Underprescription of Step III Opioids in French Cancer Survivors With Chronic Pain: A Call for Integrated Early Palliative Care in Oncology

The role of specialist palliative care in individuals "living beyond cancer": a narrative review of the literature

PURPOSE

Many patients living beyond cancer experience significant unmet needs, although few of these patients are currently reviewed by specialist palliative care teams (SPCTs). The aim of this narrative review was to explore the current and potential role of SPCTs in this cohort of patients.

METHODS

A search strategy was developed for Medline, and adapted for Embase, CINAHL, and PsycInfo. Additionally, websites of leading oncology, cancer survivorship, and specialist palliative care organisations were examined. The focus of the search was on individuals living beyond cancer rather than other groups of cancer survivors.

RESULTS

111 articles were retrieved from the search for full text review, and 101 other sources of information were identified after hand searching the reference lists of the full text articles, and the aforesaid websites. The themes of the review encompass the definition of palliative care/specialist palliative care, current models of specialist palliative care, core activities of SPCTs, relevant expertise of SPCTs, and potential barriers to change in relation to extending their support and expertise to individuals living beyond cancer. The review identified a paucity of evidence to support the role of SPCTs in the management of patients living beyond cancer.

CONCLUSIONS

Individuals living beyond cancer have many unmet needs, and specific services are required to manage these problems. Currently, there is limited evidence to support the role of specialist palliative care teams in the management of this cohort of people, and several potential barriers to greater involvement, including limited resources, and lack of relevant expertise.

Electroacupuncture for the treatment of cancer pain: a systematic review and meta-analysis of randomized clinical trials

Objective

This paper aims to review the current evidence on electroacupuncture as an effective and safe therapy for cancer pain management.

Methods

Five databases were searched from their inception through November 11, 2022. Only the randomized controlled trials that meet the eligibility criteria were finally included in the study. Literature screening and data extraction were performed independently by two reviewers, and RevMan 5.3 used for meta-analysis.

Results

A total of 17 RCTs met our inclusion criteria. We used 8 indicators to estimate the meta-analysis results, most of which proved statistically significant, including VAS scores, NRS scores, and KPS scores. To be specific, VAS scores (MD = -1.41, 95% CI: -2.42 to -0.41, P = 0.006) and NRS scores (MD = -1.19, 95% CI: -1.72 to -0.66, P < 0.0001) were significantly lower in the treatment group compared to the control group. The treatment group's KPS scores (MD = 5.48, 95% CI: 3.27 to 7.69, P < 0.00001) were higher than those of the control group. Also, in the treatment group, the number of burst pain (MD = -2.66, 95% CI: -3.32 to -1.99, P < 0.00001) and side effect rates (RR = 0.51, 95% CI: 0.39 to 0.67, P < 0.00001) greatly reduced, while the response rate (RR = 1.17, 95% CI: 1.09 to 1.26, P < 0.0001) significantly increased compared to the control group.

Conclusion

This study demonstrates the advantages of electroacupuncture in the treatment of cancer pain. Meanwhile, rigorous RCTs should be designed and conducted in the future to further demonstrate the exact efficacy of electroacupuncture.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022376148.

Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis

Experiencing pain and insufficient relief can be devastating and negatively affect a patient's quality of life. Developments in oncology such as new treatments and adjusted pain management guidelines may have influenced the prevalence of cancer pain and severity in patients. This review aims to provide an overview of the prevalence and severity of pain in cancer patients in the 2014-2021 literature period. A systematic literature search was performed using the databases PubMed, Embase, CINAHL, and Cochrane. Titles and abstracts were screened, and full texts were evaluated and assessed on methodological quality. A meta-analysis was performed on the pooled prevalence and severity rates. A meta-regression analysis was used to explore differences between treatment groups. We identified 10,637 studies, of which 444 studies were included. The overall prevalence of pain was 44.5%. Moderate to severe pain was experienced by 30.6% of the patients, a lower proportion compared to previous research. Pain experienced by cancer survivors was significantly lower compared to most treatment groups. Our results imply that both the prevalence of pain and pain severity declined in the past decade. Increased attention to the assessment and management of pain might have fostered the decline in the prevalence and severity of pain.

Inflammation in pathogenesis of chronic pain: Foe and friend

Chronic pain is a refractory health disease worldwide causing an enormous economic burden on individuals and society. Accumulating evidence suggests that inflammation in the peripheral nervous system (PNS) and central nervous system (CNS) is the major factor in the pathogenesis of chronic pain. The inflammation in the early- and late phase may have distinctive effects on the initiation and resolution of pain, which can be viewed as friend or foe. On the one hand, painful injuries lead to the activation of glial cells and immune cells in the PNS, releasing pro-inflammatory mediators, which contribute to the sensitization of nociceptors, leading to chronic pain; neuroinflammation in the CNS drives central sensitization and promotes the development of chronic pain. On the other hand, macrophages and glial cells of PNS and CNS promote pain resolution via anti-inflammatory mediators and specialized pro-resolving mediators (SPMs). In this review, we provide an overview of the current understanding of inflammation in the deterioration and resolution of pain. Further, we summarize a number of novel strategies that can be used to prevent and treat chronic pain by controlling inflammation. This comprehensive view of the relationship between inflammation and chronic pain and its specific mechanism will provide novel targets for the treatment of chronic pain.

Palliative Care's Role Managing Cancer Pain During the Opioid Crisis: A Qualitative Study of Patients, Caregivers, and Clinicians

CONTEXT

Patients with cancer face symptoms because of disease and treatment, and pain is common and complex. The opioid crisis may complicate patients' and clinicians' experiences of managing pain in cancer care.

OBJECTIVES

In our study of perceptions and experiences with palliative care (PC) at an outpatient cancer center, we examined communication around symptom management throughout cancer care, and pain and its management emerged as particularly salient. The objective of this article is to describe, from the perspectives of patients, caregivers, and oncology health care professionals, the role of PC in navigating the complicated dynamics of pain management amidst the opioid crisis.

METHODS

A qualitative descriptive study with grounded theory components was designed to investigate experiences with and perceptions of specialist PC and symptom management, including pain. Interviews were audiorecorded and transcribed, and focused coding identified themes related to pain and pain management from all three perspectives.

RESULTS

About 44 patients, caregivers, and non-PC health care professionals completed interviews. Patients with cancer and their caregivers had many concerns about pain management and were specifically concerned about opioid use and stigma. For patients, PC improved pain management and helped to destigmatize appropriate pain management. Oncology clinicians reported that partnering with PC facilitated complex pain management and also provided moral support around difficult opioid recommendations for patients.

CONCLUSION

PC offers the potential to uniquely support both patients and other oncology professionals in optimally navigating the complexity around pain management for cancer care in the midst of the opioid crisis.

Genetic implications in quality palliative care and preventing opioid crisis in cancer-related pain management

The prevalence of cancer-related pain is 64% among patients with metastatic, advanced, or terminal cancer, 59% among patients undergoing anticancer treatment, and 33% among patients who completed curative treatment. According to the World Health Organization cancer pain relief guidelines, opioid analgesics are the mainstay analgesic therapy in addition to conventional first-step analgesics, such as non-steroidal anti-inflammatory drugs and acetaminophen. The indications for strong opioids have recently been expanded to include mild-to-moderate pain in addition to moderate-to-severe pain. The U.S. Centers for Disease Control and Prevention guidelines emphasize that realistic expectations should be weighed against potential serious harm from opioids, rather than relying on the unrealized long-term benefits of these drugs. Therefore, treatment strategies for both cancer-related chronic or acute pain have been unfortunately deviated from opioid analgesics. The barriers hindering adequate cancer-related pain management with opioid analgesics are related to the inadequate knowledge of opioid analgesics (e.g., effective dose, adverse effects, and likelihood of addiction or tolerance). To achieve adequate opioid availability, these barriers should be overcome in a clinically suitable manner. Genetic assessments could play an important role in overcoming challenges in opioid management. To balance the improvement in opioid availability and the prevention of opioid misuse and addiction, the following two considerations concerning opioids and genetic polymorphisms warrant attention: (A) pain severity, opioid sensitivity, and opioid tolerance; and (B) vulnerability to opioid dependence and addiction.

Managing childhood cancer pain into survivorship: recognition and emerging principles

PURPOSE OF REVIEW

Continual refinement and further stratification of childhood cancer treatment has led to increased survivorship with recognized improvements in many long-term health outcomes. Despite this progress, persisting pain prevalence in childhood cancer survivors is increasing and emerging as a significant long-term health concern.

RECENT FINDINGS

Currently, there is no guidance on how to approach and manage persisting pain in survivors of childhood cancer.

SUMMARY

Clinicians should work with children and young people to optimize the management of pain and other symptoms on treatment. Focusing on an early post treatment screening for pain and other symptoms (including sleep and fatigue), and the role of on-going analgesic use. Follow-up should offer a multidisciplinary approach, aimed at lessening reliance on pharmacological approaches to pain management, addressing psychological concerns and promoting increased physical activity. The onus is on clinicians to mitigate the long-term risk of pharmacological reliance, particularly opioid dependency, in patients leaving their care and heading into adulthood. In this article, we highlight the emerging evidence of persisting pain in survivors of childhood cancer as a significant long-term health outcome and consider some initial principles of management.