Presenting symptoms in patients referred to a multidisciplinary clinic for bone metastases

Opiate use after total hip arthroplasty for metastatic bone disease

OBJECTIVES

To investigate post-operative opioid use following a total hip arthroplasty (THA) in metastatic bone disease (MBD) patients and identify factors associated with post-operative opioid use at 6 weeks and 90 days.

BACKGROUND

MBD commonly affects the hip, and surgical intervention including THA may be indicated for pain relief or to improve function. Following THA, patients are often prescribed short courses of opioids for post-operative pain relief. No study has evaluated opiate use following THA in patients for MBD.

METHODS

This was a retrospective review of patients using opioids preoperatively who underwent primary THA for MBD at two institutions between 2009 and 2022. Preoperative and post-operative opioid usages, respectively, at 6 weeks and 90 days were quantified through calculating daily morphine milligram equivalents (MMEs) and compared using the sign test. Factors associated with post-operative opioid use at 6 weeks and 90 days were compared using χ2 test or Fisher's exact test as appropriate.

RESULTS

Nineteen THA and 11 THA with complex acetabular reconstruction were included. At 6 weeks, 26 (86.7 percent) patients were utilizing opiates, and at 90 days, 23 (76.7 percent) patients were utilizing opiates. There was a statistically significant difference between median daily preoperative MME compared to daily MME at 90 days (p < 0.001). The only statistically significant association with opioid use at 90 days was opioid use at 6 weeks.

CONCLUSION

To our knowledge, this is the first paper evaluating post-operative opioid use following primary THA in MBD patients. After THA in the setting of MBD, patients exhibit decreased post-operative opioid use. Future studies with larger cohorts should be conducted to characterize post-operative opioid use following joint arthroplasty in MBD patients.

The Burden of Metastatic Cancer-Induced Bone Pain: A Narrative Review

Bone pain is one of the most common forms of pain reported by cancer patients with metastatic disease. We conducted a review of oncology literature to further understand the epidemiology of and treatment approaches for metastatic cancer–induced bone pain and the effect of treatment of painful bone metastases on the patient’s quality of life. Two-thirds of patients with advanced, metastatic, or terminal cancer worldwide experience pain. Cancer pain due to bone metastases is the most common form of pain in patients with advanced disease and has been shown to significantly reduce patients’ quality of life. Treatment options for cancer pain due to bone metastases include nonsteroidal anti-inflammatory drugs, palliative radiation, bisphosphonates, denosumab, and opioids. Therapies including palliative radiation and opioids have strong evidence supporting their efficacy treating cancer pain due to bone metastases; other therapies, like bisphosphonates and denosumab, do not. There is sufficient evidence that patients who experience pain relief after radiation therapy have improved quality of life; however, a substantial proportion are nonresponders. For those still requiring pain management, even with available analgesics, many patients are undertreated for cancer pain due to bone metastases, indicating an unmet need. The studies in this review were not designed to determine why cancer pain due to bone metastases was undertreated. Studies specifically addressing cancer pain due to bone metastases, rather than general cancer pain, are limited. Additional research is needed to determine patient preferences and physician attitudes regarding choice of analgesic for moderate to severe cancer pain due to bone metastases.

Interventional Radiology in the Management of Metastases and Bone Tumors

Interventional Radiology (IR) has experienced an exponential growth in recent years. Technological advances of the last decades have made it possible to use new treatments on a larger scale, with good results in terms of safety and effectiveness. In musculoskeletal field, painful bone metastases are the most common target of IR palliative treatments; however, in selected cases of bone metastases, IR may play a curative role, also in combination with other techniques (surgery, radiation and oncology therapies, etc.). Primary malignant bone tumors are extremely rare compared with secondary bone lesions: osteosarcoma, Ewing sarcoma, and chondrosarcoma are the most common; however, the role of interventional radiology in this fiels is marginal. In this review, the main techniques used in interventional radiology were examined, and advantages and limitations illustrated. Techniques of ablation (Radiofrequency, Microwaves, Cryoablation as also magnetic resonance imaging-guided high-intensity focused ultrasound), embolization, and Cementoplasty will be described. The techniques of ablation work by destruction of pathological tissue by thermal energy (by an increase of temperature up to 90 °C with the exception of the Cryoablation that works by freezing the tissue up to -40 °C). Embolization creates an ischemic necrosis by the occlusion of the arterial vessels that feed the tumor. Finally, cementoplasty has the aim of strengthening bone segment weakened by the growth of pathological tissue through the injection of cement. The results of the treatments performed so far were also assessed and presented focused the attention on the management of bone metastasis.

Combinatorial effect of radium-223 and irreversible electroporation on prostate cancer bone metastasis in mice

BACKGROUND

Metastatic prostate cancer in bone is difficult to treat as the tumor cells are relatively resistant to hormonal or chemotherapies when compared to primary prostate cancer. Irreversible electroporation (IRE) is a minimally invasive ablation procedure that has potential applications in the management of prostate cancer in bone. However, a common limitation of IRE is tumor recurrence, which arises from incomplete ablation that allows remaining cancer cells to proliferate. In this study, we combined IRE with radium-223 (Ra-223), a bone-seeking radionuclide that emits short track length alpha particles and thus is associated with reduced damage to the bone marrow and evaluated the impact of the combination treatment on bone-forming prostate cancer tumors.

METHODS

The antitumor activity of IRE and Ra-223 as single agents and in combination was tested in vitro against three bone morphogenetic protein 4 (BMP4)-expressing prostate cancer cell lines (C4-2B-BMP4, Myc-CaP-BMP4, and TRAMP-C2-BMP4). Similar evaluation was performed in vivo using a bone-forming C4-2B-BMP4 tumor model in nude mice.

RESULTS

IRE and Ra-223 as monotherapy inhibited prostate cancer cell proliferation in vitro, and their combination resulted in significant reduction in cell viability compared to monotherapy. In vivo evaluation revealed that IRE with single-dose administration of Ra-233, compared to IRE alone, reduced the rate of tumor recurrence by 40% following initial apparent complete ablation and decreased the rate of proliferation of incompletely ablated tumor as quantified in Ki-67 staining (53.58 ± 16.0% for IRE vs. 20.12 ± 1.63%; for IRE plus Ra-223; p = 0.004). Histological analysis qualitatively showed the enhanced killing of tumor cells adjacent to bone by Ra-223 compared to those treated with IRE alone.

CONCLUSION

IRE in combination with Ra-223, which enhanced the destruction of cancer cells that are adjacent to bone, resulted in reduction of tumor recurrence through improved clearance of proliferative cells in the tumor region.

Pre-radiotherapy pain intensity and health-related quality of life in patients with bone metastases at various vertebral levels

PURPOSE

The spine is the most common site of bone metastasis from cancer and can be divided into 5 locational subsections, varying in mobility. The purpose of this research was to determine if the mobility of the metastases-bearing vertebral segment influenced pre-treatment pain intensity or health-related quality of life (HR-QoL) for patients about to receive palliative radiation therapy for painful spine metastasis.

METHODS

This study was a retrospective chart review of patients referred to the Palliative Radiation Oncology Program, about to receive radiation therapy for vertebral metastasis between January 2014 and June 2016. The main variables included patient-reported Edmonton Symptom Assessment Score pain intensity, the EQ-5D score for HR-QoL and the location of the vertebral metastasis (categorized using the SINS mobility score (mobile, junctional, semi-rigid, or rigid)). Various patient, disease and treatment characteristics were also collected, and entered into a multivariate analysis.

RESULTS

The eligible sample included 196 patients. Spinal metastases were distributed with approximately equal frequency (~27%) between the junctional, mobile and semi-rigid spine segments. Rigid spine was the least common site for spinal metastases (19%). Patients with metastatic disease in the mobile spine regions experienced greater pre-treatment pain compared to patients with disease in junctional subsections (Odds Ratio [OR] 1.37; p0.012). No relationship between HR-QOL and spinal mobility was found. Multivariate analysis also revealed that spinal metastases from a primary lung diagnosis reported worse pre-treatment pain compared to those from genitourinary cancers (OR 1.15; p0.05). Only age significantly influenced HR-QoL (75-95yrs vs. 35-55yrs; p0.041).

CONCLUSIONS

Patients referred to an RT clinic for the treatment of painful spinal metastases have a different distribution of disease throughout the spine compared to those referred for surgery or SBRT. Those with metastases in mobile spine segments were more likely to experience severe pre-treatment pain than those with metastases in junctional segments. Although further corroboration is needed, our results suggest that the mobility of the metastasis-bearing spinal section could be added to the existing list of predictors that aid clinicians in identifying patients that will benefit from closer follow-up or early intervention.

En Bloc lumpectomy of T12 vertebra for progressive hepatocellular carcinoma metastases following liver transplantation: A case report

RATIONALE

Liver transplantation (LT) is the preferred surgical option for the treatment of early hepatocellular carcinoma (HCC). In contrast, surgical treatment of progressive HCC metastasized to the spine following LT constitutes a considerable challenge. Here, we report the first case of progressive HCC metastasized to the T12 vertebra after local radiotherapy, treated successfully with en bloc lumpectomy following LT for HCC.

PATIENT CONCERNS

A 40-year-old man who had undergone LT for the treatment of HCC 2 months prior presented to our clinic with symptoms of progressive back pain. Magnetic resonance imagining (MRI) and positron emission tomography (PET) examinations showed a solitary metastasis at T12 without recurrence in the liver or metastasis to other organs.

DIAGNOSES

The patient was diagnosed with HCC metastasized to the T12 vertebra after liver transplantation.

INTERVENTIONS

Local radiation therapy of the T12 vertebra was performed; however, the lesion continued to grow one month after irradiation. Accordingly, the patient was treated with en bloc lumpectomy of the T12 vertebra. After surgery, the patient reported significant pain relief. At 11 months post-surgery, a C4 metastasis with spinal cord compression was revealed by MRI. Multiple grafted liver metastases were also detected by ultrasound along with several lung metastases, which were discovered by X-ray. The patient was treated with a pedicle screw system and a mesh cage filled with frozen autografts for C4 metastasis.

OUTCOMES

The patient died 15 months after liver transplantation due to recurrence in the liver and metastasis to the lung.

LESSONS

En bloc lumpectomy may be a viable therapeutic option for patients with progressive solitary spinal metastases after LT refractory to radiotherapy. Use of immunosuppressive therapy after LT may significantly inhibit immune function, making patients more susceptible to HCC recurrence and bone metastasis.

Effect of Orthopedics Promotional Activities on Multidisciplinary Management of Patients with Bone Metastases

BACKGROUND

The rapid aging of the Japanese population is leading to an increase in the number of patients with bone metastases. Since 2014, our orthopedics department has promoted multidisciplinary hospital activities, including offering lectures to hospital staff on multidisciplinary approaches for bone metastases and holding regular cancer board meetings on bone metastases. This study investigated whether these activities were effective in promoting multidisciplinary approaches and improving outcomes of patients with bone metastasis.

METHODS

To investigate the effects of changes in medical practice on patients with bone metastases, we compared patient clinical characteristics after (January 2014 through December 2017) and before the start of the activities (January 2011 through December 2013).

RESULTS

The semiannual numbers of first-visit, referral, and orthopedic surgical patients, the number of patients with slower growing primary cancers, and the number of patients with milder pain were significantly higher post-activity than pre-activity. The number of patients without paralysis was higher after the start of the activity than before the activity, but the difference was not significant. Survival after the first visit to the orthopedics department was significantly longer after the start of the activity than before the activity.

CONCLUSIONS

The potential demand for a multidisciplinary approach to bone metastases is high, and orthopedic specialists should actively participate in this approach.

Sequential Interventional Management of Osseous Neoplasms via Embolization, Cryoablation, and Osteoplasty

The purpose of this study is to determine if sequential interventional therapy can become a mainstay option in providing palliation from fastidious osseous neoplasms in patients with pain refractory to oral analgesia and radiotherapy. This retrospective monocentric study was approved by our institutional review board. Between July 2012 and August 2014, we reviewed 15 patients (6 women, 9 men; age range of 36-81 years) who underwent embolization followed by cryoablation, with or without osteoplasty. Patient demographics and tumor characteristics, including primary histology and the location of metastasis, were included in our review. Pain intensity at baseline, after radiotherapy, and after sequential interventional therapy was reviewed using the hospital electronic medical record. The use of oral analgesia and procedural complications was also noted. Data was then assessed for normality and a two-tailed Student's t-test was performed on mean pain scores for difference phases of treatment. While radiotherapy offers pain relief with a mean pain score of 7.25 ±1.5 (p =<.0001), sequential interventional therapy results in better comfort as demonstrated by a mean pain score of 3.9 ± 2.6 (p=.0015). Moreover, all patients who reported oral analgesic use at presentation reported a decrease in their requirement after sequential interventional therapy. Embolization and cryoablation were performed in all patients, while osteoplasty was indicated in 6 cases. There was no difference in postprocedural pain intensity between patients who required osteoplasty and patients who did not (p = 0.7514). There were no complications observed during treatment. This retrospective study shows that sequential intervention with transarterial embolization, cryoablation, and osteoplasty is both safe and efficacious for bone pain refractory to the current standard of care. We demonstrated that this combination therapy has the potential to become an effective mainstay treatment paradigm in the palliative care of osseous neoplasm to improve quality of life.

IMproved MAnagement (IM-MA study) in cancer-related pain: the value of a joint approach by an integrated team of radiotherapist and anesthetist

PURPOSE

Purpose of this study was to retrospectively review our experience of multidisciplinary clinic providing a joint approach by radiation oncologist and anesthetist for patients with cancer pain to evaluate the adequacy and the IMprovement in MAnagement (IM-MA study) of this symptom.

METHODS

A Team for Pain Management (TPM) represented by radiation oncologist and anesthetist weekly provided consultations to patient presenting cancer pain. TPM prospectively reported epidemiologic, symptomatic, and pharmacological data. TPM modified pain therapy and indicated antalgic radiotherapy. Patients were evaluated at baseline and after 4 weeks after intervention.

RESULTS

From November 2015 to April 2016, 65 patients were evaluated by TPM. At the baseline, 18 patients (27.7%) were undertreated (i.e., receiving inadequate pain management); furthermore, 27 patients (41.5%) despite receiving strong opioids had uncontrolled pain. After 4 weeks from intervention, undertreated patients were reduced to 1.53%. For those patients undergone to radiotherapy, response at 34 weeks was scored as follows: complete response 28.8%, partial response 46.7%, pain progression 0.95%, indeterminate response 23.8%.

CONCLUSIONS

A multidisciplinary Team for Pain Management improved the clinical management, optimizing pain control and increasing adequacy of pharmacological management. The TPM intervention seems particularly worth for patients presenting specific features including BTcP, neuropathic pain, severe pain due to bone metastases, and any potential candidate to radiotherapy. Larger series and QoL questionnaires are required to confirm these results.

Metastatic Bone Disease in the Era of Bone-Targeted Therapy: Clinical Impact

Advances in the diagnosis and treatment of tumors by surgery, chemotherapy, biotherapy, radiotherapy and other modalities have increased the survival of cancer patients over the last 20 years. As a consequence, bone now represents the third most common site of metastatic involvement after the lung and liver. Approximately 20–25% of patients with neoplastic disease develop clinically evident bone metastases (BMs) during the natural course of their illness, with a further 50% of such lesions being identified during autopsy. BMs are the major cause of morbidity in cancer patients because of their epidemiological and clinical impact. Pain is the most frequent symptom in about 75% of patients but other serious complications can also occur, such as pathological fractures, spinal cord compression, hypercalcemia and bone marrow suppression. These complications worsen the patient's general condition and reduce patients’ mobility, facilitating the development of lung infections, skin ulcers, deep vein thrombosis, etc., and ultimately reducing prognosis and quality of life. The frequency of serious complications depends on the site and type of lesions and the treatment administered. Over the last 10 years, the introduction of bisphosphonates for the treatment of patients with BMs has led to a marked decrease in the frequency of complications, thus improving quality of life and clinical outcome. Furthermore, progress in understanding the pathophysiology of bone metastases has resulted in the development of new bone-targeted molecules such as denosumab. We therefore felt it would be useful to report on the epidemiological, clinical and economic impact of bone disease in a cancer setting.

Cost-Utility Analysis of Single-Fraction Versus Multiple-Fraction Radiotherapy in Patients with Painful Bone Metastases: An Iranian Patient's Perspective Study

OBJECTIVES

To evaluate two of the various treatment strategies of bone metastasis- single-fraction radiotherapy and multiple-fraction radiotherapy.

METHODS

A multistage Markov decision model was applied to assess the incremental costs per quality-adjusted life-year (QALY) gained of single fraction against multiple fractions. The model had a monthly cycle length over a lifetime horizon with 1000 hypothetical cohort samples. The EuroQol five-dimensional questionnaire was used to estimate the health-related quality of life in patients. To cope with parameters of uncertainty, we conducted a probabilistic sensitivity analysis using a Monte-Carlo simulation technique. Both cost and utility variables were discounted by 3% in the base model. Strategies were assessed considering a willingness-to-pay threshold of US $6578 per QALY gained.

RESULTS

The expected mean cost and quality-adjusted life-years were, respectively, US $447.28 and 5.95 months for patients receiving single-fraction radiotherapy and US $1269.66 and 7.87 months for those receiving multiple-fraction radiotherapy. The incremental cost-utility ratio was US $428.38 per QALY. Considering the Iranian gross domestic product per capita (US $6578) as the recommended willingness to pay for 1 QALY gained, the multiple-fraction method was found to be a cost-effective strategy.

CONCLUSIONS

Policymakers should advocate the multiple-fraction method instead of the single-fraction method in the treatment of patients with painful bone metastases.

AAPT Diagnostic Criteria for Chronic Cancer Pain Conditions

Chronic cancer pain is a serious complication of malignancy or its treatment. Currently, no comprehensive, universally accepted cancer pain classification system exists. Clarity in classification of common cancer pain syndromes would improve clinical assessment and management. Moreover, an evidence-based taxonomy would enhance cancer pain research efforts by providing consistent diagnostic criteria, ensuring comparability across clinical trials. As part of a collaborative effort between the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) and the American Pain Society (APS), the ACTTION-APS Pain Taxonomy initiative worked to develop the characteristics of an optimal diagnostic system. After the establishment of these characteristics, a working group consisting of clinicians and clinical and basic scientists with expertise in cancer and cancer-related pain was convened to generate core diagnostic criteria for an illustrative sample of 3 chronic pain syndromes associated with cancer (ie, bone pain and pancreatic cancer pain as models of pain related to a tumor) or its treatment (ie, chemotherapy-induced peripheral neuropathy). A systematic review and synthesis was conducted to provide evidence for the dimensions that comprise this cancer pain taxonomy. Future efforts will subject these diagnostic categories and criteria to systematic empirical evaluation of their feasibility, reliability, and validity and extension to other cancer-related pain syndromes.

PERSPECTIVE

The ACTTION-APS chronic cancer pain taxonomy provides an evidence-based classification for 3 prevalent syndromes, namely malignant bone pain, pancreatic cancer pain, and chemotherapy-induced peripheral neuropathy. This taxonomy provides consistent diagnostic criteria, common features, comorbidities, consequences, and putative mechanisms for these potentially serious cancer pain conditions that can be extended and applied with other cancer-related pain syndromes.

Attitudes of radiation oncologists toward palliative and supportive care in the United States: Report on national membership survey by the American Society for Radiation Oncology (ASTRO)

PURPOSE

Radiation oncologists are frequently involved in providing palliative and supportive care (PSC) for patients with advanced cancers through delivery of palliative radiation. Whether they are confident in their ability to assess and initiate treatments for pain, nonpain, and psychosocial distress is unknown. The American Society for Radiation Oncology surveyed its practicing members in the United States on self-assessment of their primary PSC skills and access to continuing medical education on PSC.

METHODS

We electronically surveyed 4093 practicing radiation oncologists in the United States. The survey consisted of 16-questions in 5 sections¹: demographics,² PSC training,³ domains of PSC,⁴ perceived barriers as a radiation oncologist to initiate advanced care planning, and⁵ discussion of prognosis.

RESULTS

The survey was e-mailed to 4093 American Society for Radiation Oncology members, and 649 responses were received (response rate 16%). The majority (91%) of radiation oncologists surveyed believe PSC is an important competency for radiation oncologists. Most radiation oncologists reported that they are moderately confident in their ability to assess and manage pain and gastrointestinal symptoms, but less confident in their ability to manage anorexia, anxiety, and depression. Despite areas of decreased confidence, a large number (42%) of radiation oncologists do not receive any additional PSC education beyond their residency training. Lastly, a perceived fear of upsetting referring medical oncologists and lack of clinic time are concerns for radiation oncologists who may want to initiate goals of care/advance care planning discussions with patients and their families.

CONCLUSION

Radiation oncologists are more confident in their ability to assess and manage pain than in their ability to manage depression, anxiety, anorexia, and fatigue. There is a need for increasing continuing medical educational efforts in PSC for practicing radiation oncologists, and strengthening PSC training in residency programs.

Skeletal metastases from breast cancer: pathogenesis of bone tropism and treatment strategy

Breast cancer (BC) is the most common female cancer worldwide with approximately 10 % of new cases metastatic at diagnosis and 20-50 % of patients with early BC who will eventually develop metastatic disease. Bone is the most frequent site of colonisation and the development of skeletal metastases depends on a complex multistep process, from dissemination and survival of malignant cells into circulation to the actual homing and metastases formation inside bone. Disseminated tumor cells (DTCs) can be detected in bone marrow in approximately 30 % of BC patients, likely reflecting the presence of minimal residual disease that would eventually account for subsequent metastatic disease. Patients with bone marrow DTCs have poorer overall survival compared with patients without them. Although bone-only metastatic disease seems to have a rather indolent behavior compared to visceral disease, bone metastases can cause severe and debilitating effects, including pain, spinal cord compression, hypercalcemia and pathologic fractures. Delivering an appropriate treatment is therefore paramount and ideally it should require interdisciplinary care. Multiple options are currently available, from bisphosphonates to new drugs targeting RANK ligand and radiotherapy. In this review we describe the mechanisms underlying bone colonization and provide an update on existing systemic and locoregional treatments for bone metastases.

Pain management in older adults

BACKGROUND

Chronic pain is prevalent among older adults but is underrecognized and undertreated. The approach to pain assessment and management in older adults requires an understanding of the physiology of aging, validated assessment tools, and common pain presentations among older adults.

OBJECTIVE

To identify the overall principles of pain management in older adults with a specific focus on common painful conditions and approaches to pharmacologic treatment.

METHODS

We searched PubMed for common pain presentations in older adults with heart failure, end-stage renal disease, dementia, frailty, and cancer. We also reviewed guidelines for pain management. Our review encompassed 2 guidelines, 10 original studies, and 22 review articles published from 2000 to the present. This review does not discuss nonpharmacologic treatments of pain.

RESULTS

Clinical guidelines support the use of opioids in persistent nonmalignant pain. Opioids should be used in patients with moderate or severe pain or pain not otherwise controlled but with careful attention to potential toxic effects and half-life. In addition, clinical practice guidelines recommend use of oral nonsteroidal anti-inflammatory drugs with extreme caution and for defined, limited periods.

CONCLUSION

An understanding of the basics of pain pathophysiology, assessment, pharmacologic management, and a familiarity with common pain presentations will allow clinicians to effectively manage pain for older adults.

Advances in prevention and treatment of bone metastases in prostate cancer. Role of RANK/RANKL inhibition

BACKGROUND

Bone metastases are a common complication of prostate cancer, so treatment and prevention are essential to slow the progression of the disease and the occurrence of skeletal related events (SREs), which have devastating consequences for the quality of life of patients.

SUMMARY OF EVIDENCE

Bone metastases are characterized by increased bone turnover and altered balance between osteogenesis and osteolysis, with activation of the RANK and its ligand (RANKL). In patients with metastatic prostate cancer, bisphosphonates have been the bone-targeted agents most commonly used to date. Zoledronic acid has demonstrated efficacy in the reduction and delay of SREs in patients with bone metastases. Denosumab, a RANKL inhibitor, has been demonstrated to be superior to zoledronic acid in the prevention of SREs in castration-resistant prostate cancer (CRPC). Both agents are being considered, along with other new bone-targeted agents, for the prevention of bone metastases in patients with nonmetastatic CRPC, where denosumab has already demonstrated superiority over placebo.

CONCLUSIONS

Denosumab and zoledronic acid prevent SREs in patients with prostate cancer and bone metastases. Denosumab also has a potential role in delaying bone metastases in nonmetastatic patients. Advances in the treatment of CRPC include an increasing focus on prevention of the progression of bone disease.

The role of palliative external beam radiation therapy in boney metastases pain management

Bone is the third most common organ affected by neoplastic metastases, and about 70% of patients with breast cancer or prostate cancer that develop metastases will have osseous involvement. As part of a multi-pronged approach to pain management in these patients, external beam radio therapy (EBRT) continues to be a mainstay of treatment for metastatic bone pain. This article reviews the role of radiation therapy in palliative management strategies for patients with bone metastases, including the clinical and cost-effectiveness of single fraction (SFRT) versus multiple fraction (MFRT) EBRT in pain relief. Studies indicate that SFRT is more cost-effective than MFRT, yet both are clinically effective in pain management. Therefore, EBRT use retains an important place among analgesia, bone modifying agents, chemotherapy, and hormone therapy in improving quality of life (QoL) and reducing morbidity from metastatic bone pain.

Stereotactic body radiation therapy for management of spinal metastases in patients without spinal cord compression: a phase 1-2 trial

BACKGROUND

Spinal stereotactic body radiation therapy (SBRT) is increasingly used to manage spinal metastases, yet the technique's effectiveness in controlling the symptom burden of spinal metastases has not been well described. We investigated the clinical benefit of SBRT for managing spinal metastases and reducing cancer-related symptoms.

METHODS

149 patients with mechanically stable, non-cord-compressing spinal metastases (166 lesions) were given SBRT in a phase 1-2 study. Patients received a total dose of 27-30 Gy, typically in three fractions. Symptoms were measured before SBRT and at several time points up to 6 months after treatment, by the Brief Pain Inventory (BPI) and the M D Anderson Symptom Inventory (MDASI). The primary endpoint was frequency and duration of complete pain relief. The study is completed and is registered with ClinicalTrials.gov, number NCT00508443.

FINDINGS

Median follow-up was 15·9 months (IQR 9·5-30·3). The number of patients reporting no pain from bone metastases, as measured by the BPI, increased from 39 of 149 (26%) before SBRT to 55 of 102 (54%) 6 months after SBRT (p<0·0001). BPI-reported pain reduction from baseline to 4 weeks after SBRT was clinically meaningful (mean 3·4 [SD 2·9] on the BPI pain-at-its-worst item at baseline, 2·1 [2·4] at 4 weeks; effect size 0·47, p=0·00076). These improvements were accompanied by significant reduction in opioid use during the first 6 months after SBRT (43 [28·9%] of 149 patients with strong opioid use at baseline vs 20 [20·0%] of 100 at 6 months; p=0·011). Ordinal regression modelling showed that patients reported significant pain reduction according to the MDASI during the first 6 months after SBRT (p=0·00003), and significant reductions in a composite score of the six MDASI symptom interference with daily life items (p=0·0066). Only a few instances of non-neurological grade 3 toxicities occurred: nausea (one event), vomiting (one), diarrhoea (one), fatigue (one), dysphagia (one), neck pain (one), and diaphoresis (one); pain associated with severe tongue oedema and trismus occurred twice; and non-cardiac chest pain was reported three times. No grade 4 toxicities occurred. Progression-free survival after SBRT was 80·5% (95% CI 72·9-86·1) at 1 year and 72·4% (63·1-79·7) at 2 years.

INTERPRETATION

SBRT is an effective primary or salvage treatment for mechanically stable spinal metastasis. Significant reductions in patient-reported pain and other symptoms were evident 6 months after SBRT, along with satisfactory progression-free survival and no late spinal cord toxicities.

FUNDING

National Cancer Institute of the US National Institutes of Health.

Palliation of painful metastatic disease involving bone with imaging-guided treatment: comparison of patients' immediate response to radiofrequency ablation and cryoablation

OBJECTIVE

The purpose of this article was to compare periprocedural analgesic requirements and hospital length of stay for treatment of patients with painful metastatic tumors involving bone using either percutaneous radiofrequency ablation (RFA) or cryoablation.

MATERIALS AND METHODS

A retrospective review was conducted of patients who underwent either imaging-guided cryoablation or imaging-guided RFA for painful metastatic tumors involving bone. The total analgesic usage for 24 hours after the procedure was expressed as a standard morphine-equivalent dose. Analgesic usage at admission served as a baseline for comparison. Total hospital stay was used as an additional measurement of procedure-related morbidity.

RESULTS

Fifty-eight patients underwent either cryoablation (n = 36) or RFA (n = 22) for painful metastatic tumors involving bone. Twenty-two primary tumors were treated. The most common treatment site was the pelvis (n = 31). There was no significant difference between the two groups with regard to tumor histologic type (p = 0.52) and location (p = 0.72). The median tumor diameter was 4.4 cm for the cryoablation group and 5.0 cm for the RFA group (p = 0.63). Pretreatment pain scores, measured on a scale of 0 to 10, were not significantly different between the two groups: 6.5 for cryoablation and 6.0 for RFA (p = 0.78). Analgesic use in the 24 hours immediately after the procedure decreased significantly by 24 morphine-equivalent doses after cryoablation, whereas it increased by a median of 22 morphine-equivalent doses after RFA (p = 0.03). Total hospital length of stay for patients undergoing cryoablation was a median of 2.5 days less than that for patients receiving RFA (p = 0.003).

CONCLUSION

The use of cryoablation compared with RFA is associated with a greater reduction in analgesic dose and shorter hospital stays after the procedure in the perioperative time frame.

Level of Concordance Between Proxy and Cancer Patient Ratings in Brief PainInventory

BACKGROUND

The objective of this study was to assess whether caregivers serve as valid and reliable proxies for the assessment of a patient's pain level using the Brief Pain Inventory (BPI) assessment tool.

PATIENTS AND METHODS

Twenty-seven patients with cancer with pain, referred for health care management to the Toronto Sunnybrook Regional Cancer Centre and the Sunnybrook and Women's College Health Sciences Centre, and their proxies participated in this study. Patient and proxy completed the BPI independently, with proxies given explicit instructions to rate and answer the questions from the perspective of the patient. Patient and proxy also completed a data extraction form to obtain patient/proxy characteristics such as sex, age, primary cancer site, and relationship. An intraclass correlation coefficient (ICC) was performed for each question of the BPI.

RESULTS

In this study, we found poor to good agreement for questions that are subjective (eg, average pain), whereas the highest agreement was for worst pain scoring (ICC = 0.72). Poor to moderate agreement was found for questions that are objective (eg, walking ability), suggesting that the functional interference questions of the BPI may be too vague for proxies to respond reliably.

CONCLUSION

The findings indicate that proxies and patients agree well on worst pain levels but agree much less on the effectiveness of pain medications and patients' average level of pain. Further investigations should examine other tools for pain assessment that may be more reliably used by a proxy.

Effectiveness of knowledge translation interventions to improve cancer pain management

CONTEXT

Cancer pain is prevalent, yet patients do not receive best care despite widely available evidence. Although national cancer control policies call for education, effectiveness of such programs is unclear and best practices are not well defined.

OBJECTIVES

To examine existing evidence on whether knowledge translation (KT) interventions targeting health care providers, patients, and caregivers improve cancer pain outcomes.

METHODS

A systematic review and meta-analysis were undertaken to evaluate primary studies that examined effects of KT interventions on providers and patients.

RESULTS

Twenty-six studies met the inclusion criteria. Five studies reported interventions targeting health care providers, four focused on patients or their families, one study examined patients and their significant others, and 16 studies examined patients only. Seven quantitative comparisons measured the statistical effects of interventions. A significant difference favoring the treatment group in least pain intensity (95% confidence interval [CI]: 0.44, 1.42) and in usual pain/average pain (95% CI: 0.13, 0.74) was observed. No other statistical differences were observed. However, most studies were assessed as having high risk of bias and failed to report sufficient information about the intervention dose, quality of educational material, fidelity, and other key factors required to evaluate effectiveness of intervention design.

CONCLUSION

Trials that used a higher dose of KT intervention (characterized by extensive follow-up, comprehensive educational program, and higher resource allocation) were significantly more likely to have positive results than trials that did not use this approach. Further attention to methodological issues to improve educational interventions and research to clarify factors that lead to better pain control are urgently needed.

Beyond palliative radiotherapy: a pilot multidisciplinary brain metastases clinic

PURPOSE

The purpose of this study is to determine the feasibility of a multidisciplinary palliative radiotherapy clinic for patients with brain metastases.

METHODS

We designed a 6-month pilot Rapid Access Palliative Radiotherapy Program (RAPRP) brain metastases clinic. The main goals of the clinic were: (1) to provide timely consultation and treatment, (2) to provide multidisciplinary assessment and care, (3) to facilitate accrual of patients to research studies, and (4) to be a positive experience for patients. Team members included a radiation oncologist, radiation therapist, nurse practitioner, social worker (SW), occupational therapist (OT), and registered dietitian (RD). Patients underwent multidimensional assessment with patient-reported questionnaires and completed a patient satisfaction survey. Data were collected in a prospective database and collated in a standardized fashion with descriptive statistics recorded as percentages, medians, and ranges.

RESULTS

The pilot brain metastases clinic ran weekly from August 5, 2009 to January 27, 2010. In total, 33 patients were seen. The median time from referral date to clinic date was 6 days, with 76% of patients seen within 1 week. Most patients (94%) started their radiotherapy on clinic day. Fifteen patients (45%) required assessment by a SW, 36% by an OT, and 33% by a RD. Ninety-one percent of patients participated in a research study. Eighty-six percent of patients reported being very satisfied with the clinic experience, and 97% would recommend the clinic to a patient in a similar situation.

CONCLUSIONS

The pilot RAPRP Brain Metastases Clinic was successful in providing patients with timely and multidisciplinary care and will continue beyond the pilot phase.

Neuropathic pain features in patients with bone metastases referred for palliative radiotherapy

PURPOSE

To estimate the prevalence of pain with neuropathic features among patients with metastatic bone pain and to assess differences between patients with and without neuropathic features by pain severity, functional interference, and quality-of-life (QOL) measures.

PATIENTS AND METHODS

A prospective cross-sectional survey of consecutive patients with symptomatic bone metastases was conducted between December 2006 and March 2008 at a comprehensive cancer center. Patients completed the Brief Pain Inventory (BPI), the Self-Reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30). Statistical associations between pain with neuropathic features and other measures were explored.

RESULTS

Ninety-eight patients were enrolled. Seventeen percent of patients (95% CI, 10% to 24%) had positive S-LANSS scores suggesting pain with neuropathic features. Mean worst pain and mean interference scores were 7.2 (standard deviation [SD], 2.0) and 5.8 (SD, 2.5), respectively. EORTC QLQ-C30 global QOL, function, and symptom scores were 42 (SD, 24), 52 (SD, 20), and 46 (SD, 17), respectively. Patients with neuropathic features had a higher BPI worst pain score than patients without neuropathic features (8.3 v 7.0, respectively; P = .016). Corticosteroid use, oral morphine equivalent dosing, and site of bone pain were not associated with neuropathic features.

CONCLUSION

Some patients with bone metastases manifest bone pain with distinguishable neuropathic features, and these patients reported greater pain intensity. Additional work is required to validate the S-LANSS against clinical criteria for neuropathic pain in this context and to explore the unmet pain management needs in this population.

Transcutaneous electrical nerve stimulation (TENS) for cancer bone pain

In the cancer population, painful bony metastases are common, difficult to treat and significantly reduce quality of life. Common treatments include opioid analgesics, bisphosphonates, and radiotherapy; yet these have significant side effects and are not universally effective. Transcutaneous electrical nerve stimulation (TENS) is inexpensive, relatively free from side effects, and widely available. We present a case study of successful TENS therapy in a patient with cancer bone pain and discuss the rationale for using TENS in this setting.

A multidisciplinary bone metastases clinic at Toronto Sunnybrook Regional Cancer Centre - A review of the experience from 1999 to 2005

Our objective in this study was to review the experience of a one-stop multidisciplinary bone metastases clinic (BMC) that offers a coordinated multidisciplinary approach to the care of cancer patients with bone metastases in a tertiary cancer centre. Patients with symptomatic bone metastases were referred to BMC and assessed by a team of specialists in various disciplines - interventional radiology, orthopedic surgery, palliative medicine, and radiation oncology. At initial consultation, patient demographics, reasons for referral, and case disposition were recorded. From January 1999 to February 2005, a total of 272 patients with bone metastases were referred to the BMC. The median age was 65 years (range 28-95) and median KPS score at consultation was 60 (range 30-90). The majority of patients came from home (74%), while others came from a nursing home or the hospital (9%). Almost a third (28%) of patients had 2 or more reasons of referral, yielding a total of 354 reasons. The most common reason for referral was bone pain (42%), bone metastases (21%), high risk for pathological fracture (12%), and pathological fracture (10%). Of the 272 patients who received consultation, 40% received palliative radiotherapy, 19% received interventional surgery, 7% were referred to other support services such as palliative care, physiotherapy, and 7% had further investigation or imaging. A multidisciplinary clinic is useful for co-coordinating the management of bone metastatic disease in symptomatic patients.

Image-guided percutaneous thermal ablation for the palliative treatment of chest wall masses

OBJECTIVES

To evaluate the palliative benefits of image-guided thermal ablation for the treatment of painful tumors affecting the chest wall.

METHODS

Thirty-nine patients, median age 65 years, underwent percutaneous thermal ablation of 44 chest wall masses. Thirty-eight radiofrequency ablations (RFAs), 3 microwave ablations (MWAs), and 3 cryoablations were performed. Subjective pain reports at 1 week and 1 month postablation were scored from 0 to 4 based on a standard Likert pain relief scale, with 2 or higher representing clinically significant pain relief.

RESULTS

Patients were followed for a median of 6 months. Overall, 31 of 44 procedures (70.5%) resulted in significant pain relief. Improvement followed 15 of 15 (100%) of ablations that were performed within 90 days of treatment with palliative external-beam radiation therapy (XRT), compared with 16 of 29 (55.2%) of the remaining procedures. Mean pain relief score at 1 month was 3.86 for the 15 combined procedures versus 1.96 for the 29 remaining procedures (P < 0.001). Local pain recurred after 5 of 31 positive responses (16.1%). Median survival was 11.2 +/- 2.3 months for patients with significant pain relief and 4.3 +/- 1.4 months for nonresponders (P < 0.001). Adverse events included a transient symptom "flare" (n = 5, 11.4%) and the exacerbation of a preexisting brachial plexopathy.

CONCLUSIONS

Thermal ablation results in significant pain relief for the majority of patients and shows evidence of synergistic benefit when temporally combined with XRT. This minimally invasive technique appears to be a safe and durable alternative for the palliation of chest wall masses.

Effects of skeletal morbidities on longitudinal patient-reported outcomes and survival in patients with metastatic prostate cancer

GOALS OF WORK

Patients with prostate cancer metastasized to bone frequently experience skeletal morbidities as a result of their disease. We sought to quantify the longitudinal effects on patient-reported outcomes of skeletal-related events (SREs) and to ascertain the declines in health-related quality of life (HRQOL) and pain experienced by patients who experienced SREs.

MATERIALS AND METHODS

Data are from a clinical trial for the treatment of SREs associated with advanced prostate cancer metastatic to bone. Outcome measures included the Functional Assessment of Cancer Therapy-General (FACT-G) and the Brief Pain Inventory. Among patients who survived 6 months after randomization, patients with no SREs in the initial 6 months after randomization were matched via propensity scores with those experiencing one or more SREs. Similarly, patients with one SRE were matched with a subset of patients with two or more SREs.

MAIN RESULTS

Patients with SREs in the initial period had significantly worse survival and HRQOL than those with no SREs. Significant differences were found between the pain differences, FACT-G total scores, and FACT-G physical, emotional, and functional subscales. Comparisons of patients with single vs multiple SREs showed similar patterns.

CONCLUSIONS

The presence of SREs is significantly associated with worse survival and poorer HRQOL in this patient population. Increasing SRE intensity shows a pattern of increasingly decreased survival and poorer HRQOL.

Palliation and supportive care in radiation medicine

The treatment of bone metastases represents a paradigm for evaluating palliative care in terms of symptom relief, toxicities of therapy, and the financial burden to the patient, caregivers, and society. Despite enormous expenditures to treat metastases, patients continue to sustain symptoms of the disease, and uninterrupted aggressive therapies are pursued until death that incur toxicity in approximately 25% of patients. This approach is inconsistent with the goals of palliative care, which should efficiently provide comfort using antineoplastic therapies or supportive care approaches to the patient with the fewest treatment-related side effects, recognizing that the patient will die of the disease.The development of therapies such as bisphosphonates is important in advancing options for palliative care; however, clinical trials demonstrating the efficacy of bisphosphonates have not addressed important issues for clinical practice. The primary study endpoints should primarily address pertinent patient outcomes such as pain relief rather than asymptomatic radiographic findings. These studies should define clear indications of when to start and stop the therapy, the appropriate patient populations to receive the therapy, and the cost effectiveness of the treatment relative to other available therapies such as radiation. Cost-utility analyses, which account for a broader domain of cost effectiveness, need to be performed as part of clinical trials, especially for palliative care endpoints. Clinical trials that include these criteria are critical to future practice guideline development. As health care resources continue to become more limited, the criteria for care must be better defined to avoid administration of therapy with limited benefit. Leadership must come from the specialty as clinical trials and clinical practice increasingly interface with health care policy. Goals of therapy must remain clear for the benefit of the individual and all patients.

Update in Cancer Pain Syndromes

Cancer pain assessment and management are integral to palliative medicine. This paper reviews recent publications in the period 1999-2004 in the broad categories of epidemiology, pain assessment, nonpharmacologic approaches to cancer pain (radiation therapy, anesthetic blocks, palliative surgery and chemotherapy, complementary and alternative medicine), and in nociceptive pain, neuropathic pain, visceral pain, and bone pain.

Samarium for osteoblastic bone metastases and osteosarcoma

Samarium-153 lexidronam (153Sm-EDTMP) is FDA approved for painful osteoblastic bone metastases that image on bone scan. 153Sm-EDTMP decay has a therapeutic beta-emission and a gamma-photon for bone scan imaging. Monitoring of osteosarcoma radiation treatment effectiveness was performed with bone, CT, MRI and PET/CT fusion imaging. Bone scan and PET/CT improved in 5 out of 9 and 16 out of 18 osteosarcoma sites, respectively. 153Sm-EDTMP targets multiple sites of disease, with a single administration. Side effects of 153Sm-EDTMP (0.5-2.5 mCi/kg) have been minimal and include transient thrombocytopenia and neutropenia. 153Sm-EDTMP can be combined with radiation therapy, bisphosphonates and/or chemotherapy to synergistically improve palliation. This article reviews the rationale, indications and monitoring of standard-dose samarium and investigational high-dose 153Sm-EDTMP treatment of cancer involving bone.

Painful bone metastases: a prospective observational cohort study

Incident pain related to bone metastases is a problematic symptom to treat. The difficulty in treating this type of pain is reflected in the wide variety of treatment modalities recommended. The aims of this prospective observational study were to determine the patterns of pain severity at rest and on movement over time and which treatment modalities are employed. In addition, we were interested in ascertaining any correlations between bone pain at rest, bone pain on movement and functional ability. Thirty-two patients were followed up for a mean of 22 weeks (range: 2-52). In total, there were 704 patient follow-up weeks. Patients were followed up for one year or until death. A total of 19 different treatment modalities were employed. There were strong correlations between pain at rest and pain on movement. There were no significant correlations between functional ability and pain at rest or movement. Our study demonstrates the complex management of patients with bone pain. This is the first study that highlights the correlation between pain at rest and pain on movement in patients with bone metastases in a palliative care population. It highlights the need for intensive follow-up of these patients, as they require multiple interventions to help control their pain. These data can also be used to power further interventional studies.

Symptom distress in patients attending an outpatient palliative radiotherapy clinic

Patients with advanced cancer are often polysymptomatic. Different symptoms occur with varying frequency, intensity, and impact. Despite the high prevalence of symptoms in this population, reports of symptomatology in palliative outpatients have been limited. We report the symptom distress in metastatic cancer patients attending an outpatient palliative radiotherapy clinic. Patients referred for palliative radiotherapy for symptom control to the Rapid Response Radiotherapy Program (RRRP) were asked to rate symptom distress using the Edmonton Symptom Assessment Scale (ESAS) at the time of initial consultation. Patient demographics, cancer history, disease status, and analgesic consumption during the previous 24 hours were recorded. Between January 1999 and January 2002, 1,296 patients were seen at the RRRP and consented to participate in the study. Mean symptom distress rates ranged from 1.41 to 5.04. Fatigue, poor sense of well-being, pain, and poor appetite were the highest scored symptoms consecutively. Patients with poorer performance status (KPS < or = 60) had significantly higher symptom distress scores for all nine symptoms (P < 0.001). We conclude that the symptoms of metastatic cancer, including pain, fatigue, depression, anxiety, drowsiness, poor appetite, and sense of well-being, are common among patients attending outpatient palliative clinics. Symptom assessment tools, such as the ESAS, allow for the identification of symptoms and their severity. The appropriate regimen for management of pain and symptoms in metastatic cancer patients can then be planned.

The significance of skeletal-related events for the health-related quality of life of patients with metastatic prostate cancer

BACKGROUND

We examined the clinical relevance of skeletal-related events (SREs) for health state preferences, pain and health-related quality of life in patients with advanced prostate cancer and a history of bone metastases.

PATIENTS AND METHODS

Data were from a clinical trial of zoledronic acid versus placebo in the treatment of SREs associated with advanced prostate cancer metastatic to bone. Patients (n=248) were included if they experienced an SRE during the study. Outcome measures were assessed at fixed intervals. We used mixed-effects models to estimate changes in outcomes after each patient's first SRE.

RESULTS

There were clinically meaningful and statistically significant declines in physical well-being after: radiation and pathologic fractures; functional well-being after radiation; and emotional well-being after radiation and pathologic fractures. There also were meaningful and significant declines in preference and utility scores after radiation and fracture. Pain intensity declined after radiation, but not after other SREs; no other pain measure changed substantively.

CONCLUSIONS

SREs have important and significant effects on measures of health-related quality of life in men with prostate cancer. Treatments that prevent SREs may not demonstrate corresponding effects on outcomes if the effects of SREs occur between scheduled outcome assessments. Implications for trial design are discussed.

Radiotherapy is a cost-effective palliative treatment for patients with bone metastasis from prostate cancer

BACKGROUND

To evaluate the various treatments for patients with hormone-refractory prostate cancer with bone metastases using a Markov model.

METHODS AND MATERIALS

The base case to be evaluated was of a man with hormone-refractory prostate cancer. The evaluated palliative treatments were pain medication only, chemotherapy consisting of mitoxantrone and prednisone, and single- and multifraction radiotherapy (RT). A literature search was used to generate the transition probabilities and patient utilities. Modeling was used to generate the cost estimates. Expert opinion was used to generate utilities and cost estimates in the absence of literature data. Second-order Monte Carlo simulation produced incremental cost-effectiveness scatterplots and 95% confidence ellipses.

RESULTS

Pain medication had the least expected mean cost of all the treatment options at 11,700 US dollars but also the second lowest quality-adjusted survival at 5.75 quality-adjusted life months. Chemotherapy had the highest expected mean cost, 15,300 US dollars, but the lowest quality-adjusted life months (4.93). Incremental cost-effectiveness analysis revealed that single-fraction RT was the most cost-effective treatment, with a cost of 6,857 US dollars/quality-adjusted life year; multifraction RT had an incremental cost-effectiveness ratio of 36,000 US dollars/quality-adjusted life year. Chemotherapy was dominated by pain medication.

CONCLUSION

Within the limits of the established model, single-fraction RT was the most cost-effective palliative treatment compared with pain medication, chemotherapy, and multifraction RT. The use of this model allowed comparison of different treatment regimens that could never be evaluated together in a randomized clinical trial.