Interventional Techniques for Cancer Pain Management

Interventional Pain Management for the Pediatric Cancer Patient: A Literature Review

This literature review examines the use of interventional treatments for pain management in pediatric cancer patients. While interventional procedures may be effective in cancer pain management, these procedures are infrequently employed in pediatric cohorts. This underutilization of interventional procedures may be supported by a deficit in randomized, controlled studies and literature regarding their role in pediatric cancer populations. Particularly because literature on the efficacy of interventional treatments in adult populations may not directly translate to pediatric populations, more research about the role of interventional procedures in managing pediatric cancer pain is necessary for a strengthened understanding of pediatric cancer pain treatment.

Interventional Therapies for Pain in Cancer Patients: a Narrative Review

PURPOSE OF REVIEW

Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population.

RECENT FINDINGS

A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.

Approaches and Best Practices for Managing Cancer Pain within the Constraints of the COVID-19 Pandemic in India

Novel corona virus disease 2019 (COVID-19) is an ongoing pandemic that has impacted the entire world. The Indian government has responded strongly and very stringently to the crisis, through a nationwide lockdown. The health-care (HC) systems in the country are striving hard to maintain equitable care across illness spectra, while responding the emergencies imposed by the COVID-19 crisis. Under these circumstances, guidelines for managing several diseases including that for cancer care have been modified. As modified guidelines for cancer care have their focus on disease management, cancer pain management and maintaining continuity of care for patients with advanced progressive disease have taken a backseat in the available cancer care guidelines. This article describes the challenges, approaches to solutions with evidence-based practices that can be utilized to ensure competent management of cancer pain during the COVID-19 pandemic in India. It provides an overview of adapting to telehealth consultations for identification, evaluation and management of cancer pain, safe and rational use of analgesics and adjuvant drugs, recognizing and responding to holistic care needs and addressing the total pain, ensuring continuity of pain management, and strategies when complying with narcotic drug regulations, while ensuring safety of patients and HC providers.

Cost analysis of cordotomy and intrathecal pain pump placement for refractory cancer pain

Background:

Cancer pain can be debilitating and 10–20% of patients will have refractory pain despite optimal medical management. Here, we present a cost comparison of treating terminal cancer patients with intravenous (IV) narcotics, anterolateral cordotomy, or intrathecal pain pump (ITPP) placement.

Case Description:

We evaluated and treated 2 patients with metastatic breast cancer and expected survivals of <1 year. The first patient, a 53-year-old female, had tumor invasion of the right chest wall and had failed oral pain regimens; she was admitted to receive IV Dilaudid as patient-controlled analgesia (PCA). After 7 days of treatment without improvement, she underwent a left-sided C1-2 cordotomy. For her, the cost of the cordotomy was $18,462 and the expenses for 7 days hospital stay with PCA was $89,884; the total was $108,346. The second patient, a 60-year-old female, had severe somatic pain due to invasion by tumor of the left knee cap. She, too, has failed oral therapy and was receiving in-hospital IV Dilaudid PCA. Following 2 days of failed treatment, a morphine ITPP was placed and effectively treated her pain. In patient 2, the cost of the ITPP was $80,603 and the expenses for 8 days of the hospital stay with PCA came to $84,785; the total was $165,389.

Conclusion:

The treatment of refractory pain in cancer patients is challenging. It requires invasive procedures such as cordotomy or ITPP. Although procedures may yield comparable pain control, there was a significant cost savings for cordotomy versus ITPP ($57,043 saved).

Interventional anesthesia and palliative care collaboration to manage cancer pain: a narrative review

Pain is a common symptom associated with advanced cancer. An estimated 66.4% of people with advanced cancer experience pain from their disease or treatment. Pain management is an essential component of palliative care. Opioids and adjuvant therapies are the mainstay of cancer pain management. Nevertheless, a proportion of patients may experience complex pain that is not responsive to conventional analgesia. Interventional analgesia procedures may be appropriate and necessary to manage complex, cancer-related pain. This narrative review uses a theoretical case to highlight core principles of palliative care and interventional anesthesia, and the importance of collaborative, interdisciplinary care. An overview and discussion of pragmatic considerations of peripheral nervous system interventional analgesic procedures and neuraxial analgesia infusions are provided.

Challenges and concerns of persistent opioid use in cancer patients

INTRODUCTION

As a result of advancements in the diagnosis and treatment of cancer, two-thirds of individuals suffering with cancer survive more than 5 years after diagnosis, resulting in a large proportion of patients with chronic cancer pain alone or associated with chronic noncancer pain. There is a paucity of literature in reference to diagnosis and management of chronic cancer pain, specifically in relation to persistent opioid use, its effectiveness, and adverse consequences. Areas covered: This review covers the prevalence of chronic cancer pain and its association with multiple comorbidities, persistent opioid use and related consequences, and challenges in managing persistent chronic cancer pain patients. In addition, discussion includes therapeutic opioid use, effectiveness of opioid therapy, assessment of risk of persistent opioid use, and guidance for responsible, persistent opioid prescribing for chronic cancer pain patients. Expert commentary: Despite extensive availability of opioids and related common adverse consequences, including the potential for escalating use, abuse, and deaths, greater awareness is needed to counteract the present atmosphere and appropriately manage patients with chronic cancer pain. Chronic cancer pain is a complex biopsychosocial phenomenon with multiple comorbidities. Opioid therapy has become extremely complex with negative connotations related to escalating abuse and related deaths.

'Was it worth it?' Intrathecal analgesia for cancer pain: A qualitative study exploring the views of family carers

BACKGROUND

Intrathecal drug delivery is known to reduce pain in patients where conventional systemic analgesia has been ineffective or intolerable. However, there is little information regarding the effects of intrathecal drug delivery on quality of life and function in those with advanced, incurable cancer.

AIM

Retrospective exploration of the views of bereaved carers regarding the physical and psychosocial effects of external tunnelled intrathecal drug delivery in patients with advanced incurable cancer.

DESIGN

Thematic analysis of qualitative interviews with carers of deceased individuals who received percutaneous external tunnelled intrathecal drug delivery as part of their pain management, within two UK centres.

SETTING

A total of 11 carers were recruited from two UK Palliative Care centres. Family carers of adult patients who had received external tunnelled intrathecal drug delivery analgesia for cancer pain and had died between 6 and 48 months prior to contact were included. Carer relatives who were considered likely to be too vulnerable or who had lodged a complaint about treatment within the recruiting department or who had been treated directly by the interviewer were excluded.

RESULTS

In total, 11 interviews took place. The emerging themes were (1) making the decision to have the intrathecal - relatives described desperate situations with severe pain and/or sedation, meaning that the individual would try anything; (2) timing and knowing they were having the best - an increased access to pain and palliative care services, meant carers felt everything possible was being done, making the situation more bearable; (3) was it worth it? - the success of the external tunnelled intrathecal drug delivery was judged on its ability to enable the individual to be themselves through their final illness. Side effects were often considered acceptable, if the external tunnelled intrathecal drug delivery enabled improvements in quality of life.

CONCLUSION

Carers perceived external tunnelled intrathecal drug delivery as most valuable when it improved quality of life towards the end of life, by reducing pain and side effects of conventional systemic analgesia to enable individuals 'to be themselves'. Under these circumstances, the carers judged significant side effects to be acceptable.

Anaesthetic challenges in cancer patients: current therapies and pain management

THE OBJECTIVE

The aim is to present the major effects of cancer treatment (chemotherapy, radiotherapy, surgery) that the anaesthesiologist should consider preoperatively, and to review techniques of the analgesic management of the disease.

MATERIALS AND METHODS

To summarize the major challenges that cancer patients present for the anaesthesiologists, a literature review was conducted. Articles presenting evidence or reviewing the possible effects of anaesthetics on cancer cells were also included. Online databases of Science Direct, PubMed, and ELSEVIER, as well as reference lists of included studies were searched. Articles published from 2005 to 2016 were selected.

RESULTS

Anaesthesiologists should pay attention to patients receiving chemotherapy and its side effects on organ systems. Bleomycin causes pulmonary damage, anthracyclines are cardiotoxic, and platinum-based chemotherapy agents are nephrotoxic. A lot of chemotherapy agents lead to abnormal liver function, vomiting, diarrhoea, etc. Surgery itself is suspected to be associated with an increased risk of metastasis and recurrence of cancer. Regional anaesthesia and general anaesthesia with propofol should be used and volatile agents should be avoided to prevent cancer patients from perioperative immunosuppression that leads to increased risk of cancer recurrence. Pain management for palliative patients remains a major problem.

CONCLUSIONS

To provide the best treatment for cancer patients, cooperation of anaesthesiologists with oncologists and surgeons becomes imperative. It has been established that anaesthetic techniques and drugs could minimize the perioperative inflammation. However, further research of the perioperative "onco-anaesthetic" is needed.

Surgical Site Infections in Cancer Patients with Intrathecal Drug Delivery Devices

Objectives

Our purpose was to determine the incidence of surgical site infection (SSI) in cancer patients receiving an intrathecal drug delivery system (IDDS) and compare that rate with the incidence of SSI in the general population receiving an IDDS or spinal cord stimulator. We attempted to describe risk factors for SSIs in cancer patients treated with IDDS in terms of exposure to cancer treatments.

Design

Retrospective review.

Setting

Large tertiary care center.

Patients

Cancer patients receiving an IDDS in 2006-2013.

Methods

The incidence of SSI was determined according to the US Centers for Disease Control and Prevention definition. Medication regimens and current cancer treatment were investigated to identify immunocompromised patients during IDDS placement. Microbacteriology, treatment, and overall outcomes were investigated.

Results

Sixty-four patients had an IDDS implanted in 2006-2013. SSI developed in four patients (6.2%). All four patients had received chemotherapy or radiotherapy within three months before implantation. Three of the three were receiving dexamethasone, and three of the four required explantation of the IDDS.

Conclusion

The incidence of SSI was at the upper end of the published infection rates for IDDS. The risk of SSI may be increased in this population because of factors that alter the patient's immune status, including concomitant corticosteroid use, radiotherapy near the SSI, and presence of immunomodulators. The identification and mitigation of certain risk factors for this population may prevent infection in future patients.

Encountering a Neglected Area of a Healthcare System: A Decade of Improvement in Cancer Pain Clinical Practice in Iran

Background

With the increase in the prevalence of cancer, cancer-related issues also deserve more attention especially in developing countries where there is already limited access to high-quality healthcare. Cancer-related pain, the most common and the most annoying one, is not only a symptom but also an important subspecialty and its management is still challenging.

Objectives

To assess the level of pain and cancer pain knowledge in Iran in comparison with the whole world.

Materials and Method

A search of the literature including papers published in PubMed before March 2016 was carried out.

Results

There have been an increasing number of publications on pain since 1842 and a growing number of publications on cancer pain since 1929. There has also been remarkable growth in our understanding of cancer pain, particularly since 2010. More than one-third of studies on pain and cancer-related pain were published after 2010.

Conclusion

There is a need to be more inventive with the management of cancer-related issues, especially pain in developing countries, to maximize the quality and quantity of healthcare delivery to cancer-stricken patients. It seems that non-governmental organizations like MAHAK can play a significant role in this goal.

Pain services and palliative medicine - an integrated approach to pain management in the cancer patient

The vast majority of cancer patients will experience pain during the course of their illness. Thankfully, in most instances, the consistent application of analgesic guidelines, tailored to the unique needs of each individual patient, will deliver a satisfactory outcome. These guidelines recommend the skilled use of analgesic medications, often in conjunction with a range of adjuvant therapies as may be required. Despite the consistent and rational application of such strategies, it is recognised that a small but significant proportion of cancer patients continue to experience more refractory pain. In addition, these patients may experience a plethora of unwanted dose-limiting side effects associated with their analgesic medication, sometimes even at low dose. All such patients with more complex and refractory pain syndromes require a more comprehensive review and many will require interventional therapy and/or adjuvant approaches. Unfortunately, the availability and accessibility of such services are variable. Even in circumstances in which palliative medicine and pain services co-exist in the same region, there may be poor integration between the two services. Each specialty area holds a unique set of skills and competencies, yet there is considerable overlap. Patient care and outcomes will be enhanced by establishing more formal relationships between these two specialty areas.

Pain management for the cancer patient - current practice and future developments

Anaesthesiologists will be asked to provide pain management for cancer patients in the absence of more specialised services, when interventional techniques are indicated and in the postoperative period. In all these settings, the complexity of cancer pain and its psychosocial connotations need to be considered to provide appropriate and holistic care. Principles of systemic pain management, effective in most patients, continue to follow established guidelines; identification of neuropathic pain and its appropriate treatment is important here. Interventional pain relief is required in a minority of cancer patients, but it should be considered when appropriate and then done with best available expertise. Neurolytic procedures have lost importance here over the years. Postoperative pain management should be multimodal with consideration of regional techniques when applicable. In managing postoperative pain in cancer patients, opioid tolerance needs to be addressed to avoid withdrawal and poor analgesia. Preventive techniques aiming to reduce chronic postoperative pain should be considered.

Percutaneous cervical cordotomy for the management of pain from cancer: a prospective review of 45 cases

BACKGROUND

Percutaneous cervical cordotomy (PCC) is a well recognized but infrequently performed procedure for the relief of unilateral intractable pain from malignancy. There is a paucity of data regarding efficacy and safety of PCC.

OBJECTIVES

The study's objectives were to demonstrate the efficacy and safety of PCC in cancer pain.

DESIGN

The study was a prospective review of 45 cases undergoing PCC at a tertiary referral center over a three-year period.

SETTINGS/SUBJECTS

All patients were suffering from severe, refractory unilateral pain secondary to malignancy with poor pain relief or intolerable side effects of conventional analgesics including opioids and adjuvants.

MEASUREMENTS

Variables recorded preprocedure, at 2 days, and at 28 days postprocedure were numerical rating scale for maximum and average pain, oral morphine equivalent dose, and global impression of change. Adverse events and survival postprocedure were recorded.

RESULTS

Prospective data was obtained in 45 patients. Survival postprocedure ranged from 7 days to 33 months. There was a significant reduction from baseline in pain scores at 2 days and at 28 days postprocedure. Thirty-two patients experienced significant pain relief--average numerical rating scale (NRS) of zero--on day 2. Improvement in pain scores was sustained at 28 days. There were no serious adverse events observed such as respiratory failure.

CONCLUSIONS

PCC is a safe and highly effective procedure to treat intractable unilateral cancer pain. It offers significant advantages over other pain control methods. Patient selection and attention to detail is paramount for a successful outcome.

Interventional management of cancer pain

PURPOSE OF REVIEW

Interventional techniques were the mainstay for cancer pain management before the WHO ladder and opioids were freely available. The three-step WHO ladder has its limitations, and cancer pain is often under treated. Advances in treatment options mean that cancer patients are living longer and pain interventions may have a role to play even early in the cancer diagnosis for better quality of analgesia. The role of high doses of opioids in pain management is also currently under scrutiny.

RECENT FINDINGS

Recent advances in intrathecal analgesia, radiofrequency techniques, both in tumour ablation and neurotomies, are being widely used for palliation. Vertebroplasty techniques have been used not only for pain relief, but also for stabilization. Improved imaging and thoracoscopic techniques have made coeliac plexus and splanchnic blockade safer and more efficacious. There has been recent interest in percutaneous cordotomy with newer techniques using computed tomography/MRI and endoscopy guidance. Percutaneous electrical nerve stimulation and 8% capsaicin patches have been successfully used for managing neuropathic pain in cancer.

SUMMARY

Interventions form an integral part in providing pain relief in complex cancer pains. Oncologists and palliative care physicians are to be educated on the usefulness and timing of interventions in the management of complex cancer pain.