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Wong AK, Klepstad P, Somogyi AA, Vogrin S, Rubio J, Le B, Philip J. Influence of COMT (rs4680) and OPRM1 (rs1799971) on Cancer Pain, Opioid Dose, and Adverse Effects. J Palliat Med 2024. [PMID: 39253879 DOI: 10.1089/jpm.2024.0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
Background: The influence of pharmacogenomics on opioid response, particularly with COMT (rs4680) and OPRM1 (rs1799971) variants, has been studied individually and in combination. However, most studies are in a noncancer context and not all their possible variant combinations have been examined. Objectives: This study examined COMT (rs4680) and OPRM1 (rs1799971), and their allele combinations, in advanced cancer to examine associations with pain scores, opioid dose, and adverse effects. Setting/Subjects: This multicenter prospective cohort study recruited patients receiving opioids for advanced cancer pain in Melbourne, Australia. Clinical data (demographics, opioids), validated instruments (pain and adverse effects), and blood (DNA) were collected. Descriptive analyses were used. Univariate and multivariate logistic regression analyses were used to evaluate associations between clinical outcomes (opioid dose, pain, adverse effects) and genotypes of interest. Results: Fifty-four participants were recruited to the study. Those with COMT A allele required lower opioid doses [130 mg (interquartile range [IQR] 67.5,230) versus 180 mg (IQR 55,322.5), p = 0.047] and experienced greater adverse effects [sickness response aOR (adjusted odds ratio) 7.1 (95% CI 1.51,33.41), p = 0.01]. Those with the COMT GG/OPRM1 G allele combination required higher opioid doses [322.5 mg (IQR 264,360) versus 125 mg (65,225), (p = 0.04)]. Those with COMT AG/OPRM1 AA experienced higher average pain [aOR 1.55 (95% CI 1.03, 2.33), p = 0.04] and moderate-severe nausea [aOR 5.47 (95% CI 1.35, 22.21), p = 0.02] but reduced drowsiness [aOR 0.25 (95% CI 0.06, 1.02), p = 0.05]. Conclusions: Patients with cancer with the COMT alternate (A) allele have greater sickness response adverse effects, which may be responsible for the lower opioid doses observed. Significant results of two new COMT/OPRM1 genotype combinations are presented that have not previously been studied, with plausible phenotype descriptions suggested.
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Affiliation(s)
- Aaron K Wong
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Pal Klepstad
- Department Intensive Care Medicine, St. Olavs University Hospital, Trondheim, Norway
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital Melbourne, University of Melbourne, Melbourne, Australia
| | - Justin Rubio
- Florey Institute of Neuroscience & Mental Health, Victoria, Australia
| | - Brian Le
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, Parkville, Australia
| | - Jennifer Philip
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
- St Vincent's Hospital, Palliative Care Service, Fitzroy, Australia
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Bimonte S, Di Gennaro P, Crispo A, Coluccia S, Luongo A, Amore A, Celentano E, Del Prato F, Schiavo D, Nocerino D, Cascella M, Cuomo A. Assessing Gender Differences for Non-Predictable Breakthrough Cancer Pain Phenomenon: A Secondary Analysis from IOPS-MS Study. J Pain Res 2024; 17:2861-2871. [PMID: 39253738 PMCID: PMC11382666 DOI: 10.2147/jpr.s445222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 05/09/2024] [Indexed: 09/11/2024] Open
Abstract
Purpose Breakthrough cancer pain (BTcP) is a temporary exacerbation of pain that "breaks through" a phase of adequate pain control by an opioid-based therapy. The non-predictable BTcP (NP-BTcP) subtype occurs in the absence of any specific activity. Evidence showed that gender differences exist in pain response sensitivity and clinical pain risk. This analysis aimed to signify the gender differences for the NP-BTcP phenomenon. Patients and Methods This is a secondary analysis of the Italian Oncologic Pain multiSetting-Multicentric Survey (IOPS-MS), the largest study on BTcP. The subset of NP-BTcP cases for non-gender-specific cancer was considered. Univariable and multivariate analyses were conducted to identify gender differences for the NP-BTcP profile about its intensity, number of episodes per day, and type. A metastatic status-stratified analysis was performed to compare gender with the main clinical variables among the population with NP-BTcP. Results Males exhibited a higher occurrence of BTcP in the thorax region compared to females (15% vs 11%, respectively, p = 0.03). Males also had a higher onset of BTcP, a higher BTcP therapy dosage (33% vs 28%, p = 0.04, mean: 201 vs 186, p = 0.02) and a lower Karnofsky score (mean: 46.9 vs 49.2, p = 0.03) compared to females. Similar gender differences were found for metastatic patients in the BTcP site (14% vs 8.5%, respectively; p = 0.01), peak onset (33% vs 27%, p = 0.02), BTcP therapy dosage (199 vs 185, p=0.04), and Karnofsky score (mean 47.5 vs 50.4, p = 0.009). Phenotype 2 was more characterized by non-metastatic males (41% vs 23%, p = 0.020) while non-metastatic females presence was predominant among others. Conclusion In this study, gender differences according to site, onset and dosage of BTcP were found. The phenotype characterization of BTcP needs to be further investigated for a possible useful function in the management of cancer-related pain in non-metastatic patients.
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Affiliation(s)
- Sabrina Bimonte
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Piergiacomo Di Gennaro
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Anna Crispo
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Sergio Coluccia
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Assunta Luongo
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Alfonso Amore
- Melanoma and Sarcoma Surgery Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
- PhD School of Applied Medical-Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Egidio Celentano
- Epidemiology and Biostatistics Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Francesco Del Prato
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Daniela Schiavo
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Davide Nocerino
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
| | - Marco Cascella
- Department of Medicine, University of Salerno, Salerno, Italy
| | - Arturo Cuomo
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, Italy
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Chiang YH, Lien CT, Su WH, Yen TY, Chen YJ, Lai YL, Lim KH, Dai KY, Chung HP, Hung CY, Leu YS. Effectiveness of fentanyl buccal soluble film in cancer patients with inadequate breakthrough pain control. BMC Palliat Care 2024; 23:150. [PMID: 38877477 PMCID: PMC11177451 DOI: 10.1186/s12904-024-01483-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 06/06/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Clinical evidence for the rapidity and effectiveness of fentanyl buccal soluble film (FBSF) in reducing pain intensity of breakthrough cancer pain (BTcP) remains inadequate. This study aimed to evaluate the efficacy of FBSF proportional to the around-the-clock (ATC) opioid regimens in rapidly relieving the intensity of BTcP episodes by determining the percentage of patients requiring further dose titration. METHODS The study procedure included a dose-finding period followed by a 14-day observation period. Pain intensity was recorded with a Numeric Rating Scale (NRS) at onset and 5, 10, 15, and 30 min after FBSF self-administration. Meaningful pain relief was defined as the final NRS score ≤ 3. Satisfaction survey was conducted for each patient after treatment using the Global Satisfaction Scale. RESULTS A total of 63 BTcP episodes occurred in 30 cancer patients. Only one patient required rescue medication at first BTcP episode and then achieved meaningful pain relief after titrating FBSF by 200 µg. Most BTcP episodes relieved within 10 min. Of 63 BTcP episodes, 30 (47.6%), 46 (73.0%), and 53 (84.1%) relieved within 5, 10, and 15 min after FBSF administration. Only grade 1/2 adverse events were reported, including somnolence, malaise, and dizziness. Of the 63 BTcP episodes, 82.6% were rated as excellent/good satisfaction with FBSF. CONCLUSION FBSF can be administrated "on demand" by cancer patients at the onset of BTcP, providing rapid analgesia by achieving meaningful pain relief within 10 min. TRIAL REGISTRATION This study was retrospectively registered 24 December, 2021 at Clinicaltrial.gov (NCT05209906): https://clinicaltrials.gov/study/NCT05209906 .
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Affiliation(s)
- Yi-Hao Chiang
- Division of Hematology and Oncology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Laboratory of Good Clinical Research Center, Department of Medical Research, MacKay Memorial Hospital, New Taipei City, Taiwan
| | - Ching-Ting Lien
- Department of Nursing, MacKay Memorial Hospital, Taipei, Taiwan
| | - Wen-Hao Su
- Hospice and Palliative Care Center, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Tsung-Yu Yen
- Hospice and Palliative Care Center, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Death Care Service, Nursing and Management, MacKay Junior College of Medicine, Taipei, Taiwan
| | - Yu-Jen Chen
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yuen-Liang Lai
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Hospice and Palliative Care Center, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ken-Hong Lim
- Division of Hematology and Oncology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Laboratory of Good Clinical Research Center, Department of Medical Research, MacKay Memorial Hospital, New Taipei City, Taiwan
| | - Kun-Yao Dai
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
- Department of Radiation Oncology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Hsin-Pei Chung
- Chest Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chia-Yen Hung
- Division of Hematology and Oncology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yi-Shing Leu
- Department of Otolaryngology-Head Neck Surgery, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamsui District, New Taipei City, 25160, Taiwan.
- Cancer Center, MacKay Memorial Hospital, Taipei, Taiwan.
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Al Eleiwah AA, Abdalrahim MS, Rayan A, ALBashtawy M, Hani SB, ALBashtawy S. Barriers to Pain Management as Perceived by Cancer and Noncancer Patients With Chronic Disease. Pain Manag Nurs 2024; 25:294-299. [PMID: 38453586 DOI: 10.1016/j.pmn.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/21/2024] [Accepted: 02/11/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Pain is the most common symptom experienced by both cancer and non-cancer patients. A wide variety of barriers may hinder the optimal treatment of cancer and noncancer pain that are related to the health care system, health care providers, and patients. PURPOSE To explore the barriers to pain management as perceived by patients with cancer and noncancer chronic diseases. METHOD A descriptive, cross-sectional correlational design was employed to recruit a sample of 200 patients (n = 100 patients with cancer, n= 100 patients with noncancer) from two hospitals in Jordan. Patients filled out an Arabic version of Barriers Questionnaire II (ABQ-II). RESULTS Harmful effects of medications were the greatest barrier to effective pain management, while fatalism had the lowest mean scores. Age was negatively correlated with physiological effects (r = -0.287, p < .01), communication (r = -0.263, p < .01), harmful effects (r = -0.284, p < .01), and the overall barrier score (r = -0.326, p < .01) among noncancer patients with chronic disease and (p > .05) for patients with cancer. Patients with cancer had higher mean scores (M = 2.12, SD = 0.78) in the fatalism subscale than those with noncancer chronic disease (M = 1.91, SD = 0.68), while patients with noncancer chronic disease had significantly higher mean scores (M = 2.78, SD = 0.78) in the communication subscale than patients with cancer (M = 2.49, SD = 0.65), (t = -2.899, p = .005). CONCLUSION To improve the quality of care for patients who are in pain, it is recommended to address pain management barriers as they arise.
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Affiliation(s)
| | | | - Ahmad Rayan
- Faculty of Nursing, Zarqa University, Zarqa, Jordan
| | - Mohammed ALBashtawy
- Department of Community and Mental Health, Princess Salma Faculty of Nursing, Al al-Bayt University, Mafraq, Jordan
| | - Salam Bani Hani
- Nursing Department, Faculty of Nursing, Irbid National University, Irbid, Jordan.
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Mercadante S, Bruera E. Different Colors for Breakthrough ESAS Items. J Pain Symptom Manage 2024; 67:e923-e925. [PMID: 38447623 DOI: 10.1016/j.jpainsymman.2024.02.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Sebastiano Mercadante
- Supportive care and Rehabilitation, MD Anderson, Houston, TX, USA; Pain relief and supportive/palliative care, La Maddalena Cancer center, Palermo, Italy.
| | - Eduardo Bruera
- Supportive care and Rehabilitation, MD Anderson, Houston, TX, USA
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6
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Bäckryd E. Should cancer pain still be considered a separate category alongside acute pain and chronic non-cancer pain? Reflections on ICD-11. FRONTIERS IN PAIN RESEARCH 2024; 5:1397413. [PMID: 38756912 PMCID: PMC11096455 DOI: 10.3389/fpain.2024.1397413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/24/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Traditionally, cancer pain has often been viewed as an independent third major category in pain medicine alongside acute pain and chronic non-cancer pain. However, the new chronic pain category MG30 in the eleventh version of International Classification of Diseases (ICD-11) includes cancer-related pain as one of its seven subgroups. In light of this, the aim of the paper is to investigate whether the traditional trichotomy should be replaced by a dichotomy between acute pain and chronic pain, cancer-related pain being part of both groups depending on the duration of pain. Methods The rationale for viewing cancer pain as a separate category is reviewed. Results Cancer being a deadly disease, cancer pain has a life-and-death and existential dimension that is different from non-cancer pain. It seems sensible to believe that this is an additional dimension to the suffering caused by cancer pain, and that clinicians should therefore take this existential dimension into consideration when assessing pain. Conclusion Without challenging the place of chronic cancer-related pain under the MG30 heading, it is concluded that while using ICD-11 in the future, pain clinicians should continue being mindful of the fact that the reality of death shapes the experience of cancer pain. The traditional trichotomy is therefore still valid and mirrors the fact that human beings are vulnerable (acute pain), temporal (chronic pain) and mortal (cancer pain).
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Affiliation(s)
- Emmanuel Bäckryd
- Pain and Rehabilitation Center, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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7
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Dawson E, Greenfield K, Carter B, Bailey S, Anderson AK, Rajapakse D, Renton K, Mott C, Hain R, Harrop E, Johnson M, Liossi C. Definition and Assessment of Paediatric Breakthrough Pain: A Qualitative Interview Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:485. [PMID: 38671702 PMCID: PMC11049523 DOI: 10.3390/children11040485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024]
Abstract
Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals' insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: 'the elusive nature of breakthrough pain', 'breakthrough pain assessment', 'positive attitudes towards', 'reservations towards' and 'features to include in' a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept.
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Affiliation(s)
- Eleanor Dawson
- School of Psychology, University of Southampton, Highfield SO17 1BJ, UK (K.G.)
| | - Katie Greenfield
- School of Psychology, University of Southampton, Highfield SO17 1BJ, UK (K.G.)
| | - Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, St Helens Road, Ormskirk L39 4QP, UK;
| | - Simon Bailey
- Department of Children’s Oncology, Great North Children’s Hospital, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
| | | | - Dilini Rajapakse
- The Louis Dundas Centre, Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
| | - Kate Renton
- University Hospital Southampton NHS Trust, Tremona Road, Southampton SO16 6YD, UK
- Naomi House & Jacksplace, Stockbridge Road, Sutton Scotney, Winchester SO21 3JE, UK
| | - Christine Mott
- Acorns Children’s Hospice, 103 Oak Tree Lane, Selly Oak, Birmingham B29 6HZ, UK
- Birmingham Children’s Hospital, Birmingham, Steelhouse Lane, Birmingham B4 6NH, UK
| | - Richard Hain
- Department of Child Health, Swansea University, Swansea SA2 8PP, UK;
| | - Emily Harrop
- Helen & Douglas House Hospices, 14A Magdalen Road, Oxford OX4 1RW, UK;
- Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
| | | | - Christina Liossi
- School of Psychology, University of Southampton, Highfield SO17 1BJ, UK (K.G.)
- Psychological Medicine, Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK
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8
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Mercadante S. An overview of the current drug treatment strategies for moderate to severe, chronic malignant tumor-related pain. Expert Opin Pharmacother 2024; 25:171-179. [PMID: 37016731 DOI: 10.1080/14656566.2023.2200137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/04/2023] [Indexed: 04/06/2023]
Abstract
INTRODUCTION The pharmacological management of cancer pain is a complex issue that requires knowledge and experience in the use of analgesics. The aim of this expert review is to provide a panorama of the pharmacological strategies in cancer pain management. AREAS COVERED Opioid dose titration is a delicate process regarding the start of opioid treatment in different clinical conditions. How to improve the opioid response is a fundamental step, which includes different strategies when an initial treatment with opioids fails. The use of adjuvants is another relevant issue that should be considered in some specific circumstances to optimize the management of cancer pain management. Some clinical conditions, such as neuropathic pain and breakthrough pain, deserve a special attention. Relevant literature was selected to provide an overview of cancer pain management strategies. EXPERT OPINION Opioid therapy still remains the cornerstone of pharmacological management of cancer pain. Opioids should be used according to the level of tolerance, also personalizing the treatment (route, drug, and dosing). Adjuvant drugs may help in specific conditions, although their use should be balanced with the adverse effects. Breakthrough pain requires expertise in tailoring a treatment according to patient's profile and characteristics of episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main regional center of pain relief and supportive/palliative care, La Maddalena Cancer Center, Palermo, Italy
- Home palliative care program, Regional Home care program, SAMOT, Palermo, Italy
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Zhao Q, Qiu X, Liu W, Nian Z, Chen T, Chen J, Xie R, Yang L. Application of a WeChat Mini Program to provide pharmaceutical care for cancer pain patients: A randomized controlled trial. Digit Health 2024; 10:20552076241255654. [PMID: 38766359 PMCID: PMC11100405 DOI: 10.1177/20552076241255654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/29/2024] [Indexed: 05/22/2024] Open
Abstract
Objective This study aimed to develop an individual WeChat Mini Program to provide pharmaceutical care to better manage cancer pain patients and to evaluate its feasibility and the differences in analgesic efficacy, medication adherence and safety versus conventional pharmacy interventions. Methods In this parallel randomized clinical trial, 42 cancer pain patients were equally allocated into the experimental group and the control group. The experimental group received individualized pharmaceutical care based on the "Yao Nin You Wo" WeChat Mini Program, while the control group received conventional care during the 4-week period. Main outcomes contained pain scores, medication adherence, incidences and relief rates of breakthrough pain, and incidences of adverse events. Relief rates of pain were also calculated according to pain scores. Results At the beginning of intervention, none of the pain scores and medication adherence showed relevant differences between the two groups (all P > .05). After intervention, the experimental group had significantly lower pain scores compared to the control group (P = .003). Breakthrough pain of both groups was alleviate; not only the incidence of breakthrough pain considerably was lower at 4 weeks than at baseline, but the relief rate of breakthrough in the experimental group was higher than that in the control group. Compared with the control group, the medication adherence rate of the experimental group was significantly improved (P = .02). Types of adverse events that happened in experimental and groups were similar, but the total incidence of adverse events in the experimental group was lower than that in the control group. Conclusions WeChat Mini Program is a useful and facilitative tool with the potential to improve cancer pain self-management ability in discharged patients. In addition, pharmacists could play a key role through the Mini Program to connect with patients successfully by providing personalized pharmaceutical services.
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Affiliation(s)
- Qiuling Zhao
- Department of pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Xiuliang Qiu
- Department of pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Wenbin Liu
- Department of pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Zilin Nian
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Ting Chen
- Department of pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Juan Chen
- Department of pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Ruixiang Xie
- Department of pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
| | - Lin Yang
- Department of pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, Fujian, China
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10
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Cuomo A. Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits. Drugs Context 2023; 12:2023-10-2. [PMID: 38148830 PMCID: PMC10751104 DOI: 10.7573/dic.2023-10-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/14/2023] [Indexed: 12/28/2023] Open
Abstract
Cancer pain is an important challenge in treatment and requires a rapid onset of action for its control. In particular, breakthrough cancer pain (BTcP) should be adequately controlled with a stable dose of a short-acting oral opioid. Fentanyl is a synthetic, highly selective opioid with many advantageous chemical properties, including high lipophilicity and distinct pharmacokinetic properties. It is recommended for pain management in a variety of settings, including acute pain, chronic pain and BTcP. To date, its variously designed formulations allow non-invasive administration; amongst others, sublingual fentanyl has proven useful in the management of BTcP and in improving the quality of life of patients with cancer. This review provides an update on the management of BTcP with fentanyl, with consideration of safety, as it remains an important tool in the treatment of cancer pain.
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Affiliation(s)
- Arturo Cuomo
- Istituto Nazionale dei Tumori, IRCCS Fondazione G. Pascale, Naples,
Italy
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11
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Løhre ET, Jakobsen G, Solheim TS, Klepstad P, Thronæs M. Breakthrough and Episodic Cancer Pain from a Palliative Care Perspective. Curr Oncol 2023; 30:10249-10259. [PMID: 38132380 PMCID: PMC10742182 DOI: 10.3390/curroncol30120746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/23/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023] Open
Abstract
Cancer pain intensity (PI) fluctuates, but the relationship between pain flares and background pain with respect to pain management is not settled. We studied how flare and background PIs corresponded with treatment results for background cancer pain. Patients admitted to an acute palliative care unit with average and/or worst PI ≥ 1 on the 11-point numeric rating scale were included. Average and worst PI at admission and average PI at discharge were collected. We examined how the difference and ratio between worst and average PI and average PI at admission, were associated with average PI development during hospitalization. Positive differences between worst and average PI at admission were defined as pain flares. Ninety out of 131 patients had pain flares. The reduction in average PI for patients with flares was 0.9 and for those without, 1.9 (p = 0.02). Patients with large worst minus average PI differences reported the least improvement, as did those with large worst/average PI ratios. Patients with pain flares and average PI ≤ 4 at admission had unchanged average PI during hospitalization, while those with pain flares and average PI > 4 experienced pain reduction (2.1, p < 0.001). Large pain flares, in absolute values and compared to background PI, were associated with inferior pain relief.
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Affiliation(s)
- Erik Torbjørn Løhre
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
| | - Gunnhild Jakobsen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Tora Skeidsvoll Solheim
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Morten Thronæs
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
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12
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Crawford GB, Lakhani A, Palmer L, Sebalj M, Rolan P. A systematic review of qualitative research exploring patient and health professional perspectives of breakthrough cancer pain. Support Care Cancer 2023; 31:619. [PMID: 37812248 PMCID: PMC10562491 DOI: 10.1007/s00520-023-08076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Breakthrough cancer pain (BtCP) is a prevalent health issue which is difficult to manage. A plethora of quantitative research in this area exists. There is a paucity of research on the perspectives of health professionals and patients surrounding domains impacting effective treatment, including definitions of BtCP, treatment, and education opportunities. This review aims to identify and synthesize the extent of qualitative research exploring health professional and patient perspectives of BtCP. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach was undertaken. The approach was registered with Prospero. MEDLINE, EMBASE, and Web of Science were searched for peer-reviewed literature published any date prior to May 19, 2022. Eligible sources must have considered health professional and/or patient perspectives of BtCP. A narrative synthesis approach was utilized. RESULTS Three sources met the review criteria. One source explored nurse perspectives, while two sources explored patient perspectives. Study quality was moderate to high. Overlapping themes across the three studies included communication, defining BtCP, impact of BtCP, management of BtCP, perceptions of BtCP, analgesia and pain relief, and training and professional development. CONCLUSION Given limited research investigating clinician and patient perspectives of BtCP, a rich understanding informed by exploratory qualitative methods around identification, best management strategies, professional development, and factors promoting and inhibiting best practice remains unclear. Further qualitative inquiry is warranted, and it is expected such research will inform BtCP clinical guidelines.
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Affiliation(s)
- G B Crawford
- Faculty of Health & Medical Sciences, University of Adelaide, Adelaide Medical School, North Terrace, Adelaide, SA, 5000, Australia.
- Northern Adelaide Palliative Service, Northern Adelaide Local Health Network, Modbury Hospital, 41-69 Smart Road, Modbury, SA, 5092, Australia.
| | - A Lakhani
- The School of Psychology and Public Health, La Trobe University, 360 Collins St, Melbourne, VIC, 3000, Australia
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, University Drive, Logan CampusMeadowbrook, QLD, 4131, Australia
- Palliative Care Department, Eastern Health, 251 Mountain Highway, Wantirna, VIC, 3152, Australia
| | - L Palmer
- Faculty of Health & Medical Sciences, University of Adelaide, Adelaide Medical School, North Terrace, Adelaide, SA, 5000, Australia
- Northern Adelaide Palliative Service, Northern Adelaide Local Health Network, Modbury Hospital, 41-69 Smart Road, Modbury, SA, 5092, Australia
| | - M Sebalj
- The School of Psychology and Public Health, La Trobe University, 360 Collins St, Melbourne, VIC, 3000, Australia
| | - P Rolan
- Faculty of Health & Medical Sciences, University of Adelaide, Adelaide Medical School, North Terrace, Adelaide, SA, 5000, Australia
- Northern Adelaide Pain Service, Northern Adelaide Local Health Network, Modbury Hospital, 41-69 Smart Road, Modbury, SA, 5092, Australia
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13
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Mercadante S. Alcoholization of Intercostal Nerves for Incident Pain Due to Rib Metastases. J Pain Symptom Manage 2023; 66:e427-e429. [PMID: 37343899 DOI: 10.1016/j.jpainsymman.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Rib metastases may cause incident pain on coughing, deep respiration, or on specific thoracic wall movement. Proper titration of opioid doses relieves the background pain adequately, but does not allow a good pain control for incident pain. METHODS A patient with rib metastases presented incident pain due to minimal chest wall movement, limiting breathing. Alcoholization of intercostal nerves at T6,T7, T8, and T9, at level of ribs angle, RESULTS: Intercostal blocks were highly effective in relieving incident pain due to rib metastases. DISCUSSION A simple and safe procedure may produce effective analgesia preventing incident pain due to rib metastases. Differently from other sites of bone metastases, ribs are easily localized and the neurolytic block results to be effective and safe.
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Affiliation(s)
- Sebastiano Mercadante
- Director of Anesthetics, La Maddalena Cancer Center, (S.M.), Main Regional Center of Pain Relief and Supportive/Palliative Care, Palermo, Italy.
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14
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Mercadante S. Once again... breakthrough cancer pain: an updated overview. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:23. [PMID: 37480136 PMCID: PMC10360268 DOI: 10.1186/s44158-023-00101-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/26/2023] [Indexed: 07/23/2023]
Abstract
Breakthrough cancer pain (BTcP) is a complex and variegate phenomenon that may change its presentation during the course of patients' disease in the same individual. An appropriate assessment is fundamental for depicting the pattern of BTcP. This information is determinant for a personalized management of BTcP. The use of opioids as needed is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective. The most controversial point regards the opioid dose to be used. The presence of opioid tolerance suggests to use a dose proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested to use the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never ended question.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthetics, Main Regional Center for Pain Relief & Palliative Care Unit, La Maddalena Cancer Center, Acute Supportive/Palliative Care Unit & Hospice, 90146, Palermo, Italy.
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15
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Wong AK, Somogyi AA, Rubio J, Pham TD, Le B, Klepstad P, Philip J. Effectiveness of Opioid Switching in Advanced Cancer Pain: A Prospective Observational Cohort Study. Cancers (Basel) 2023; 15:3676. [PMID: 37509337 PMCID: PMC10378198 DOI: 10.3390/cancers15143676] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Opioid switching is a common practice of substituting one opioid for another to improve analgesia or adverse effects; however, it has limited evidence. This study aimed to examine the effectiveness of opioid switching in advanced cancer. This multi-center prospective cohort study recruited patients assessed to switch opioids (opioid switch group) or to continue ongoing opioid treatment (control group). Clinical data (demographics, opioids) and validated instruments (pain and adverse effects) were collected over two timepoints seven days apart. Descriptive analyses were utilized. Non-parametric tests were used to determine differences. Fifty-four participants were recruited (23 control group, 31 switch group). At the follow-up, opioid switching reduced pain (worst, average, and now) (p < 0.05), uncontrolled breakthrough pain (3-fold reduction, p = 0.008), and psychological distress (48% to 16%, p < 0.005). The switch group had a ≥25% reduction in the reported frequency of seven moderate-to-severe adverse effects (score ≥ 4), compared to a reduction in only one adverse effect in the control group. The control group experienced no significant pain differences at the follow-up. Opioid switching is effective at reducing pain, adverse effects, and psychological distress in a population with advanced cancer pain, to levels of satisfactory symptom control in most patients within 1 week.
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Affiliation(s)
- Aaron K Wong
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne 3052, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Melbourne 3050, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville 3052, Australia
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5005, Australia
| | - Justin Rubio
- Florey Institute of Neuroscience & Mental Health, Parkville 3050, Australia
| | - Tien Dung Pham
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville 3052, Australia
| | - Brian Le
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne 3052, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Melbourne 3050, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville 3052, Australia
| | - Pal Klepstad
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway
| | - Jennifer Philip
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne 3052, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Melbourne 3050, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville 3052, Australia
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16
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Mestdagh F, Steyaert A, Lavand'homme P. Cancer Pain Management: A Narrative Review of Current Concepts, Strategies, and Techniques. Curr Oncol 2023; 30:6838-6858. [PMID: 37504360 PMCID: PMC10378332 DOI: 10.3390/curroncol30070500] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023] Open
Abstract
Pain is frequently reported during cancer disease, and it still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Therefore, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discusses the different options currently available to manage pain in (former) cancer patients in light of progress made in the last decade. Major progress in the field includes the recent development of a chronic cancer pain taxonomy now included in the International Classification of Diseases (ICD-11) and the update of the WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, with opioids being considered as the mainstay. The opioids crisis has prompted the reassessment of opioids use in cancer patients and survivors. This review focuses on the current utilization of opioids, the neuropathic pain component often neglected, and the techniques and non-pharmacological strategies available which help to personalize patient treatment. Cancer pain management is now closer to the management of chronic non-cancer pain, i.e., "an integrative and supportive pain care" aiming to improve patient's quality of life.
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Affiliation(s)
- François Mestdagh
- Department of Anesthesiology and Pain Clinic, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - Arnaud Steyaert
- Department of Anesthesiology and Pain Clinic, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - Patricia Lavand'homme
- Department of Anesthesiology and Acute Postoperative & Transitional Pain Service, Cliniques Universitaires Saint Luc, University Catholic of Louvain, Av Hippocrate 10, B-1200 Brussels, Belgium
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17
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Bang YH, Choi YH, Park M, Shin SY, Kim SJ. Clinical relevance of deep learning models in predicting the onset timing of cancer pain exacerbation. Sci Rep 2023; 13:11501. [PMID: 37460584 DOI: 10.1038/s41598-023-37742-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 06/27/2023] [Indexed: 07/20/2023] Open
Abstract
Cancer pain is a challenging clinical problem that is encountered in the management of cancer pain. We aimed to investigate the clinical relevance of deep learning models that predict the onset of cancer pain exacerbation in hospitalized patients. We defined cancer pain exacerbation (CPE) as the pain with a numerical rating scale (NRS) score of ≥ 4. We investigated the performance of the deep learning models using the Matthews correlation coefficient (MCC) with different input lengths and time binning. All the pain records were obtained from the electronic medical records of the hematology-oncology wards in a Samsung Medical Center between July 2016 and February 2020. The model was externally validated using the holdout method with 20% of the datasets. The most common type of cancer was lung cancer (n = 745, 21.7%), and the median CPE per day was 1.01. The NRS pain records showed circadian patterns that correlated with NRS pain patterns of the previous days. The correlation of the NRS scores showed a positive association with the closeness of the NRS pattern of the day with forecast date and size of time binning. The long short-term memory-based model exhibited a good performance by demonstrating 9 times the best performance and 8 times the second-best performance among 21 different settings. The best performance was achieved with 120 h input and 12 h bin lengths (MCC: 0.4927). Our study demonstrated the possibility of predicting CPE using deep learning models, thereby suggesting that preemptive cancer pain management using deep learning could potentially improve patients' daily life.
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Affiliation(s)
- Yeong Hak Bang
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, 81 Irwon-Ro, Gangnam-Gu, Seoul, Korea
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon Ho Choi
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, 81 Irwon-Ro, Gangnam-Gu, Seoul, Korea
| | - Mincheol Park
- Center for Artificial Intelligence, Korea Institute of Science and Technology, Seoul, Korea
| | - Soo-Yong Shin
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, 81 Irwon-Ro, Gangnam-Gu, Seoul, Korea.
| | - Seok Jin Kim
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, Korea.
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18
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Mercadante S. Breakthrough cancer pain in the radiotherapy setting: a systematic and critical review. Expert Rev Anticancer Ther 2023; 23:229-234. [PMID: 36809181 DOI: 10.1080/14737140.2023.2182773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Breakthrough pain (BP) is a complex phenomenon that has been reported to have a relevant role in the global management of cancer pain. Radiotherapy (RT) has a fundamental part in the treatment of many pain conditions, particularly oral mucositis and painful bone metastases. AREAS COVERED The literature regarding the phenomenon of BP in the radiotherapy setting was reviewed. Three areas were assessed, including epidemiology, pharmacokinetics, and clinical data. EXPERT OPINION Qualitative and quantitative data regarding BP in the RT setting are poor in terms of scientific evidence. Most papers assessed fentanyl products, particularly fentanyl pectin nasal spray, to resolve possible problems with transmucosal absorption of fentanyl due to mucositis of the oral cavity in patients with head and neck cancer or to prevent and treat procedural pain during RT sessions. According to the lack of clinical studies with large number of patients, BP should be included in the agenda of radiation oncologists.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief & palliative/supportive Care, La Maddalena Cancer Center, Palermo
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19
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Porzio G, Capela A, Giusti R, Lo Bianco F, Moro M, Ravoni G, Zułtak-Baczkowska K. Multidisciplinary approach, continuous care and opioid management in cancer pain: case series and review of the literature. Drugs Context 2023; 12:dic-2022-11-7. [PMID: 37077766 PMCID: PMC10108666 DOI: 10.7573/dic.2022-11-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/10/2023] [Indexed: 04/21/2023] Open
Abstract
Underlying cancer pain has heterogenous aetiologies and mechanisms. It requires detailed and comprehensive pain assessment, combined with personalized treatment. A multidisciplinary team is essential to providing the best management of cancer pain at every disease stage, improving the quality of life and outcomes in patients with cancer. This narrative literature review emphasizes the value of providing all patients with multidisciplinary pain management in their preferred care setting. Real-life experiences are also reported to witness the efforts of physicians to properly manage cancer pain. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.
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Affiliation(s)
| | - Andreia Capela
- Centro Hospitalar Vila Nova de Gaia, Espinho; Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO), Arcozelo – Vila Nova de Gaia, Portugal
| | - Raffaele Giusti
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Francesca Lo Bianco
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Mirella Moro
- Medical Oncology Unit, Sant’Andrea Hospital of Rome, Sapienza University of Rome, Rome, Italy
| | - Giulio Ravoni
- Tuscany Tumor Association, Home Care Service, Florence, Italy
| | - Katarzyna Zułtak-Baczkowska
- Zakład Zdrowia Publicznego, Wydział Nauk o Zdrowiu, Pomorski Uniwersytet Medyczny w Szczecinie, Stettin, Poland
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20
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LeBaron V, Homdee N, Ogunjirin E, Patel N, Blackhall L, Lach J. Describing and visualizing the patient and caregiver experience of cancer pain in the home context using ecological momentary assessments. Digit Health 2023; 9:20552076231194936. [PMID: 37654707 PMCID: PMC10467200 DOI: 10.1177/20552076231194936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/28/2023] [Indexed: 09/02/2023] Open
Abstract
Background Pain continues to be a difficult and pervasive problem for patients with cancer, and those who care for them. Remote health monitoring systems (RHMS), such as the Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C), can utilize Ecological Momentary Assessments (EMAs) to provide a more holistic understanding of the patient and family experience of cancer pain within the home context. Methods Participants used the BESI-C system for 2-weeks which collected data via EMAs deployed on wearable devices (smartwatches) worn by both patients with cancer and their primary family caregiver. We developed three unique EMA schemas that allowed patients and caregivers to describe patient pain events and perceived impact on quality of life from their own perspective. EMA data were analyzed to provide a descriptive summary of pain events and explore different types of data visualizations. Results Data were collected from five (n = 5) patient-caregiver dyads (total 10 individual participants, 5 patients, 5 caregivers). A total of 283 user-initiated pain event EMAs were recorded (198 by patients; 85 by caregivers) over all 5 deployments with an average severity score of 5.4/10 for patients and 4.6/10 for caregivers' assessments of patient pain. Average self-reported overall distress and pain interference levels (1 = least distress; 4 = most distress) were higher for caregivers (x ¯ 3.02, x ¯ 2.60 , respectively ) compared to patients (x ¯ 2.82, x ¯ 2.25, respectively) while perceived burden of partner distress was higher for patients (i.e., patients perceived caregivers to be more distressed, x ¯ 3.21, than caregivers perceived patients to be distressed, x ¯ 2.55 ). Data visualizations were created using time wheels, bubble charts, box plots and line graphs to graphically represent EMA findings. Conclusion Collecting data via EMAs is a viable RHMS strategy to capture longitudinal cancer pain event data from patients and caregivers that can inform personalized pain management and distress-alleviating interventions.
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Affiliation(s)
- Virginia LeBaron
- University of Virginia School of Nursing, Charlottesville, VA, USA
| | - Nutta Homdee
- Center for Research Innovation and Biomedical Informatics, Faculty of Medical Technology, Mahidol University, Nakhon Pathom, Thailand
| | - Emmanuel Ogunjirin
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, USA
| | - Nyota Patel
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, USA
| | - Leslie Blackhall
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John Lach
- The George Washington University School of Engineering & Applied Science, Washington, DC, USA
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21
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Mercadante S, Adile C, Ferrera P, Grassi Y, Cascio AL, Casuccio A. Conversion ratios for opioid switching: a pragmatic study. Support Care Cancer 2022; 31:91. [PMID: 36580152 DOI: 10.1007/s00520-022-07514-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/03/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The final conversion ratios among opioids used for successful switching are unknown. The aim of this study was to determine the initial and final conversion ratios used for a successful opioid switching in cancer patients, and eventual associated factors. METHODS Ninety-five patients who were successfully switched were evaluated. The following data were collected: age, gender, Karnofsky performance score, primary cancer, cognitive function, the presence of neuropathic, and incident pain. Opioids, route of administration, and their doses expressed in oral morphine equivalents used before OS were recorded as well as opioids use for starting opioid switching, and at time of stabilization. Physical and psychological symptoms were routinely evaluated by Edmonton Symptom Assessment Scale. RESULTS No statistical changes were observed between the initial conversion ratios and those achieved at time of stabilization for all the sequences of opioid switching. When considering patients switched to methadone, there was no association between factors taken into considerations. CONCLUSION Opioid switching is a highly effective and safe technique, improving analgesia and reducing the opioid-related symptom burden. The final conversion ratios were not different from those used for starting opioid switching. Patients receiving higher doses of opioids should be carefully monitored for individual and unexpected responses in an experienced palliative care unit, particularly those switched to methadone. Future studies should provide data regarding the profile of patients with difficult pain to be hospitalized.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Yasmine Grassi
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Alessio Lo Cascio
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
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Batistaki C, Graczyk M, Janecki M, Lewandowska AA, Moutinho R, Vagdatli K. Relationship between breakthrough cancer pain, background cancer pain and analgesic treatment - case series and review of the literature. Drugs Context 2022; 11:dic-2022-9-4. [PMID: 36660261 PMCID: PMC9828877 DOI: 10.7573/dic.2022-9-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/17/2022] [Indexed: 12/30/2022] Open
Abstract
The assessment and treatment of breakthrough cancer pain (BTcP) remain a major challenge in medicine due to its high impact on several aspects of health-related quality of life. BTcP should be carefully monitored in all cancer care settings by a multidisciplinary team to provide an appropriate and personalized clinical approach. The aim of this paper is to provide healthcare professionals involved in cancer pain management with a review of the relevant literature on the relationship between background cancer pain and BTcP which, by definition, occurs despite adequately controlled background cancer pain. The clinical cases presented contribute to a better understanding of this issue and underline its impact in daily clinical practice. This article is part of the Management of breakthrough cancer pain Special Issue: https://www.drugsincontext.com/special_issues/management-of-breakthrough-cancer-pain.
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Affiliation(s)
| | - Michal Graczyk
- Department of Palliative Care, Faculty of Health Sciences, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Marcin Janecki
- Department of Palliative Care and Palliative Medicine, Medical University of Silesia, Katowice, Poland
| | | | - Rita Moutinho
- Multidisciplinary Pain Unit, Centro Hospitalar de Vila Nova de Gaia/Espinho EPE, Porto, Portugal
| | - Kiriaki Vagdatli
- Anaesthesia Department General Hospital of Athens “G. Gennimatas”, Athens, Greece
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Smith AE, Muralidharan A, Smith MT. Prostate cancer induced bone pain: pathobiology, current treatments and pain responses from recent clinical trials. Discov Oncol 2022; 13:108. [PMID: 36258057 PMCID: PMC9579264 DOI: 10.1007/s12672-022-00569-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022] Open
Abstract
PURPOSE Metastatic spread of prostate cancer to the skeleton may result in debilitating bone pain. In this review, we address mechanisms underpinning the pathobiology of metastatic prostate cancer induced bone pain (PCIBP) that include sensitization and sprouting of primary afferent sensory nerve fibres in bone. We also review current treatments and pain responses evoked by various treatment modalities in clinical trials in this patient population. METHODS We reviewed the literature using PubMed to identify research on the pathobiology of PCIBP. Additionally, we reviewed clinical trials of various treatment modalities in patients with PCIBP with pain response outcomes published in the past 7 years. RESULTS Recent clinical trials show that radionuclides, given either alone or in combination with chemotherapy, evoked favourable pain responses in many patients and a single fraction of local external beam radiation therapy was as effective as multiple fractions. However, treatment with chemotherapy, small molecule inhibitors and/or immunotherapy agents, produced variable pain responses but pain response was the primary endpoint in only one of these trials. Additionally, there were no published trials of potentially novel analgesic agents in patients with PCIBP. CONCLUSION There is a knowledge gap for clinical trials of chemotherapy, small molecule inhibitors and/or immunotherapy in patients with PCIBP where pain response is the primary endpoint. Also, there are no novel analgesic agents on the horizon for the relief of PCIBP and this is an area of large unmet medical need that warrants concerted research attention.
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Affiliation(s)
- A. E. Smith
- St Vincent’s Hospital, Darlinghurst, Sydney, NSW Australia
| | - A. Muralidharan
- Neurobiology of Chronic Pain, The Charles Perkins Centre, Faculty of Science, The University of Sydney, Sydney, NSW 2006 Australia
| | - M. T. Smith
- Centre for Integrated Preclinical Drug Development, School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, St Lucia Campus, Brisbane, QLD 4072 Australia
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Abstract
Management of cancer pain is challenging. Despite the poor evidence, opioid therapy still remains the cornerstone for the management of cancer-related pain. Opioids should be given according to the clinical presentation in the different stages of disease. There is no drug of choice, as most opioids are effective. Thus, the choice should be based on the individual characteristics of patients. Optimization of opioid therapy may allow individual treatment according to the patient's characteristics and pain syndromes, providing timely alternatives in the different stages of disease. While most patients respond to an appropriate treatment associated with a comprehensive assessment and symptom control, a high level of experience and knowledge is necessary in determining conditions to maximize the analgesic response, eventually adding adjuvants in some specific circumstances. Alternative opioids may improve the balance between analgesia and adverse effects in the presence of a poor response to the first opioid in a large number of patients. Finally, a selected population can benefit from some interventional procedures.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy.
- Regional Home Care Program, SAMOT, Palermo, Italy.
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LeBaron V, Alam R, Bennett R, Blackhall L, Gordon K, Hayes J, Homdee N, Jones R, Lichti K, Martinez Y, Mohammadi S, Ogunjirin E, Patel N, Lach J. Deploying the Behavioral and Environmental Sensing and Intervention for Cancer Smart Health System to Support Patients and Family Caregivers in Managing Pain: Feasibility and Acceptability Study. JMIR Cancer 2022; 8:e36879. [PMID: 35943791 PMCID: PMC9399893 DOI: 10.2196/36879] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/03/2022] [Accepted: 07/04/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Distressing cancer pain remains a serious symptom management issue for patients and family caregivers, particularly within home settings. Technology can support home-based cancer symptom management but must consider the experience of patients and family caregivers, as well as the broader environmental context. OBJECTIVE This study aimed to test the feasibility and acceptability of a smart health sensing system-Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C)-that was designed to support the monitoring and management of cancer pain in the home setting. METHODS Dyads of patients with cancer and their primary family caregivers were recruited from an outpatient palliative care clinic at an academic medical center. BESI-C was deployed in each dyad home for approximately 2 weeks. Data were collected via environmental sensors to assess the home context (eg, light and temperature); Bluetooth beacons to help localize dyad positions; and smart watches worn by both patients and caregivers, equipped with heart rate monitors, accelerometers, and a custom app to deliver ecological momentary assessments (EMAs). EMAs enabled dyads to record and characterize pain events from both their own and their partners' perspectives. Sensor data streams were integrated to describe and explore the context of cancer pain events. Feasibility was assessed both technically and procedurally. Acceptability was assessed using postdeployment surveys and structured interviews with participants. RESULTS Overall, 5 deployments (n=10 participants; 5 patient and family caregiver dyads) were completed, and 283 unique pain events were recorded. Using our "BESI-C Performance Scoring Instrument," the overall technical feasibility score for deployments was 86.4 out of 100. Procedural feasibility challenges included the rurality of dyads, smart watch battery life and EMA reliability, and the length of time required for deployment installation. Postdeployment acceptability Likert surveys (1=strongly disagree; 5=strongly agree) found that dyads disagreed that BESI-C was a burden (1.7 out of 5) or compromised their privacy (1.9 out of 5) and agreed that the system collected helpful information to better manage cancer pain (4.6 out of 5). Participants also expressed an interest in seeing their own individual data (4.4 out of 5) and strongly agreed that it is important that data collected by BESI-C are shared with their respective partners (4.8 out of 5) and health care providers (4.8 out of 5). Qualitative feedback from participants suggested that BESI-C positively improved patient-caregiver communication regarding pain management. Importantly, we demonstrated proof of concept that seriously ill patients with cancer and their caregivers will mark pain events in real time using a smart watch. CONCLUSIONS It is feasible to deploy BESI-C, and dyads find the system acceptable. By leveraging human-centered design and the integration of heterogenous environmental, physiological, and behavioral data, the BESI-C system offers an innovative approach to monitor cancer pain, mitigate the escalation of pain and distress, and improve symptom management self-efficacy. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/16178.
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Affiliation(s)
- Virginia LeBaron
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Ridwan Alam
- Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Rachel Bennett
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Leslie Blackhall
- University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Kate Gordon
- Virginia Commonwealth University Health, Richmond, VA, United States
| | - James Hayes
- Trident Systems, Inc, Fairfax, VA, United States
| | - Nutta Homdee
- Faculty of Medical Technology, Mahidol University, Nakhon Pathom, Thailand
| | - Randy Jones
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Kathleen Lichti
- University of Virginia School of Nursing, Charlottesville, VA, United States
| | - Yudel Martinez
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Sahar Mohammadi
- Penn Medicine, University of Pennsylvania Health System, Philadelphia, PA, United States
| | - Emmanuel Ogunjirin
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - Nyota Patel
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA, United States
| | - John Lach
- The George Washington University School of Engineering & Applied Science, Washington, DC, United States
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Lo Bianco G, Lanza E, Provenzano S, Federico M, Papa A, Imani F, Shirkhany G, Laudicella R, Quartuccio N. A Multimodal Clinical Approach for the Treatment of Bone Metastases in Solid Tumors. Anesth Pain Med 2022; 12:e126333. [PMID: 36818479 PMCID: PMC9923334 DOI: 10.5812/aapm-126333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022] Open
Abstract
Context Bone metastasis (BM) is a frequent complication of cancer, representing the third most common site of secondary spread in solid cancers behind the lung and liver. Bone metastasis is found in up to 90% of prostate and breast cancer patients. They can cause significant complications, such as pathological fractures and paralysis of the spine, which decrease daily functioning and quality of life (QoL) and worsen prognosis. The growing life expectancy of cancer patients due to improvements in systemic therapies may further increase BM's eventuality and clinical burden in cancer patients. Evidence Acquisition Four physicians from five different specialties were interviewed and resumed the most relevant literature of the last 20 years focusing on pain treatment in BM patients. Results Treatment for BM ideally involves various types of specialists and assessments. The disease status and patient background should be considered, requiring holistic care and expertise from various medical specialties. Conclusions Interventional, nuclear medicine, radiotherapy, and mini-invasive techniques can be safe and effective for relieving pain and modifying health-related QoL in BM patients.
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Affiliation(s)
- Giuliano Lo Bianco
- Department of Biomedical and Biotechnological Sciences, University of Catania, Italy
- Anesthesiology and Pain Department, Fondazione Istituto G. Giglio, Cefalù, Italy
- Corresponding Author: Department of Biomedical and Biotechnological Sciences, University of Catania, Italy.
| | - Ezio Lanza
- Department of Radiology, Humanitas Clinical and Research Center – IRCCS, Milan, Italy
| | - Salvatore Provenzano
- Cancer Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Manuela Federico
- Casa di cura Macchiarella, U.O. Radioterapia Oncologica, Palermo, Italy
| | - Alfonso Papa
- Pain Department, A.O. Dei Colli - V. Monaldi Hospital, Napoli, Italy
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamhosein Shirkhany
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Anesthesiology, School of Medicine, Sabzevar University of Medical Sciences, Iran
- Corresponding Author: Department of Anesthesiology, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.
| | - Riccardo Laudicella
- Nuclear Medicine Unit, Fondazione Istituto G.Giglio, Cefalù, Italy
- Nuclear Medicine Unit, Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, Messina, Italy
- Department of Nuclear Medicine, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Natale Quartuccio
- Nuclear Medicine Unit, A.R.N.A.S. Ospedali Civico, Di Cristina e Benfratelli, Palermo, Italy
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Bossi P, Escobar Y, Pea F. Rapid-Onset Opioids for Management of Breakthrough Cancer Pain: Considerations for Daily Practice. FRONTIERS IN PAIN RESEARCH 2022; 3:893530. [PMID: 35721659 PMCID: PMC9204512 DOI: 10.3389/fpain.2022.893530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background and Objective Rapid-onset opioids (ROOs) are effective treatments for breakthrough cancer pain (BTcP) given their rapid onset of action and relatively short duration of analgesia. The aim of this article is to describe specific considerations for the use of ROOs in daily practice, focusing on dose titration and treatment of specific populations. Type of Review We conducted a narrative review on the use of ROOs for BTcP. We selected papers according to the following search terms: “breakthrough cancer pain” and “rapid onset opioids”. Results ROOs may be considered as the most suitable drugs to treat BTcP and can be used “on-demand”. Several fentanyl formulations are available and have been associated with control of BTcP and with improvement in quality of life. Various titration schemes have been used to optimize ROO dosing; however, a dose-proportional scheme could be considered safe and effective in most patients. Specific formulations may be more suitable for specific patient subgroups; for example, patients with oral mucositis may prefer intranasal to oral formulations. Moreover, elderly patients or those without caregivers should be clearly educated on the use of these formulations. A key element in achieving successful treatment of BTcP is awareness of the barriers to pain management, including poor overall assessment, patient reluctance to take opioids or report pain, and physician reluctance to prescribe opioids. Conclusion A personalized approach is fundamental when prescribing a medication for BTcP, and careful attention should be given to drug choice and route of administration, and to the need for alternative therapeutic options.
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Affiliation(s)
- Paolo Bossi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health - Medical Oncology, ASST-Spedali Civili, University of Brescia, Brescia, Italy
- *Correspondence: Paolo Bossi
| | - Yolanda Escobar
- Medical Oncology, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero Universitaria Sant'Orsola, Bologna, Italy
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Katta MR, Valisekka SS, Agarwal P, Hameed M, Shivam S, Kaur J, Prasad S, Bethineedi LD, Lavu DV, Katamreddy Y. Non-pharmacological integrative therapies for chronic cancer pain. J Oncol Pharm Pract 2022; 28:1859-1868. [DOI: 10.1177/10781552221098437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Chronic pain is one of the most detrimental symptoms exhibited by cancer patients, being an indication for opioid therapy in up to half of the patients’ receiving chemotherapy and in 90% of advanced cases. Various successful non-pharmacological integrative therapy options have been explored and implemented to improve the quality of life in these patients. This review aims to highlight the mechanisms implicated; assessment tools used for cancer pain and summarize current evidence on non-pharmacological approaches in the treatment of chronic cancer pain. Data sources A review of the literature was conducted using a combination of MeSH keywords including “Chronic cancer pain,” “Assessment,” “Non-pharmacological management,” and “Integrative therapy.” Data summary Data on the approach and assessment of chronic cancer pain as well as non-pharmacological integrative options have been displayed with the help of figures and tables. Of note, non-pharmacological integrative management was divided into three subcategories; physical therapy (involving exercise, acupuncture, massage, and transcutaneous electric nerve stimulation), psychosocial therapy (e.g. mindful practices, supportive therapy), and herbal supplementation. Conclusions The use of non-pharmacological integrative therapy in the management of chronic cancer pain has been grossly underestimated and must be considered before or as an adjuvant of other treatment regimens to ensure appropriate care.
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Affiliation(s)
| | | | - Pahel Agarwal
- Bhaskar Medical College, Hyderabad, Telangana, India
| | - Maha Hameed
- AlFaisal University, College of Medicine, Riyadh, Kingdom of Saudi Arabia
| | - Swadha Shivam
- Bhaskar Medical College, Hyderabad, Telangana, India
| | | | - Sakshi Prasad
- Faculty of Medicine, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
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Clinical Practice Guidelines in the Management of Breakthrough Cancer Pain: A Systematic Review using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Instrument. Pain Manag Nurs 2022; 23:411-417. [PMID: 35305935 DOI: 10.1016/j.pmn.2022.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Several clinical practice guidelines (CPGs), consensus statements, and recommendations currently exist for the diagnosis and management of breakthrough cancer pain (BTcP). These documents have considerable variability amongst them, and to date, their quality and methodologic rigor have not been appraised. AIM We aim to identify and perform a quality appraisal of CPGs for the diagnosis and management of BTcP using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. METHODS A comprehensive literature search was performed in MEDLINE (via PubMed), EMBASE, and SCOPUS databases up until January 1, 2021. Four reviewers independently evaluated each guideline using the AGREE II instrument. Scaled domain scores were generated and the threshold used for satisfactory quality was >60%. Additionally, intraclass correlation coefficients (ICC) were calculated to determine level of agreement between reviewers. RESULTS Eleven guidelines were selected for final evaluation based on inclusion/exclusion criteria. Only one guideline was classified of "average" quality while the rest were classified as "low" quality. The "Editorial Independence" (70.46 ± 35.7) and "Scope and Purpose" (64.78 ± 12.5) domains received the highest mean scores, while the "Applicability" (32.58 ± 13.5) and "Rigor of Development" (35.04 ± 9.0) domains received the lowest mean scores. ICC statistical analysis showed high magnitude of agreement between reviewers with a range of (0.790-0.988). CONCLUSIONS Reflecting upon our quality appraisal, it is evident that the quality and methodologic rigor of BTcP guidelines can be improved upon in the future. Our findings also elucidate the existing variability/discrepancies among guidelines in diagnostic criteria and management of BTcP.
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The Assessment and Management of Acute and Chronic Cancer Pain Syndromes. Semin Oncol Nurs 2022; 38:151248. [DOI: 10.1016/j.soncn.2022.151248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lalli D, Santoboni F, Vallorani R, Vetrano M, Latini E, Nusca SM, Vulpiani MC. Acupuncture for Breakthrough pain in cancer: A medical record. WORLD JOURNAL OF ACUPUNCTURE-MOXIBUSTION 2021. [DOI: 10.1016/j.wjam.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Multidimensional Statistical Technique for Interpreting the Spontaneous Breakthrough Cancer Pain Phenomenon. A Secondary Analysis from the IOPS-MS Study. Cancers (Basel) 2021; 13:cancers13164018. [PMID: 34439173 PMCID: PMC8391336 DOI: 10.3390/cancers13164018] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 01/09/2023] Open
Abstract
Breakthrough cancer pain (BTcP) is a temporary exacerbation of pain that "breaks through" a phase of adequate pain control by an opioid-based therapy. The non-predictable BTcP (NP-BTcP) is a subtype of BTcP that occurs in the absence of any specific activity. Since NP-BTcP has an important clinical impact, this analysis is aimed at characterizing the NP-BTcP phenomenon through a multidimensional statistical technique. This is a secondary analysis based on the Italian Oncologic Pain multiSetting-Multicentric Survey (IOPS-MS). A correlation analysis was performed to characterize the NP-BTcP profile about its intensity, number of episodes per day, and type. The multiple correspondence analysis (MCA) determined the identification of four groups (phenotypes). A univariate analysis was performed to assess differences between the four phenotypes and selected covariates. The four phenotypes represent the hierarchical classification according to the status of NP-BTcP: from the best (phenotype 1) to the worst (phenotype 4). The univariate analysis found a significant association between the onset time >10 min in the phenotype 1 (37.3%)' vs. the onset > 10 min in phenotype 4 (25.8%) (p < 0.001). Phenotype 1 was characterized by the gastrointestinal type of cancer (26.4%) with respect to phenotype 4, where the most frequent cancer affected the lung (28.8%) (p < 0.001). Phenotype 4 was mainly managed with rapid-onset opioids, while in phenotype 1, many patients were treated with oral, subcutaneous, or intravenous morphine (56.4% and 44.4%, respectively; p = 0.008). The ability to characterize NP-BTcP can offer enormous benefits for the management of this serious aspect of cancer pain. Although requiring validation, this strategy can provide many indications for identifying the diagnostic and therapeutic gaps in NP-BTcP management.
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Abstract
PURPOSE OF REVIEW An overview on breakthrough cancer pain (BTCP), including inherent limitations of the terminology, assessment, clinical presentation, and treatment options. RECENT FINDINGS The estimated prevalence of BTCP is dependent on the defined cutoffs for controlled background pain and the magnitude of the pain flare. In addition, pain flares outside the definition of BTCP are prevalent. In the 11th Revision of the International Classification of Diseases, the temporal characteristics of cancer pain are described as continuous background pain and intermittent episodic pain. BTCP should be assessed by validated methods, and the patient perspective should be included. The pain may be related to neoplastic destruction of bone, viscera, or nerve tissue and is characterized by rapid onset, high intensity, and short duration. Treatment directed towards painful metastases must be considered. Due to pharmacological properties mirroring the pain characteristics, transmucosal fentanyl formulations are important for the treatment of BTCP. Oral immediate release opioids can be used for slow-onset or predictable BTCP. For more difficult pain conditions, parenteral, or even intrathecal pain medication, may be indicated. SUMMARY All clinically relevant episodic pains must be adequately treated in accordance with the patient's preferences. Transmucosal fentanyl formulations are effective for BTCP.
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Bossi P, Antonuzzo A, Armento G, Consoli F, Giuliani J, Giusti R, Lucchesi M, Mirabile A, Palermo L, Scagliarini S. What to Do and What Not to Do in the Management of Cancer Pain: A Physician Survey and Expert Recommendations. Cancer Manag Res 2021; 13:5203-5210. [PMID: 34234563 PMCID: PMC8256821 DOI: 10.2147/cmar.s310651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite the prevalence of pain among patients with cancer and the availability of pertinent guidelines, the clinical management of oncological pain is decisively insufficient. To address this issue, we evaluated current trends in clinical practice and subsequently generated a list of ten corrective actions-five things to do and five things not to do-for the diagnosis, management, and monitoring of cancer pain. METHODS The survey included 18 questions about clinical practice surrounding background pain and breakthrough cancer pain (BTcP). Survey questions were developed by a scientific board of 10 physician experts and communicated via email to an expanded panel of physicians in Italy. Responses were tabulated descriptively for analysis. RESULTS Of 51 invited physicians, 32 (63%) provided complete survey responses. The responses revealed several incongruencies with current guideline recommendations: physicians did not always diagnose or monitor pain using diagnostically validated or disease-specific instruments; frequently based clinical decision-making on time availability or convenience; and pharmacological therapy was often inappropriate (eg, prescribing NSAIDs or corticosteroids for BTcP). The list of corrective actions generated by the scientific board favored a guideline-oriented approach that systematically characterizes oncological pain and implements treatment based on pain characteristics (eg, fast-acting transmucosal opioids for BTcP) and evidence-based recommendations. CONCLUSION Oncologists require better education and training about the diagnosis, treatment, and monitoring of oncological pain. Physicians should be aware of current guideline recommendations as well as available pharmacological tools for BTcP.
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Affiliation(s)
- Paolo Bossi
- Department of Medical Oncology, ASST-Spedali Civili, Brescia, Italy
| | - Andrea Antonuzzo
- Medical Oncology Unit 1 SSN, Oncology Center, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Grazia Armento
- Department of Medical Oncology, Campus Bio-Medico University Hospital, Rome, Italy
| | | | - Jacopo Giuliani
- Unit Department Medical Oncology, Mater Salutis, Hospital, Legnago, Italy
| | - Raffaele Giusti
- Unit Department Medical Oncology, Sant ‘Andrea University Hospital, Rome, Italy
| | - Maurizio Lucchesi
- Pneumology Unit - Thoracic Oncology Service, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Aurora Mirabile
- Department of Oncology, San Raffaele University Hospital, Milan, Italy
| | - Loredana Palermo
- Unit Department Medical Oncology, IRCCS Giovanni Paolo, Bari, Italy
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Characterizing Breakthrough Cancer Pain Using Ecological Momentary Assessment with a Smartphone App: Feasibility and Clinical Findings. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115991. [PMID: 34204871 PMCID: PMC8199778 DOI: 10.3390/ijerph18115991] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND mobile applications (apps) facilitate cancer pain ecological momentary assessment (EMA) and provide more reliable data than retrospective monitoring. The aims of this study are (a) to describe the status of persons with cancer pain when assessed ecologically, (b) to analyze the utility of clinical alarms integrated into the app, and (c) to test the feasibility of implementing an app for daily oncological pain monitoring. METHODS in this feasibility study, 21 patients (mean age = 56.95 years, SD = 10.53, 81.0% men) responded to an app-based evaluation of physical status (baseline and breakthrough cancer pain (BTcP)) and mental health variables (fatigue, mood, and coping) daily during 30 days. RESULTS cancer pain characterization with the app was similar to data from the literature using retrospective assessments in terms of BTcP duration and perceived medication effectiveness. However, BTcP was less frequent when evaluated ecologically. Pain, fatigue, and mood were comparable in the morning and evening. Passive coping strategies were the most employed daily. Clinical alarms appear to be useful to detect and address adverse events. App implementation was feasible and acceptable. CONCLUSION apps reduce recall bias and facilitate a rapid response to adverse events in oncological care. Future efforts should be addressed to integrate EMA and ecological momentary interventions to facilitate pain self-management via apps.
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A Longitudinal Study of Breakthrough Cancer Pain: An Extension of IOPS-MS Study. J Clin Med 2021; 10:jcm10112273. [PMID: 34073907 PMCID: PMC8197313 DOI: 10.3390/jcm10112273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022] Open
Abstract
The aim of this study was to longitudinally assess the characteristics of background pain and breakthrough pain (BTcP), analgesic treatment, and satisfaction with treatment four weeks after the first assessment. METHODS Adult cancer patients with a diagnosis of BTcP were included. At T0, age, gender, visit setting, cancer diagnosis, the extent of the disease, ongoing anticancer treatments, and Karnofsky level were recorded. The background pain intensity in the last 24 h (on a numerical scale 0-10), opioids used for background pain, and their doses, expressed as oral morphine equivalents (OME), as well as other analgesic drugs, were recorded. The number of BTcP episodes, their intensity, predictability and precipitating factors, onset duration of untreated episodes, and interference with daily activities were collected. Analgesics and doses used for BTcP, and the mean time to meaningful pain relief after taking medication, were assessed. The level of satisfaction with BTcP medication was also assessed. Adverse effects to be attributed to these medications were also recorded. At T4, the same data were evaluated. RESULTS After one-month follow-up, patients had a lower number of BTcP episodes and peak intensity, possibly due to the optimization of background analgesia. The principal characteristics of BTcP did not change significantly. CONCLUSION A careful and continuous assessment should be guaranteed to all patients to limit the burden induced by BTcP, other than treating BTcP episodes with short-onset opioids.
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Intrathecal patient-controlled analgesia has nothing to do with breakthrough cancer pain. Pain 2021; 162:1586. [PMID: 33857033 DOI: 10.1097/j.pain.0000000000002232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kwok CYL, Chan DNS, So WKW. Effect of a theory-driven educational intervention on the level of knowledge, attitudes, and assessment practices regarding breakthrough cancer pain (BTCP) management among medical nurses in Hong Kong. Eur J Oncol Nurs 2021; 52:101945. [PMID: 33813183 DOI: 10.1016/j.ejon.2021.101945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 02/02/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To examine the effect of an educational intervention intended to improve medical nurses' adherence to breakthrough cancer pain (BTCP) assessment practices and their level of knowledge, attitudes and perceived assessment practices regarding BTCP management. METHODS Nurses working in a regional hospital were recruited to this quasi-experimental study. The intervention group received a 3-h educational workshop and one session of individual clinical instruction, whilst the control group did not receive any intervention. Chart audits were performed to examine adherence to BTCP assessment practices as the primary outcome. A self-developed questionnaire was used to measure nurses' knowledge, attitudes and perceived assessment practices regarding BTCP management as the secondary outcomes. The chi-square or Fisher's exact test was used to compare the rate of adherence to BTCP assessment practices between groups. A generalised estimating equation was used to compare changes in knowledge, attitudes, and perceived assessment practices between groups over time. RESULTS One hundred and five nurses completed the study. The chart audits revealed a significantly higher rate of adherence to BTCP assessment practices in the intervention group after the intervention (p < .05). The intervention group exhibited significant positive changes in scores for knowledge (β = 25.49, p < .001), attitude (β = 0.98 to 2.81, p < .01), and their perceived assessment practices (β = 1.33 to 3.14, p < .002) when compared with the control group. CONCLUSIONS This theory-driven educational intervention significantly improved the medical nurses' adherence to BTCP assessment practices and their level of knowledge attitudes and perceived assessment practices regarding BTCP management.
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Affiliation(s)
- Carman Y L Kwok
- Haven of Hope Sister Annie Skau Holistic Centre, Hong Kong, SAR, China
| | - Dorothy N S Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, SAR, China.
| | - Winnie K W So
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong, SAR, China
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Intranasal Fentanyl for Intervention-Associated Breakthrough Pain After Cardiac Surgery. Clin Pharmacokinet 2021; 60:907-919. [PMID: 33686630 PMCID: PMC8249268 DOI: 10.1007/s40262-021-01002-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/29/2022]
Abstract
Background Cardiac bypass surgery patients have early postoperative interventions that elicit breakthrough pain. We evaluated the use of intranasal fentanyl for breakthrough pain management in these patients. Methods Multimodal analgesia (paracetamol 1 g three times a day, oxycodone 2–3 mg boluses with a patient-controlled intravenous pump) was used in 16 patients (age 49–70 years, weight 59–129 kg) after cardiac bypass surgery. Intranasal fentanyl 100 µg or 200 µg was used to manage breakthrough pain on the first and third postoperative mornings in a randomised order. Blood samples were collected for up to 3 h after fentanyl administration, pain was assessed with a numeric rating scale of 0–10. Plasma fentanyl concentration was assayed using liquid chromatography-mass spectrometry. Body composition was measured with a bioelectrical impedance device. Results Bioavailability of intranasal fentanyl was high (77%), absorption half-time short (< 2 min) and an analgesic plasma concentration ≥ 0.5 ng/mL was achieved in 31 of 32 administrations. Fentanyl exposure correlated inversely with skeletal muscle mass and total body water. Fentanyl analgesia was effective both on the first postoperative morning with chest pleural tube removal and during physiotherapy on the third postoperative morning. The median time of subsequent oxycodone administration was 1.1 h after intranasal fentanyl 100 µg and 2.1 h after intranasal fentanyl 200 µg, despite similar oxycodone concentrations (median 13.8, range 5.2–35 ng/mL) in both fentanyl dose groups. Conclusions Intranasal fentanyl 100 µg provided rapid-onset analgesia within 10 min and is an appropriate starting dose for incidental breakthrough pain in the first 3 postoperative days after cardiac bypass surgery. Clinical Trial Registration EudraCT Number: 2018-001280-22. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01002-4.
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Mercadante S, Maltoni M, Russo D, Adile C, Ferrera P, Rossi R, Rosati M, Casuccio A. The Prevalence and Characteristics of Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain. Cancers (Basel) 2021; 13:cancers13051058. [PMID: 33801478 PMCID: PMC7958843 DOI: 10.3390/cancers13051058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. This prospective study showed that in this population, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes. Abstract The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. A consecutive sample of advanced cancer patients receiving less than 60 mg/day of oral morphine equivalent (OME) was selected. Epidemiological data, background pain intensity, and current analgesic therapy were recorded. The presence of BTcP was diagnosed according to a standard algorithm. The number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, satisfaction with BTcP medication, and time to meaningful pain relief were collected. A total of 126 patients were screened. The mean intensity of background pain was 2.71 (1.57), and the mean OME was 28.5 mg/day (SD15.8). BTP episodes were recorded in 88 patients (69.8%). The mean number/day of BTP episodes was 4.1 (SD 7.1, range 1–30). In a significant percentage of patients, BTcP was both predictable and unpredictable (23%). The BTcP onset was less than 20 min in the majority of patients. The mean duration of untreated episodes was 47.5 (SD 47.6) minutes. The mean time to meaningful pain relief after taking a BTcP medication was >20 min in 44.5% of patients. The efficacy of BTcP medication was not considered good in more than 63% of patients. Gender (females) (OR = 4.16) and lower Karnofsky (OR = 0.92) were independently associated with BTcP. A higher number of BTcP episodes/day was associated with gender (females) (p = 0.036), short duration of BTcP (p = 0.005), poorer efficacy of BTcP medication (none or mild) (p = 0.001), and late meaningful pain relief (p = 0.024). The poor efficacy of BTcP medication was independently associated with a higher number of episodes/day (OR = 0.22). In patients who were receiving low doses of opioids, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
- Correspondence:
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Domenico Russo
- Hospice and the Palliative Care Service, Clinica San Marco, 04100 Latina, Italy;
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Marta Rosati
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy;
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Mercadante S, Portenoy RK. Understanding the Chameleonic Breakthrough Cancer Pain. Drugs 2021; 81:411-418. [PMID: 33515376 DOI: 10.1007/s40265-021-01466-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Abstract
Breakthrough cancer pain (BTcP) is a variegated phenomenon, that often presents in different ways in each individual, and may change its presentation in the same individual during the course of disease. An appropriate assessment is fundamental for depicting the pattern of BTcP in individuals. This information is determinant for a personalised management of BTcP. The use of opioids as needed, is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective, providing analgesia in 5-15 min. The most controversial point regards the opioid dose to be used. The presence of tolerance suggests using a dose that is proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested using the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never-ending question.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative Care Unit, La Maddalena Cancer Centre, Via San Lorenzo 312, 90146, Palermo, Italy. .,Regional Home Care Programme, SAMOT, Palermo, Italia.
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, 39 Broadway, 3rd Floor, New York, NY, 10006, USA. .,Neurology and Family and Social Medicine, Albert Einstein College of Medicine, New York, USA.
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Siemens W, Boehlke C, Bennett MI, Offner K, Becker G, Gaertner J. Transcutaneous electrical nerve stimulation for advanced cancer pain inpatients in specialist palliative care-a blinded, randomized, sham-controlled pilot cross-over trial. Support Care Cancer 2020; 28:5323-5333. [PMID: 32128614 PMCID: PMC7547037 DOI: 10.1007/s00520-020-05370-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/19/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE Transcutaneous electrical nerve stimulation (TENS) is a treatment option for cancer pain, but the evidence is inconclusive. We aimed to evaluate the efficacy and safety of TENS. METHODS A blinded, randomized, sham-controlled pilot cross-over trial (NCT02655289) was conducted on an inpatient specialist palliative care ward. We included adult inpatients with cancer pain ≥ 3 on an 11-point numerical rating scale (NRS). Intensity-modulated high TENS (IMT) was compared with placebo TENS (PBT). Patients used both modes according to their preferred application scheme during 24 h with a 24-h washout phase. The primary outcome was change in average pain intensity on the NRS during the preceding 24 h. Responders were patients with at least a "slight improvement." RESULTS Of 632 patients screened, 25 were randomized (sequence IMT-PBT = 13 and PBT-IMT = 12). Finally, 11 patients in IMT-PBT and 9 in PBT-IMT completed the study (N = 20). The primary outcome did not differ between groups (IMT minus PBT: - 0.2, 95% confidence interval - 0.9 to 0.6). However, responder rates were higher in IMT (17/20 [85%] vs. 10/20 [50%], p = 0.0428). Two patients experienced an uncomfortable feeling caused by the current, one after IMT and one after PBT. Seven patients (35%) desired a TENS prescription. Women and patients with incident pain were most likely to benefit from TENS. CONCLUSION TENS was safe, but IMT was unlikely to offer more analgesic effects than PBT. Even though many patients desired a TENS prescription, 50% still reported at least "slight pain relief" from PBT. Differences for gender and incident pain aspects demand future trials.
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Affiliation(s)
- Waldemar Siemens
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany.
| | - Christopher Boehlke
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences (LIHS), School of Medicine, University of Leeds, Leeds, UK
| | - Klaus Offner
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerhild Becker
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany
| | - Jan Gaertner
- Center for Palliative Care Hildegard, Basel, Switzerland
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Irman, Helianthi DR. The Roles of Battlefield Acupuncture and Electroacupuncture in a Patient with Cancer-Related Pain. Med Acupunct 2020; 32:234-240. [PMID: 32879650 DOI: 10.1089/acu.2020.1423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Pain is one of the most-frightening complications of cancer and disrupts quality of life. Cancer-related pain can be caused by primary cancer itself, metastases that occur, and interventions to treat cancer. Almost all cancer-related pain is pain with moderate-to-severe intensity. Thus, cancer-related pain management often involves administration of opioid analgesics. However, administration of opioid analgesics can cause side-effects that cause new problems for these patients. Several studies have shown that acupuncture can reduce cancer-related pain and data show that acupuncture therapy is safe and can provide clinically meaningful improvements when used in conjunction with standard therapy. Case: A 72-year-old female patient had pain throughout her body since 1 month prior to before being admitted to the hospital. She was unable to sleep at night often cried because she was unable to stand the pain. This was reduced by morphine 3 × /day. Because of the drug's side-effects, she slept more often during the day, could not sleep at night, and was constipated. She also had breakthrough pain, on an average of 2-3 × /day. She had a history of malignancy in the pleura, liver, lungs, and cervix. There was an increase in some tumor markers. Her baseline numeric rating scale (NRS) assessment was 4 with an oral morphine slow-release tablet 3 × 15 mg/day. Acupuncture therapy was performed at Battlefield Acupuncture points of the right ear and body acupuncture points (LI 4, LI 11, ST 36, SP 6, and LR 3) was treated with 3-Hz continuous-wave electroacupuncture for 30 minutes at each session. During this therapy, there were reductions in pain (baseline NRS 4 became 2), need for morphine, morphine side-effects, and frequency of breakthrough pain. There were no significant side-effects due to acupuncture. Conclusions: Acupuncture is an effective and safe therapeutic option for reducing cancer pain with minimal side-effects. Acupuncture can enable a reduced need for narcotic analgesics.
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Affiliation(s)
- Irman
- Department of Medical Acupuncture, Faculty of Medicine Universitas Indonesia/RSUPN Dr. Cipto Mangunkusumo, Central Jakarta, Indonesia
| | - Dwi Rachma Helianthi
- Department of Medical Acupuncture, Faculty of Medicine Universitas Indonesia/RSUPN Dr. Cipto Mangunkusumo, Central Jakarta, Indonesia
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Episodic Breathlessness with and without Background Dyspnea in Advanced Cancer Patients Admitted to an Acute Supportive Care Unit. Cancers (Basel) 2020; 12:cancers12082102. [PMID: 32751099 PMCID: PMC7464712 DOI: 10.3390/cancers12082102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/18/2022] Open
Abstract
Aim: To characterize episodic breathlessness (EB) in patients with advanced cancer, and to determine factors influencing its clinical appearance. Methods: A consecutive sample of advanced cancer patients admitted to an acute palliative care unit was surveyed. Continuous dyspnea and EB were measured by a numerical scale. The use of drugs used for continuous dyspnea and EB was recorded. Patients were asked about the characteristics of EB (frequency, intensity, duration and triggers). The Multidimensional dyspnea profile (MDP), the Brief dyspnea inventory (BDI), the Athens sleep scale (AIS) and the Hospital Anxiety and Depression Scale (HADS) were also administered. Results: From 439 advanced cancer patients surveyed, 34 and 27 patients had EB, without and with background dyspnea, respectively. The mean intensity and the number of episodes were higher in patients with background dyspnea (p < 0.0005 and p = 0.05, respectively). No differences in duration were observed. Most episodes lasted <10 min. A recognizable cause triggering EB was often found. The presence of both background dyspnea and EB was associated with higher values of MDP and BDI. EB was independently associated with frequency and intensity of background dyspnea (OR = 20.9, 95% CI (Confidence interval) 9.1–48.0; p < 0.0005 and OR = 1.97, 95% CI 1.09–3.58; p = 0.025, respectively) and a lower Karnofsky level (OR = 0.96, 95%CI 0.92–0.98, p = 0.05). Discussion: EB may occur in patients with and without continuous dyspnea, and is often induced by physical and psychological factors. EB intensity is higher in patients with continuous dyspnea. The duration was often so short that the use of drugs, as needed, may be too late, unless administered pre-emptively when the trigger was predictable.
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Mercadante S. The Endless Question of Opioid Doses for Breakthrough Pain. Oncologist 2020; 25:e1134-e1135. [PMID: 32400063 PMCID: PMC7356757 DOI: 10.1634/theoncologist.2020-0312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 11/17/2022] Open
Abstract
This letter to the editor responds to comments in the still open debate regarding the use of breakthrough pain medications in cancer patients.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain and Supportive Palliative Care, La Maddalena Cancer CenterPalermoItaly
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Mercadante S, Masedu F, Valenti M, Aielli F. Breakthrough Pain in Patients with Lung Cancer. A Secondary Analysis of IOPS MS Study. J Clin Med 2020; 9:jcm9051337. [PMID: 32375331 PMCID: PMC7290905 DOI: 10.3390/jcm9051337] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/28/2022] Open
Abstract
Aim: To characterize breakthrough cancer pain (BTcP) in patients with lung cancer. Methods: This was a secondary analysis of multicenter study of patients with BTcP. Background pain intensity and opioid dose were recorded. The number of BTcP episodes, their intensity, predictability, onset, duration and interference with daily activities were collected. Opioids used for BTcP, the mean time to meaningful pain relief after taking medication, satisfaction and adverse effects were assessed. Results: 1087 patients with lung cancer were examined. In comparison with other tumors, patients with lung cancer showed: higher background pain intensity (p = 0.006), lower opioid doses (p = 0.005), higher intensity of BTcP (p = 0.005), movement (79.5%) and cough (8.2%), as principal triggers for predictable BTcP (p < 0.009), larger BTcP interference with daily activity (p = 0.0001), higher use of adjuvants (p = 0.0001). No relevant differences in the other parameters examined were found. Conclusion: Patients with lung cancer have their own peculiarities, including higher basal and BTcP pain intensity and the use of more adjuvant drugs for background pain. The most frequent triggers for predictable BTcP are movement and cough. Future studies should be performed to analyze the prevalence of BTcP in patients with different lung cancers as well as the optimal management strategy for background pain and BTcP.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain, Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy
- Correspondence:
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L’Aquila, 67100 L’Aquila, Italy; (F.M.); (M.V.)
| | - Marco Valenti
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L’Aquila, 67100 L’Aquila, Italy; (F.M.); (M.V.)
| | - Federica Aielli
- Department of Medical Oncology, AUSL Teramo, 64100 Teramo, Italy;
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Mercadante S, Caraceni A, Masedu F, Scipioni T, Aielli F. Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain. Oncologist 2020; 25:156-160. [PMID: 31862860 PMCID: PMC7011660 DOI: 10.1634/theoncologist.2019-0542] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study aimed to assess the characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain in comparison with patients receiving at least 60 mg of oral morphine equivalents (OME). MATERIALS AND METHODS Patients with advanced cancer receiving less than 60 mg/day of OME with episodes of BTcP were included in the analysis (group L). Data were compared with patients receiving doses of opioids ≥60 mg of OME (group H). Pain intensity, current analgesic therapy, number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, and time to meaningful pain relief were collected. Adverse effects imputable to a BTcP medication were recorded. RESULTS A total of 1,418 and 2,474 patients were included in groups L and H, respectively. A lower number of BTcP episodes (p = .005), a lower BTcP intensity (p = .0001), a faster BTcP onset (p = .024), and a longer time to meaningful pain relief after taking a BTcP medication (p = .009) were found in group L as compared with group H. In group L, BTcP interference on daily activity was less than in group H (p = .009). Patients in group L were less likely to be prescribed an opioid as BTcP medication in comparison with patients in group H (p = .0001). Opioid doses used for BTcP were significantly higher in group H. Patients in group L were more likely to be less satisfied (p = .003) than patients in group H. No adverse effects of severe intensity were reported in both groups. CONCLUSION Patients receiving lower doses of opioids exhibit some differences in BTcP presentation: fewer episodes with lower intensity and a faster onset, a longer time to meaningful pain relief, and less satisfaction with BTcP medication. A relevant percentage of patients was receiving fentanyl preparations normally reserved for patients receiving higher doses of opioids. IMPLICATIONS FOR PRACTICE Breakthrough pain is present in patients receiving low doses of opioids. It has its own peculiarities: less frequent, lower intensity, faster onset, longer time to meaningful pain relief, and less satisfaction with medication. Many patients were prescribed fentanyl preparations, which are normally reserved for patients receiving higher doses of opioids.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer CenterPalermoItaly
- Supportive/Palliative Care, MD Anderson Cancer CenterHoustonTexasUSA
| | | | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'AquilaL'AquilaItaly
| | - Teresa Scipioni
- Medical Oncology Department, Hospital “Giuseppe Mazzini”TeramoItaly
| | - Federica Aielli
- Medical Oncology Department, Hospital “Giuseppe Mazzini”TeramoItaly
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Camps Herrero C, Batista N, Díaz Fernández N, Escobar Álvarez Y, Gonzalo Gómez A, Isla Casado D, Salud A, Terrasa Pons J, Guillem Porta V. Breakthrough cancer pain: review and calls to action to improve its management. Clin Transl Oncol 2020; 22:1216-1226. [DOI: 10.1007/s12094-019-02268-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/08/2019] [Indexed: 02/04/2023]
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Effects of age and gender in patients receiving doses of opioids for breakthrough pain proportional to background opioid doses. Support Care Cancer 2019; 28:3813-3818. [PMID: 31832823 DOI: 10.1007/s00520-019-05227-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
AIM To identify the role of age and gender in analgesic and adverse effects after administering fentanyl products for breakthrough pain (BT), given in doses proportional to opioid doses given for background pain. METHODS Data from nine studies, in which patients with BP were given fentanyl products in doses proportional to their basal opioid regimen, were analyzed. RESULTS A total 462 patients presenting 1905 episodes of BP were included in this analysis. In older patients, the decrease in pain intensity was more pronounced 15 min after administration of a BP medication. No gender differences were found. No significant differences in frequency and intensity of adverse effects for age and gender were found. CONCLUSION Fentanyl products given for BP in doses proportional to background opioid regimen were more effective in older patients without adding risks of adverse effects. Gender did not influence analgesia and adverse effects of fentanyl products.
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Benefits of using the Brief Pain Inventory in patients with cancer pain: an intervention study conducted in Swedish hospitals. Support Care Cancer 2019; 28:3721-3729. [PMID: 31823057 PMCID: PMC7316672 DOI: 10.1007/s00520-019-05200-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 11/20/2019] [Indexed: 11/29/2022]
Abstract
Purpose The prevalence of cancer pain is too high. There is a need for improvement of pain management in cancer care. The aim of this study was to explore whether the use of the multidimensional pain assessment questionnaire Brief Pain Inventory (BPI) could improve pain relief in hospitalized patients with cancer. Methods A controlled intervention study was performed at two hospitals in western Sweden, 264 patients were included, 132 formed a control group and 132 an intervention group. All participants completed the BPI and the Edmonton Symptom Assessment Scale (ESAS) at baseline. Only the researcher had access to questionnaires from the control group. The completed forms from the intervention group were presented to the patients’ care team. A follow-up took place after 2–5 days when patients in both groups rated the scales a second time. Results In the intervention group, significant differences in all measured items of the BPI were found at follow-up compared with baseline. Symptoms rated with the ESAS also decreased significantly, except shortness of breath. At follow-up, a significant increase in regular use of paracetamol, anti-neuropathic pain drugs and opioids was found, as well as elevated doses of fixed-schedule opioids. In the control group, differences between baseline and follow-up were significant regarding average pain and worst pain over the past 24 h. Conclusion Presenting the patient-reported BPI to the care team helped them to focus on patients’ pain, identify pain mechanisms and adjust analgesics accordingly. A possible explanation for the results is changes in the medication prescribed.
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