Differences in demographic, clinical, and symptom characteristics and quality of life outcomes among oncology patients with different types of pain

Exploration of the Relationships Between Stress and Distinct Pain and Sleep Disturbance Profiles in Patients Undergoing Chemotherapy

BACKGROUND

Unrelieved pain and sleep disturbance are common symptoms in oncology patients. Increased stress may be an underlying cause for both symptoms.

OBJECTIVES

The purposes of this study were to identify subgroups of outpatients with distinct pain and sleep disturbance profiles and to evaluate differences among these subgroups in demographic and clinical characteristics. Differences in global stress, cancer-specific stress, and cumulative life stress, as well as resilience and coping, were evaluated.

METHODS

Patients (N = 1343) completed self-report questionnaires for demographic and clinical characteristics and stress, resilience, and coping. Latent profile analysis was used to identify subgroups of patients with distinct pain and sleep disturbance profiles. Differences among the subgroups were determined using parametric and nonparametric tests.

RESULTS

Three distinct profiles were identified (ie, No Pain + Moderate Sleep Disturbance (SD) (27.6%), Moderate Pain + Moderate SD (38.6%), Severe Pain + High SD (33.8%)). Compared with the other 2 classes, Severe Pain + High SD class was younger, had fewer years of education, was more likely to be female, more likely to live alone, less likely to be employed, and had a higher level of comorbidity. This class had the highest stress scores and was more likely to report higher rates of adverse childhood experiences.

CONCLUSION

Over 70% of our sample reported clinically meaningful levels of both symptoms, and 33.8% reported relatively high rates of adverse childhood experiences.

IMPLICATION FOR PRACTICE

Clinicians need to perform routine assessments, particularly of adverse childhood experiences, and initiate appropriate referrals.

Increased Stress Is Associated With Severe Pain and Decrements in Cognitive Function in Patients Receiving Chemotherapy

OBJECTIVES

Purposes were to identify subgroups of adult oncology patients (n = 1342) with distinct joint profiles of worst pain and cognitive function (CF) and evaluate for differences in demographic and clinical characteristics, as well as the severity of three distinct types of stress, resilience, and coping.

DATA SOURCES

Measures of pain and CF were evaluated six times over two cycles of chemotherapy. The other measures of demographic and clinical characteristics, stress, resilience, and coping were completed at enrollment (ie, prior to the second or third cycle of chemotherapy).

RESULTS

Using latent profile analysis, four distinct profiles were identified (ie, no pain + moderate CF [27.6%], moderate pain + high CF [22.4%] moderate pain and moderate CF [32.4%, both moderate], severe pain and low CF [17.5%, both severe]). Both moderate and both severe classes reported higher global, cancer-specific, and cumulative life stress, lower levels of resilience, and greater use of disengagement coping strategies. The Both severe class had higher occurrence rates for a number of adverse childhood experiences (ie, family violence in childhood, physical abuse at <16 years, forced sex at <16 years). Risk factors associated with membership in the two worst profiles included: being female, having a lower annual income, having a higher comorbidity burden, and having a poorer functional status.

CONCLUSION

Findings suggest that 72.4% of the patients reported pain scores in the moderate to severe range and 77.6% reported low to moderate levels of CF. Clinicians need to assess for both symptoms and various types of stress on a routine basis.

Surgical Approach and Persistent Opioid Use in Medicare Patients Undergoing Lung Cancer Resection

BACKGROUND

Robotic and video-assisted thoracoscopic surgery (VATS) approaches for lung resection are associated with decreased inpatient opioid use compared with open surgery. Whether these approaches affect outpatient persistent opioid use remains unknown.

METHODS

Non-small cell lung cancer patients aged 66 years or more who underwent lung resection between 2008 and 2017 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Persistent opioid use was defined as filling an opioid prescription 3 to 6 months after lung resection. Adjusted analyses were performed to evaluate surgical approach and persistent opioid use.

RESULTS

We identified 19,673 patients: 7479 (38%) underwent open surgery, 10,388 (52.8%) VATS, and 1806 (9.2%) robotic surgery. Persistent opioid use was 38% in the entire cohort, including 27% of opioid naïve patients, and highest after open surgery (42.5%), followed by VATS (35.3%) and robotic (33.1%, P < .001). In multivariable analyses, robotic (odds ratio 0.84; 95% CI, 0.72-0.98; P = .028) and VATS (odds ratio 0.87; 95% CI, 0.79-0.95; P = .003) approaches were both associated with decreased persistent opioid use compared with open surgery in opioid naïve patients. At 12 months, patients resected using a robotic approach had the lowest oral morphine equivalent per month compared with VATS (133 vs 160, P < .001) and open surgery (133 vs 200, P < .001). Among chronic opioid patients, surgical approach was not associated with postoperative opioid use.

CONCLUSIONS

Persistent opioid use after lung resection is common. Both robotic and VATS approaches were associated with decreased persistent opioid use compared with open surgery among opioid naïve patients. Whether a robotic approach yields additional long-term advantages over VATS warrants further investigation.

Distinct Worst Pain Profiles in Oncology Outpatients Undergoing Chemotherapy

BACKGROUND

While pain is a significant problem for oncology patients, little is known about interindividual variability in pain characteristics.

OBJECTIVE

The aims of this study were to identify subgroups of patients with distinct worst pain severity profiles and evaluate for differences among these subgroups in demographic, clinical, and pain characteristics and stress and symptom scores.

METHODS

Patients (n = 934) completed questionnaires 6 times over 2 chemotherapy cycles. Worst pain intensity was assessed using a 0- to 10-point numeric rating scale. Brief Pain Inventory was used to assess various pain characteristics. Latent profile analysis was used to identify subgroups of patients with distinct pain profiles.

RESULTS

Three worst pain profiles were identified (low [17.5%], moderate [39.9%], severe [42.6%]). Compared with the other 2 classes, severe class was more likely to be single and unemployed and had a lower annual household income, a higher body mass index, a higher level of comorbidity, and a poorer functional status. Severe class was more likely to have both cancer and noncancer pain, a higher number of pain locations, higher frequency and duration of pain, worse pain quality scores, and higher pain interference scores. Compared with the other 2 classes, severe class reported lower satisfaction with pain management and higher global, disease-specific, and cumulative life stress, as well as higher anxiety, depression, fatigue, sleep disturbance, and cognitive dysfunction scores.

CONCLUSIONS

Unrelieved pain is a significant problem for more than 80% of outpatients.

IMPLICATIONS FOR PRACTICE

Clinicians need to perform comprehensive pain assessments; prescribe pharmacologic and nonpharmacologic interventions; and initiate referrals for pain management and psychological services.

Perturbations in Neuroinflammatory Pathways Are Associated With a Worst Pain Profile in Oncology Patients Receiving Chemotherapy

Unrelieved pain occurs in 55% of cancer patients. Identification of molecular mechanisms for pain may provide insights into therapeutic targets. Purpose was to evaluate for perturbations in neuroinflammatory pathways between oncology patients with and without severe pain. Worst pain severity was rated using a 0 to 10 numeric rating scale six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct pain profiles. Pathway impact analyses were performed in two independent samples using gene expression data obtained from RNA sequencing (n = 192) and microarray (n = 197) technologies. Fisher's combined probability test was used to identify significantly perturbed pathways between None versus the Severe pain classes. In the RNA sequencing and microarray samples, 62.5% and 56.3% of patients were in the Severe pain class, respectively. Nine perturbed pathways were related to neuroinflammatory mechanisms (i.e., retrograde endocannabinoid signaling, gamma-aminobutyric acid synapse, glutamatergic synapse, Janus kinase-signal transducer and activator of transcription signaling, phagosome, complement and coagulation cascades, cytokine-cytokine receptor interaction, chemokine signaling, calcium signaling). First study to identify perturbations in neuroinflammatory pathways associated with severe pain in oncology outpatients. Findings suggest that complex neuroimmune interactions are involved in the maintenance of chronic pain conditions. Perspective: In this study that compared oncology patients with none versus severe pain, nine perturbed neuroinflammatory pathways were identified. Findings suggest that complex neuroimmune interactions are involved in the maintenance of persistent pain conditions.

Psychosocial characteristics of chronic pain in cancer survivors referred to an Australian multidisciplinary pain clinic

OBJECTIVE

To describe the clinical and psychosocial characteristics of chronic pain in cancer survivors referred to one Australian hospital's ambulatory pain clinic over a 7-year period (2013-19), and to compare cancer treatment-related pain with comorbid non-malignant pain.

METHOD

Retrospective chart review including responses to standardized self-report questionnaires (Brief Pain Inventory, Depression Anxiety Stress Scale, Pain Self-Efficacy Questionnaire, Pain Catastrophizing Scale), routinely collected in all patients referred to pain clinics at Australian and New Zealand hospitals.

RESULTS

Of 3510 new referrals during the study period, 267 (7.5%) had a history of cancer and 176 (5.0%) met the study's eligibility criteria. Their average age was 63 ± 13 years, with 55% female. Breast cancer survivors were commonest, followed by hematological, prostate, melanoma, and colorectal, a median of 3 years post-diagnosis. Pain was attributed to cancer treatment in 87 (49%), surgery being the commonest modality. Multimodal treatment (n = 89, 58%) was significantly commoner in the treatment-related pain group (p &lt; 0.001). Average pain severity was moderate, as was pain-related disability and distress. Pain cognitions were often maladaptive (low pain self-efficacy, high pain catastrophizing), predicted by pre-existing anxiety and depression. Associations between pain cognitions and outcomes were medium-to-large. Differences between treatment pain and comorbid pain were small-to-medium. Their scores were similar to Australian pain clinic norms.

CONCLUSION

Cancer treatment causes tissue damage, but pain-related distress and disability in survivors is associated with maladaptive pain cognitions. Survivors with poor pain outcomes should be evaluated for unhelpful thoughts and beliefs especially when they have pre-existing depression or anxiety.

End-of-life cancer patients' total pain: the necessity to supplement pharmacology with psycho-socio-spiritual treatments

Aim: To analyze pain considering its different bio-psycho-social-spiritual manifestations and to assess the effectiveness of the analgesic treatments in end-of-life cancer patients. Materials & methods: The study was cross-sectional. A total of 376 end-of-life cancer inpatients participated in the research. Their socio-demographic and clinical data were collected and, during the first psychological consultancy, they filled in a set of validated rating scales assessing pain, anxiety, depression and quality of life. Results: The results show that physical pain was well managed for almost all patients. Nevertheless, the majority showed clinically significant levels of psychological distress. Conclusion: Treating pain means caring for all its possible manifestations including psychological symptoms and reduced wellbeing. Thus, integrating pharmacological treatment with psycho-socio-spiritual interventions, in other words, psychological, social and spiritual support, could be effective and desirable.

Prevalence of Opioid Misuse Risk in Patients With Cancer

BACKGROUND

Opioid misuse risk may be similar in individuals with chronic cancer and noncancer pain. However, risk screening is not uniformly used for patients with cancer, so its prevalence is unknown.

OBJECTIVES

The primary aim of this study was to estimate the level of risk for opioid misuse among patients with cancer. Secondary aims were to compare opioid misuse risk across cancer types and specialties and to explore psychosocial factors that may contribute to opioid misuse risk.

METHODS

Clinicians were trained to administer the Opioid Risk Tool during ambulatory visits. Data were retrieved from electronic health records and analyzed using descriptive statistics.

FINDINGS

Five percent of patients seen in the cancer center during the data collection period were screened for opioid misuse risk. Of the 226 patients screened, 163 were at low risk, 34 were at moderate risk, and 29 were at high risk for future opioid misuse. The most frequent cancer diagnoses for patients at moderate or high risk were lung (n = 15), breast (n = 16), gastrointestinal (n = 10), and genitourinary (n = 8). Of the 63 patients at moderate or high risk, 50 had a family history of substance misuse, 45 had a personal history of substance misuse, and 29 had a history of psychological disease.

A high stress profile is associated with severe pain in oncology patients receiving chemotherapy

PURPOSE

Oncology patients receiving chemotherapy can experience both cancer and non-cancer pain. In addition, oncology patients face numerous stressors and their responses are highly variable. Stress and pain are intricately linked. The purpose of this study was to evaluate for differences in pain characteristics and mood disturbance among oncology patients with distinct stress profiles.

METHODS

From a sample of 957 patients with and without pain, latent profile analysis identified three groups of patients with distinct stress profiles (i.e., Stressed, Normative, Resilient). In the subset of 671 patients with pain, receiving chemotherapy for breast, lung, gastrointestinal, or gynecologic cancer, we evaluated for differences among the stress profiles in terms of pain characteristics (e.g., intensity, qualities, interference) and mood disturbance (anxiety, depressive symptoms).

RESULTS

Compared to Normative patients (n = 333; 49.6%), Stressed patients (n = 305; 45.5%) reported higher levels of pain intensity, pain interference, anxiety, and depressive symptoms and more commonly described pain as throbbing, shooting, burning, exhausting, tiring, penetrating, nagging, miserable, and unbearable. Compared to Resilient patients (n = 33; 4.9%), Stressed patients reported significantly higher mood-related pain interference scores and more severe anxiety and depressive symptoms.

CONCLUSIONS

A high stress profile is common (45.5%) and is associated with more severe pain and associated symptoms. Efforts to identify and target this group for interventions may improve patient outcomes.

Pharmacologic Management of Persistent Pain in Cancer Survivors

Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges  associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered.

Worst Pain Severity Profiles of Oncology Patients Are Associated With Significant Stress and Multiple Co-Occurring Symptoms

Little is known about the associations between pain, stress, and co-occurring symptoms in oncology patients. Purpose was to identify subgroups of patients with distinct worst pain profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, as well as stress and symptom scores. Oncology outpatients (n = 1305) completed questionnaires prior to their second or third chemotherapy cycle. Worst pain intensity was assessed 6 times over 2 chemotherapy cycles using a 0 to 10 numeric rating scale. The 371 patients (28.4%) who had ≤1 occurrence of pain over the 6 assessments were classified as the None class. For the remaining 934 patients whose data were entered into the latent profile analysis, 3 distinct worst pain profiles were identified (ie Mild [12.5%], Moderate [28.6%], Severe [30.5%]). Compared to None class, Severe class had fewer years of education and a lower annual income; were less likely to be employed and married; less likely to exercise on a regular basis, had a higher comorbidity burden, and a worse functional status. Compared to None class, Severe class reported higher levels of general, disease-specific, and cumulative life stress and lower levels of resilience, as well as higher levels of depressive symptoms, anxiety, fatigue, sleep disturbance, and cognitive dysfunction. This study is the first to identify distinct worst pain profiles in a large sample of oncology patients receiving chemotherapy and associated risk factors. PERSPECTIVE: Unrelieved pain remains a significant problem for oncology patients receiving chemotherapy. High levels of stress and co-occurring symptoms contribute to a more severe pain profile in these patients.

Compromised end-of-life syndrome: Concept development from the condition of adults and older adults in palliative care

PURPOSE

This study aimed to develop the nursing diagnosis concept "compromised end-of-life syndrome" in palliative care.

METHODS

The authors used the integrative strategy by Meleis to develop the concept in this study and identifying clinical indicators from a literature review. For data organization, we applied the Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA).

FINDINGS

Some clusters of unpleasant signs and symptoms in palliative care patients at the end of life, such as pain, dyspnea, depression, constipation, and anxiety, were identified. Through conceptualization, the authors propose a new nursing diagnosis, "compromised end-of-life syndrome." The manuscript includes a model case of a patient with nursing diagnosis syndrome as a clinical example.

CONCLUSIONS

Simultaneous patterns of signs and symptoms present in the literature reinforce the utility of the proposition of end-of-life syndrome as a nursing diagnostic construct.

IMPLICATIONS FOR NURSING PRACTICE

The concept development related to patients' unpleasant signs and symptoms critically ill at palliative care supports the proposition of a new nursing diagnosis relevant to selecting adequate nursing interventions and nursing outcomes. Some clusters of unpleasant signs and symptoms in palliative care patients at the end of life, such as pain, dyspnea, depression, constipation, and anxiety were identified. Conceptualization was used to propose a new nursing diagnosis, "compromised end-of-life syndrome." A model case of a patient with nursing diagnosis syndrome is described as a clinical example.

CONCLUSION

Simultaneous patterns of signs and symptoms present in the literature reinforce the utility of the proposition of end-of-life syndrome as nursing diagnostic construct.

IMPLICATIONS FOR NURSING PRACTICE

The concept development related to patients' unpleasant signs and symptoms critically ill at palliative care supports the proposition of a new nursing diagnosis relevant to selecting adequate nursing interventions and nursing outcomes.

Symptom experience of older oncology patients with low versus high levels of multimorbidity prior to chemotherapy

PURPOSE

Evaluate for differences in demographic and clinical characteristics between older oncology patients with low multimorbidity (<2 multimorbidities) and high multimorbidity (≥2 multimorbidities) and evaluate for differences in symptom occurrence, severity, and distress ratings between the two groups.

METHODS

Symptoms of older oncology patients (n = 125) were assessed using the Memorial Symptom Assessment Scale prior to chemotherapy administration. Data were analyzed using t-tests for continuous variables and Chi-square or Fisher's exact tests for categorical variables.

RESULTS

For the total sample, lack of energy and pain were the two most common symptoms. Compared to the low multimorbidity group, the high multimorbidity group had a higher number of symptoms and significantly higher occurrence rates for feeling nervous, difficulty sleeping, dry mouth, and pain. Compared to the low multimorbidity group, the high multimorbidity group had significantly higher severity ratings for pain, feeling sad, lack of energy, feeling drowsy, and worrying. For distress, the high multimorbidity group reported significantly higher ratings for pain, worrying, feeling sad, feeling nervous, and "I don't look like myself". No differences were found in any demographic or clinical characteristics between the two multimorbidity groups.

CONCLUSIONS

Multimorbidity is associated with higher symptom occurrence, severity, and distress in older oncology patients. Our findings suggest that the symptoms with the highest severity ratings were not the most distressing. Clinicians should identify multimorbidities and assess symptoms prior to chemotherapy to identify patients at increased risk and initiate referrals for interventions.

The Experience of Complex Pain Dynamics in Oncology Outpatients: A Longitudinal Qualitative Analysis

BACKGROUND

Few qualitative studies of cancer patients' everyday experiences with pain exist within the large body of cancer pain research. Longitudinal qualitative studies are particularly sparse, and no studies have qualitatively described patients' pain experience over time during participation in a self-management intervention.

OBJECTIVE

To longitudinally describe patients' pain experiences during a 10-week pain self-management intervention.

METHODS

This qualitative study was embedded in a randomized controlled trial of a psychoeducational pain management intervention. The data consisted of transcribed audio recordings of each intervention session. An emergent, interpretive approach was used in this longitudinal qualitative analysis.

RESULTS

Forty-two adult patients were included. The analysis revealed the strikingly dynamic nature of individual patient's pain experiences. Multiple facets of pain contributed to its dynamic nature, including pain in changing locations, co-occurring sources of pain, and varying patterns of pain intensity over time. For individual patients, the cumulative effect of these multiple facets resulted in a phenomenon we termed "complex pain dynamics."

CONCLUSION

The results contribute to knowledge about the dynamic nature of cancer patients' pain experiences over a relatively short period. They suggest the need for a new paradigm for management of pain in cancer patients and raise questions about the interpretation of randomized controlled trial results in the absence of qualitative data.

IMPLICATIONS FOR PRACTICE

Frequent assessments and reassessments of pain are needed in cancer patients with the ongoing development of highly individualized self-management strategies. A large repertoire of interventions is needed to effectively manage pain in cancer patients over time.

Perceived Efficacy of Medical Cannabis in the Treatment of Co-Occurring Health-Related Quality of Life Symptoms

For persons living with chronic conditions, health-related quality of life (HRQoL) symptoms, such as pain, anxiety, depression, and insomnia, often interact and mutually reinforce one another. There is evidence that medical cannabis (MC) may be efficacious in ameliorating such symptoms and improving HRQoL. As many of these HRQoL symptoms may mutually reinforce one another, we conducted an exploratory study to investigate how MC users perceive the efficacy of MC in addressing co-occurring HRQoL symptoms. We conducted a cross-sectional online survey of persons with a state medical marijuana card in Illinois (N = 367) recruited from licensed MC dispensaries across the state. We conducted tests of ANOVA to measure how perceived MC efficacy for each HRQoL symptom varied by total number of treated symptoms reported by participants. Pain was the most frequently reported HRQoL treated by MC, followed by anxiety, insomnia, and depression. A large majority of our sample (75%) reported treating two or more HRQoL symptoms. In general, perceived efficacy of MC in relieving each HRQoL symptom category increased with the number of co-occurring symptoms also treated with MC. Perceived efficacy of MC in relieving pain, anxiety, and depression varied significantly by number of total symptoms experienced. This exploratory study contributes to our understanding of how persons living with chronic conditions perceive the efficacy of MC in treating co-occurring HRQoL symptoms. Our results suggest that co-occurring pain, anxiety, and depression may be particularly amenable to treatment with MC.

Pain and Spirituality Outcomes Among Women With Advanced Breast Cancer Participating in a Foot Reflexology Trial

OBJECTIVES

To examine pain and spirituality, demographic and clinical factors associated with pain and spirituality, the contribution of spirituality to experiences of pain over time, and how pain and spirituality relate to engagement with a caregiver-delivered intervention.

SAMPLE & SETTING

Women with advanced breast cancer (N = 256) enrolled in a home-based randomized controlled trial of foot reflexology.

METHODS & VARIABLES

Secondary analyses were conducted with baseline and postintervention data. Stepwise model building, linear mixed-effects modeling, and negative binomial regression were used.

RESULTS

Participants who were younger, not married or partnered, not employed, or receiving hormonal therapy had increased odds of higher pain levels. Those who were older, non-White, or Christian had increased odds of higher spirituality. Spirituality's contribution to pain was not significant over time.

IMPLICATIONS FOR NURSING

Women in this sample experienced moderate pain, on average, at baseline. Women with specific demographic and clinical characteristics may require additional support with pain management and spiritual care.

Association Between Physical Activity Levels and Chemotherapy-Induced Peripheral Neuropathy Severity in Cancer Survivors

OBJECTIVES

To evaluate for differences in demographic and clinical characteristics, as well as subjective and objective measures of chemotherapy-induced peripheral neuropathy (CIPN), among different exercise groups.

SAMPLE & SETTING

Cancer survivors (N = 290) were recruited from throughout the San Francisco Bay Area.

METHODS & VARIABLES

Based on the recommended 150 minutes or more of exercise per week, survivors were classified into the no exercise (NoEx), less exercise (LessEx), or recommended exercise (RecEx) group. Survivors completed self-report questionnaires and underwent sensory and balance testing.

RESULTS

Compared to the RecEx group, survivors in the NoEx group had less education, were less likely to be married/partnered, had a lower household income, had a higher level of comorbidity, and had poorer functional status. No differences were found among the groups in CIPN duration; pain intensity scores; or changes in light touch, cold, and pain sensations.

IMPLICATIONS FOR NURSING

Clinicians can recommend walking as a therapeutic option for survivors with CIPN and refer them to physical therapy.

Gender Differences in Medical Cannabis Use: Symptoms Treated, Physician Support for Use, and Prescription Medication Discontinuation

Background: Medical cannabis (MC) utilization continues to expand in the United States, as a growing body of evidence supports the use of cannabis and cannabinoids in the treatment of a range of chronic conditions. To date, gender-related differences in MC use are not widely reported, and little is known regarding physicians' support of patients' use of MC to address symptoms associated with chronic conditions. Materials and Methods: We conducted a cross-sectional online survey of MC users in Illinois (n = 361). We summarized participants' qualifying conditions, symptoms treated with MC, perceived physician support for MC use, use of MC and prescription medications, then analyzed differences by participant gender. Results: Bivariate analyses indicate that men report higher levels of support for MC use from both specialist and primary care physicians. Women were significantly more likely to increase use of cannabis after acquiring an MC card, and to discontinue prescription medications through MC use. Multivariable analyses indicate that being a woman, using MC to treat multiple symptoms, and reporting higher levels of support for MC use from a primary care provider significantly increased the likelihood of discontinuing prescription medication through MC use. Discussion: Women are more likely to report decreased use of prescription medications to treat symptoms, and report lower levels of support from physicians for MC use. Future research on gender differences in this population may benefit from more detailed data related to symptomology, utilization, dosing, and outcomes associated with MC, and interactions with the health care system to extend these findings.

Patterns of opioid use in older people diagnosed with cancer in New South Wales, Australia

PURPOSE

Opioids provide effective analgesia for most cancer patients, but little is known about individual-level opioid use after cancer diagnosis. We examined the patterns of and factors associated with opioid use in older people diagnosed with cancer.

METHODS

We used the Department of Veterans' Affairs (DVA) client data linked with the New South Wales (NSW) Cancer Registry and the Repatriation Pharmaceutical Benefits Scheme data. We included people aged ≥65 years diagnosed with cancer in NSW, Australia in 2005 to 2015. We examined patterns of opioid use in the 12 months after cancer diagnosis and used cause-specific hazards models to examine factors associated with opioid use.

RESULTS

Of 13 527 people diagnosed with cancer, 51% were dispensed opioids after their diagnosis. We observed the highest proportions of use in people diagnosed with pancreas, liver, or lung cancers. Opioid use was associated with female sex, younger age, more advanced degree of cancer spread, opioid use before cancer diagnosis, and multimorbidity. Forty-four percentages of all people dispensed opioids had a history of opioid use in the 12 months before their cancer diagnosis; these people had higher median number of different opioids and opioid dispensings, and a shorter time to first opioid dispensing than opioid-naive people.

CONCLUSION

Our study suggests that many older cancer patients were dispensed opioids before their cancer diagnosis. Previously opioid-treated people had more intense opioid use patterns after diagnosis than opioid-naïve people. Acknowledging the history of opioid use is important as it may complicate pain treatment in clinical practice.

Pain, fatigue, anxiety and depression in older home-dwelling people with cancer

Aim

Globally, cancer incidence counts for more than 14 million cases and the number increases with age. The aim of this study was to investigate the occurrence of pain, fatigue, anxiety and depression in association with demographic and clinical factors.

Design

A cross-sectional descriptive design was used.

Methods

We performed descriptive statistics to analyse the questionnaires completed from 174 older home-dwelling people with cancer.

Results

The people with cancer reported low occurrence of pain, fatigue, anxiety and depression. We found strong correlation between anxiety and depression. Women reported significantly higher scores of anxiety and depression than men. A higher pain score was associated with higher scores of fatigue and anxiety.

Conclusions

Home care personnel meeting older home-dwelling people with cancer should emphasize these people' mental health problems and be aware that pain, fatigue and anxiety may occur at the same time.

Opioid use and misuse: health impact, prevalence, correlates and interventions

Objective: To provide a broad overview of the state of drug misuse research, particularly focusing on opioid drug use in the U.S.A. Design: An overview of published reviews of the literature. Results: Prescription opioid use has increased globally from 2008 to 2013, while use of opiates such as heroin and opium have remained stable in many countries, although, decreases have been observed in parts of Europe. Opioid misuse is highest in the United States; approximately 11.8 million Americans misused opioids in 2016. Demographic, genetic, psychosocial and structural/environmental factors all play a role in determining who will become an opioid misuser. Strategies such as increased prescribing of non-opioid derived pain relievers, expansion of medication treatment, distribution of naloxone for overdose reversal and supervised consumption sites are some of the solutions posed to reduce the spread and consequences of opioid misuse. Conclusion: Research focused on understanding of opioid neurobiology, as well as empirically based, effective alternatives to pain management and implementation studies on combined prevention and treatment approaches are needed. It will take the combined effort of community members, healthcare professionals, policymakers and researchers in order to prevent and treat opioid misuse.

Deleterious Effects of Higher Body Mass Index on Subjective and Objective Measures of Chemotherapy-Induced Peripheral Neuropathy in Cancer Survivors

CONTEXT

Recent, albeit, limited evidence suggests that body mass index (BMI) may be a modifiable risk factor to reduce the deleterious effects of chemotherapy-induced peripheral neuropathy (CIPN) in cancer survivors.

OBJECTIVES

To evaluate for differences in demographic, clinical, pain, sensation, and balance characteristics among three BMI groups. We hypothesized that as BMI increased, survivors would report higher pain intensity scores and have significant decrements in measures of sensation and balance.

METHODS

A total of 416 survivors with CIPN were evaluated using subjective and objective measures of CIPN. Survivors were divided into three BMI groups (i.e., normal weight, overweight, and obese). Differences among the BMI groups were evaluated using parametric and nonparametric statistics.

RESULTS

Of the 416 survivors, 45.4% were normal weight, 32.5% were overweight, and 22.1% were obese. Compared with the normal-weight group, survivors in the other two groups had lower functional status scores, a higher comorbidity burden, higher pain intensity scores, and higher interference scores. In addition, compared with the normal-weight group, survivors in the other two BMI groups had significantly worse balance scores.

CONCLUSION

Our findings support the hypothesis that as BMI increased, pain sensation and balance characteristics worsened. Our findings suggest that nutritional counseling as well as exercise and weight management programs in survivors with CIPN may improve these clinically important problems.

Age-related differences in patient-reported and objective measures of chemotherapy-induced peripheral neuropathy among cancer survivors

PURPOSE

While older adults with cancer are more likely to develop chemotherapy-induced peripheral neuropathy (CIPN), the study aimed to determine if patient-reported and objective measures of CIPN differ by age among cancer survivors.

METHODS

Cancer survivors with persistent CIPN after completion of platinum and/or taxane chemotherapy completed CIPN questionnaires (severity, interference with activities, sensory, and motor symptoms) and objective testing (light touch, vibration, pain, cold sensation). CIPN measures were compared by age group (< 65 n = 260 versus ≥ 65 n = 165) using parametric and nonparametric tests.

RESULTS

Among 425 cancer survivors with CIPN, mean age was 60.9 (SD 10.5). CIPN location did not differ by age (overall 68% hands and feet, 27% only feet, 5% only hands). For patient-reported measures, older survivors reported less severe pain in the hands and feet than younger survivors. In addition, older survivors reported lower interference with general activity, routine activities, normal work, enjoyment of life, sleep, mood, relations with other people, and sexual activity. No age differences in sensory and motor symptom scores were found. In contrast, for objective measures, older survivors had worse light touch and cold sensations in their feet and worse vibration detection in their hands and feet.

CONCLUSIONS

Despite having worse light touch, cold, and vibration sensations, older cancer survivors with CIPN reported less severe pain and interference with activities. This discordance highlights the importance of including both patient-reported and objective measures to assess CIPN in cancer survivors to better evaluate this clinical condition.

Co-Occurring Symptoms Contribute to Persistent Fatigue in Prostate Cancer

PURPOSE

Cancer-related fatigue is one of the most debilitating side effects of cancer and cancer therapy. We aimed to investigate co-occurring symptoms associated with persistent fatigue in men receiving external beam radiation therapy (EBRT) for nonmetastatic prostate cancer.

METHODS

A sample of 47 men with prostate cancer scheduled to receive radiotherapy (RT) were followed at baseline and 1 year after RT. Clinical and demographic data were obtained from chart review. Symptom measurements included urinary dysfunction (American Urological Association symptoms score), fatigue (Functional Assessment of Cancer Therapy - Fatigue questionnaire), sleep disturbance (Patient-Reported Outcomes Measurement Information System - Sleep Disturbance form), pain (physical well-being domain pain item of the Functional Assessment of Cancer Therapy - General), and depressive symptoms (Hamilton Depression Rating Scale). Paired t tests, correlations, general linear models, and logistic regressions were used to determine associations between fatigue and other symptom scores.

RESULTS

At 1 year after RT, 34% of subjects continued to experience fatigue. Urinary dysfunction was the best clinical predictor of persistent fatigue. Pain and depressive symptoms further improved the predictive power of the model. A multivariate linear regression model containing all these three clinical variables (urinary dysfunction, pain, and depressive symptoms) explained 74% of total variance associated with persistent fatigue after RT.

CONCLUSIONS

Persistent fatigue at 1 year after EBRT in prostate cancer survivors is likely related to a cluster of symptoms elicited by chronic inflammation. Therapies that target each of these symptoms will likely reduce fatigue in this patient population.

Pain in patients with newly diagnosed or relapsed acute leukemia

PURPOSE

Acute leukemia (AL) is associated with substantial morbidity and mortality. We assessed the prevalence and correlates of pain in patients with newly diagnosed or relapsed AL.

METHODS

Patients with newly diagnosed or relapsed AL admitted to a comprehensive cancer center completed the Memorial Symptom Assessment Scale (MSAS), which assesses prevalence, severity, and distress associated with pain and other symptoms. Factors associated with severe pain were assessed using logistic regression. Two raters completed chart reviews in duplicate for patients with severe pain (MSAS severity ≥ 3/4) to determine the site of pain.

RESULTS

Three hundred eighteen patients were recruited from January 2008 to October 2013: 245 (77.0%) had acute myeloid or acute promyelocytic leukemia (AML/APL) and 73 (23.0%) had acute lymphoblastic leukemia (ALL); 289 (90.9%) were newly diagnosed and 29 (9.1%) had relapsed disease. Pain was reported in 156/318 (49.2%), of whom 55/156 (35.3%) reported severe pain (≥ 3/4). Pain was associated with all psychological symptoms (all p < 0.005) and some physical symptoms. Severe pain was associated with younger age (p = 0.02), worse performance status (p = 0.04), ALL diagnosis (p = 0.04), and time from onset of chemotherapy (p = 0.03), with pain peaking at 4 weeks after chemotherapy initiation. The most common sites of severe pain were oropharynx (22; 40%), head (12; 21.8%), and abdomen (11; 20%). Only 3 patients (0.9%) were referred to the symptom control/palliative care team during the month prior to or following assessment.

CONCLUSIONS

Pain is frequent, distressing, and predictable in patients undergoing induction chemotherapy for AL. Further research is needed to assess the efficacy of early supportive care in this population.

Satisfaction with pain management and impact of pain on quality of life in cancer patients

AIM

To evaluate the prevalence of pain in cancer outpatients in Taiwan and to investigate the impact of pain on quality of life (QoL) and patient satisfaction. Results were compared to those of a similarly designed study conducted in 2008 to identify trends.

METHODS

Adult patients with cancer treated as outpatients in hospitals throughout Taiwan were recruited. Pain intensity and the extent to which pain interfered with QoL were self-reported using a modified version of the Brief Pain Inventory. Patients also indicated their level of satisfaction with their physician, as well as with their pain control.

RESULTS

A total of 2652 patients were enrolled from 16 sites. Of these, 1167 (44.0%) patients reported experiencing pain during the previous week. Prevalence and severity of pain were highest in patients with progressive disease. A higher pain severity score was significantly associated with greater interference in both physical and psychological functions. Overall, 86.0% of all participants expressed satisfaction with their physician and 84.8% were satisfied with their pain control; satisfaction rates were associated with pain severity. Compared with the findings from the 2008 study, pain prevalence was notably lower and patient satisfaction was significantly greater in the current study.

CONCLUSIONS

Prevalence and severity of pain were associated with disease stage. Pain interference on QoL correlated significantly with pain severity. Treatment of pain in cancer patients in Taiwan seems to have improved from 2008 to 2014, possibly attributable to new cancer pain treatment guidelines and the wider availability of novel analgesic therapies.

Older Age, Early Symptoms and Physical Function are Associated with the Severity of Late Symptom Clusters for Men Undergoing Radiotherapy for Prostate Cancer

AIMS

To identify symptom clusters and predisposing factors associated with long-term symptoms and health-related quality of life after radiotherapy in men with prostate cancer.

MATERIALS AND METHODS

Patient-reported outcomes (PROs) data from the Medical Research Council RT01 radiotherapy with neoadjuvant androgen deprivation therapy trial of 843 patients were used. PROs were collected over 5 years with the University of California, Los Angeles Prostate Cancer Index (UCLA-PCI) and the 36 item Short-Form Health Survey (SF-36). Symptom clusters were explored using hierarchical cluster analysis. The association of treatment dose, baseline patient characteristics and early symptom clusters with the change in severity of PROs over 3 years was investigated with multivariate linear mixed effects models.

RESULTS

Seven symptom clusters of three or more symptoms were identified. The clusters were stable over time. The longitudinal profiles of symptom clusters showed the onset of acute symptoms during treatment for all symptom clusters and significant recovery by 6 months. Some clusters, such as physical health and sexual function, were adversely affected more than others by androgen deprivation therapy, and were less likely to return to pretreatment levels over time. Older age was significantly associated with decreased long-term physical function, physical health and sexual function (P < 0.001). Both baseline and acute symptom clusters were significant antecedents for impaired function and health-related quality of life at 3 years.

CONCLUSIONS

Men with poorer physical function and health before or during treatment were more likely to report poorer PROs at year 3. Early assessment using PROs and lifestyle interventions should be used to identify those with higher needs and provide targeted rehabilitation and symptom management.

Challenges and concerns of persistent opioid use in cancer patients

INTRODUCTION

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

Patient-Reported Outcomes and Opioid Use by Outpatient Cancer Patients

The Memorial Sloan Kettering Pain Registry contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,534 chronic pain cancer patients who were seen at outpatient pain service clinics. Average pain intensity (Brief Pain Inventory) was reported as mild by 24.6% of patients, moderate by 41.5%, and severe by 33.9%. The patient's report of average percent pain relief and health state (EuroQOL 5 dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Eighty-six percent of patients received an opioid at 1 or more clinic encounters. Regression analysis revealed that male sex or being younger (65 years of age or younger) was associated with a greater likelihood of an opioid ordered. Male sex nearly doubled the likelihood of a higher dose being ordered than female sex. Bivariate analysis found that patients receiving opioids reported significantly more pain relief than no-opioid patients. However, patients receiving opioids had higher pain interference scores, lower index of health state, and more physical distress than no-opioid patients Our results identify the need to consider opioid use and dosage when attempting to understand patient-reported outcomes (PROs) and factors affecting pain management.

PERSPECTIVE

This report describes the results of the analyses of PROs and patient-related electronic health record data collected under standard of care from cancer patients at outpatient pain management clinics of Anesthesiology and Palliative Care at the Memorial Sloan Kettering Cancer Center. Consideration of sex and age as predictors of opioid use is critical in attempting to understand PROs and their relationship to pain management.

Chemotherapy-Induced Neuropathy in Cancer Survivors

CONTEXT

Evidence suggests that chemotherapy-induced neuropathy (CIN) is a significant problem for cancer survivors. However, a detailed phenotypic characterization of CIN in cancer survivors is not available.

OBJECTIVES

To evaluate between-group differences in demographic and clinical characteristics, as well as in measures of sensation, function, and postural control, in a sample of cancer survivors who received a platinum and/or a taxane-based CTX regimen and did (n = 426) and did not (n = 197) develop CIN.

METHODS

Survivors completed self-report questionnaires and underwent objective testing (i.e., light touch, pain sensation, cold sensation, vibration, muscle strength, grip strength, Purdue Pegboard test, Timed Get Up and Go test, Fullerton Advanced Balance test). Parametric and nonparametric statistics were used to compare between-group differences in study outcomes.

RESULTS

Of the 426 survivors with CIN, 4.9% had CIN only in their upper extremities, 27.0% only in their lower extremities, and 68.1% in both their upper and lower extremities. Demographic and clinical characteristics associated with CIN included the following: older age, lower annual income, higher body mass index, a higher level of comorbidity, being born prematurely, receipt of a higher cumulative dose of chemotherapy, and a poorer functional status. Survivors with CIN had worse outcomes for all of the following objective measures: light touch, pain, temperature, vibration, upper and lower extremity function, and balance.

CONCLUSIONS

This study is the first to provide a detailed phenotypic characterization of CIN in cancer survivors who received a platinum and/or a taxane compound. These data can serve as a benchmark for future studies of CIN in cancer survivors.

Predictors of the multidimensional symptom experience of lung cancer patients receiving chemotherapy

PURPOSE

Few studies have examined interindividual variability in the symptom experience of lung cancer patients. We aimed to identify the most prevalent, severe, and distressing symptoms, and risk factors associated with increased symptom burden.

METHODS

Lung cancer patients (n = 145) reported occurrence, severity, and distress for 38 symptoms on the Memorial Symptom Assessment Scale 1 week after chemotherapy. Using multidimensional subscales, risk factors for higher global distress, physical, and psychological symptoms were evaluated using simultaneous linear regression.

RESULTS

Mean age was 64.0 years and 56.6% were female. Mean Karnofsky Performance Status score was 79.1 (SD 14.6) and mean Self-Administered Comorbidity Questionnaire score was 7.3 (SD 3.9). The most distressing and prevalent symptom was fatigue. Problems with sexual interest/activity had the highest mean severity rating. Patients with lower functional status (p = 0.001) and higher comorbidity (p = 0.02) reported higher global distress. Similarly, lower functional status (p = 0.003) and higher comorbidity (p = 0.04) were associated with a higher physical symptom burden along with lower body mass index (p = 0.02). Higher psychology symptom burden was associated with lower functional status (p = 0.01), younger age (p = 0.02), non-metastatic disease (p = 0.03), higher number of prior treatments (p = 0.04), and income (p = 0.03).

CONCLUSIONS

Fatigue was the most distressing and prevalent symptom among lung cancer patients receiving chemotherapy. Lower functional status was associated with a higher burden of global distress, physical, and psychological symptoms. Younger age and non-metastatic disease were additional risk factors for increased psychological symptoms. Together, these risk factors can help clinicians identify lung cancer patients at increased need for aggressive symptom management.

Anti-nerve growth factor therapy increases spontaneous day/night activity in mice with orthopedic surgery-induced pain

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are 2 of the most common and successful surgical interventions to relieve osteoarthritis pain. Control of postoperative pain is critical for patients to fully participate in the required physical therapy which is the most influential factor in effective postoperative knee rehabilitation. Currently, opiates are a mainstay for managing postoperative orthopedic surgery pain including TKA or THA pain. Recently, issues including efficacy, dependence, overdose, and death from opiates have made clinicians and researchers more critical of use of opioids for treating nonmalignant skeletal pain. In the present report, a nonopiate therapy using a monoclonal antibody raised against nerve growth factor (anti-NGF) was assessed for its ability to increase the spontaneous activity of the operated knee joint in a mouse model of orthopedic surgery pain-induced by drilling and coring the trochlear groove of the mouse femur. Horizontal activity and velocity and vertical rearing were continually assessed over a 20 hours day/night period using automated activity boxes in an effort to reduce observer bias and capture night activity when the mice are most active. At days 1 and 3, after orthopedic surgery, there was a marked reduction in spontaneous activity and vertical rearing; anti-NGF significantly attenuated this decline. The present data suggest that anti-NGF improves limb use in a rodent model of joint/orthopedic surgery and as such anti-NGF may be useful in controlling pain after orthopedic surgeries such as TKA or THA.