulties in self-care, particularly in relation to sleep, nutrition, and recreation. In total, 83.7% patients needed pain relief medication related to uncontrolled pain. Both mentioned that they would have benefited from a digital application to ease the communication with the healthcare professionals of the chronic pain unit, as well as non-pharmacological interventions, such as therapeutic massage.

CONCLUSIONS

Recognizing that chronic pain leads to significant limitations, it is essential to implement and anticipate objective and effective responses in pain management.

Brain stimulation for chronic pain management: a narrative review of analgesic mechanisms and clinical evidence

Chronic pain constitutes one of the most common chronic complaints that people experience. According to the International Association for the Study of Pain, chronic pain is defined as pain that persists or recurs longer than 3 months. Chronic pain has a significant impact on individuals' well-being and psychosocial health and the economy of healthcare systems as well. Despite the availability of numerous therapeutic modalities, treatment of chronic pain can be challenging. Only about 30% of individuals with non-cancer chronic pain achieve improvement from standard pharmacological treatment. Therefore, numerous therapeutic approaches were proposed as a potential treatment for chronic pain including non-opioid pharmacological agents, nerve blocks, acupuncture, cannabidiol, stem cells, exosomes, and neurostimulation techniques. Although some neurostimulation methods such as spinal cord stimulation were successfully introduced into clinical practice as a therapy for chronic pain, the current evidence for brain stimulation efficacy in the treatment of chronic pain remains unclear. Hence, this narrative literature review aimed to give an up-to-date overview of brain stimulation methods, including deep brain stimulation, motor cortex stimulation, transcranial direct current stimulation, repetitive transcranial magnetic stimulation, cranial electrotherapy stimulation, and reduced impedance non-invasive cortical electrostimulation as a potential treatment for chronic pain.

The prospect of Xihuang pill in the treatment of cancers

Background

Xihuang pill, a Traditional Chinese Medicine (TCM) prescription and a representative of Huoxuehuayu therapy (one of the TCM therapies to promote blood circulation and remove blood stasis), has been widely used in breast cancer treatments. Although some evidence suggests the efficacy and safety of the Xihuang pill in treating certain cancer, the overall efficacy of the Xihuang pill in other cancer treatment is uncertain.

Objective

This study aimed to summarize the current clinical literature and provided evidence support for addressing the research question of whether the Xihuang pill is safe and effective in the treatment of various cancers as Huoxuehuayu therapy, and possibly identify the clinical dosage range and therapeutic effect of Xihuang pills.

Method

Seven Chinese and English databases such as PubMed, CNKI, and Google Scholar were searched to collect the publications on Xihuang pill and cancer. Then the researchers extracted data from the articles that met the inclusion criteria and used SAS statistical program version 9.4 (by SAS Institute, Cary, North Carolina, USA) for statistical statistics.

Results

Our search identified 78 studies, including 69 RCTs (randomized control trials), 6 NRCCs (non-randomized concurrent control trials), and 3 BAS (before-after study), evaluating 3151 patients in total. The daily doses of Xihuang pills/capsule were between 2 g and 60 g, and duration between 2 weeks and 5 years, mostly used in the middle or late stage of cancer. The therapeutic effect of the Xihuang pill was mainly reflected in improving Complete Response (CR, a term from The Response Evaluation Criteria In Solid Tumors) or Partial Response (PR, a term from The Response Evaluation Criteria In Solid Tumors), reducing adverse reactions, promoting quality of life (QoL), regulating immunity, alleviating pain, prolonging survival, reducing metastasis and recurrence, reducing inflammation, regulating estrogen levels, decreasing hypercoagulative status, and reducing tumor markers.

Conclusion

Xihuang pill representing Huoxuehuayu therapy has a good prospect in the treatment of cancer.

Adherence to Analgesic Drugs and its Associated Factors among Patients with Cancer Pain: A Crosssectional Study in China

Objectives: Pain is one of the most common and distressing symptoms co-occurring with cancer progression and treatment, and medication adherence plays an important role in achieving good pain control. However, research on medication adherence and influential factors among individuals with cancer pain (CP) is limited in China. The present study aimed to investigate the adherence to analgesics in patients with CP in China and to identify factors that may influence adherence. Methods: A cross-sectional study was conducted from June 2020 to February 2021. Study instruments consisted of a set of validated questionnaires, 5 measurement instruments including the numerical rating scale (NRS), ID-Pain, Morisky Medication Adherence Scale-Chinese validated version (MMAS-C), Beliefs about Medicines Questionnaire (BMQ) - Specific, and the Hospital Anxiety and Depression Scale (HADS). Results: A total of 141 participants with CP including 71 males (50.4%), aged 54.5±15.5 years were surveyed in this study. Overall, 83 patients (58.9%) showed adherence, but 58 patients (41.1%) showed non-adherence to analgesics. The univariate analysis showed that analgesic adherence was associated with pain duration of>3 months, outbreaks of pain in the last 24 hours, presence of side effects, getting analgesics in time, presence of neuropathic pain, stopping analgesics or adjusting dosage by themselves, presence of anxiety and depression, and beliefs about medicines. Moreover, the multivariate logistic regression showed that getting analgesic drugs in time (odds ratio [OR]=5.218, 95% confidence interval [CI] 1.691-16.100) and high BMQ-Necessity (OR=1.907, 95% CI 1.418-2.565) were associated with high adherence, stopping analgesics or adjusting dosage by themselves (OR=7.958, 95% CI 2.443-25.926) and high BMQ-Concern (OR=0.760, 95% CI 0.600-0.964) were more likely to be associated with non-adherence. Conclusion: In view of our findings, it may be critical for individuals to have a better understanding and strong beliefs about their prescribed analgesic drugs. Pain education, counseling and follow-up of patients and their caregivers, and removal of barriers to accessing analgesic drugs could be considered in further intervention strategies.