Cancer Pain Management

Comparative Analysis of Stereotactic Radiation Therapy and Conventional Radiation Therapy in Cancer Pain Control: A Systematic Review and Meta-Analysis

AIMS

Approximately 55% of patients diagnosed with primary or metastatic cancer endure pain directly attributable to the disease. Consequently, it becomes imperative to address pain management through a comparative analysis of stereotactic radiotherapy (SRT) and conventional radiation therapy (CRT), especially in light of the less efficacious improvement achieved solely through pharmacological interventions.

MATERIALS AND METHODS

A systematic exploration was undertaken on PubMed, the Cochrane Library, and Elsevier's ScienceDirect databases to identify studies that compare Stereotactic Radiotherapy to Conventional radiation therapy for pain management in individuals with metastatic bone cancer. The analyses were executed utilizing the random-effects model.

RESULTS

A cohort of 1152 participants with metastatic bone cancer was analyzed, demonstrating significantly higher complete pain relief in the Stereotactic Radiotherapy group during both early and late follow-up (RR: 1.61; 95% CI: 1.17, 2.23, p-value: 0.004; I2: 0%). Stereotactic Radiotherapy also showed a non-significant increase in the incidence of partial pain relief (RR: 1.07; 95% CI: 0.85, 1.34, p-value: 0.56; I2: 18%). Furthermore, Stereotactic Radiotherapy was associated with a significantly reduced risk of stationary pain throughout follow-up (RR: 0.61; 95%CI: 0.48, 0.76, p-value: <0.0001; I2: 0. The incidence of progressive pain was non-significantly reduced with Stereotactic Radiotherapy during both early and late follow-up (RR: 0.77; 95% CI: 0.50, 1.17, p-value: 0.22; I2: 0%). Secondary outcomes exhibited a non-significant trend favoring Stereotactic Radiotherapy for dysphagia, esophagitis, pain, and radiodermatitis, while a non-significant increase was observed for nausea, fatigue, and vertebral compression fracture.

CONCLUSION

In summary, stereotactic radiation therapy (SRT) has improved in achieving complete pain relief while exhibiting a decreased probability of delivering stationary pain compared to conventional radiation therapy (CRT). Nevertheless, it is crucial in future research to address a noteworthy limitation, specifically, the risk of vertebral compression fracture.

Membrane Lipid Replacement for reconstituting mitochondrial function and moderating cancer-related fatigue, pain and other symptoms while counteracting the adverse effects of cancer cytotoxic therapy

Cancer-related fatigue, pain, gastrointestinal and other symptoms are among the most familiar complaints in practically every type and stage of cancer, especially metastatic cancers. Such symptoms are also related to cancer oxidative stress and the damage instigated by cancer cytotoxic therapies to cellular membranes, especially mitochondrial membranes. Cancer cytotoxic therapies (chemotherapy and radiotherapy) often cause adverse symptoms and induce patients to terminate their anti-neoplastic regimens. Cancer-related fatigue, pain and other symptoms and the adverse effects of cancer cytotoxic therapies can be safely moderated with oral Membrane Lipid Replacement (MLR) glycerolphospholipids and mitochondrial cofactors, such as coenzyme Q10. MLR provides essential membrane lipids and precursors to maintain mitochondrial and other cellular membrane functions and reduces fatigue, pain, gastrointestinal, inflammation and other symptoms. In addition, patients with a variety of chronic symptoms benefit from MLR supplements, and MLR also has the ability to enhance the bioavailability of nutrients and slowly remove toxic, hydrophobic molecules from cells and tissues.

Pain management in cervical cancer

Cervical cancer (CC) occupies the second place in incidence and mortality among women in México. Despite this, Cervical Cancer continues to have a late diagnosis which leads to a high rate of complications. Pain represents the most feared and disabling symptom, being present in up to 86% of patients with advanced disease. The approach to managing pain in this population has not been studied and described to a full extent. In addition, there is a pressing need to provide concise recommendations to promote adequate pain control. We performed a review of the literature in CC and had experts in the field of pain management evaluate the evidence found. We then issued relevant recommendations on pharmacology and interventional pain management. Thus, the approach to pain management must be comprehensive and individualized, considering the timely and appropriate use of pharmacologic treatment as well as interventional procedures.

Medical cannabis is effective for cancer-related pain: Quebec Cannabis Registry results

OBJECTIVES

To evaluate the safety and effectiveness of medical cannabis (MC) in reducing pain and concurrent medications in patients with cancer.

METHODS

This study analysed data collected from patients with cancer who were part of the Quebec Cannabis Registry. Brief Pain Inventory (BPI), revised Edmonton Symptom Assessment System (ESAS-r) questionnaires, total medication burden (TMB) and morphine equivalent daily dose (MEDD) recorded at 3-month, 6-month, 9-month and 12-month follow-ups were compared with baseline values. Adverse events were also documented at each follow-up visit.

RESULTS

This study included 358 patients with cancer. Thirteen out of 15 adverse events reported in 11 patients were not serious; 2 serious events (pneumonia and cardiovascular event) were considered unlikely related to MC. Statistically significant decreases were observed at 3-month, 6-month and 9-month follow-up for BPI worst pain (5.5±0.7 baseline, 3.6±0.7, 3.6±0.7, 3.6±0.8; p<0.01), average pain (4.1±0.6 baseline, 2.4±0.6, 2.3±0.6, 2.7±0.7; p<0.01), overall pain severity (3.7±0.5 baseline, 2.3±0.6, 2.3±0.6, 2.4±0.6; p<0.01) and pain interference (4.3±0.6 baseline, 2.4±0.6, 2.2±0.6, 2.4±0.7, p<0.01). ESAS-r pain scores decreased significantly at 3-month, 6-month and 9-month follow-up (3.7±0.6 baseline, 2.5±0.6, 2.2±0.6, 2.0±0.7, p<0.01). THC:CBD balanced strains were associated with better pain relief as compared with THC-dominant and CBD-dominant strains. Decreases in TMB were observed at all follow-ups. Decreases in MEDD were observed at the first three follow-ups.

CONCLUSIONS

Real-world data from this large, prospective, multicentre registry indicate that MC is a safe and effective complementary treatment for pain relief in patients with cancer. Our findings should be confirmed through randomised placebo-controlled trials.

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.

Practical Considerations for the Use of Cannabis in Cancer Pain Management—What a Medical Oncologist Should Know

Pain is a highly debilitating emotional and sensory experience that significantly affects quality of life (QoL). Numerous chronic conditions, including cancer, are associated with chronic pain. In the setting of malignancy, pain can be a consequence of the tumor itself or of life-saving interventions, including surgery, chemotherapy, and radiotherapy. Despite significant pharmacological advances and awareness campaigns, pain remains undertreated in one-third of patients. To date, opioids have been the mainstay of cancer pain management. The problematic side effects and unsatisfactory pain relief of opioids have revived patients’ and physicians’ interest in finding new solutions, including cannabis and cannabinoids. The medical use of cannabis has been prohibited for decades, and it remains in Schedule 1 of the Misuse of Drugs Regulations. Currently, the legal context for its usage has become more permissive. Various preclinical and observational studies have aimed to prove that cannabinoids could be effective in cancer pain management. However, their clinical utility must be further supported by high-quality clinical trials.

Scrambler Therapy Enhances Quality of Life in Cancer Patients in a Palliative Care Setting: A Randomised Controlled Trial

Objectives:

Given the known side effects of opioids and the negative impact of these side effects on quality of life (QOL), there is a need for therapies that can reduce opioid intake and improve QOL in patients suffering from cancer pain. Scrambler therapy (ST) is a neuromodulatory therapy that has been shown to reduce cancer pain, but its effect on QOL is not well understood. This study intended to evaluate the efficacy of ST for enhancing QOL in cancer patients through minimising pain and opioid intake.

Material and Methods:

This was a randomised controlled trial including 80 patients with head, neck and thoracic cancer. In both arms, patients were given pain management drugs following the WHO analgesic ladder for ten consecutive days. In the intervention arm each day ST was given. Pain, morphine intake, and QOL (WHOQOL-BREF) were assessed.

Results:

All domains of QOL improved significantly in the intervention arm in comparison to the control arm. In comparison to baseline, pain improved in both the intervention and the control arm on day 10 and at follow-up. However, QOL significantly improved in the intervention arm, while morphine intake decreased. In the control arm, QOL deteriorated, while morphine intake increased.

Conclusion:

ST significantly improved QOL. Since the increase in QOL took place along with a significantly lower morphine intake, the improvement in QOL may not only be explained by lower pain scores but, also, by a reduced intake of morphine, because the lower dosages of morphine will decrease the likelihood of side effects associated with the drug.

Knowledge, attitudes, and practices toward cancer pain management amongst healthcare workers (physicians, pharmacists, and nurses): a cross-sectional study from first-tier cities in China

PURPOSE

China is currently one of the countries with the largest increased number of new cancer cases in the world, but cancer pain management (CPM) is still inadequate. This study uses a questionnaire to demonstrate the status and differences in knowledge, attitude and practice (KAP) of CPM among healthcare workers (HCWs) in developed regions of China, to find deficiencies and priorities for improvement, from which areas and advantages of the role of pharmacists and mobile devices can be explored.

METHODS

This study used data from a questionnaire on CPM from March to June 2019. The study population consisted of a total of 515 HCWs in four first-tier developed cities in China. The questionnaire has four major components, analysis of differences in KAP of different occupations through one-way analysis of variance (ANOVA).

RESULTS

Among the respondents, the physicians had the highest knowledge scores toward CPM, pharmacists had the lowest practice scores. Around half of the respondents indicated that their hospital or department have a pharmacist participating in CPM. Physicians and nurses were more likely to expect pharmacists to provide drug counseling. The HCWs interviewed most expect that the mobile-based pain management system can automatically screen and mark patients with pain.

CONCLUSION

From this study, it can be suggested that pharmacists and nurses in the CPM team should actively promote relevant knowledge. Besides, pharmacists should focus on improving practical ability such as increasing the frequency of pain assessment. Multidisciplinary collaboration and the introduction of mobile devices can improve and refine the CPM.

Non-pharmacological integrative therapies for chronic cancer pain

Objective

Chronic pain is one of the most detrimental symptoms exhibited by cancer patients, being an indication for opioid therapy in up to half of the patients’ receiving chemotherapy and in 90% of advanced cases. Various successful non-pharmacological integrative therapy options have been explored and implemented to improve the quality of life in these patients. This review aims to highlight the mechanisms implicated; assessment tools used for cancer pain and summarize current evidence on non-pharmacological approaches in the treatment of chronic cancer pain.

Data sources

A review of the literature was conducted using a combination of MeSH keywords including “Chronic cancer pain,” “Assessment,” “Non-pharmacological management,” and “Integrative therapy.”

Data summary

Data on the approach and assessment of chronic cancer pain as well as non-pharmacological integrative options have been displayed with the help of figures and tables. Of note, non-pharmacological integrative management was divided into three subcategories; physical therapy (involving exercise, acupuncture, massage, and transcutaneous electric nerve stimulation), psychosocial therapy (e.g. mindful practices, supportive therapy), and herbal supplementation.

Conclusions

The use of non-pharmacological integrative therapy in the management of chronic cancer pain has been grossly underestimated and must be considered before or as an adjuvant of other treatment regimens to ensure appropriate care.

Bioactive Peptides: Synthesis, Sources, Applications, and Proposed Mechanisms of Action

Bioactive peptides are a group of biological molecules that are normally buried in the structure of parent proteins and become active after the cleavage of the proteins. Another group of peptides is actively produced and found in many microorganisms and the body of organisms. Today, many groups of bioactive peptides have been marketed chemically or recombinantly. This article reviews the various production methods and sources of these important/ubiquitous and useful biomolecules. Their applications, such as antimicrobial, antihypertensive, antioxidant activities, blood-lipid-lowering effect, opioid role, antiobesity, ability to bind minerals, antidiabetic, and antiaging effects, will be explored. The types of pathways proposed for bioactive applications will be in the next part of the article, and at the end, the future perspectives of bioactive peptides will be reviewed. Reading this article is recommended for researchers interested in various fields of physiology, microbiology, biochemistry, and nanotechnology and food industry professionals.

A Survey of Knowledge and Barriers of Healthcare Professionals toward Opioid Analgesics in Cancer Pain Management

PURPOSE

Pain is among the most frequent and troubling symptoms in cancer patients. Despite the availability of updated treatment guidelines and effective pharmacological therapies, undertreatment of cancer pain remains a global problem. Opioids are the mainstay analgesics to treat moderate-to-severe cancer pain. The goal of this study was to assess the knowledge and barriers towards opioid analgesics for cancer pain management among healthcare professionals in Oncology Units in Jordan.

METHODS

A structured questionnaire was administered to healthcare professionals (consultant doctors, resident doctors, pharmacists, and nurses) at three Oncology Units in a cross-sectional study design.

RESULTS

A total of 201 healthcare professionals completed the questionnaire. The average age was 34.8 ± 8.1 years (range 23-58) and 49.3% of respondents were nurses. The mean score for the knowledge of opioids was 12.5 ± 3.2 out of 24 points (range 2-20). An acceptable level of knowledge was observed in 50.7% of participants, while 49.3% had poor knowledge. Knowledge items mostly answered incorrectly were related to opioid administration, pharmacology, dosing, adverse events, rotation, and toxicity. Knowledge scores were significantly higher for consultant doctors compared to pharmacists and nurses (p=0.016 and p < 0.001, respectively). Healthcare professionals who handled opioid analgesics had significantly higher mean knowledge scores than those who did not (p=0.012). Linear regression analysis revealed that being a consultant physician has an independent, statistically significant association with higher knowledge scores. Among perceived barriers to using opioids, fear of addiction by patients was the most frequently reported barrier by respondents (79.6%). Other highly recognized barriers were fear of adverse effects by patients (67.2%) and lack of training programs on opioid dosing and monitoring (63.7%).

CONCLUSIONS

This study revealed major gaps in the knowledge of opioids and pain management among healthcare professionals. There is an urgent need for developing innovative interventions to improve the knowledge of opioid analgesics and the understanding of pain management guidelines among healthcare professionals in Jordan.

Cross Disciplinary Role Agreement is Needed When Coordinating Long-Term Opioid Prescribing for Cancer: a Qualitative Study

BACKGROUND

Cancer pain is highly prevalent and often managed in primary care or by oncology providers in combination with primary care providers.

OBJECTIVES

To understand interdisciplinary provider experiences coordinating opioid pain management for patients with chronic cancer-related pain in a large integrated healthcare system.

DESIGN

Qualitative research.

PARTICIPANTS

We conducted 20 semi-structured interviews with interdisciplinary providers in two large academically affiliated VA Medical Centers and their associated community-based outpatient clinics. Participants included primary care providers (PCPs) and oncology-based personnel (OBPs).

APPROACH

We deductively identified 94 examples of care coordination for cancer pain in the 20 interviews. We secondarily used an inductive open coding approach and identified themes through constant comparison coming to research team consensus.

RESULTS

Theme 1: PCPs and OBPs generally believed one provider should handle all opioid prescribing for a specific patient, but did not always agree on who that prescriber should be in the context of cancer pain. Theme 2: There are special circumstances where having multiple prescribers is appropriate (e.g., a pain crisis). Theme 3: A collaborative process to opioid cancer pain management would include real-time communication and negotiation between PCPs and oncology around who will handle opioid prescribing. Theme 4: Providers identified multiple barriers in coordinating cancer pain management across disciplines.

CONCLUSIONS

Our findings highlight how real-time negotiation about roles in opioid pain management is needed between interdisciplinary clinicians. Lack of cross-disciplinary role agreement may result in delays in clinically appropriate cancer pain management.

Focused Ultrasound (FUS) for Chronic Pain Management: Approved and Potential Applications

Chronic pain is one of the leading causes of disability and disease burden worldwide, accounting for a prevalence between 6.9% and 10% in the general population. Pharmacotherapy alone results ineffective in about 70-60% of patients in terms of a satisfactory degree of pain relief. Focused ultrasound is a promising tool for chronic pain management, being approved for thalamotomy in chronic neuropathic pain and for bone metastases-related pain treatment. FUS is a noninvasive technique for neuromodulation and for tissue ablation that can be applied to several tissues. Transcranial FUS (tFUS) can lead to opposite biological effects, depending on stimulation parameters: from reversible neural activity facilitation or suppression (low-intensity, low-frequency ultrasound, LILFUS) to irreversible tissue ablation (high-intensity focused ultrasounds, HIFU). HIFU is approved for thalamotomy in neuropathic pain at the central nervous system level and for the treatment of facet joint osteoarthritis at the peripheral level. Potential applications include HIFU at the spinal cord level for selected cases of refractory chronic neuropathic pain, knee osteoarthritis, sacroiliac joint disease, intervertebral disc nucleolysis, phantom limb, and ablation of peripheral nerves. FUS at nonablative dosage, LILFUS, has potential reversible and tissue-selective effects. FUS applications at nonablative doses currently are at a research stage. The main potential applications include targeted drug and gene delivery through the Blood-Brain Barrier, assessment of pain thresholds and study of pain, and reversible peripheral nerve conduction block. The aim of the present review is to describe the approved and potential applications of the focused ultrasound technology in the field of chronic pain management.

Scrambler therapy for incident pain in bone metastases

Incident pain, described as pain induced by bone metastasis and produced by movement, can be devastating. The high doses of opioids needed to control such pain may sedate the patient and cause additional complications. Treatment of incident pain with pharmaceuticals has rarely been studied; only eight patients have been reported in the literature who did not receive additional opioids. We present the case of a 69 year old man with shoulder destruction due to bone metastases who was able to use his arm for normal activities without pain after three sessions of scrambler therapy, a noninvasive form of electrical neuromodulation that requires further study.

Pain Standards for Accredited Healthcare Organizations (ACDON Project): A Mixed Methods Study

Up to 50% of cancer patients and up to 90% of those in terminal stages experience pain associated with disease progression, poor quality of life, and social impact on caregivers. This study aimed to establish standards for the accreditation of oncological pain management in healthcare organizations. A mixed methods approach was used. First, a pragmatic literature review was conducted. Second, consensus between professionals and patients was reached using the Nominal Group and Delphi technique in a step that involved anesthesiologists, oncologists, family physicians, nurses, psychologists, patient representatives, and caregivers. Third, eight hospitals participated in a pilot assessment of the level of fulfillment of each standard. A total of 37 standards were extracted. The Nominal Group produced additional standards, of which 60 were included in Questionnaire 0 that was used in the Delphi Technique. Two Delphi voting rounds were performed to reach a high level of consensus, and involved 64 and 62 participants with response rates of 90% and 87%, respectively. Finally, 39 standards for the management of cancer pain were agreed upon. In the self-evaluation, the average range of compliance was between 56.4% and 100%. The consensus standards of the ACDON Project might improve the monitoring of cancer pain management. These standards satisfied the demands of professionals and patients and could be used for the accreditation of approaches in cancer pain management.

Non-opioid Analgesics and Emerging Therapies

Pain is a common and debilitating symptom of cancer. Cancer-related pain can occur at any point along the continuum from diagnosis to treatment to survivorship¹. A systematic review published in 2016 estimated the prevalence of cancer pain to be 55% in those undergoing antineoplastic treatment, 66.4% in advanced cancer, and 39.3% in the post-treatment population. Thirty-eight percent of cancer patients in this pooled analysis experienced moderate to severe pain².

Mobile Health-Collected Biophysical Markers in Children with Serious Illness-Related Pain

Context: There is an ongoing established need to develop engaging pain assessment strategies to provide more effective individualized care to pediatric patients with serious illnesses. This study explores the acceptability of wireless devices as one option. Objective: To evaluate the ability of wrist-wearable technology to collect physiological data from children with serious illnesses. Methods: Single-site prospective observational study conducted between September 2017 and September 2018 at Rady Children's Hospital, San Diego, California, inpatient wards. Pediatric patients with diagnoses of cancer and sickle cell disease admitted to the hospital for acute-on-chronic pain and taking opioid pain medications were asked to complete two 24-hour continuous monitoring periods with the Empatica E4 wristband. Results: Data collected from the device correlated with manually obtained vital signs. Children responded favorably to wearing the device. Participants with reported subjective pain versus no pain had average heart rate increased by 16.4 bpm, skin temperature decreased by 3.5°C, and electrodermal activity decreased by 0.27. Conclusions: This study shows the possibility of collecting continuous biophysical data in a nonobtrusive manner in seriously ill children experiencing acute-on-chronic pain using wearable devices. It provides the framework for larger studies to explore the utility of such data in relation to metrics of pain and suffering in this patient population.

Attitudes and appropriateness of pain management in cancer patients using pain management index

Objectives

Inadequate management of cancer pain (CP) remains a global medical problem. In this study, the aim was to assess attitudes of cancer patients towards their CP treatment and to evaluate effectiveness of pain management.

Methods

A sample of 300 adult cancer patients admitted to a single hospital were face-to-face interviewed in a cross-sectional study design using a structured questionnaire. The short form of the Brief Pain Inventory was used to collect data on pain, and Pain Management Index (PMI) was calculated to assess adequacy of pain management.

Key findings

Median age of patients was 53 years (interquartile range, 43–63). Half of patients (50.5%) believed their pain therapy needs improvement. Almost half patients had severe pain at interview (49.8%). Pain interfered most with patient enjoyment of life with a mean interference score 6.13 ± 2.37. Majority of cancer patients (84.3%) received a non-opioid analgesic while a minority (15.7%) received opioid analgesic in which morphine was the most common drug. The use of non-opioid adjuvants was minimal. Mean PMI for patients was −1.15 ± 0.75 (range −2 to +1), and most patients (80.3%) had inadequate pain treatment. Gender and smoking status of patients were significantly associated with adequacy of pain management (P = 0.009 and P = 0.004, respectively). There were no associations between patient age, educational level or tumour characteristics and adequacy of pain management.

Conclusions

Cancer patients in this study present with severe pain and the rates of undertreatment are high. There is an urgent need to improve management plans to assure appropriate use of therapeutic modalities for treatment of cancer-related pain.

The Roles of Battlefield Acupuncture and Electroacupuncture in a Patient with Cancer-Related Pain

Background: Pain is one of the most-frightening complications of cancer and disrupts quality of life. Cancer-related pain can be caused by primary cancer itself, metastases that occur, and interventions to treat cancer. Almost all cancer-related pain is pain with moderate-to-severe intensity. Thus, cancer-related pain management often involves administration of opioid analgesics. However, administration of opioid analgesics can cause side-effects that cause new problems for these patients. Several studies have shown that acupuncture can reduce cancer-related pain and data show that acupuncture therapy is safe and can provide clinically meaningful improvements when used in conjunction with standard therapy. Case: A 72-year-old female patient had pain throughout her body since 1 month prior to before being admitted to the hospital. She was unable to sleep at night often cried because she was unable to stand the pain. This was reduced by morphine 3 × /day. Because of the drug's side-effects, she slept more often during the day, could not sleep at night, and was constipated. She also had breakthrough pain, on an average of 2-3 × /day. She had a history of malignancy in the pleura, liver, lungs, and cervix. There was an increase in some tumor markers. Her baseline numeric rating scale (NRS) assessment was 4 with an oral morphine slow-release tablet 3 × 15 mg/day. Acupuncture therapy was performed at Battlefield Acupuncture points of the right ear and body acupuncture points (LI 4, LI 11, ST 36, SP 6, and LR 3) was treated with 3-Hz continuous-wave electroacupuncture for 30 minutes at each session. During this therapy, there were reductions in pain (baseline NRS 4 became 2), need for morphine, morphine side-effects, and frequency of breakthrough pain. There were no significant side-effects due to acupuncture. Conclusions: Acupuncture is an effective and safe therapeutic option for reducing cancer pain with minimal side-effects. Acupuncture can enable a reduced need for narcotic analgesics.

Interventions for Managing a Symptom Cluster of Pain, Fatigue, and Sleep Disturbances During Cancer Survivorship: A Systematic Review

PROBLEM IDENTIFICATION

More than 40% of cancer survivors experience a symptom cluster of pain, fatigue, and sleep disturbances, which can greatly reduce quality of life.

LITERATURE SEARCH

A literature search was performed using CINAHL®, Google ScholarTM, PubMed®, PsycINFO®, and Web of Science. Articles included randomized controlled trials of interventions aimed at managing a symptom cluster of pain, fatigue, and sleep disturbances.

DATA EVALUATION

11 studies were assessed for quality, risk of bias, cancer type, sample size, intervention type, duration, and setting. For an intervention to be considered effective, the reduction of symptom severity or distress had to be statistically significant.

SYNTHESIS

Data from the 11 studies were summarized. Four interventions were found to be effective in managing the symptom cluster, but evidence on long-term effectiveness was insufficient.

IMPLICATIONS FOR NURSING

Oncology nurses can assess the patterns and characteristics of simultaneous symptoms experienced by cancer survivors and administer interventions to relieve symptom burden and improve quality of life.

Systematic review of the effectiveness of self-initiated interventions to decrease pain and sensory disturbances associated with peripheral neuropathy

PURPOSE

A small number of studies report that patients with peripheral neuropathy (PN) who engage in activities that promote a sense of personal well-being and provide physical, emotional, or spiritual comfort have a better quality of life and higher levels of adjustment to the changes generated by their illness and accompanying symptoms. This systematic review sought to evaluate the effectiveness of self-management activities that patients with PN initiate themselves to relieve PN symptoms and improve quality of life.

METHODS

Search terms were limited to include self-management activities initiated by patients (i.e., activities with no or minimal involvement from clinicians) that aim to provide relief of PN symptoms. Outcomes included in searches were pain, numbness, and tingling, associated with PN and quality of life.

RESULTS

The database searches identified 2979 records, of which 1620 were duplicates. A total of 1322 papers were excluded on the basis of screening the abstract. An additional 21 full text articles were excluded because they did not meet the eligibility criteria. A total of 16 papers were included in the review.

CONCLUSION

This review identified that a number of self-management strategies that were initiated by patients, including heat, exercise, meditation, and transcutaneous electrical nerve stimulation (TENS) therapy, may reduce self-reported PN symptoms. As the available studies were of low quality, these strategies warrant further investigation with more homogeneous samples, using more rigorously designed trials and larger samples.

IMPLICATIONS FOR CANCER SURVIVORS

Patients experiencing PN may find a range of self-initiated strategies beneficial in reducing PN symptoms and improving quality of life. However, because of the low quality of the available studies, clinicians need to monitor patients' responses to determine the effectiveness of these interventions as adjuncts to clinician-initiated interventions.

Ketamine exhibits anti-gastric cancer activity via induction of apoptosis and attenuation of PI3K/Akt/mTOR

INTRODUCTION

Gastric cancer (GC) is the most widespread type of cancer after lung and liver cancer in men and after breast cancer in women. Thus, the present study was intended to evaluate the effect of ketamine (KET) on gastric cancer cells.

MATERIAL AND METHODS

The effect of KET was analyzed in vitro by the MTT assay against human gastric cancer cell lines BGC-823, MKN-45 and MKN-28. The effect KET on apoptosis, cell migration and cell cycle arrest was also quantified. Western blot analysis was performed to estimate the effect of KET on apoptosis mediators and PI3K/AKT/mTOR pathway mediators. A mouse xenograft assay was also conducted to further confirm the anticancer activity.

RESULTS

KET causes reduction of cellular viability of BGC-823, MKN-45 and MKN-28, with a more significant effect against BGC-823 cells. The KET treatment showed a dose-dependent increase in apoptotic cells among BGC-823 cells. KET causes a significant dose-dependent decline in migration of treated cells. It causes induction of apoptosis mediated via the mitochondrial pathway, where it causes a decline in Bcl2 and mitochondrial cytochrome c level together with increase in expression of Bax, cytosolic cytochrome c and cytosolic apoptotic protease activating factor-1 (Apaf-1). The level of p-PI3K, p-mTOR, p-GSK3β and p-AKT was found to be downregulated in a dose-dependent manner in KET-treated cells. In a mouse xenograft model, KET causes a reduction in relative tumour volume and tumour weight.

CONCLUSIONS

Our results suggest that ketamine has the ability to inhibit progression of gastric cancer via induction of apoptosis and attenuation of PI3K/Akt/mTOR.

Ameliorative effects of aqueous extract of Forsythiae suspensa fruits on oxaliplatin-induced neurotoxicity in vitro and in vivo

Background

The dried fruits of Forsythia suspensa has generally been used to clear heat and detoxify in traditional Korean and Chinese medicine. Oxaliplatin is a first-line treatment chemotherapeutic agent for advanced colorectal cancer, but it induces peripheral neuropathy as an adverse side effect affecting the treatment regimen and the patient’s quality of life. The present study was conducted to evaluate the neuroprotective effects of an aqueous extract of F. suspensa fruits (EFSF) on oxaliplatin-induced peripheral neuropathy.

Methods

The chemical components from EFSF were characterized and quantified using the ultra-high performance liquid chromatography-diode array detector system. The cytotoxicities of anticancer drugs in cancer cells and PC12 cells were assessed by the Ez-Cytox viability assay. To measure the in vitro neurotoxicity, the neurite outgrowth was analyzed in the primary dorsal root ganglion (DRG) cells, and neural PC12 cells that were differentiated with nerve growth factor. To evaluate the in vivo neuroprotective activity, the von Frey test was performed in six-week-old male mice (C57BL/6) receiving EFSF (60–600 mg/kg) in the presence of 20–30 mg/kg cumulative doses of oxaliplatin. Thereafter, the mice were euthanized for immunohistochemical staining analysis with an antibody against PGP9.5.

Results

EFSF attenuated the cytotoxic activities of the various anticancer drugs in neural PC12 cells, but did not affect the anticancer activity of oxaliplatin in human cancer cells. Oxaliplatin remarkably induced neurotoxicities including cytotoxicity and the inhibited neurite outgrowth of DRG and neural PC12 cells. However, the co-treatment of EFSF (100 μg/ml) with oxaliplatin completely reversed the oxaliplatin-induced neurotoxicity. Forsythoside A, the major component of EFSF, also exerted remarkable neuroprotective effects against the oxaliplatin-induced neurotoxicity. In addition, EFSF (60–200 mg/kg) significantly alleviated the oxaliplatin-induced mechanical allodynia and loss of intra-epidermal nerve fiber to the levels of the vehicle control in the mouse peripheral neuropathy model.

Conclusions

EFSF could be considered a useful herbal medicine for the treatment of peripheral neuropathy in cancer patients receiving chemotherapy with oxaliplatin.

Neuropathic pain and prognosis of a dog submitted to limb amputation after diagnosis of soft tissue sarcoma - case report

ABSTRACT Neuropathic pain occurs when there is a lesion or a dysfunction of the nervous system. Humans and veterinary patients may develop neuropathic pain, but in veterinary it is not often reported probably because of its mistaken diagnosis. A canine patient was admitted to the Veterinary Hospital of UNESP-Jaboticabal-SP, Brazil with a nodule on the left thoracic limb. The nodule was surgically removed, and histopathological analysis demonstrated the tumor was a soft tissue sarcoma (STS) and the margins were not clean. Based on the patient’s health condition and the lack of suitable equipment, the next procedure was limb amputation. The patient received analgesic medication in the post-surgery period; nevertheless, clinical signs of neuropathic pain were present, such as compulsive licking and other behavioral disorders. Medications were administered for forty days, but clinical signs ceased only when replaced with a tryciclic antidepressant drug, Amitriptyline. Therapeutic management of the patient in this report can be considered effective, since five years after the end of the treatment there was no recurrence or presence of metastasis.

Influence of Pain and Analgesia on Cancer Research Studies

Mice and rats are valuable and commonly used as models for the study of cancer. The models and methods of experimentation have the potential to cause pain to some degree, and all charged with ensuring animal welfare must determine how to manage it. A commonly posed question, especially from investigators and IACUC, is whether the provision of analgesic agents will render the model invalid. Left untreated, pain is a stressor and has negative consequences, most notably immune system perturbations. In addition, analgesic agents in the opioid and NSAID drug classes exhibit immunomodulatory activity and influence processes such as cell proliferation, apoptosis, and angiogenesis that are important in cancer formation. Therefore, both pain and the agents used to alleviate it have the potential to act as confounding factors in a study. This review article presents data from both human medicine and work with animal models in an attempt to help inform discussions about the withholding of analgesic agents from animals used in cancer studies.

Intrathecal betamethasone for cancer pain: A study of its analgesic efficacy and safety

BACKGROUND

A preliminary study has shown effective cancer pain relief by intrathecal betamethasone (ITB). However, further evidence is needed to support this new approach.

METHODS

Cancer patients with opioid-resistant pain received lumbar intrathecal administration of betamethasone 2 or 3 mg once a week for 28 days. Immediate and short-term analgesia (using a percentage pain reduction scale and a numerical rating scale, NRS) and long-term analgesia (using NRS) were assessed. Patients were classified into two groups according to the most painful site of metastasis: vertebral column and/or surrounding nerve plexus metastases (group A) and other metastases distal from the vertebral column (group B).

RESULTS

A total of 104 patients received ITB. Pain relief was observed not only in the lower half but also in the upper half of the body. The proportion of group A patients who experienced immediate analgesia was 81% (47/58), which was significantly greater than that of group B (P < 0.001). A decrease in NRS scores 1 day after ITB administration was observed in significantly more patients in group A than in group B (P < 0.001). Long-term analgesia was also recorded in a greater proportion of patients in group A than in group B in the 7-day (59%, 38/64 vs 6%, 2/33) and 28-day periods (71%, 40/56 vs 31%, 8/26) (P < 0.001). No adverse effects related to neurotoxicity were recorded.

CONCLUSION

Intrathecal injection of betamethasone produced analgesia for opioid-resistant cancer pain, and may be a potent therapeutic option for intolerable pain from vertebral column and/or surrounding nerve plexus metastases.

Neuroprotective Effects of an Aqueous Extract of Forsythia viridissima and Its Major Constituents on Oxaliplatin-Induced Peripheral Neuropathy

The dried fruits of Forsythia viridissima have been prescribed to relive fever, pain, vomiting, and nausea in traditional medicine. Oxaliplatin (LOHP) is used to treat advanced colorectal cancer; however, it frequently induces peripheral neuropathies. This study was done to evaluate the neuroprotective effects of an aqueous extract of Forsythia viridissima fruits (EFVF) and its major constituents. Chemical constituents from EFVF were characterized and quantified with the UHPLC-diode array detector method, and three major constituents were identified as arctiin, matairesinol, and arctigenin. The in vitro cytotoxicity was measured by the Ez-cytox viability assay, and the in vivo neuroprotection activity was evaluated by a von Frey test in two rodent animal models that were administered LOHP. EFVF significantly alleviated the LOHP-induced mechanical hypersensitivity in the induction model. EFVF also prevented the induction of mechanical hyperalgesia by LOHP in the pre- and co-treatment of LOHP and EFVF. Consistently, EFVF exerted protective effects against LOHP-induced neurotoxicity as well as inhibited neurite outgrowths in PC12 and dorsal root ganglion cells. Among the major components of EFVF, arctigenin and matairesinol exerted protective effects against LOHP-induced neurotoxicity. Therefore, EFVF may be useful for relieving or preventing LOHP-induced peripheral neuropathy in cancer patients undergoing chemotherapy with LOHP.

Systematic review and meta-analysis on non-opioid analgesics in palliative medicine

Non-opioid analgesics are widely used for pain relief in palliative medicine. However, there is a lack of evidence-based recommendations addressing the efficacy, tolerability, and safety of non-opioids in this field. A comprehensive systematic review and meta-analysis on current evidence can provide a basis for sound recommendations in clinical practice. A database search for controlled trials on the use of non-opioids in adult palliative patients was performed in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, and EMBASE from inception to 18 February 2018. Endpoints were pain intensity, opioid-sparing effects, safety, and quality of life. Studies with similar patients, interventions, and outcomes were included in the meta-analyses. Our systematic search was able to only identify studies dealing with cancer pain. Of 5991 retrieved studies, 43 could be included (n = 2925 patients). There was no convincing evidence for satisfactory pain relief by acetaminophen alone or in combination with strong opioids. We found substantial evidence of moderate quality for a satisfactory pain relief in cancer by non-steroidal anti-inflammatory drugs (NSAIDs), flupirtine, and dipyrone compared with placebo or other analgesics. There was no evidence for a superiority of one specific non-opioid. There was moderate quality of evidence for a similar pain reduction by NSAIDs in the usual dosage range compared with up to 15 mg of morphine or opioids of equianalgesic potency. The combination of NSAID and step III opioids showed a beneficial effect, without a decreased tolerability. There is scarce evidence concerning the combination of NSAIDs with weak opioids. There are no randomized-controlled studies on the use of non-opioids in a wide range of end-stage diseases except for cancer. Non-steroidal anti-inflammatory drugs, flupirtine, and dipyrone can be recommended for the treatment of cancer pain either alone or in combination with strong opioids. The use of acetaminophen in the palliative setting cannot be recommended. Studies are not available for long-term use. There is a lack of evidence regarding pain treatment by non-opioids in specific cancer entities.

Metastatic breast cancer patients' expectations and priorities for symptom improvement

PURPOSE

Little research has examined cancer patients' expectations, goals, and priorities for symptom improvement. Thus, we examined these outcomes in metastatic breast cancer patients to provide patients' perspectives on clinically meaningful symptom improvement and priorities for symptom management.

METHODS

Eighty women with metastatic breast cancer participated in a survey with measures of comorbidity, functional status, engagement in roles and activities, distress, quality of life, and the modified Patient-Centered Outcomes Questionnaire that focused on 10 common symptoms in cancer patients.

RESULTS

On average, patients reported low to moderate severity across the 10 symptoms and expected symptom treatment to be successful. Patients indicated that a 49% reduction in fatigue, 48% reduction in thinking problems, and 43% reduction in sleep problems would represent successful symptom treatment. Cluster analysis based on ratings of the importance of symptom improvement yielded three clusters of patients: (1) those who rated thinking problems, sleep problems, and fatigue as highly important, (2) those who rated pain as moderately important, and (3) those who rated all symptoms as highly important. The first patient cluster differed from other subgroups in severity of thinking problems and education.

CONCLUSIONS

Metastatic breast cancer patients report differing symptom treatment priorities and criteria for treatment success across symptoms. Considering cancer patients' perspectives on clinically meaningful symptom improvement and priorities for symptom management will ensure that treatment is consistent with their values and goals.

Cancer pain management needs and perspectives of patients from Chinese backgrounds: a systematic review of the Chinese and English literature

Objective

More than half of all cancer patients experience unrelieved pain. Culture can significantly affect patients’ cancer pain-related beliefs and behaviors. Little is known about cultural impact on Chinese cancer patients’ pain management. The objective of this review was to describe pain management experiences of cancer patients from Chinese backgrounds and to identify barriers affecting their pain management.

Method

A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported pain management experiences of adult cancer patients from Chinese backgrounds. Five databases were searched for peer-reviewed articles published in English or Chinese journals between1990 and 2015. The quality of included studies was assessed using Joanna Briggs Institution's appraisal tools.

Results

Of 3,904 identified records, 23 articles met criteria and provided primary data from 6,110 patients. Suboptimal analgesic use, delays in receiving treatment, reluctance to report pain, and/or poor adherence to prescribed analgesics contributed to the patients’ inadequate pain control. Patient-related barriers included fatalism, desire to be good, low pain control belief, pain endurance beliefs, and negative effect beliefs. Patients and family shared barriers about fear of addiction and concerns on analgesic side effects and disease progression. Health professional–related barriers were poor communication, ineffective management of pain, and analgesic side effects. Healthcare system–related barriers included limited access to analgesics and/or after hour pain services and lack of health insurance.

Significance of results

Chinese cancer patients’ misconceptions regarding pain and analgesics may present as the main barriers to optimal pain relief. Findings of this review may inform health interventions to improve cancer pain management outcomes for patients from Chinese backgrounds. Future studies on patients’ nonpharmacology intervention-related experiences are required to inform multidisciplinary and biopsychosocial approaches for culturally appropriate pain management.

Parents' Voice in Managing the Pain of Children with Cancer during Palliative Care

Context:

Pain experienced by children can adversely affect their growth and development. Pain is a major health problem for cancer patients and remains an unresolved problem.

Aim:

To know how the experiences of mothers managing their children's pain during palliative care following cancer diagnosis.

Background:

Pain experienced by children can adversely affect their growth and development.

Subject and Methods:

Using qualitative methods within a descriptive phenomenological approach, in-depth interviews were conducted with parents (mostly mothers) of eight children diagnosed with cancer. The data were collected using the snowball sampling method.

Results:

Participants experienced in managing the pain of children with cancer. Analysis of the results identified 8 themes: the dimensions of pain experienced by children undergoing palliative care; mothers' physical and psychological responses; mothers' emotional responses; barriers encountered by mothers when taking care of their child at home; mothers' interventions to reduce their child's pain; mothers' efforts to distract their child from pain; giving encouragement when the child is in pain; and mothers' efforts and prayers to make their child comfort.

Conclusion:

It can be concluded that the child's pain is the main cause of mothers' stress and pressure and also affects the daily lives of mothers and children. Along with the most effective intervention, nurses need to provide mothers and children with adequate information about cancer pain.

Anti-hypersensitivity effects of the phthalimide derivative N-(4methyl-phenyl)-4-methylphthalimide in different pain models in mice

The treatment of chronic pain remains a challenge for clinicians worldwide, independent of its pathogenesis. It motivates several studies attempting to discover strategies to treat the disease. The in silico analysis using molecular docking approach demonstrated that the phthalimide N-(4methyl-phenyl)-4-methylphthalimide (MPMPH-1) presented high affinity to adenylyl-cyclase enzyme (AC). It also prominently reduced the mechanical hypersensitivity of mice challenged by Forskolin, an AC activator. This effect lasted for up to 48h after Forskolin injection, presenting activity longer than MDL-12330A (AC inhibitor). MPMPH-1 was also effective in reducing the hypersensitivity induced by IL-1β, bradykinin, prostaglandin E₂ or epinephrine, chemical mediators that have, among others, AC as pivotal protein in their signalling cascade to induce mechanical-pain behaviour. The compound presented marked inhibition in inflammatory-pain models induced by carrageenan, lipopolysaccharide or complete Freund's adjuvant, including neutrophil migration inhibition. Furthermore, it also seems to act in both peripheral and pain central-control pathways, being also effective in reducing the persistent cancer-pain behaviour induced by melanoma cells in mice. MPMPH-1 could represent a promising pharmacological tool to treat acute and chronic painful diseases, with good bioavailability, local activity, and lack of locomotor-activity interference. Further studies are necessary to determine the exact mechanism of action but it seems to involve AC enzyme as possible target.

Sativex oromucosal spray as adjunctive therapy in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy: two double-blind, randomized, placebo-controlled phase 3 studies

BACKGROUND

Opioids are critical for managing cancer pain, but may provide inadequate relief and/or unacceptable side effects in some cases.

OBJECTIVE

To assess the analgesic efficacy of adjunctive Sativex (Δ9-tetrahydrocannabinol (27 mg/mL): cannabidiol (25 mg/mL)) in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy.

METHODS

This report describes two phase 3, double-blind, randomized, placebo-controlled trials. Eligible patients had advanced cancer and average pain numerical rating scale (NRS) scores ≥4 and ≤8 at baseline, despite optimized opioid therapy. In Study-1, patients were randomized to Sativex or placebo, and then self-titrated study medications over a 2-week period per effect and tolerability, followed by a 3-week treatment period. In Study-2, all patients self-titrated Sativex over a 2-week period. Patients with a ≥15% improvement from baseline in pain score were then randomized 1:1 to Sativex or placebo, followed by 5-week treatment period (randomized withdrawal design).

RESULTS

The primary efficacy endpoint (percent improvement (Study-1) and mean change (Study-2) in average daily pain NRS scores) was not met in either study. Post hoc analyses of the primary endpoints identified statistically favourable treatment effect for Sativex in US patients <65 years (median treatment difference: 8.8; 95% confidence interval (CI): 0.00-17.95; p = 0.040) that was not observed in patients <65 years from the rest of the world (median treatment difference: 0.2; 95% CI: -5.00 to 7.74; p = 0.794). Treatment effect in favour of Sativex was observed on quality-of-life questionnaires, despite the fact that similar effects were not observed on NRS score. The safety profile of Sativex was consistent with earlier studies, and no evidence of abuse or misuse was identified.

CONCLUSIONS

Sativex did not demonstrate superiority to placebo in reducing self-reported pain NRS scores in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy, although further exploration of differences between United States and patients from the rest of the world is warranted.

Recent advances in understanding and managing cancer pain

Cancer pain remains a significant clinical problem worldwide. Causes of cancer pain are multifactorial and complex and are likely to vary with an array of tumor-related and host-related factors and processes. Pathophysiology is poorly understood; however, new laboratory research points to cross-talk between cancer cells and host’s immune and neural systems as an important potential mechanism that may be broadly relevant to many cancer pain syndromes. Opioids remain the most effective pharmaceuticals used in the treatment of cancer pain. However, their role has been evolving due to emerging awareness of risks of chronic opioid therapy. Despite extensive research efforts, no new class of analgesics has been developed. However, many potential therapeutic targets that may lead to the establishment of new pharmaceuticals have been identified in recent years. It is also expected that the role of non-pharmacological modalities of treatment will grow in prominence. Specifically, neuromodulation, a rapidly expanding field, may play a major role in the treatment of neuropathic cancer pain provided that further technological progress permits the development of non-invasive and inexpensive neuromodulation techniques.

Latin-American guidelines for cancer pain management

Cancer is a major public health issue. Poor pain management has devastating consequences that seriously affect quality of life, diminish functionality and place a huge emotional burden on patients and their relatives. A group of Latin American opinion leaders were invited to participate in a meeting to discuss areas associated with cancer pain. The expert panel reviewed the latest literature to draft region-specific guidelines for effective pain management. The guidelines make recommendations on tailoring treatment to the specific type of pain and provide local physicians with the state-of-the art findings in the field. Management should be with pharmacological approaches (nonopioid, adjuvant and opioid analgesics, as well as oncologic therapies and interventional procedures) and nonpharmacological approaches.

Future Directions in Pain Management: Integrating Anatomically Selective Delivery Techniques With Novel Molecularly Selective Agents

Treatment for chronic, locoregional pain ranks among the most prevalent unmet medical needs. The failure of systemic analgesic drugs, such as opioids, is often due to their off-target toxicity, development of tolerance, and abuse potential. Interventional pain procedures provide target specificity but lack pharmacologically selective agents with long-term efficacy. Gene therapy vectors are a new tool for the development of molecularly selective pain therapies, which have already been proved to provide durable analgesia in preclinical models. Taken together, advances in image-guided delivery and gene therapy may lead to a new class of dual selective analgesic treatments integrating the molecular selectivity of analgesic genes with the anatomic selectivity of interventional delivery techniques.