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Khatoon H, Faudzi SMM. Balancing acts: The dual faces of fentanyl in medicine and public health. Leg Med (Tokyo) 2024; 71:102507. [PMID: 39127024 DOI: 10.1016/j.legalmed.2024.102507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 07/14/2024] [Accepted: 08/06/2024] [Indexed: 08/12/2024]
Abstract
Fentanyl is a potent synthetic opioid widely used in medicine for its effective analgesic properties, particularly in surgical procedures and in the treatment of severe, chronic pain. In recent decades, however, there has been a worrying increase in the illicit use of fentanyl, particularly in North America. This rise in illicit use is concerning because fentanyl is associated with polydrug abuse, which adds layers of complexity and dangerous. This review provides a comprehensive examination of fentanyl, focusing on its synthesis and medical use. It also discusses the significance of the piperidine ring in medicinal chemistry as well as the critical role of fentanyl in pain management and anesthesia. Furthermore, it addresses the challenges associated with the abuse potential of fentanyl and the resulting public health concerns. The study aims to strike a balance between the clinical benefits and risks of fentanyl by advocating for innovative uses while addressing public health issues. It examines the chemistry, pharmacokinetics and pharmacodynamics of fentanyl and highlights the importance of personalized medicine in the administration of opioids. The review underscores the necessity of continuous research and adaptation in both clinical use and public health strategies.
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Affiliation(s)
- Hena Khatoon
- Department of Chemistry, Faculty of Science, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia.
| | - Siti Munirah Mohd Faudzi
- Department of Chemistry, Faculty of Science, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia; Natural Medicines and Product Research Laboratory, Institute of Bioscience, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
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2
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Greenfield K, Schoth DE, Hain R, Bailey S, Mott C, Rajapakse D, Harrop E, Renton K, Anderson AK, Carter B, Johnson M, Liossi C. A rapid systematic review of breakthrough pain definitions and descriptions. Br J Pain 2024; 18:215-226. [PMID: 38751563 PMCID: PMC11092936 DOI: 10.1177/20494637231208093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
Background Breakthrough pain is common in life-limiting conditions and at end-of-life. Despite over 30 years of study, there is little consensus regarding the definition and characteristics of breakthrough pain. Objective This study aims to update and expand a 2010 systematic review by Haugen and colleagues to identify (1) all definitions of breakthrough pain and (2) all descriptions and classifications of breakthrough pain reported by patients, caregivers, clinicians, and experts. Design This rapid systematic review followed the Cochrane Rapid Review Methods Group guidelines. A protocol is published on PROSPERO (CRD42019155583). Data sources CINAHL, MEDLINE, PsycINFO, and the Web of Science were searched for breakthrough pain terms from the inception dates of each database to 26th August 2022. Results We identified 65 studies that included data on breakthrough pain definitions, descriptions, or classifications from patients (n = 30), clinicians (n = 6), and experts (n = 29), but none with data from caregivers. Most experts proposed that breakthrough pain was a sudden, severe, brief pain occurring in patients with adequately controlled mild-moderate background pain. However, definitions varied and there was no consensus. Pain characteristics were broadly similar across studies though temporal factors varied widely. Experts classified breakthrough pain into nociceptive, neuropathic, visceral, somatic, or mixed types. Patients with breakthrough pain commonly experienced depression, anxiety, and interference with daily life. Conclusions Despite ongoing efforts, there is still no consensus on the definition of breakthrough pain. A compromise is needed on breakthrough pain nomenclature to collect reliable incidence and prevalence data and to inform further refinement of the construct.
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Affiliation(s)
| | - Daniel E Schoth
- School of Psychology, University of Southampton, Highfield, UK
| | - Richard Hain
- Paediatric Palliative Medicine, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
| | - Simon Bailey
- Sir James Spence Institute,Royal Victoria Infirmary, Newcastle upon Tyne,UK
| | - Christine Mott
- Acorns Children’s Hospice, Birmingham,UK
- Birmingham Children’s Hospital, Birmingham,UK
| | - Dilini Rajapakse
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Emily Harrop
- Helen & Douglas House Hospices, Oxford, UK
- Oxford University Hospitals NHS Trust,John Radcliffe Hospital, Oxford, UK
| | - Kate Renton
- University Hospital Southampton NHS Trust, Southampton General Hospital, Southampton, UK
- Naomi House & Jacksplace, Winchester, UK
| | | | - Bernie Carter
- Faculty of Health, Social Care and Medicine,Edge Hill University, Ormskirk, UK
| | | | - Christina Liossi
- School of Psychology, University of Southampton, Highfield, UK
- Psychological Services Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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3
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Kim JH, Shin JY, Lee SY. Treatment of Pelvic and Spinal Bone Metastases: Radiotherapy and Hyperthermia Alone vs. in Combination. Cancers (Basel) 2024; 16:1604. [PMID: 38672685 PMCID: PMC11049148 DOI: 10.3390/cancers16081604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
Painful pelvic and spinal bone metastases are a considerable challenge for doctors and patients. Conventional therapies include morphine-equivalent medication (MeM) and local radiotherapy (RT), but these interventions are not always successful. More recently, hyperthermia (HT) has been applied to complement RT and MeM, and this complex approach has shown promising synergistic results. The objective of our study was to present the results of RT combined with a special kind of HT (modulated electrohyperthermia, mEHT), in which some of the thermal effect is contributed by equivalent nonthermal components, drastically reducing the necessary power and energy. This retrospective study included 61 patients divided into three groups with pelvic and spinal bone metastases to compare the effects of RT and mEHT alone and in combination (RT + mEHT). A detailed evaluation of pain intensity, measured by the brief pain inventory score, MeM use, and breakthrough pain episodes, revealed no significant differences between RT and mEHT alone; thus, these individual methods were considered equivalent. However, RT + mEHT yielded significantly better results in terms of the above parameters. Clinically, mEHT has a lower risk of adverse thermal effects, and due to its efficacy, mEHT can be used to treat RT-resistant lesions.
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Affiliation(s)
- Jong-Hun Kim
- Division of Thoracic and Cardiovascular Surgery, Jeonbuk National University Hospital-Jeonbuk National University Medical School, Jeonju 54907, Republic of Korea;
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Republic of Korea;
| | - Jin-Yong Shin
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Republic of Korea;
- Department of Plastic and Reconstructive Surgery, Jeonbuk National University Hospital-Jeonbuk National University Medical School, Jeonju 54907, Republic of Korea
| | - Sun-Young Lee
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju 54907, Republic of Korea;
- Department of Radiation Oncology, Jeonbuk National University Hospital-Jeonbuk National University Medical School, Jeonju 54907, Republic of Korea
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Dawson E, Greenfield K, Carter B, Bailey S, Anderson AK, Rajapakse D, Renton K, Mott C, Hain R, Harrop E, Johnson M, Liossi C. Definition and Assessment of Paediatric Breakthrough Pain: A Qualitative Interview Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:485. [PMID: 38671702 PMCID: PMC11049523 DOI: 10.3390/children11040485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024]
Abstract
Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals' insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: 'the elusive nature of breakthrough pain', 'breakthrough pain assessment', 'positive attitudes towards', 'reservations towards' and 'features to include in' a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept.
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Affiliation(s)
- Eleanor Dawson
- School of Psychology, University of Southampton, Highfield SO17 1BJ, UK (K.G.)
| | - Katie Greenfield
- School of Psychology, University of Southampton, Highfield SO17 1BJ, UK (K.G.)
| | - Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, St Helens Road, Ormskirk L39 4QP, UK;
| | - Simon Bailey
- Department of Children’s Oncology, Great North Children’s Hospital, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
| | | | - Dilini Rajapakse
- The Louis Dundas Centre, Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
| | - Kate Renton
- University Hospital Southampton NHS Trust, Tremona Road, Southampton SO16 6YD, UK
- Naomi House & Jacksplace, Stockbridge Road, Sutton Scotney, Winchester SO21 3JE, UK
| | - Christine Mott
- Acorns Children’s Hospice, 103 Oak Tree Lane, Selly Oak, Birmingham B29 6HZ, UK
- Birmingham Children’s Hospital, Birmingham, Steelhouse Lane, Birmingham B4 6NH, UK
| | - Richard Hain
- Department of Child Health, Swansea University, Swansea SA2 8PP, UK;
| | - Emily Harrop
- Helen & Douglas House Hospices, 14A Magdalen Road, Oxford OX4 1RW, UK;
- Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
| | | | - Christina Liossi
- School of Psychology, University of Southampton, Highfield SO17 1BJ, UK (K.G.)
- Psychological Medicine, Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
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Tekie Y, Nigatu YA, Mekonnen W, Berhe YW. Breakthrough pain among cancer patients at oncology units in Northern Ethiopia; a multi-center study. Front Oncol 2024; 13:1248921. [PMID: 38264754 PMCID: PMC10805268 DOI: 10.3389/fonc.2023.1248921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024] Open
Abstract
Background Breakthrough cancer pain (BTCP) is a transient exacerbation of pain that affects the length of hospitalization and quality of life of patients. The objective of this study was to determine the prevalence and factors associated with BTCP among cancer patients at oncology units in Northern Ethiopia in 2022. Methods A multi-center cross-sectional study was conducted from April to June 2022. After obtaining ethical approval, data were collected prospectively from 424 adult cancer patients admitted to oncology units. Breakthrough cancer pain was assessed by the numeric rating scale. Descriptive and binary logistic regression analyses were performed to determine the factors associated with BTCP. The strength of association was described in adjusted odds ratio (AOR) with 95% confidence intervals and variables with a P-value < 0.05 were considered to have a statistically significant association with BTCP. Result The prevalence of BTCP among cancer patients was 41.5%. The factors that were found to be associated with BTCP were colorectal cancer (AOR: 7.7, 95% CI: 1.8, 32.3), lung cancer (AOR: 6.9, 95% CI: 1.9, 26.0), metastasis (AOR: 9.3, 95% CI: 3.0, 29.1), mild background pain (AOR: 7.5, 95% CI: 2.5, 22.6), moderate background pain (AOR: 7.0, 95% CI: 2.2, 23.1), severe background pain (AOR: 7.1, 95% CI: 2.2, 22.8), no analgesics taken for background pain (AOR: 5.1, 95% CI: 2.8, 9.3) and uncontrolled background pain (AOR: 3.3, 95% CI: 1.8, 6.1). Conclusion The prevalence of BTCP was high. Colorectal cancer, lung cancer, the presence of metastasis, the presence of background pain, not taking analgesics for background pain, and uncontrolled background pain were significantly associated with BTCP.
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Affiliation(s)
- Yohanes Tekie
- Department of Anesthesia, Aksum University, Aksum, Ethiopia
| | | | - Wudie Mekonnen
- Department of Anesthesia, University of Gondar, Gondar, Ethiopia
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Meghani SH, Quinn R, Robinson A, Chittams J, Vapiwala N, Naylor M, Cheatle M, Knafl GJ. Trajectories and predictors of high-occurrence pain flares in ambulatory cancer patients on opioids. JNCI Cancer Spectr 2024; 8:pkae003. [PMID: 38268502 PMCID: PMC10880071 DOI: 10.1093/jncics/pkae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Pain flares have a substantive impact on the quality of life and well-being of patients with cancer. We identified longitudinal trajectories (clusters) of cancer pain flares in ambulatory patients and sociodemographic and clinical predictors of these trajectories. METHODS In a prospective cohort study using ecological momentary assessment (mEMA), we collected patient-reported daily pain flare ratings data over 5 months and identified predictors and correlates using validated measures. RESULTS The mean age of the sample (N = 270) was 60.9 years (SD = 11.2), 64.8% were female, and 32.6% self-identified as African American. Four pain flare clusters were identified. The "high-occurrence" cluster (23% of patients) experienced 5.5 (SD = 5.47) daily flares, whereas low-moderate clusters (77%) reported 2.4 (SD = 2.74) daily flares (P < .000). Those in the high-occurrence cluster reported higher pain scores (P = .000), increased pain-related interference (P = .000), depressive symptoms (P = .023), lower quality of life (P = .001), and reduced pain self-efficacy (P = .006). Notably, 67.2% of those prescribed opioids as needed (PRN only) were in the high-occurrence pain flare cluster, compared with 27.9% with PRN and around-the-clock opioid prescriptions (P = .024). Individual predictors of high-occurrence pain flares were income below $30 000, unemployment, being African American, lower education level, Medicaid insurance, current opioid misuse (COMM), baseline inpatient hospital stay duration, and PRN-only opioid regimen. In the multiple predictor model, lower education level, unemployment, COMM score, extended inpatient duration, and PRN-only opioid regimen remained significant. CONCLUSION In ambulatory patients with cancer, high occurrence of pain flares may be mitigated by attention to opioid prescription factors and addressing social determinants of health needs of underserved patients.
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Affiliation(s)
- Salimah H Meghani
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Quinn
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew Robinson
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Jesse Chittams
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Neha Vapiwala
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Naylor
- Department of Biobehavioral Health Sciences; NewCourtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Cheatle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George J Knafl
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Zhang P, Yao S, Tang Y, Wan S, Chen X, Ma L. A Side-Effect-Free Interventional Therapy for Precisely Eliminating Unresectable Cancer Pain. ACS NANO 2023; 17:23535-23544. [PMID: 38084419 DOI: 10.1021/acsnano.3c06511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Of patients bearing unresectable tumors at advanced stages, most undergo serious pain. For unresectable tumors adjacent to vital organs or nerves, eliminating local cancer pain without adverse effects remains a formidable challenge. Interventional ablative therapies (IATs), such as radio frequency ablation (RFA), microwave ablation, and irreversible electroporation, have been clinically adopted to treat various carcinomas. In this study, we established another palliative interventional therapy to eliminate local cancer pain, instead of relieving nociception temporarily. Here, we developed another interventional ablative therapy (termed nanoparticle-mediated microknife ablation) to locoregionally eliminate cancer pain and tumors. The IAT system was composed of self-assembled nanodrugs, infusion catheters, puncture needles, injection pump, and an empirical tumor ablation formula. Notably, the ablation formula established in the IAT system enables us to predict the essential nanoparticle (NP) numbers used for completely destroying tumors. In a mouse model of cancer pain, tumor-targeted nanodrugs made of Paclitaxel and Hematoporphyrin, which have an extremely high drug-loading efficiency (more than 60%), were infused into tumors through injection pumps under imaging guidance. In conclusion, when compared to classic chemotherapeutic agents, IAT showed significantly higher effectiveness in cancer pain removal. It also presented no damage to the nervous, sensory, and motor capabilities of the treated mice. All of these merits resulted from NPs' long-lasting retention, targeted ablation, and confined diffusion in tumor stroma. Therefore, this safe treatment modality has great potential to eradicate local cancer pain in the clinic.
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Affiliation(s)
- Pengfei Zhang
- Institute of Molecular Immunology, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou 510000, China
| | - Sheng Yao
- Guangdong Provincial Key Laboratory of Medical Image Processing, Guangdong Province Engineering Laboratory for Medical Imaging and Diagnostic Technology, School of Biomedical Engineering, Southern Medical University, Guangzhou 510000, China
| | - Yu Tang
- Institute of Molecular Immunology, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou 510000, China
| | - Shanhe Wan
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Science, Southern Medical University, Guangzhou 510000, China
| | - Xiaoyuan Chen
- Departments of Diagnostic Radiology, Surgery, Chemical and Biomolecular Engineering, and Biomedical Engineering, Clinical Imaging Research Centre, Nanomedicine Translational Research Program, Yong Loo Lin School of Medicine and Faculty of Engineering, National University of Singapore, Singapore 699010, Singapore
| | - Li Ma
- Institute of Molecular Immunology, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou 510000, China
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Løhre ET, Jakobsen G, Solheim TS, Klepstad P, Thronæs M. Breakthrough and Episodic Cancer Pain from a Palliative Care Perspective. Curr Oncol 2023; 30:10249-10259. [PMID: 38132380 PMCID: PMC10742182 DOI: 10.3390/curroncol30120746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/23/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023] Open
Abstract
Cancer pain intensity (PI) fluctuates, but the relationship between pain flares and background pain with respect to pain management is not settled. We studied how flare and background PIs corresponded with treatment results for background cancer pain. Patients admitted to an acute palliative care unit with average and/or worst PI ≥ 1 on the 11-point numeric rating scale were included. Average and worst PI at admission and average PI at discharge were collected. We examined how the difference and ratio between worst and average PI and average PI at admission, were associated with average PI development during hospitalization. Positive differences between worst and average PI at admission were defined as pain flares. Ninety out of 131 patients had pain flares. The reduction in average PI for patients with flares was 0.9 and for those without, 1.9 (p = 0.02). Patients with large worst minus average PI differences reported the least improvement, as did those with large worst/average PI ratios. Patients with pain flares and average PI ≤ 4 at admission had unchanged average PI during hospitalization, while those with pain flares and average PI > 4 experienced pain reduction (2.1, p < 0.001). Large pain flares, in absolute values and compared to background PI, were associated with inferior pain relief.
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Affiliation(s)
- Erik Torbjørn Løhre
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
| | - Gunnhild Jakobsen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Tora Skeidsvoll Solheim
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Morten Thronæs
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
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Yu Y, Zhang P, Chen D, Jiang SF. Knowledge and practice of the management of breakthrough cancer pain among general practitioners providing palliative care in Shanghai, China: a cross-sectional survey. BMJ Open 2023; 13:e073670. [PMID: 37770268 PMCID: PMC10546098 DOI: 10.1136/bmjopen-2023-073670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/01/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE This study examined knowledge and practice of breakthrough cancer pain (BTcP) management among general practitioners (GPs) providing palliative care in Shanghai. DESIGN Cross-sectional study using a self-administered questionnaire. SETTING AND PARTICIPANTS A total of 393 GPs providing palliative care in 32 community health service centres in Shanghai were recruited by stratified cluster random sampling between 1 May and 30 June 2022. OUTCOME MEASURES Knowledge and practice concerning BTcP management. RESULTS A total of 375 questionnaires were collected and declared valid. The median knowledge score was 11 out of 21 points. Only 36.3% (n=136) of the participating GPs scored 11 points or more, which was categorised as good knowledge. Only 24.8% (n=93) of the GPs used Davies' adapted diagnostic algorithm as the gold standard for diagnosis. All of the GPs assessed the intensity of BTcP; however, less than a quarter of the GPs evaluated the relationship between background pain and BTcP (22.1%, n=83), the impact of BTcP on activities of daily living (24.0%, n=90), the impact of BTcP on social relationships (14.4%, n=54) and the impact of BTcP on mood (10.1%, n=38). 56.5% (n=212) of the GPs reported that they used pain tools in the assessment of BTcP. All of the GPs prescribed immediate-release morphine as rescue medication for relieving BTcP; however, 60.5% (n=227) prescribed the dose based on their personal experiences, irrespective of the basal opioid dose, and 57.3% (n=215) did not conduct dose titration after providing the initial dose. No GPs reported that they ever administered interventional treatment to their patients. CONCLUSIONS Insufficient knowledge and inappropriate behaviours in BTcP diagnosis, assessment and treatment were identified. There is an urgent need to improve BTcP management among GPs providing palliative care in Shanghai.
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Affiliation(s)
- Ying Yu
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Panpan Zhang
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Danxia Chen
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
| | - Sun Fang Jiang
- Department of General Practice, Zhongshan Hospital Fudan University, Shanghai, China
- Department of Health Management Center, Zhongshan Hospital Fudan University, Shanghai, China
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Mercadante S. Once again... breakthrough cancer pain: an updated overview. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:23. [PMID: 37480136 PMCID: PMC10360268 DOI: 10.1186/s44158-023-00101-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/26/2023] [Indexed: 07/23/2023]
Abstract
Breakthrough cancer pain (BTcP) is a complex and variegate phenomenon that may change its presentation during the course of patients' disease in the same individual. An appropriate assessment is fundamental for depicting the pattern of BTcP. This information is determinant for a personalized management of BTcP. The use of opioids as needed is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective. The most controversial point regards the opioid dose to be used. The presence of opioid tolerance suggests to use a dose proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested to use the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never ended question.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthetics, Main Regional Center for Pain Relief & Palliative Care Unit, La Maddalena Cancer Center, Acute Supportive/Palliative Care Unit & Hospice, 90146, Palermo, Italy.
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11
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Roldán-Jiménez C, Martín-Martín J, Pajares B, Ribelles N, Alba E, Cuesta-Vargas AI. Factors associated with upper limb function in breast cancer survivors. PM R 2023; 15:151-156. [PMID: 34713595 DOI: 10.1002/pmrj.12731] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 09/24/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Breast cancer survivors may have side effects from treatment, such as impaired upper limb function after surgery, which may be affected by a range of factors. OBJECTIVE To analyze the association between upper limb function and strength, fear avoidance, and central sensitization symptoms among breast cancer survivors, and to explore how these variables are associated with upper limb function. DESIGN Validation cohort. SETTING Institutional practice at a public hospital. PATIENTS One hundred seventy-four breast cancer survivors who had been undergone surgery for a primary tumor. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Upper limb function was measured by the Upper Limb Functional Index (ULFI-Sp). Independent outcomes were: handgrip strength, which was measured using a Jamar dynamometer on the dominant side; fear avoidance, measured using the Fear-Avoidance Components Scale (FACS-Sp); and central sensitization symptoms, which were measured using the Central Sensitisation Inventory (CSI-Sp). A linear regression model explaining the ULFI-Sp results was constructed with the variables. RESULTS The regression model was significant (F = 46.826; p < .0001), and explained 45% of the variance of the ULFI values. All variables showed strong associations with upper limb function. CONCLUSIONS Greater upper limb function is associated with higher grip strength, lower fear-avoidance behavior and fewer central sensitization symptoms among breast cancer survivors. These variables explained 45% of the upper limb function in the regression model, and concur with earlier research showing that factors such as central sensitization symptoms and kinesiophobia negatively affect upper limb function in such patients. Clinicians should therefore take into account strength, fear avoidance, and central sensitization symptoms when considering interventions aimed at improving upper limb function among breast cancer survivors.
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Affiliation(s)
- Cristina Roldán-Jiménez
- Departamento de Fisioterapia, Facultad de Ciencias de la Salud, Universidad de Málaga, Andalucía Tech., Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Grupo de Clinimetría (F-14), Málaga, Spain
| | - Jaime Martín-Martín
- Instituto de Investigación Biomédica de Málaga (IBIMA), Grupo de Clinimetría (F-14), Málaga, Spain.,Department of Human Anatomy, Legal Medicine and History of Science; Area of Legal Medicine, University of Málaga, Faculty of Medicine, Málaga, Spain
| | - Bella Pajares
- Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Nuria Ribelles
- Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Emilio Alba
- Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Antonio I Cuesta-Vargas
- Departamento de Fisioterapia, Facultad de Ciencias de la Salud, Universidad de Málaga, Andalucía Tech., Málaga, Spain.,Instituto de Investigación Biomédica de Málaga (IBIMA), Grupo de Clinimetría (F-14), Málaga, Spain.,School of Clinical Science, Faculty of Health Science, Queensland University Technology, Brisbane, Queensland, Australia
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12
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Batistaki C, Graczyk M, Janecki M, Lewandowska AA, Moutinho R, Vagdatli K. Relationship between breakthrough cancer pain, background cancer pain and analgesic treatment - case series and review of the literature. Drugs Context 2022; 11:dic-2022-9-4. [PMID: 36660261 PMCID: PMC9828877 DOI: 10.7573/dic.2022-9-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/17/2022] [Indexed: 12/30/2022] Open
Abstract
The assessment and treatment of breakthrough cancer pain (BTcP) remain a major challenge in medicine due to its high impact on several aspects of health-related quality of life. BTcP should be carefully monitored in all cancer care settings by a multidisciplinary team to provide an appropriate and personalized clinical approach. The aim of this paper is to provide healthcare professionals involved in cancer pain management with a review of the relevant literature on the relationship between background cancer pain and BTcP which, by definition, occurs despite adequately controlled background cancer pain. The clinical cases presented contribute to a better understanding of this issue and underline its impact in daily clinical practice. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.
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Affiliation(s)
| | - Michal Graczyk
- Department of Palliative Care, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Marcin Janecki
- Department of Palliative Care and Palliative Medicine, Medical University of Silesia, Katowice, Poland
| | | | - Rita Moutinho
- Multidisciplinary Pain Unit, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Porto, Portugal
| | - Kiriaki Vagdatli
- Anaesthesia Department General Hospital of Athens “G. Gennimatas”, Athens, Greece
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13
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Samolsky Dekel BG, Gori A, Gunnellini M, Gioia A, Di Marco M, Casale G, Bevilacqua M, Bersani P, Melotti RM. The Italian Questionnaire for Cancer Breakthrough Pain Diagnosis, a Multicenter Validation Study. Pain Ther 2021; 10:1171-1188. [PMID: 34091817 PMCID: PMC8586321 DOI: 10.1007/s40122-021-00274-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 05/17/2021] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION The literature lacks formally validated and reliable tools for the diagnosis of breakthrough cancer pain (BTcP). The Italian Questionnaire for BTcP diagnosis (IQ-BTP) is an 11-item questionnaire aimed at detecting potential-BTP and classifying it into three likelihood classes: high, intermediate, and low. METHODS A multicenter, prospective, and observational study was designed to validate the IQ-BTP. In three consecutive visits with each cancer patient, the demographic and clinical details of the patient, the Brief Pain Inventory (BPI) scores, IQ-BTP outcomes, and clinicians' autonomous BTcP diagnosis (gold standard) and the agreement of this diagnosis with IQ-BTP outcomes were recorded. The assessed domains for IQ-BTP validation were: Validity, including content and face validity, construct validity (hypothesis testing, and cross-cultural validity\measurement invariance), and criterion validity; Reliability (internal consistency, reliability, and measurement error); Interpretability, and Responsiveness. RESULTS Seven palliative and pain management facilities in Italy recruited 280 patients, yielding 753 evaluations. Using the IQ-BTP, the rate of potential-BTcP was 27.2%, of which its likely presence was high in 52.7% of patients, intermediate in 38.5, and low in 8.8%. The BPI item scores differed significantly between the two IQ-BTP classes (no-BTcP and potential-BTcP classes). The correlation of the latter class with BPI items was significant but low. The IQ-BTcP showed two principal components, accounting for 66.6% of the variance. Cronbach's α was 0.71. The agreement rate between the gold standard and IQ-BTP outcomes was 82%. Cohen's [Formula: see text] was 0.535. The IQ-BTP showed sensitivity and specificity of 69 and 86%, respectively. CONCLUSIONS The IQ-BTP extensive formal validation showed satisfactory psychometric and validity properties. Its content, face, construct, and criterion validities and its reliability, interpretability, and responsiveness were shown. Its use enabled potential-BTcP to be identified and differentiated into three likelihood classes with direct therapeutic and epidemiological implications. The latter may be confirmed in future studies.
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Affiliation(s)
- Boaz Gedaliahu Samolsky Dekel
- Department of Medicine and Surgery Sciences, University of Bologna, via Massarenti n. 9, 40138, Bologna, Italy. .,Anesthesia and Pain Therapy Unit, IRCCS AOSP di Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy. .,Post Graduate School of Anaesthesia, Intensive Care and Pain Medicine, University of Bologna, Via Massarenti n. 9, 40138, Bologna, Italy.
| | - Alberto Gori
- grid.6292.f0000 0004 1757 1758Post Graduate School of Anaesthesia, Intensive Care and Pain Medicine, University of Bologna, Via Massarenti n. 9, 40138 Bologna, Italy
| | - Marco Gunnellini
- Medical Oncology and Paliative Care Unit, USL Umbria 1, Presidio Ospedaliero di Gubbio, Gualdo Tadino, Largo Unità D’Italia, 1, 06024 Gubbio, Italy ,Ospedale Media Valle del Tevere, Vocabolo Buda, Todi, 06059, Perugia, Italy
| | - Angela Gioia
- Hospice, UF Cure Palliative, Azienda USL Toscana NordOvest, via Cocchi, 7-9, Pisa, Italy
| | - Mariacristina Di Marco
- grid.412311.4Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi University Hospital, Via Albertoni, 15, Bologna, Italy
| | - Giuseppe Casale
- Antea Foundation Research Group, piazza Santa Maria della pietà 5, 00135 Rome, Italy
| | - Marzio Bevilacqua
- Dipartimento di Anestesia, Rianimazione e Terapia Intensiva U.O.C. di Medicina e Terapia del Dolore, ULSS2, Marca Trevigiana, Treviso, Italy
| | - Pietro Bersani
- Gigi Ghirotti Association, Home Care, Corso Europa, 50/9, 16132 Genoa, Italy
| | - Rita Maria Melotti
- grid.6292.f0000 0004 1757 1758Department of Medicine and Surgery Sciences, University of Bologna, via Massarenti n. 9, 40138 Bologna, Italy ,grid.412311.4Anesthesia and Pain Therapy Unit, IRCCS AOSP di Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138 Bologna, Italy ,grid.6292.f0000 0004 1757 1758Post Graduate School of Anaesthesia, Intensive Care and Pain Medicine, University of Bologna, Via Massarenti n. 9, 40138 Bologna, Italy
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14
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Thronæs M, Løhre ET, Kvikstad A, Brenne E, Norvaag R, Aalberg KO, Moen MK, Jakobsen G, Klepstad P, Solberg A, Solheim TS. Interventions and symptom relief in hospital palliative cancer care: results from a prospective longitudinal study. Support Care Cancer 2021; 29:6595-6603. [PMID: 33942192 PMCID: PMC8464577 DOI: 10.1007/s00520-021-06248-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To study the use of interventions and symptom relief for adult patients with incurable cancer admitted to an acute palliative care unit providing integrated oncology and palliative care services. METHODS All admissions during 1 year were assessed. The use of interventions was evaluated for all hospitalizations. Patients with assessments for worst and average pain intensity, tiredness, drowsiness, nausea, appetite, dyspnea, depression, anxiety, well-being, constipation, and sleep were evaluated for symptom development during hospitalization. Descriptive statistics was applied for the use of interventions and the paired sample t-test to compare symptom intensities (SIs). RESULTS For 451 admissions, mean hospital length of stay was 7.0 days and mean patient age 69 years. More than one-third received systemic cancer therapy. Diagnostic imaging was performed in 66% of the hospitalizations, intravenous rehydration in 45%, 37% received antibiotics, and 39% were attended by the multidisciplinary team. At admission and at discharge, respectively, 55% and 44% received oral opioids and 27% and 45% subcutaneous opioids. For the majority, opioid dose was adjusted during hospitalization. Symptom registrations were available for 180 patients. Tiredness yielded the highest mean SI score (5.6, NRS 0-10) at admission and nausea the lowest (2.2). Significant reductions during hospitalization were reported for all assessed SIs (p ≤ 0.01). Patients receiving systemic cancer therapy reported symptom relief similar to those not on systemic cancer therapy. CONCLUSION Clinical practice and symptom relief during hospitalization were described. Symptom improvements were similar for oncological and palliative care patients.
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Affiliation(s)
- Morten Thronæs
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway. .,Cancer Clinic, St Olavs University Hospital, Trondheim, Norway.
| | - Erik Torbjørn Løhre
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Cancer Clinic, St Olavs University Hospital, Trondheim, Norway
| | - Anne Kvikstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Cancer Clinic, St Olavs University Hospital, Trondheim, Norway
| | - Elisabeth Brenne
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Cancer Clinic, St Olavs University Hospital, Trondheim, Norway
| | - Robin Norvaag
- Cancer Clinic, St Olavs University Hospital, Trondheim, Norway
| | - Kathrine Otelie Aalberg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Martine Kjølberg Moen
- Department of Anaesthesiology and Intensive Care Medicine, St Olavs University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Gunnhild Jakobsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Cancer Clinic, St Olavs University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Anaesthesiology and Intensive Care Medicine, St Olavs University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Arne Solberg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Cancer Clinic, St Olavs University Hospital, Trondheim, Norway
| | - Tora Skeidsvoll Solheim
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Cancer Clinic, St Olavs University Hospital, Trondheim, Norway
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15
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Mercadante S, Maltoni M, Russo D, Adile C, Ferrera P, Rossi R, Rosati M, Casuccio A. The Prevalence and Characteristics of Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain. Cancers (Basel) 2021; 13:cancers13051058. [PMID: 33801478 PMCID: PMC7958843 DOI: 10.3390/cancers13051058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. This prospective study showed that in this population, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes. Abstract The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. A consecutive sample of advanced cancer patients receiving less than 60 mg/day of oral morphine equivalent (OME) was selected. Epidemiological data, background pain intensity, and current analgesic therapy were recorded. The presence of BTcP was diagnosed according to a standard algorithm. The number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, satisfaction with BTcP medication, and time to meaningful pain relief were collected. A total of 126 patients were screened. The mean intensity of background pain was 2.71 (1.57), and the mean OME was 28.5 mg/day (SD15.8). BTP episodes were recorded in 88 patients (69.8%). The mean number/day of BTP episodes was 4.1 (SD 7.1, range 1–30). In a significant percentage of patients, BTcP was both predictable and unpredictable (23%). The BTcP onset was less than 20 min in the majority of patients. The mean duration of untreated episodes was 47.5 (SD 47.6) minutes. The mean time to meaningful pain relief after taking a BTcP medication was >20 min in 44.5% of patients. The efficacy of BTcP medication was not considered good in more than 63% of patients. Gender (females) (OR = 4.16) and lower Karnofsky (OR = 0.92) were independently associated with BTcP. A higher number of BTcP episodes/day was associated with gender (females) (p = 0.036), short duration of BTcP (p = 0.005), poorer efficacy of BTcP medication (none or mild) (p = 0.001), and late meaningful pain relief (p = 0.024). The poor efficacy of BTcP medication was independently associated with a higher number of episodes/day (OR = 0.22). In patients who were receiving low doses of opioids, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
- Correspondence:
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Domenico Russo
- Hospice and the Palliative Care Service, Clinica San Marco, 04100 Latina, Italy;
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Marta Rosati
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy;
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16
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Mercadante S, Portenoy RK. Understanding the Chameleonic Breakthrough Cancer Pain. Drugs 2021; 81:411-418. [PMID: 33515376 DOI: 10.1007/s40265-021-01466-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Abstract
Breakthrough cancer pain (BTcP) is a variegated phenomenon, that often presents in different ways in each individual, and may change its presentation in the same individual during the course of disease. An appropriate assessment is fundamental for depicting the pattern of BTcP in individuals. This information is determinant for a personalised management of BTcP. The use of opioids as needed, is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective, providing analgesia in 5-15 min. The most controversial point regards the opioid dose to be used. The presence of tolerance suggests using a dose that is proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested using the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never-ending question.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative Care Unit, La Maddalena Cancer Centre, Via San Lorenzo 312, 90146, Palermo, Italy. .,Regional Home Care Programme, SAMOT, Palermo, Italia.
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, 39 Broadway, 3rd Floor, New York, NY, 10006, USA. .,Neurology and Family and Social Medicine, Albert Einstein College of Medicine, New York, USA.
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17
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Jesson T, Runge N, Schmid AB. Physiotherapy for people with painful peripheral neuropathies: a narrative review of its efficacy and safety. Pain Rep 2020; 5:e834. [PMID: 33490836 PMCID: PMC7808681 DOI: 10.1097/pr9.0000000000000834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/28/2020] [Accepted: 06/04/2020] [Indexed: 01/12/2023] Open
Abstract
Pharmacological treatment for peripheral neuropathic pain has only modest effects and is often limited by serious adverse responses. Alternative treatment approaches including physiotherapy management have thus gained interest in the management of people with peripheral neuropathies. This narrative review summarises the current literature on the efficacy and safety of physiotherapy to reduce pain and disability in people with radicular pain and chemotherapy-induced peripheral neuropathy, 2 common peripheral neuropathies. For chemotherapy-induced peripheral neuropathy, the current evidence based on 8 randomised controlled trials suggests that exercise may reduce symptoms in patients with established neuropathy, but there is a lack of evidence for its preventative effect in patients who do not yet have symptoms. For radicular pain, most of the 21 trials investigated interventions targeted at improving motor control or reducing neural mechanosensitivity. The results were equivocal, with some indication that neural tissue management may show some benefits in reducing pain. Adverse events to physiotherapy seemed rare; however, these were not consistently reported across all studies. Although it is encouraging to see that the evidence base for physiotherapy in the treatment of peripheral neuropathic pain is growing steadily, the mixed quality of available studies currently prevents firm treatment recommendations. Based on promising preliminary data, suggestions are made on potential directions to move the field forward.
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Affiliation(s)
- Tom Jesson
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Nils Runge
- Connect Health, Benton Lane, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - Annina B. Schmid
- Nuffield Department for Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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18
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Acupuncture for Cancer-Induced Bone Pain in Animal Models: A Systemic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:5606823. [PMID: 32802130 PMCID: PMC7414378 DOI: 10.1155/2020/5606823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 06/11/2020] [Accepted: 07/02/2020] [Indexed: 12/09/2022]
Abstract
Background Cancer-induced bone pain (CIBP) is a highly prevalent symptom, which afflicts vast majority of patients who suffer from cancer. The current treatment options failed to achieve satisfactory effect and the side effects were prominent. Recent randomized controlled trials (RCTs) of animal demonstrate the benefit of acupuncture for CIBP. We sought to determine if the pooled data from available RCTs supports the use of acupuncture for CIBP. Methods A literature search for randomized controlled trials was conducted in six electronic databases from inception to May 31, 2019. Meta-analysis was performed with Review Manager 5.3 software; the publication bias was assessed by Stata 12.0 software. We used random effects model for pooling data because heterogeneity is absolute among studies to some extent. Results Twenty-four trials were included in the review, of which 12 trials provided detailed data for meta-analyses. Preliminary evidence indicates that compared to wait list/sham group, acupuncture was effective on increasing paw withdrawal threshold (PWT) and paw withdrawal latency (PWL). Compared to medicine, acupuncture was less effective on PWT, but as effective as medicine on PWL. Acupuncture can reinforce medicine's effect on PWT and PWL. Compared to the control group, acupuncture was superior to increase body weight (BW), decrease spinal cord glial fibrillary acidic protein (GFAP), and interleukin-1β (IL-1β). Furthermore, some studies showed acupuncture delay or partially reverse morphine tolerance. Three studies found acupuncture has no effect on PWT, but 2 of them found acupuncture could enhance small dose of Celebrex's effect on CIBP. Conclusions Acupuncture was superior to wait list/sham acupuncture on increasing PWT and has no less effect on increasing PWL compared to medicine; acupuncture improved the efficacy of drugs, increased the CIBP animals' body weight, and decreased their spinal cord GFAP and IL-1β. High-quality studies are necessary to confirm the results.
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19
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Episodic Cancer Pain: Patient Reporting, Prevalence, and Clinicodemographic Associations at Initial Cancer Pain Clinic Assessment. Pain Res Manag 2020; 2020:6190862. [PMID: 32566062 PMCID: PMC7261329 DOI: 10.1155/2020/6190862] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 05/02/2020] [Indexed: 01/11/2023]
Abstract
Background Better understanding of the episodic cancer pain (CP) spectrum, including pains that occur in addition to its conventionally defined breakthrough CP (BTcP) and incident CP (IcP) components, may inform CP assessment and management. This study aimed to determine the prevalence of episodic patient-reported CP and the prevalence and associations of study-defined BTcP (S-BTcP) and IcP (S-IcP) in patients with CP. Methods In a cross-sectional study at their first CP clinic attendance, participants with CP had the following assessments: Brief Pain Inventory (BPI); Pain Management Index (PMI), with PMI-negative status indicating undertreatment; standardized neuropathic pain component (NPC) status; S-BTcP (no trigger identified) and S-IcP (trigger identified) status, based on a preceding 7-day history of transitory pain flares distinct from background pain, and BPI-Worst or BPI-Now pain intensity ≥ 4. Clinicodemographic variables' association with S-BTcP and S-IcP was examined in logistic regression analyses. Results Of 371 participants, 308 (83%) had episodic CP by history alone; 140 (37.7%) and 181 (48.8%) had S-BTcP and S-IcP, respectively. Multivariable analyses demonstrated significant (p < 0.05) associations (odds ratios: 95% CIs) for 6 variables with S-BTcP: head and neck pain location (2.53; 1.20–5.37), NPC (2.39; 1.34–4.26), BPI average pain (1.64; 1.36–1.99), abdominal pain (0.324; 0.120–0.873), S-IcP (0.207; 0.116–0.369), and PMI-negative status (0.443; 0.213–0.918). Similar independent associations (p < 0.05) occurred for S-IcP with NPC, BPI average pain, and PMI-negative status, in addition to radiotherapy, S-BTcP, soft tissue pain, and sleep interference. Conclusions Episodic or transient patient-reported CP flares often do not meet the more conventional criteria that define BTcP and IcP, the principal episodic CP types. Both BTcP and IcP occur frequently and both are associated with a NPC, higher pain intensity, and less opioid underuse in the management of CP. Further studies are warranted to both better understand the complex presentations of episodic CP and inform its classification.
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20
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Greenfield K, Holley S, Schoth DE, Bayliss J, Anderson AK, Jassal S, Rajapakse D, Fraser LK, Mott C, Johnson M, Wong I, Howard R, Harrop E, Liossi C. A protocol for a systematic review and meta-analysis to identify measures of breakthrough pain and evaluate their psychometric properties. BMJ Open 2020; 10:e035541. [PMID: 32229524 PMCID: PMC7170606 DOI: 10.1136/bmjopen-2019-035541] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Breakthrough pain is common in children and adults with cancer and other conditions, including those approaching end-of-life, although it is often poorly managed, possibly partly due to a lack of validated assessment tools. This review aims to (1) identify all available instruments measuring breakthrough pain in infants, children, adolescents or adults and (2) critically appraise, compare and summarise the quality of the psychometric properties of the identified instruments using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria. METHODS AND ANALYSIS Two searches will be carried out between October 2019 and January 2020, one for each aim of the review. The Cochrane Library, International Prospective Register of Systematic Reviews, Embase, Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online (MEDLINE), PsycINFO, Web of Science Core Collection, Google Scholar, the ProQuest Dissertations & Theses Database, Evidence Search and OpenGrey databases will be searched from database inception until the date the search is conducted. Reference lists of eligible articles will be screened and authors in the field contacted. For search 1, articles will be screened by two reviewers by abstract, and full-text where necessary, to identify if a breakthrough pain assessment was used. Search 2 will then be conducted to identify studies evaluating measurement properties of these assessments. Two reviewers will screen articles from search 2 by title and abstract. All potentially relevant studies will be screened by full text by both reviewers. For search 2, data will be extracted in parallel with the quality assessment process, as recommended by COSMIN. Two reviewers will assess methodological quality using the COSMIN Risk of Bias checklist and the COSMIN updated criteria for good measurement properties. Findings will be summarised and, if possible, data will be pooled using meta-analysis. The quality of the evidence will be graded and summarised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines. ETHICS AND DISSEMINATION Results of this review will be submitted for publication in a peer review journal and presented at conferences. PROSPERO REGISTRATION NUMBER CRD42019155583.
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Affiliation(s)
- Katie Greenfield
- School of Psychology, University of Southampton, Southampton, Hampshire, UK
| | - Simone Holley
- School of Psychology, University of Southampton, Southampton, Hampshire, UK
| | - Daniel Eric Schoth
- School of Psychology, University of Southampton, Southampton, Hampshire, UK
| | - Julie Bayliss
- The Louis Dundas Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Satbir Jassal
- Paediatric Palliative Care, Rainbows Hospice for Children and Young People, Loughborough, Leicestershire, UK
| | - Dilini Rajapakse
- The Louis Dundas Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lorna Katharine Fraser
- Martin House Research Centre, Department of Health Sciences, University of York, York, UK
| | - Christine Mott
- Paediatric Palliative Care, Hummingbird House Hospice, Brisbane, Queensland, Australia
| | - Margaret Johnson
- Patient & Pubic Representative c/o Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Ian Wong
- School of Pharmacy, University College London, London, UK
| | - Richard Howard
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Emily Harrop
- Paediatric Palliative Care, Helen & Douglas House Hospice, Oxford, UK
- Paediatric Palliative Care, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Christina Liossi
- School of Psychology, University of Southampton, Southampton, Hampshire, UK
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Prevalence and characterization of breakthrough pain in patients with cancer in Spain: the CARPE-DIO study. Sci Rep 2019; 9:17701. [PMID: 31776408 PMCID: PMC6881364 DOI: 10.1038/s41598-019-54195-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/04/2019] [Indexed: 01/22/2023] Open
Abstract
We aimed to evaluate the prevalence, characteristics and impact of breakthrough pain (BTP) in patients with cancer attending the main specialties involved in the diagnosis and management of BTP in Spain using a multicenter, observational, cross-sectional, multidisciplinary study. Investigators had to record all patients seen at the clinic during 1 month, determine whether the patients had cancer pain, and apply the Davies algorithm to ascertain whether the patients were suffering from BTP. Of the 3,765 patients with cancer, 1,117 (30%) had cancer-related pain, and of these patients, 539 had BTP (48%, 95%CI:45–51). The highest prevalence was found in patients from palliative care (61%, 95%CI:54–68), and the lowest was found in those from hematology (25%, 95%CI:20–31). Prevalence varied also according to sex and type of tumor. According to the Alberta Breakthrough Pain Assessment Tool duration, timing, frequency, location, severity, quality, causes, and predictability of the BTP varied greatly among these patients. BTP was moderate (Brief Pain Inventory [BPI]-severity median score = 5.3), and pain interference was moderate (BPI-interference median score = 6.1) with a greater interference with normal work, general activity, and enjoyment of life. Patients with BTP showed a mean ± standard deviation score of 28.5 ± 8.0 and 36.9 ± 9.5 in the physical and mental component, respectively, of the SF-12 questionnaire. In conclusion, prevalence of BTP among patients exhibiting cancer-related pain is high. Clinical presentation is heterogeneous, and therefore, BTP cannot be considered as a single entity. However, uniformly BTP has an important impact on a patient’s functionality, which supports the need for early detection and treatment.
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Camps Herrero C, Antón Torres A, Cruz-Hernández JJ, Carrato A, Constenla M, Díaz-Rubio E, Feyjoo Saus M, Garcia-Foncillas J, Gascón P, Guillem V. Working towards a consensus on the oncological approach of breakthrough pain: a Delphi survey of Spanish experts. J Pain Res 2019; 12:2349-2358. [PMID: 31534359 PMCID: PMC6681159 DOI: 10.2147/jpr.s203903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 07/02/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose There is a lack of standards for the diagnosis, assessment and management of breakthrough cancer pain (BTcP). La Fundación ECO (the Foundation for Excellence and Quality in Oncology) commissioned a study to establish a consensus and lay the foundations for the appropriate management of BTcP in oncology patients. Patients and methods A modified Delphi survey comprising two rounds was used to gather and analyze data, which was conducted over the Internet. Each statement that reached a consensus with the respondents was defined as a median consensus score (MED) of ≥7, and agreement among panelists as an interquartile range (IQR) of ≤3. Results In total, 69 medical oncologists responded, with a broad consensus that BTcP implied exacerbations of high-intensity pain, as opposed to moderate pain. Furthermore, they concurred that appropriate diagnostic equipment is needed, and that rapid-onset fentanyl formulations should be the preferred treatment for BTcP management. The panelists agreed that a lack of appropriate information and training to attend to patients, as well as limited patient visitation rights, were barriers to effective BTcP management. Regarding gaps in detected knowledge, the panelists were unsure of the measures necessary to assess the burden of the disease on the patient’s quality of life and associated medication costs. Alongside this, there was a lack of awareness of the technical specifics of the different formulations of rapid-onset fentanyl. Conclusion These results represent the current status of BTcP management. They may inform recommendations and provide a framework for future research.
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Affiliation(s)
- Carlos Camps Herrero
- Jefe de Servicio de Oncología Médica, Consorcio Hospital General Universitario, Valencia, Spain
| | - Antonio Antón Torres
- Jefe del Servicio de Oncología Médica, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Alfredo Carrato
- Jefe del Servicio de Oncología Médica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Manuel Constenla
- Jefe de Servicio de Oncología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Eduardo Díaz-Rubio
- Jefe del Servicio de Oncología Médica, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - Jesus Garcia-Foncillas
- Jefe de Servicio de Oncología Médica, Hospital Universitario "Fundación Jiménez Díaz", Madrid, Spain
| | - Pere Gascón
- Jefe del Servicio de Oncología Médica, Hospital Clínic, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Vicente Guillem
- Jefe del Servicio de Oncología Médica, Instituto Valenciano de Oncología, Valencia, Spain
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Krogstad H, Brunelli C, Sand K, Andersen E, Garresori H, Halvorsen T, Haukland EC, Jordal F, Kaasa S, Loge JH, Løhre ET, Raj SX, Hjermstad MJ. Development of EirV3: A Computer-Based Tool for Patient-Reported Outcome Measures in Cancer. JCO Clin Cancer Inform 2019; 1:1-14. [PMID: 30657392 DOI: 10.1200/cci.17.00051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Immediate transfer of patient-reported outcome measures (PROMs) for use in medical consultations is facilitated by electronic assessments. We aimed to describe the rationale and development of Eir version 3 (EirV3), a computer-based symptom assessment tool for cancer, with emphasis on content and user-friendliness. METHODS EirV3's specifications and content were developed through multiprofessional, stepwise, and iterative processes (from 2013 to 2016), with literature reviews on traditional and electronic assessment and classification methods, formative iterative usability tests with end-users, and assessment of patient preferences for paper versus electronic assessments. RESULTS EirV3 has the following two modules: Eir-Patient for PROMs registration on tablets and Eir-Doctor for presentation of PROMs in a user-friendly interface on computers. Eir-Patient starts with 19 common cancer symptoms followed by specific, in-depth questions for endorsed symptoms. The pain section includes a body map for pain location and intensity, whereas physical functioning, nutritional intake, and well-being are standard questions for all. Data are wirelessly transferred to Eir-Doctor. Symptoms with intensity scores ≥ 3 (on a 0 to 10 scale) are marked in red, with brighter colors corresponding to higher intensity, and supplemented with graphs displaying symptom development over time. Usability results showed that patients and health care providers found EirV3 to be intuitive, easy to use, and relevant. When comparing PROM assessments on paper versus tablets (n = 114), 19% of patients preferred paper, 41% preferred tablets, and 40% had no preference. Median intraclass correlation coefficient between paper and tablets (0.815) was excellent. CONCLUSION Iterative test rounds followed by continuous improvements led to a user-friendly, applicable symptom assessment tool, EirV3, developed for and by end-users. EirV3 is undergoing international testing of clinical and cross-cultural adaptability.
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Affiliation(s)
- Hilde Krogstad
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Cinzia Brunelli
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Kari Sand
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Eivind Andersen
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Herish Garresori
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Tarje Halvorsen
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Ellinor C Haukland
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Frode Jordal
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Stein Kaasa
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Jon Håvard Loge
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Erik Torbjørn Løhre
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Sunil X Raj
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
| | - Marianne Jensen Hjermstad
- Hilde Krogstad, Cinzia Brunelli, Kari Sand, Tarje Halvorsen, Stein Kaasa, Jon Håvard Loge, Erik Torbjørn Løhre, Sunil X. Raj, and Marianne Jensen Hjermstad, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital; Hilde Krogstad, Tarje Halvorsen, Erik Torbjørn Løhre, and Sunil X. Raj, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital; Eivind Andersen, NTNU Technology Transfer AS, Trondheim; Stein Kaasa, Jon Håvard Loge, and Marianne Jensen Hjermstad, Oslo University Hospital, Oslo; Herish Garresori, Stavanger University Hospital, Stavanger; Ellinor C. Haukland, Nordland Hospital Trust, Bodø; Frode Jordal, Østfold Hospital Trust, Grålum, Norway; and Cinzia Brunelli, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale dei Tumori, Milano, Italy
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Piotrowska W, Leppert W, Majkowicz M. Comparison of analgesia, adverse effects, and quality of life in cancer patients during treatment of procedural pain with intravenous morphine, fentanyl nasal spray, and fentanyl buccal tablets. Cancer Manag Res 2019; 11:1587-1600. [PMID: 30863169 PMCID: PMC6388998 DOI: 10.2147/cmar.s179012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aim Comparison of analgesia, adverse effects, and quality of life (QoL) of cancer patients in the treatment of procedural pain induced by nursing procedures with the use of intravenous morphine, fentanyl nasal spray, and fentanyl buccal tablets. Methods In adults with cancer with opioid tolerance and suffering procedural pain, intravenous morphine was used at an inpatient palliative medicine unit (20 patients) and fentanyl by intranasal (15 patients) and buccal routes (nine patients) at home. Five procedural pain episodes were examined: the Mini-Mental State Examination was used to assess cognitive function, the Brief Pain Inventory – short form (BPI-SF) to assess intensity and impact of pain on daily activities, a pain and adverse-effect questionnaire to assess the intensity of pain and adverse effects, and the European Organisation for Research and Treatment of Cancer QLQ-C15-PAL to assess QoL. Results All five procedural pain episodes were completed by 32 patients. Twelve patients stopped treatment due to death or referral to the hospital (four patients in each group), changes in the treatment of background pain (three patients), and intense drowsiness (one patient). Similar beneficial analgesic effects were observed in all patient groups. During fentanyl therapy, a smaller negative effect of pain on patients’ activity, walking, and work (BPI-SF) was observed. Among adverse effects, fewer breaths (10–14 per minute) were observed in 17 patients and slight disturbances of consciousness in seven. For QoL, an improvement in emotional functioning, overall QoL, and fatigue was observed. Patients treated with intranasal and buccal fentanyl had higher physical functioning and were more active. Conclusion In the treatment of procedural pain induced by nursing procedures in cancer patients, intravenous morphine and rapid-onset fentanyl show similarly high analgesic efficacy, with good tolerance of treatment and improvement in QoL.
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Affiliation(s)
- Wieslawa Piotrowska
- Laboratory of Quality of Life Research, Chair and Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland,
| | - Wojciech Leppert
- Laboratory of Quality of Life Research, Chair and Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland,
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Mercadante S, Adile C, Masedu F, Marchetti P, Costanzi A, Aielli F. Factors influencing the use of opioids for breakthrough cancer pain: A secondary analysis of the IOPS-MS study. Eur J Pain 2018; 23:719-726. [PMID: 30421474 DOI: 10.1002/ejp.1339] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/19/2018] [Accepted: 11/07/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Controversies exist about the choice and the doses of opioid medication in breakthrough cancer pain (BTcP). METHODS The aim was to assess factors influencing the use and the doses of opioids prescribed for BTcP. There was performed a secondary analysis of a national, multicentre study that involving 32 centres performed in patients having BTcP. Diagnosis of BTcP was based on a definite algorithm. Patients using opioids for background pain and for BTcP were selected. Average pain intensity and opioids used for background pain and BTcP, and adverse effects were assessed, as well as patient's satisfaction and the grade of mucositis. RESULTS The analysis was performed in 2,771 patients. Opioid doses given for BTcP were significantly associated with those given for background pain. No relationship between adverse effects and the use and the doses of opioids used for BTcP was found. Drugs and doses were not correlated to the grade of oral mucositis. Nasal fentanyl preparations provided the fastest meaningful pain relief in comparison with other fentanyl transmucosal preparations or morphine preparations (P = 0.000). The majority of patients were satisfied with opioid medications given for BTcP. Only 2.8% of patients reported adverse effects related to opioid medication used for BTcP. Age and gender were independently associated with dosages of some fentanyl products. CONCLUSIONS Opioids for BTcP were effective and safe in a large sample of cancer patients with different stages of disease. Doses of opioids proportional to doses used for background pain seem to guarantee both efficacy and safety. SIGNIFICANCE The use of opioids for breakthough cancer pain was effective and safe in a large sample of advanced cancer patients recruited in different stages of disease and settings. Doses of opioids proportional to opioid doses used for background analgesia, seem to guarantee both effectiveness and safety.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy.,Department of Supportive/Palliative Care, MD Anderson, Houston, Texas
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Paolo Marchetti
- Medical Oncology, Sapienza University of Rome and IDI-IRCCS Rome, Rome, Italy
| | - Andrea Costanzi
- Medical Oncology, Sapienza University of Rome and IDI-IRCCS Rome, Rome, Italy
| | - Federica Aielli
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
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Campagna S, Sperlinga R, Milo A, Sannuto S, Acquafredda F, Saini A, Gonella S, Berruti A, Scagliotti GV, Tampellini M. The Circadian Rhythm of Breakthrough Pain Episodes in Terminally-ill Cancer Patients. Cancers (Basel) 2018; 11:cancers11010018. [PMID: 30586878 PMCID: PMC6356835 DOI: 10.3390/cancers11010018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 12/22/2022] Open
Abstract
Opioid therapy must be adjusted to the rhythm of a cancer patient’s pain to ensure adequate symptom control at the end of life (EOL). However, to-date no study has explored the rhythm of breakthrough pain (BTP) episodes in terminally-ill cancer patients. This prospective longitudinal study was aimed at verifying the existence of a circadian rhythm of BTP episodes in terminally-ill cancer patients. Consecutive adult cancer patients at their EOL treated with long-acting major opioids to control background pain (Numeric Rating Scale ≤ 3/10) were recruited from two Italian palliative care services. Using a personal diary, patients recorded the frequency and onset of BTP episodes and the analgesic rescue therapy taken for each episode over a 7-day period. Rhythms identified in BTP episodes were validated by Cosinor analysis. Overall, 101 patients were enrolled; nine died during the study period. A total of 665 BTP episodes were recorded (average of 7.2 episodes, mean square error 0.8) per patient, with 80.6% of episodes recorded between 8:00 a.m. and 12:00 a.m. At Cosinor analysis, a circadian rhythm of BTP episodes was observed, with a Midline Estimating Statistics of the Rhythm (MESOR) of 1.5, a double amplitude of 1.8, and an acrophase at 12:30 p.m. (p < 0.001). Oral morphine was the most frequent analgesic rescue therapy employed. In terminally-ill cancer patients, BTP episodes follow a circadian rhythm; thus, tailoring the timing of opioid administration to this rhythm may prevent such episodes. This circadian rhythm of BTP episodes in terminally-ill cancer patients should be confirmed in larger samples.
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Affiliation(s)
- Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, 10126 Torino, Italy.
| | - Riccardo Sperlinga
- School of Nursing, Catholic University of the Sacred Heart, Cottolengo Hospital, 10152 Torino, Italy.
| | - Antonella Milo
- FARO Foundation-Hospice Sergio Sugliano, 10121 Torino, Italy.
| | - Simona Sannuto
- School of Nursing, Catholic University of the Sacred Heart, Cottolengo Hospital, 10152 Torino, Italy.
| | - Fabio Acquafredda
- School of Nursing, Catholic University of the Sacred Heart, Cottolengo Hospital, 10152 Torino, Italy.
| | - Andrea Saini
- Medical Oncology, University of Torino; Department of Oncology, San Luigi Gonzaga Hospital, 10043 Orbassano, Italy.
| | - Silvia Gonella
- Department of Public Health and Pediatrics, University of Torino, 10126 Torino, Italy.
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia, ASST-Spedali Civili, 25123 Brescia, Italy.
| | - Giorgio Vittorio Scagliotti
- Medical Oncology, University of Torino; Department of Oncology, San Luigi Gonzaga Hospital, 10043 Orbassano, Italy.
| | - Marco Tampellini
- Medical Oncology, University of Torino; Department of Oncology, San Luigi Gonzaga Hospital, 10043 Orbassano, Italy.
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Fearon D, Hughes S, Brearley SG. A philosophical critique of the UK's National Institute for Health and Care Excellence guideline 'Palliative care for adults: strong opioids for pain relief'. Br J Pain 2018; 12:183-188. [PMID: 30057763 DOI: 10.1177/2049463717753021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The National Institute for Health and Care Excellence (NICE) promotes evidence-based medicine throughout contemporary health care. Its guidelines are employed in the United Kingdom and elsewhere, influencing the type and quality of health care provided. NICE considers a range of evidence in the process of creating guidelines; however, the research accepted as evidence greatly relies on positivist methodologies. At times, it is unnecessarily restricted to quantitative methods of data collection. Using the Clinical Guideline 140, opioids in palliative care, as an example, it is demonstrated that the research accepted as evidence is unable to provide answers to complex problems. In addition, several inherent biases are discussed, such as age inequality and pharmaceutical company influence. In order to provide coherent and useful guidelines relevant to complex problems in a real world setting, NICE must move away from focusing on data from randomised controlled trials. Its epistemological foundation must be questioned, paving the way for alternative research paradigms to be considered as evidence and thereby enriching subsequent guidelines.
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Affiliation(s)
- David Fearon
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK.,Cairdeas International Palliative Care Trust, Mauritania, West Africa
| | - Sean Hughes
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Sarah G Brearley
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Davies AN, Elsner F, Filbet MJ, Porta-Sales J, Ripamonti C, Santini D, Webber K. Breakthrough cancer pain (BTcP) management: a review of international and national guidelines. BMJ Support Palliat Care 2018; 8:241-249. [PMID: 29875184 DOI: 10.1136/bmjspcare-2017-001467] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 04/10/2018] [Accepted: 05/09/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Breakthrough cancer pain (BTcP) is common and has a significant impact on the quality of life of patients with cancer. This review compares current national/international BTcP guidelines in order to identify disparities and priorities for further research. METHODS Relevant guidelines were identified using searches of PubMed, the National Guideline Clearinghouse, the internet (commercial search engines), and correspondence with key opinion leaders and relevant pharmaceutical companies. Identified guidelines were compared, using the Association for Palliative Medicine of Great Britain and Ireland recommendations as the 'reference' guideline. RESULTS Ten specific BTcP guidelines were identified/reviewed, as well as major international generic cancer pain guidelines. In general, there was good agreement between the specific BTcP guidelines, although there remain some differences in terms of definition, diagnostic criteria and treatment of BTcP. Disparities between the different BTcP guidelines invariably reflect personal opinion rather than research evidence. Generic cancer pain guidelines continue to support the use of oral opioids as rescue medication, while specific BTcP guidelines invariably endorse the use of transmucosal opioids as rescue medication. CONCLUSION Current guidelines agree on many aspects of the management of BTcP. However, the evidence to support current guidelines remains low grade, and so more research is needed in this area of care. Moreover, there needs to be an international consensus on the definition and diagnosis criteria of BTcP.
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Affiliation(s)
- Andrew Neil Davies
- Department of Supportive and Palliative Care, Royal Surrey County Hospital, Guildford, UK
| | - Frank Elsner
- Department of Palliative Medicine, Uniklinik RWTH Aachen University, Aachen, Germany
| | | | - Josep Porta-Sales
- Palliative Care Service, Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Carla Ripamonti
- Supportive Care in Cancer Unit, Istituto Nazionale dei Tumori, Milan, Italy
| | - Daniele Santini
- Department of Medical Oncology, Università 'Campus Bio-Medico di Roma', Rome, Italy
| | - Kath Webber
- Department of Supportive and Palliative Care, Royal Surrey County Hospital, Guildford, UK
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Factors Influencing the Clinical Presentation of Breakthrough Pain in Cancer Patients. Cancers (Basel) 2018; 10:cancers10060175. [PMID: 29865170 PMCID: PMC6025469 DOI: 10.3390/cancers10060175] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 11/17/2022] Open
Abstract
Background: The aim of this study was to identify potential variables influencing the clinical presentation of breakthrough cancer pain (BTP). Methods: Cancer patients with a diagnosis of BTP were enrolled. Demographic and clinical characteristics, as well as background pain and BTP characteristics were collected. Multivariate analyses were conducted to assess the correlation between BTP characteristics and the variables examined. Results: Data of 4016 patients were analysed. Average daily number of BTP episodes was 2.4, mean intensity was 7.5, and a mean duration was 43.3 min. A short onset BTP was observed in 68.9% of patients. In 30.5% of patients BTP was predictable. There were 86.0% of participants who reported a marked interference of BTP with their daily activities. Furthermore, 86.8% of patients were receiving opioids for the management of BTP. The average time to meaningful pain relief was 16.5 min and 70.9% of patients were satisfied with their BTP medications. Age, head and neck cancer, Karnofsky, background pain intensity, predictable and fast onset BTP were independently associated with the number of BTP episodes. BTP pain intensity was independently associated with background pain intensity, fast onset BTP, and Karnofsky. Neuropathic pain mechanism was independently associated with unpredictable BTP. Variables independently associated with a longer duration of BTP were age, place of visit, cancer diagnosis, disease-oriented therapy, background pain intensity and mechanism, and unpredictable BTP. Age, Karnofsky, background pain intensity, fast onset, and long duration of BTP were independently associated with interference with daily activity. Conclusions: BTP has a variable presentation depending on interdependent relationships among its different characteristics.
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Canal-Sotelo J, Trujillano-Cabello J, Larkin P, Arraràs-Torrelles N, González-Rubió R, Rocaspana-Garcia M, Barallat-Gimeno E. Prevalence and characteristics of breakthrough cancer pain in an outpatient clinic in a Catalan teaching hospital: incorporation of the Edmonton Classification System for Cancer pain into the diagnostic algorithm. BMC Palliat Care 2018; 17:81. [PMID: 29807537 PMCID: PMC5971419 DOI: 10.1186/s12904-018-0336-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/23/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Breakthrough cancer pain (BTcP) is defined according to its principal characteristics: high intensity, short time interval between onset and peak intensity, short duration, potential recurrence over 24 h and non-responsiveness to standard analgesic regimes. The Edmonton Classification System for Cancer Pain (ECS-CP) is a classification tool that evaluates different dimensions of pain. The aim of this study was to measure prevalence and the main characteristics of BTcP in a sample of advanced cancer patients and to explore the complexity observed when ECS-CP is incorporated into BTcP diagnostics algorithm. METHODS Descriptive prevalence study (Retrospective chart review). Davies' algorithm was used to identify BTcP and ECS-CP was used to recognize appropriate dimensions of pain. The study was conducted in a sample of advanced cancer patients attending hospital outpatient clinic in Lleida, Spain. 277 patients were included from 01/01/2014 to 31/12/2015. No direct contact was made with participants. The following information was extracted from the palliative care outpatient clinic database: age, gender, civil status, cognitive impairment status, functional performance status and variables related to tumour. Only BTcP cases were included. RESULTS Prevalence of BTcP was 39.34% (63.9% men). Mean of age was 68.2 years. Main diagnosis was lung cancer (n = 154; 31.6%). Metastases were diagnosed in 83% of the sample. 138 patients (49.8%) were diagnosed with 1 type of BTcP and 139 (50.2%) were diagnosed with more than one type of BTcP. In total, 488 different types of BTcP were recorded (mean 1.75 ± 0, 9), 244 of these types (50%) presented a component of neuropathic pain. Addictive behaviour, measured through CAGE test, was present in 29.2% (N = 81) of the patients and psychological distress was present in 40.8% (n = 113). CONCLUSIONS Prevalence of BTcP (39.34%) is similar to the one reflected in the existing literature. Study results indicate that the routine use of ECS-CP in a clinical setting allows us to detect more than one type of BTcP as well as additional complexity associated with pain (neuropathic, addictive behavior and psychological distress).
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Affiliation(s)
- Jaume Canal-Sotelo
- Hospital Universitari Arnau de Vilanova, UFISS GSS, Alcalde Rovira Roure, 80, 25198 Lleida, Spain
| | | | - Philip Larkin
- University College Dublin, School of Nursing and Midwifery and health Systems Health Sciences, Belfield, Dublin, Ireland
| | | | | | - Mariona Rocaspana-Garcia
- Faculty of Nursing and Phisiotherapy, Universitat de Lleida, Montserrat Roig 2, 25198 Lleida, Spain
| | - Eva Barallat-Gimeno
- Faculty of Nursing and Phisiotherapy, Universitat de Lleida, Montserrat Roig 2, 25198 Lleida, Spain
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32
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Lawlor PG, Lawlor NA, Reis-Pina P. The Edmonton Classification System for Cancer Pain: a tool with potential for an evolving role in cancer pain assessment and management. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/23809000.2018.1467211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Niamh A Lawlor
- Ottawa Hospital Cancer Program, The Ottawa Hospital (NAL), Ottawa, Canada
| | - Paulo Reis-Pina
- Palliative Care Unit, Casa de Saúde da Idanha, Sintra, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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33
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Six S, Laureys S, Poelaert J, Bilsen J, Theuns P, Deschepper R. Comfort in palliative sedation (Compas): a transdisciplinary mixed method study protocol for linking objective assessments to subjective experiences. BMC Palliat Care 2018; 17:62. [PMID: 29669562 PMCID: PMC5907466 DOI: 10.1186/s12904-018-0316-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 04/08/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In case of untreatable suffering at the end of life, palliative sedation may be chosen to assure comfort by reducing the patient's level of consciousness. An important question here is whether such sedated patients are completely free of pain. Because these patients cannot communicate anymore, caregivers have to rely on observation to assess the patient's comfort. Recently however, more sophisticated techniques from the neurosciences have shown that sometimes consciousness and pain are undetectable with these traditional behavioral methods. The aim of this study is to better understand how unconscious palliative sedated patients experience the last days of their life and to find out if they are really free of pain. METHODS In this study we will observe 40 patients starting with initiation of palliative sedation until death. Assessment of comfort based on behavioral observations will be related with the results from a NeuroSense monitor, an EEG-based monitor used for evaluation of the adequacy of anesthesia and sedation in the operating room and an ECG-based Analgesia Nociception Index (ANI) monitor, which informs about comfort or discomfort condition, based on the parasympathetic tone. An innovative and challenging aspect of this study is its qualitative approach; "objective" and "subjective" data will be linked to achieve a holistic understanding of the study topic. The following data will be collected: assessment of pain/comfort by the patients themselves (if possible) by scoring a Visual Analogue Scale (VAS); brain function monitoring; monitoring of parasympathetic tone; caregivers' assessment (pain, awareness, communication); relatives' perception of the quality of the dying process; assessment by 2 trained investigators using observational scales; video and audio registration. DISCUSSION Measuring pain and awareness in non-communicative dying patients is both technically and ethically challenging. ANI and EEG have shown to be promising technologies to detect pain that otherwise cannot be detected with the "traditional" methods. Although these technologies have the potential to provide objective quantifiable indicators for distress and awareness in non-communicative patients, strikingly they have not yet been used to check whether the current assessments for non-communicative patients are reliable. TRIAL REGISTRATION The study is registered on ClinicalTrials.gov (Identifier: NCT03273244 ; registration date: 7.9.2017).
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Affiliation(s)
- Stefaan Six
- Mental Health and Wellbeing research group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium.
| | - Steven Laureys
- Coma Science group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liège, Avenue de l'hôpital 11, 4000, Liège, Belgium
| | - Jan Poelaert
- Department of Anesthesiology & Perioperative Medicine, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
| | - Johan Bilsen
- Mental Health and Wellbeing research group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
| | - Peter Theuns
- Department of Experimental and Applied Psychology, Vrije Universiteit Brussel, Pleinlaan 2, 1000, Brussels, Belgium
| | - Reginald Deschepper
- Mental Health and Wellbeing research group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Jette, Belgium
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care &Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
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35
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Oncologist’s knowledge and implementation of guidelines for breakthrough cancer pain in Spain: CONOCE study. Clin Transl Oncol 2017; 20:613-618. [DOI: 10.1007/s12094-017-1756-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/19/2017] [Indexed: 12/20/2022]
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Cabezón-Gutiérrez L, Viloria-Jiménez MA, Pérez-Cajaraville J, Álamo-González C, López-Trigo JA, Gil-Gregorio P. [Breakthrough cancer pain in the elderly]. Rev Esp Geriatr Gerontol 2017; 52:271-277. [PMID: 27979661 DOI: 10.1016/j.regg.2016.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 10/15/2016] [Accepted: 10/24/2016] [Indexed: 11/24/2022]
Abstract
Breakthrough pain is defined as an acute exacerbation of pain with rapid onset, short duration and moderate or high intensity, which occurs spontaneously or in connection with a predictable or unpredictable event despite there being stabilised and controlled baseline pain. However, there are doubts about the definition, terminology, epidemiology, and assessment of breakthrough pain, with no clear answers or consensus, especially in the elderly population. This non-systematic review summarises the most important aspects of breakthrough pain in the elderly, based on the limited publications there are in that population group.
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Affiliation(s)
| | | | | | | | - José Antonio López-Trigo
- Servicio de Geriatría, Hospital Quirón de Málaga, Málaga, España; Presidente de la Sociedad Española de Geriatría y Gerontología
| | - Pedro Gil-Gregorio
- Servicio de Geriatría, Hospital Clínico Universitario San Carlos, Madrid, España; Coordinador del Comité de Expertos del Dolor de la Sociedad Española de Geriatría y Gerontología
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Peterson A, Carlfjord S, Schaller A, Gerdle B, Larsson B. Using education and support strategies to improve the way nurses assess regular and transient pain – A quality improvement study of three hospitals. Scand J Pain 2017; 16:15-21. [DOI: 10.1016/j.sjpain.2017.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 12/21/2022]
Abstract
Abstract
Background and aims
Systematic and regular pain assessment has been shown to improve pain management. Well-functioning pain assessments require using strategies informed by well-established theory. This study evaluates documented pain assessments reported in medical records and by patients, including reassessment using a Numeric Rating Scale (NRS) after patients receive rescue medication.
Methods
Documentation surveys (DS) and patient surveys (PS) were performed at baseline (BL), after six months, and after 12 months in 44 in-patient wards at the three hospitals in Östergötland County, Sweden. Nurses and nurse assistants received training on pain assessment and support. The Knowledge to Action Framework guided the implementation of new routines.
Results
According to DS pain assessment using NRS, pain assessment increased significantly: from 7% at baseline to 36% at 12 months (p < 0.001). For PS, corresponding numbers were 33% and 50% (p < 0.001). According to the PS, the proportion of patients who received rescue medication and who had been reassessed increased from 73% to 86% (p = 0.003). The use of NRS to document pain assessment after patients received rescue medication increased significantly (4% vs. 17%; p < 0.001).
Conclusions
After implementing education and support strategies, systematic pain assessment increased, an encouraging finding considering the complex contexts of in-patient facilities. However, the achieved assessment levels and especially reassessments related to rescue medication were clinically unsatisfactory. Future studies should include nursing staff and physicians and increase interactivity such as providing online education support. A discrepancy between documented and reported reassessment in association with given rescue medication might indicate that nurses need better ways to provide pain relief.
Implications
The fairly low level of patient-reported pain via NRS and documented use of NRS before and 12 months after the educational programme stresses the need for education on pain management in nursing education. Implementations differing from traditional educational attempts such as interactive implementations might complement educational programmes given at the work place. Standardized routines for pain management that include the possibility for nurses to deliver pain medication within well-defined margins might improve pain management and increase the use of pain assessments. Further research is needed that examines the large discrepancy between patient-reported pain management and documentation in the medical recording system of transient pain.
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Affiliation(s)
- Anna Peterson
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences , Linköping University , SE-581 85 Linköping , Sweden
| | - Siw Carlfjord
- Division of Community Medicine , Department of Medical and Health Sciences , Linköping University , SE 581 85 Linköping , Sweden
| | - Anne Schaller
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences , Linköping University , SE-581 85 Linköping , Sweden
- Division of Community Medicine , Department of Medical and Health Sciences , Linköping University , SE 581 85 Linköping , Sweden
| | - Björn Gerdle
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences , Linköping University , SE-581 85 Linköping , Sweden
- Division of Community Medicine , Department of Medical and Health Sciences , Linköping University , SE 581 85 Linköping , Sweden
| | - Britt Larsson
- Pain and Rehabilitation Centre and Department of Medical and Health Sciences , Linköping University , SE-581 85 Linköping , Sweden
- Division of Community Medicine , Department of Medical and Health Sciences , Linköping University , SE 581 85 Linköping , Sweden
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Samolsky Dekel BG, Palma M, Sorella MC, Gori A, Vasarri A, Melotti RM. Development and performance of a diagnostic/prognostic scoring system for breakthrough pain. J Pain Res 2017; 10:1327-1335. [PMID: 28615964 PMCID: PMC5459964 DOI: 10.2147/jpr.s126132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Variable prevalence and treatment of breakthrough pain (BTP) in different clinical contexts are partially due to the lack of reliable/validated diagnostic tools with prognostic capability. We report the statistical basis and performance analysis of a novel BTP scoring system based on the naïve Bayes classifier (NBC) approach and an 11-item IQ-BTP validated questionnaire. This system aims at classifying potential BTP presence in three likelihood classes: "High," "Intermediate," and "Low." METHODS Out of a training set of n=120 mixed chronic pain patients, predictors associated with the BTP likelihood variables (Pearson's χ2 and/or Fisher's exact test) were employed for the NBC planning. Adjusting the binary classification to a three-likelihood classes case enabled the building of a scoring algorithm and to retrieve the score of each predictor's answer options and the Patient's Global Score (PGS). The latter medians were used to establish the NBC thresholds, needed to evaluate the scoring system performance (leave-one-out cross-validation). RESULTS Medians of PGS in the "High," "Intermediate," and "Low" likelihood classes were 3.44, 1.53, and -2.84, respectively. Leading predictors for the model (based on score differences) were flair frequency (ΔS=1.31), duration (ΔS=5.25), and predictability (ΔS=1.17). Percentages of correct classification were 63.6% for the "High" and of 100.0% for either the "Intermediate" and "Low" likelihood classes; overall accuracy of the scoring system was 90.9%. CONCLUSION The NBC-based BTP scoring system showed satisfactory performance in classifying potential BTP in three likelihood classes. The reliability, flexibility, and simplicity of this statistical approach may have significant relevance for BTP epidemiology and management. These results need further impact studies to generalize our findings.
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Affiliation(s)
- Boaz Gedaliahu Samolsky Dekel
- Department of Medicine and Surgery Sciences, University of Bologna.,Department of Emergency-Urgency, Bologna's University Teaching Hospital, Policlinic S. Orsola-Malpighi.,University of Bologna, Post Graduate School of Anaesthesia and Intensive Care
| | - Marco Palma
- Collegio Superiore, Istituto di Studi Superiori - ISS, University of Bologna, Bologna, Italy
| | - Maria Cristina Sorella
- Department of Medicine and Surgery Sciences, University of Bologna.,Department of Emergency-Urgency, Bologna's University Teaching Hospital, Policlinic S. Orsola-Malpighi.,University of Bologna, Post Graduate School of Anaesthesia and Intensive Care
| | - Alberto Gori
- University of Bologna, Post Graduate School of Anaesthesia and Intensive Care
| | - Alessio Vasarri
- University of Bologna, Post Graduate School of Anaesthesia and Intensive Care
| | - Rita Maria Melotti
- Department of Medicine and Surgery Sciences, University of Bologna.,Department of Emergency-Urgency, Bologna's University Teaching Hospital, Policlinic S. Orsola-Malpighi.,University of Bologna, Post Graduate School of Anaesthesia and Intensive Care
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Havelin J, Imbert I, Sukhtankar D, Remeniuk B, Pelletier I, Gentry J, Okun A, Tiutan T, Porreca F, King TE. Mediation of Movement-Induced Breakthrough Cancer Pain by IB4-Binding Nociceptors in Rats. J Neurosci 2017; 37:5111-5122. [PMID: 28438966 PMCID: PMC5444195 DOI: 10.1523/jneurosci.1212-16.2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 03/30/2017] [Accepted: 04/14/2017] [Indexed: 02/04/2023] Open
Abstract
Cancer-induced bone pain is characterized by moderate to severe ongoing pain that commonly requires the use of opiates. Even when ongoing pain is well controlled, patients can suffer breakthrough pain (BTP), episodic severe pain that "breaks through" the medication. We developed a novel model of cancer-induced BTP using female rats with mammary adenocarcinoma cells sealed within the tibia. We demonstrated previously that rats with bone cancer learn to prefer a context paired with saphenous nerve block to elicit pain relief (i.e., conditioned place preference, CPP), revealing the presence of ongoing pain. Treatment with systemic morphine abolished CPP to saphenous nerve block, demonstrating control of ongoing pain. Here, we show that pairing BTP induced by experimenter-induced movement of the tumor-bearing hindlimb with a context produces conditioned place avoidance (CPA) in rats treated with morphine to control ongoing pain, consistent with clinical observation of BTP. Preventing movement-induced afferent input by saphenous nerve block before, but not after, hindlimb movement blocked movement-induced BTP. Ablation of isolectin B4 (IB4)-binding, but not TRPV1+, sensory afferents eliminated movement-induced BTP, suggesting that input from IB4-binding fibers mediates BTP. Identification of potential molecular targets specific to this population of fibers may allow for the development of peripherally restricted analgesics that control BTP and improve quality of life in patients with skeletal metastases.SIGNIFICANCE STATEMENT We present a novel preclinical measure of movement-induced breakthrough pain (BTP) that is observed in the presence of morphine controlling ongoing pain. Blockade of sensory input before movement prevented BTP, whereas nerve block after movement failed to reverse BTP. These observations indicate that blocking peripheral sensory input may prevent BTP and targeting central sites may be required for pain relief once BTP has been initiated. Preventing sensory input from TRPV1-expressing fibers failed to alter movement-induced BTP. In contrast, preventing sensory input from isolectin B4 (IB4)-binding fibers blocked movement-induced BTP. Therefore, examining molecular targets on this population of nociceptive fibers may prove useful for developing an improved strategy for preventing BTP in cancer patients with skeletal metastases.
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Affiliation(s)
- Joshua Havelin
- Department of Biomedical Sciences, College of Osteopathic Medicine, Center for Excellence in the Neurosciences, University of New England, Biddeford, Maine 04005, and
| | - Ian Imbert
- Department of Biomedical Sciences, College of Osteopathic Medicine, Center for Excellence in the Neurosciences, University of New England, Biddeford, Maine 04005, and
| | | | | | - Ian Pelletier
- Department of Biomedical Sciences, College of Osteopathic Medicine, Center for Excellence in the Neurosciences, University of New England, Biddeford, Maine 04005, and
| | - Jonathan Gentry
- Department of Biomedical Sciences, College of Osteopathic Medicine, Center for Excellence in the Neurosciences, University of New England, Biddeford, Maine 04005, and
| | - Alec Okun
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona 85724
| | - Timothy Tiutan
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona 85724
| | - Frank Porreca
- Department of Cancer Biology, Arizona Cancer Center, and
- Department of Pharmacology, College of Medicine, University of Arizona, Tucson, Arizona 85724
| | - Tamara E King
- Department of Biomedical Sciences, College of Osteopathic Medicine, Center for Excellence in the Neurosciences, University of New England, Biddeford, Maine 04005, and
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Sharma S, Singh B, Koul A, Mittal BR. Comparative Therapeutic Efficacy of 153Sm-EDTMP and 177Lu-EDTMP for Bone Pain Palliation in Patients with Skeletal Metastases: Patients' Pain Score Analysis and Personalized Dosimetry. Front Med (Lausanne) 2017; 4:46. [PMID: 28507988 PMCID: PMC5410571 DOI: 10.3389/fmed.2017.00046] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/07/2017] [Indexed: 12/22/2022] Open
Abstract
Introduction The aim of the present study was to compare the therapeutic efficacy of 153Sm-EDTMP and 177Lu-EDTMP in pain palliation in cancer patients with skeletal metastases. Materials and methods Thirty patients (25 M:5 F, mean age: 66.0 ± 14.7 years) of breast/prostate cancer with documented skeletal metastases were recruited prospectively. Twenty patients were considered randomly for treatment with 153Sm-EDTMP and with 177Lu-EDTMP in 10 patients, respectively. Using fixed dose of 37.0 MBq/kg body weight of each, the mean administered doses of 153Sm-EDTMP and 177Lu-EDTMP were 2,155.2 ± 419.6 MBq (1,347–2,857) and 1,935.1 ± 559.4 MBq (1,073–2,627), respectively. Anterior and posterior whole body images were acquired at different time points following radioactivity administration. The first data set of pre-void images (acquired at 0.5 h) representing the total activity of either of 153Sm-EDTMP or 177Lu-EDTMP was considered as reference images. All the serial images were used for patients’ dosimetry analysis by using organ level internal dosimetry assessment algorithm. Reduction in pain scoring was assessed clinically over 8 weeks by using appropriate WHO criteria and correlated with the absorbed dose to the metastatic sites. Results A total of 86 metastatic lesions clearly visualized on post-therapy serial images (matching on bone scans) were evaluated for absorbed dose calculations. Both 153Sm-EDTMP and 177Lu-EDTMP delivered similar absorbed dose to the metastatic sites, i.e., 6.22 ± 4.21 and 6.92 ± 3.92 mSv/MBq, respectively. The mean absorbed doses to various other organs were found to be comparable and within the safe limits. A complete response (CR) for each radionuclide was evaluated as 80.0%. No significant alternation in blood parameters and no untoward reaction were observed. However, a mild to severe toxicity was observed in two patients (1 each with 153Sm-EDTMP and 177Lu-EDTMP). Kaplan–Meier survival analysis demonstrated that 27/30 patients had pain-free survival (CR) up to the observational period of 8 weeks. However, no statistically significant correlation could be established between the pain scoring and absorbed dose to metastatic sites. Conclusion Both the radionuclides thus offer an effective and comparable therapeutic efficacy for bone pain palliation at an affordable cost and can be used interchangeably as per the availability.
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Affiliation(s)
- Sarika Sharma
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Baljinder Singh
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Koul
- Department of Biophysics, Panjab University, Chandigarh, India
| | - Bhagwant Rai Mittal
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Viet CT, Dang D, Aouizerat BE, Miaskowski C, Ye Y, Viet DT, Ono K, Schmidt BL. OPRM1 Methylation Contributes to Opioid Tolerance in Cancer Patients. THE JOURNAL OF PAIN 2017; 18:1046-1059. [PMID: 28456745 DOI: 10.1016/j.jpain.2017.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/13/2017] [Accepted: 04/01/2017] [Indexed: 11/28/2022]
Abstract
Cancer patients in pain require high doses of opioids and quickly become opioid-tolerant. Previous studies have shown that chronic cancer pain as well as high-dose opioid use lead to mu-opioid receptor downregulation. In this study we explore downregulation of the mu-opioid receptor gene (OPRM1), as a mechanism for opioid tolerance in the setting of opioid use for cancer pain. We demonstrate in a cohort of 84 cancer patients that high-dose opioid use correlates with OPRM1 hypermethylation in peripheral leukocytes of these patients. We then reverse-translate our clinical findings by creating a mouse cancer pain model; we create opioid tolerance in the mouse cancer model to mimic opioid tolerance in the cancer patients. Using this model we determine the functional significance of OPRM1 methylation on cancer pain and opioid tolerance. We focus on 2 main cells within the cancer microenvironment: the cancer cell and the neuron. We show that targeted re-expression of mu-opioid receptor on cancer cells inhibits mechanical and thermal hypersensitivity, and prevents opioid tolerance, in the mouse model. The resultant analgesia and protection against opioid tolerance are likely due to preservation of mu-opioid receptor expression on the cancer-associated neurons. PERSPECTIVE We demonstrate that epigenetic regulation of OPRM1 contributes to opioid tolerance in cancer patients, and that targeted gene therapy could treat cancer-induced nociception and opioid tolerance in a mouse cancer model.
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Affiliation(s)
- Chi T Viet
- Department of Oral Maxillofacial Surgery, New York University, New York, New York; Bluestone Center for Clinical Research, New York University, New York, New York
| | - Dongmin Dang
- Department of Oral Maxillofacial Surgery, New York University, New York, New York; Bluestone Center for Clinical Research, New York University, New York, New York
| | - Bradley E Aouizerat
- Bluestone Center for Clinical Research, New York University, New York, New York; School of Nursing, University of California, San Francisco, California; Institute for Human Genetics, University of California, San Francisco, California
| | | | - Yi Ye
- Department of Oral Maxillofacial Surgery, New York University, New York, New York; Bluestone Center for Clinical Research, New York University, New York, New York
| | - Dan T Viet
- Bluestone Center for Clinical Research, New York University, New York, New York
| | - Kentaro Ono
- Department of Oral Maxillofacial Surgery, New York University, New York, New York; Bluestone Center for Clinical Research, New York University, New York, New York
| | - Brian L Schmidt
- Department of Oral Maxillofacial Surgery, New York University, New York, New York; Bluestone Center for Clinical Research, New York University, New York, New York.
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Lara-Solares A, Ahumada Olea M, Basantes Pinos ADLÁ, Bistre Cohén S, Bonilla Sierra P, Duarte Juárez ER, Símon Escudero OA, Santacruz Escudero JG, Flores Cantisani JA. Latin-American guidelines for cancer pain management. Pain Manag 2017; 7:287-298. [PMID: 28326952 DOI: 10.2217/pmt-2017-0006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Argelia Lara-Solares
- Department of Pain Medicine & Palliative Care, Instituto Nacional de Ciencias Médicas y Nutrición 'Salvador Zubirán', Mexico City, Mexico
| | - Marisol Ahumada Olea
- CR Alivio Dolor & CP INCANCER, Asociación Chilena para el Estudio del Dolor (ACHED), Asociación Latino Americana de Cuidados Paliativos (ALCP), Santiago de Chile, Chile
| | | | | | | | - Eva Rossina Duarte Juárez
- Palliative Care & Symptoms Control Service, Institutode Cancerología, Palliative Medicine Unit, Hospital 'Nuestra Señora del Pilar', GuatemalaCity, Guatemala
| | - Omar A Símon Escudero
- Department of Oncolgy, Surgical Oncology Service, Hospital Nacional 'Daniel Alcides Carrión', Cancer Pain Therapy and Palliative Care, ADAMO (Atención Ambulatoria del Adulto Mayor y Paciente Oncológico), Dirección Regional de Salud (DIRESA) Callao, Lima, Perú
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Zecca E, Brunelli C, Centurioni F, Manzoni A, Pigni A, Caraceni A. Fentanyl Sublingual Tablets Versus Subcutaneous Morphine for the Management of Severe Cancer Pain Episodes in Patients Receiving Opioid Treatment: A Double-Blind, Randomized, Noninferiority Trial. J Clin Oncol 2017; 35:759-765. [DOI: 10.1200/jco.2016.69.9504] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Fentanyl sublingual tablets (FST) are a potentially useful alternative to parenteral opioids such as subcutaneous morphine (SCM) to treat severe cancer pain episodes. No direct comparison between FST and SCM is available. The aim of this study was to test noninferiority of FST versus SCM during the first 30 min postadministration. Methods Patients receiving stable opioid therapy and experiencing a severe pain episode were randomly assigned to either 100 µg FST or 5 mg SCM in a double-blind, double-dummy trial. Average pain intensity (PI) assessed on a 0 to 10 numerical rating scale at 10, 20, and 30 min postadministration was the main end point. Analysis of covariance, adjusted by baseline PI, was the main analysis. The noninferiority margin (NIm) for the between-group difference was set at −0.6, that is, equal to one third of the minimum clinically important PI difference of two points. Results A total of 114 patients were randomly assigned to either FST (n = 58) or SCM (n = 56). One patient (in the FST group) withdrew consent before drug administration and was excluded from analysis. Baseline mean PIs were 7.5 in both groups; mean average PIs assessed at 10, 20, and 30 min postadministration were 5.0 and 4.5 for FST and SCM, respectively, with the 95% CI of the between-group difference including the NIm (−0.49; 95% CI, −1.10 to 0.09). Patients taking FST received a second drug dose after 30 min more frequently than did patients taking SCM (51% v 37%, respectively; risk difference, −13%; 95% CI, −30% to 3%). Both treatments were well tolerated, with average follow-up adverse event scores below the response of “A Little.” Ninety-three percent of patients preferred the sublingual administration. Conclusion This trial did not show noninferiority of FST versus SCM within the chosen NIm. Both treatments were safe, and patients preferred the sublingual route of administration. FST provides analgesia with modest to moderate increased risk of lower efficacy compared with SCM.
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Affiliation(s)
- Ernesto Zecca
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cinzia Brunelli
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Fabio Centurioni
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Andrea Manzoni
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Alessandra Pigni
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
| | - Augusto Caraceni
- Ernesto Zecca, Cinzia Brunelli, Fabio Centurioni, Andrea Manzoni, Alessandra Pigni, and Augusto Caraceni, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; and Cinzia Brunelli, Norwegian University of Science and Technology, Trondheim, Norway
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Janknegt R, van den Beuken M, Schiere S, Überall M, Knaggs R, Hanley J, Thronaes M. Rapid acting fentanyl formulations in breakthrough pain in cancer. Drug selection by means of the System of Objectified Judgement Analysis. Eur J Hosp Pharm 2017; 25:e2. [PMID: 29732145 PMCID: PMC5931243 DOI: 10.1136/ejhpharm-2016-001127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/17/2016] [Accepted: 11/28/2016] [Indexed: 11/20/2022] Open
Abstract
Drug selection of rapid acting fentanyl formulations in the treatment of breakthrough pain in patients with cancer is performed by the System of Objectified Judgement Analysis method. All seven available formulations were included in the analysis. The following selection criteria were used: number of available strengths, variability in the rate of absorption, interactions, clinical efficacy, side effects, ease of administration and documentation. No direct double-blind comparative studies between two or more formulations were identified and the clinical documentation of all formulations is limited. The most distinguishing criterion was ease of use. This led to slightly higher scores for Abstral, Instanyl and PecFent than for the other formulations. The pros and cons of each formulation should be discussed with the patient, and the most suitable formulation selected for each individual patient.
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Affiliation(s)
- Robert Janknegt
- Department of Clinical Pharmacy and Toxicology, Zuyderland Medical Centre, Sittard, The Netherlands
| | | | | | - Michael Überall
- IFNAP Institute for Neurosciences, Algesiology and Paediatrics, Nürnberg, Germany
| | - Roger Knaggs
- University of Nottingham, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Morten Thronaes
- Faculty of Medicine, Department of Cancer Research and Molecular Medicine, European Palliative Care Research Centre (PRC), Norwegian University of Science and Technology (NTNU) and St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Mercadante S, Marchetti P, Cuomo A, Caraceni A, Mediati RD, Mammucari M, Natoli S, Lazzari M, Dauri M, Airoldi M, Azzarello G, Bandera M, Blasi L, Cartenì G, Chiurazzi B, Costanzo BVP, Degiovanni D, Fusco F, Guardamagna V, Iaffaioli V, Liguori S, Lorusso V, Mameli S, Mattioli R, Mazzei T, Melotti RM, Menardo V, Miotti D, Moroso S, De Santis S, Orsetti R, Papa A, Ricci S, Sabato AF, Scelzi E, Sofia M, Tonini G, Aielli F, Valle A. Breakthrough Cancer Pain: Preliminary Data of The Italian Oncologic Pain Multisetting Multicentric Survey (IOPS-MS). Adv Ther 2017; 34:120-135. [PMID: 27873235 PMCID: PMC5216057 DOI: 10.1007/s12325-016-0440-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Indexed: 11/29/2022]
Abstract
Introduction An ongoing national multicenter survey [Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS)] is evaluating the characteristics of breakthrough cancer pain (BTP) in different clinical settings. Preliminary data from the first 1500 cancer patients with BTP enrolled in this study are presented here. Methods Thirty-two clinical centers are involved in the survey. A diagnosis of BTP was performed by a standard algorithm. Epidemiological data, Karnofsky index, stage of disease, presence and sites of metastases, ongoing oncologic treatment, and characteristics of background pain and BTP and their treatments were recorded. Background pain and BTP intensity were measured. Patients were also questioned about BTP predictability, BTP onset (≤10 or >10 min), BTP duration, background and BTP medications and their doses, time to meaningful pain relief after BTP medication, and satisfaction with BTP medication. The occurrence of adverse reactions was also assessed, as well as mucosal toxicity. Results Background pain was well controlled with opioid treatment (numerical rating scale 3.0 ± 1.1). Patients reported 2.5 ± 1.6 BTP episodes/day with a mean intensity of 7.5 ± 1.4 and duration of 43 ± 40 min; 977 patients (65.1%) reported non-predictable BTP, and 1076 patients (71.7%) reported a rapid onset of BTP (≤10 min). Higher patient satisfaction was reported by patients treated with fast onset opioids. Conclusions These preliminary data underline that the standard algorithm used is a valid tool for a proper diagnosis of BTP in cancer patients. Moreover, rapid relief of pain is crucial for patients’ satisfaction. The final IOPS-MS data are necessary to understand relationships between BTP characteristics and other clinical variables in oncologic patients. Funding Molteni Farmaceutici, Italy.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Supportive Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| | - Paolo Marchetti
- Molecular and Clinical Medicine, Medical Oncology, La Sapienza University of Rome, Rome, Italy
| | - Arturo Cuomo
- Anesthesiology, Resuscitation, and Pain Therapy Department, National Cancer Institute, IRCCS Foundation Pascale, Naples, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, National Cancer Institute IRCCS Foundation, Milan, Italy
| | | | | | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Marzia Lazzari
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Mario Airoldi
- 2nd Medical Oncology Division, Città della Salute e della Scienza Hospital of Turin, Turin, Italy
| | - Giuseppe Azzarello
- Medical Specialties Department, Oncology and Oncologic Hematology, ASL 13 Mirano, Venice, Italy
| | - Mauro Bandera
- Medical Oncology Unit, Ospedale di Circolo e Fondazione Macchi Hospital, Varese, Italy
| | - Livio Blasi
- Medical Oncology Unit, ARNAS Ospedale Civico, Di Cristina, Benfratelli, Palermo, Italy
| | | | | | | | | | - Flavio Fusco
- Palliative Care Unit, Department of Primary and Community Care, ASL3 Genovese, Genoa, Italy
| | - Vittorio Guardamagna
- Palliative Care and Pain Therapy Unit, European Oncology Institute IRCCS, Milan, Italy
| | - Vincenzo Iaffaioli
- Abdominal Medical Oncology, National Cancer Institute, IRCCS Foundation Pascale, Naples, Italy
| | - Simeone Liguori
- Palliative Care and Pain Therapy Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Vito Lorusso
- Medical Oncology Unit, National Cancer Research Centre "Giovanni Paolo II", Bari, Italy
| | - Sergio Mameli
- Pain Therapy Unit, "A. Businco" Hospital, ASL 8, Cagliari, Italy
| | | | - Teresita Mazzei
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Rita Maria Melotti
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
| | | | - Danilo Miotti
- Palliative Care Unit, Salvatore Maugeri-IRCCS Foundation, Pavia, Italy
| | - Stefano Moroso
- Medical Oncology, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Stefano De Santis
- Palliative Care and Oncologic Pain Service, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Remo Orsetti
- Pain Medicine Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Alfonso Papa
- Pain Relief, A.O. Dei Colli, Monaldi Hospital, Naples, Italy
| | - Sergio Ricci
- Division of Medical Oncology, Department of Oncology, S. Chiara University Hospital, Pisa, Italy
| | - Alessandro Fabrizio Sabato
- Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
- Department of Emergency, Admission and Critical Area, Policlinic of Tor Vergata, Rome, Italy
| | - Elvira Scelzi
- Medical Oncology, Castelfranco Veneto Hospital, Treviso, Italy
| | - Michele Sofia
- Department of Palliative Care with Hospice and Pain Therapy Unit, "G.Salvini" Hospital, Garbagnate Milanese, Milan, Italy
| | - Giuseppe Tonini
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Davies A, Dickman A, Farquhar-Smith P, Webber K, Zeppetella J. Letter to the Editor re 'Characteristics of breakthrough cancer pain and its influence on quality of life in an international cohort of patients with cancer ( BMJ Support Palliat Care 2016;6:344-52)'. BMJ Support Palliat Care 2016; 7:264. [PMID: 27965212 DOI: 10.1136/bmjspcare-2016-001249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 11/21/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Andrew Davies
- Supportive and Palliative Care Department, Royal Surrey County Hospital, Guildford, UK
| | - Andrew Dickman
- Pharmacy Department, Royal Victoria Hospital, Blackpool, UK
| | | | - Katherine Webber
- Supportive and Palliative Care Department, Royal Surrey County Hospital, Guildford, UK
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Vellucci R, Fanelli G, Pannuti R, Peruselli C, Adamo S, Alongi G, Amato F, Consoletti L, Lamarca L, Liguori S, Lo Presti C, Maione A, Mameli S, Marinangeli F, Marulli S, Minotti V, Miotti D, Montanari L, Moruzzi G, Palermo S, Parolini M, Poli P, Tirelli W, Valle A, Romualdi P. What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion. Drugs 2016; 76:315-30. [PMID: 26755179 PMCID: PMC4757619 DOI: 10.1007/s40265-015-0519-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Clinical management of breakthrough cancer
pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five ‘things to do’ and five ‘things not to do’ in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.
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Affiliation(s)
| | - R Vellucci
- SOD Cure Palliative e Terapia del Dolore, Ospedale Universitario Careggi, Florence, Italy.
| | - G Fanelli
- SC Anestesia, Rianimazione e Terapia Antalgica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - R Pannuti
- Fondazione ANT Italia Onlus, Andria, Italy
| | - C Peruselli
- SC Cure Palliative, Ospedale di Biella, Ponderano, BI, Italy
| | - S Adamo
- UO Terapia del Dolore, ARNAS Civico di Palermo, Palermo, Italy
| | - G Alongi
- Hospice e Cure Palliative, ASP 1di Agrigento, Agrigento, Italy
| | - F Amato
- UOC Terapia del Dolore e Cure Palliative, Azienda ospedaliera di Cosenza, Cosenza, Italy.,Past President Feder Dolore-SICD, Cosenza, Italy
| | - L Consoletti
- Struttura di Medicina del Dolore, Ospedale Universitario "Ospedali Riuniti", Foggia, Italy
| | - L Lamarca
- UOS Cure Palliative e Terapia Antalgica, Azienda ULSS N. 10 "Veneto Orientale", San Donà di Piave, VE, Italy
| | - S Liguori
- USC Cure Palliative Terapia del Dolore, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - C Lo Presti
- UOD Terapia del Dolore e Cure Palliative, ACO San Filippo Neri, ASLRME, Rome, Italy
| | - A Maione
- Terapia antalgica e Cure Palliative, Presidio Ospedaliero "S. Maria della Pietà", Nola, NA, Italy
| | - S Mameli
- SC Terapia del Dolore, Presidio Ospedaliero "A. Businco", Cagliari, Italy
| | - F Marinangeli
- Scuola di Specializzazione di Anestesia, Rianimazione e Terapia Intensiva, Università dell'Aquila, L'Aquila, Italy
| | - S Marulli
- OC Anestesia, Rianimazione e Terapia Iperbarica, UOS-I Gruppo Operatorio, Ospedale "Vito Fazzi", Lecce, Italy
| | - V Minotti
- SC Oncologia Medica, Azienda Ospedaliera "S.M. della Misericordia", Perugia, Italy
| | - D Miotti
- UO Cure Palliative e Terapia del Dolore, Fondazione Salvatore Maugeri-IRCCS, Pavia, Italy
| | - L Montanari
- UO Semplice Cure Palliative, Ravenna, Italy.,Dipartimento Onco-ematologico, AUSL della Romagna c/o Presidio Ospedaliero Umberto I, Lugo di Ravenna, Italy
| | - G Moruzzi
- UOS Hospice, Azienda Sanitaria Provinciale di Siracusa, Siracuse, Italy
| | - S Palermo
- UOC Terapia Antalgica, IRCCS San Martino-IST, Genoa, Italy
| | - M Parolini
- UOC Anestesia e Rianimazione B, Azienda Universitaria integrata di Verona, Verona, Italy
| | - P Poli
- UO Terapia del Dolore, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - W Tirelli
- Centro di Terapia del Dolore, Hospice "Fondazione Roma Sanità", Rome, Italy.,Centro di Rianimazione e Terapia del Dolore e Cure Palliative, Istituto Nazionale Tumori "Regina Elena", Rome, Italy
| | - A Valle
- Fondazione FARO, Turin, Italy
| | - P Romualdi
- Dipartimento di Farmacia e Biotecnologie, Alma mater studiorum, Università di Bologna, Bologna, Italy
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Løhre ET, Klepstad P, Bennett MI, Brunelli C, Caraceni A, Fainsinger RL, Knudsen AK, Mercadante S, Sjøgren P, Kaasa S. Authors' Reply to Davies et al. J Pain Symptom Manage 2016; 52:e1-e2. [PMID: 27693897 DOI: 10.1016/j.jpainsymman.2016.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/29/2016] [Indexed: 11/22/2022]
Affiliation(s)
- Erik T Løhre
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Pål Klepstad
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Michael I Bennett
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Cinzia Brunelli
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Augusto Caraceni
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Robin L Fainsinger
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne K Knudsen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Sebastiano Mercadante
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Per Sjøgren
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Hjermstad MJ, Kaasa S, Caraceni A, Loge JH, Pedersen T, Haugen DF, Aass N. Characteristics of breakthrough cancer pain and its influence on quality of life in an international cohort of patients with cancer. BMJ Support Palliat Care 2016; 6:344-52. [PMID: 27342412 DOI: 10.1136/bmjspcare-2015-000887] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/31/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Breakthrough cancer pain (BTP) represents a treatment challenge. Objectives were to examine the prevalence and characteristics of BTP in an international sample of patients with cancer, and to investigate the relationship between BTP and quality of life (QoL). METHODS This was an observational cross-sectional multicentre study. Participating patients completed self-report questionnaires on a touch-screen laptop computer, including the Brief Pain Inventory, Alberta Breakthrough Pain Assessment Tool (ABPAT) and European Organisation for Research and Treatment of Cancer 30-item Core Quality of Life Questionnaire (EORTC QLQ-C30). The study was performed in 17 centres in 8 countries and involved 4 languages (Norwegian, Italian, German and English). RESULTS Records from a convenience sample of 978 patients with advanced cancer were analysed; mean age was 62.2 years, 48.3% were women and 84.4% had metastatic disease. A total of 296 patients (30%) had no pain, defined as worst pain in the past 24 hours <1 on a 0-10 scale. Of the 682 patients with a pain score ≥1, 393 (58%) reported no BTP on the screening item, while 289 (30%) confirmed flare ups of BTP. Patients with BTP reported significantly higher pain intensity scores (<0.001) than patients without BTP; 57.1% of patients rated BTP at its worst as being severe: ≥7 on a 0-10 scale. Time from onset to peak intensity was <10 min for 42.9%, and average time to pain relief was 27.1 min. BTP was commonly triggered by medication wearing off (28%). Patients with BTP had significantly worse mean outcomes on 10 of 15 functional and symptom scales of the EORTC QLQ-C30 (<0.001). Severe pain intensity in the last week was a powerful predictor of BTP (OR 4.1) and poor QoL (OR 1.9). CONCLUSIONS BTP is highly prevalent with prolonged episodes despite analgaesics, and has a pervasive impact on QoL. Patients reporting high pain intensity should be carefully evaluated for BTP and efficacy of analgaesic treatment, to provide optimal pain management and improve QoL. TRIAL REGISTRATION NUMBER NCT00972634; Results.
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Affiliation(s)
- Marianne Jensen Hjermstad
- Department of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital, Oslo, Norway Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Stein Kaasa
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Augusto Caraceni
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Department of Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milano, Italy
| | - Jon H Loge
- Department of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital, Oslo, Norway Department of Behavioural Sciences in Medicine, University of Oslo, Oslo, Norway
| | - Tore Pedersen
- Bjørknes University College, Oslo, Norway National Institute of Occupational Health, Oslo, Norway
| | - Dagny Faksvåg Haugen
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | - Nina Aass
- Department of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital, Oslo, Norway Faculty of Medicine, University of Oslo, Oslo, Norway
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