Pain prevalence in cancer patients: status quo or opportunities for improvement?

The use of interventional procedures for cancer pain. A brief review

CONTEXT

Pain is a common experience in people living with cancer. Concerns around opioid prescribing have seen a move toward a multi-modality management approach, which includes interventional pain procedures.

PURPOSE

In this paper we discuss the interventional pain procedures used to treat cancer pain at two major tertiary centers in Australia.

METHODS AND RESULTS

This expert review provides practical insights on cancer pain management from healthcare providers in different specialties. These insights can be used to guide the management of a wide range of cancer pain types.

CONCLUSIONS

Furthermore, this review identifies the need for a systematic and comprehensive approach to the management of cancer pain that is broader than that of a single specialty. With recent advances in pain management procedures, an interdisciplinary approach is essential in order to provide an up to date, patient tailored approach to pain management. This review will help inform the development of a cancer pain intervention registry.

Cancer-related pain experienced in daily life is difficult to communicate and to manage - for patients and for professionals

OBJECTIVES

The aim of this study was to gain qualitative insight into cancer patients' experiences, explanations, and management strategies regarding their cancer-related pain (CP).

METHODS

Seventeen patients with CP were interviewed using a semi-structured interview approach. Braun and Clarke's thematic analysis method was used to analyze the transcribed interviews. The patients all participated in cancer rehabilitation courses arranged by the research clinic at The Danish Knowledge Centre for Rehabilitation and Palliative Care.

RESULTS

Three themes were identified: (1) Explaining CP: Patients found it difficult to explain how they experienced their pain. They lacked words, and they frequently used invasive metaphors such as "Pain feels like a heart attack" (2). Strategies and barriers to the management of CP: Initiatives provided by healthcare professionals (HCPs) were perceived as insufficient, and the patients missed guidance in both pharmacological and non-pharmacological approaches to pain management. Several saw medicine as unnatural for their body, and they focused on side effects and the medicine affecting their quality of life. (3) Responsibility for managing CP: A lack of responsiveness from the HCPs and taking on responsibility for pain management were experienced by several of the patients. The patients expressed uncertainty about whom to contact for help with the management of their CP.

CONCLUSION

The patients' difficulties in explaining, understanding, and communicating their pain and pain management contributed to insufficient pain management. They were also uncertain about who had the responsibility to help them to achieve pain relief. These results share the evidence drawn from studies on patients with chronic non-cancer pain. This qualitative study highlights the need for having more focus on a common language and shared understanding between patients and HCPs. It also underpins the importance of HCPs to assume their responsibility to help patients manage their pain conditions.

Quality of life beyond measure: Advanced cancer patients, wellbeing and medicinal cannabis

Experiences of advanced cancer are assembled and (re)positioned with reference to illness, symptoms and maintaining 'wellbeing'. Medical cannabis is situated at a borderline in this and the broader social domain: between stigmatised and normalised; recreational and pharmaceutical; between perception, experience, discourse and scientific proof of benefit. Yet, in the hyper-medicalised context of randomised clinical trials (RCTs), cancer, wellbeing and medical cannabis are narrowly assessed using individualistic numerical scores. This article attends to patients' perceptions and experiences at this borderline, presenting novel findings from a sociological sub-study embedded within RCTs focused on the use of medical cannabis for symptom relief in advanced cancer. Through a Deleuzo-Guattarian-informed framework, we highlight the fragmentation and reassembling of bodies and propose body-situated experiences of wellbeing in the realm of advanced cancer. Problematising 'biopsychosocial' approaches that centre an individualised disconnected patient body in understandings of wellbeing, experiences of cancer and potential treatments, our findings foreground relational affect and embodied experience, and the role of desire in understanding what wellbeing is and can be. This also underpins and enables exploration of the affective reassembling ascribed to medical cannabis, with particular focus on how it is positioned within RCTs.

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma: Part 2. Treatment-Update 2023

In order to update recommendations on treatment, supportive care, education, and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV), and the European Organisation of Research and Treatment of Cancer (EORTC) was formed. Recommendations were based on an evidence-based literature review, guidelines, and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable), and distant metastatic cSCC. For common primary cSCC, the first-line treatment is surgical excision with postoperative margin assessment or micrographically controlled surgery. Achieving clear surgical margins is the most important treatment consideration for patients with cSCCs amenable to surgery. Regarding adjuvant radiotherapy for patients with high-risk localised cSCC with clear surgical margins, current evidence has not shown significant benefit for those with at least one high-risk factor. Radiotherapy should be considered as the primary treatment for non-surgical candidates/tumours. For cSCC with cytologically or histologically confirmed regional nodal metastasis, lymph node dissection is recommended. For patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiotherapy, anti-PD-1 agents are the first-line systemic treatment, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drugs Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC, include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiotherapy. Multidisciplinary board decisions are mandatory for all patients with advanced cSCC, considering the risks of toxicity, the age and frailty of patients, and co-morbidities, including immunosuppression. Patients should be engaged in informed, shared decision-making on management and be provided with the best supportive care to improve symptom management and quality of life. The frequency of follow-up visits and investigations for subsequent new cSCC depends on underlying risk characteristics.

Patients' Experiences of Cancer Pain: A Descriptive Qualitative Study

OBJECTIVE

The aim of this study was to explore the cancer pain experiences of Iranian patients.

DESIGN

A qualitative descriptive design was used.

METHODS

This qualitative descriptive study was performed on 17 participants between December 2020 and September 2021. Data were collected using semistructured interviews and analyzed by Graneheim and Lundman's content analysis method.

RESULTS

Three main categories emerged in relation to patients' experiences of cancer pain. Categories included (1) characteristics of cancer pain, (2) pain self-management strategies, and (3) influence of pain on patient and her/his family.

CONCLUSIONS

Most patients believe that pain is God's will, and family members, doctors, and nurses can assist patients cope with pain by respecting this belief and supporting spiritual healing. Strengthening pain management strategies, expanding social networks, and convincing the patients that they are not an interruption to their families can all help patients maintain their fighting spirit and pain tolerance. To provide holistic care, healthcare providers, particularly nurses, should consider the physical, sociocultural, and spiritual aspects of cancer pain.

Dying with behavioral and psychological symptoms of dementia in Australian nursing homes: a retrospective case-control study

Objectives

To identify predictors of mortality in people with active and challenging behavioral and psychological symptoms of dementia (BPSD).

Design

A retrospective case-control study was designed to compare those referred to Dementia Support Australia (DSA) who died in the 12 months to November 2016, with an equal number of controls who did not die. An audit tool was designed after literature review and expert opinion from the service. Odds ratio calculations and the Mann-Whitney U test were used to assess for difference.

Setting

Residents of Australian residential aged care facilities with BPSD referred to the DSA service.

Participants

Of 476 patients referred to DSA during the study period, 44 died. 44 controls were randomly selected from those remaining matched for age and sex.

Results

Significant differences included higher rates of benzodiazepine use, drowsiness, delirium, reduced oral intake and discussions about goals of care in those who died. Those who died were referred to the service for a shorter period and had more frequent contact between DSA and nurses at the nursing homes. Increase in opioid use and loss of skin integrity in those who died approached significance. The overall end of life course demonstrated a complex set of needs with frequent delirium, pain and frailty.

Conclusion

Further study is required to determine the optimal care for those with BPSD at the end of their lives. This study would indicate complex end of life care needs and point to a role for palliative care support.

Patient Goals in Hospice Cancer Pain Management: A Total Pain Case Scenario

Evidence-based clinical practice guidelines and hospice agency policies and procedures direct nursing assessment and interventions for the care of persons with cancer-related pain. Guidelines assert that pain should be assessed from a holistic perspective that considers physical, psychological, social, and spiritual aspects. In addition, guidelines maintain that hospice nurses should ascertain patient goals for pain management. Assessment and documentation of goals other than pain intensity goals is an area of nursing practice that has not been developed. Without inclusion of personally meaningful goals in pain assessment instruments, such goals cannot be routinely or consistently included in the hospice care plan. To address the assessment of pain and patient goals for pain management, this scenario-based article merges theoretical knowledge about pain from concept analyses with clinical guideline recommendations. Although research is needed to develop pain goal assessment tools, nurses can use this empirically based approach for asking about goals and integrating them into the plan of care.

Pain Self-management Strategies in Patients With Cancer: A Qualitative Study

Successful pain management in patients with cancer is a significant challenge, and paying more attention to patients' experiences of pain self-management strategies has particular importance. This study aimed to explore pain self-management strategies in Iranian patients with cancer. This qualitative study was conducted on 14 patients with cancer. Data were collected using semistructured interviews and analyzed through the Graneheim and Lundman content analysis approach. Two main categories emerged from data analysis: (1) psychological pain self-management strategies, and (2) behavioral pain self-management strategies. Psychological strategies included pain distraction techniques, spiritual tendencies, increasing social interactions and support networks, pain tolerance and self-control, and resistance to pain. Behavioral strategies included massage and touch, heat and cold therapy, opium (Taryak in Persian) and tobacco use, herbal and home remedies, and proper diet.

Pain Treatment and Cancer Patients: Are we Heeding Quality of Life?

The use of opioid analgesics remains the primary therapy for pain control in cancer patients. However, ample evidence persists showing that treatment is still inadequate. This cross-sectional study was carried out during one year in a Brazilian Cancer Hospital to evaluate the impact of opioid use on analgesia and patients' quality of life. The Pain Management Index (PMI), EORTC QLQ.C30 (Quality of Life of Cancer Patients), Karnofsky Performance Status (KPS), Douleur Neuropathique 4 (DN4), and Brief Pain Inventory-Short Form (BPI-SF) were used. A hundred patients with advanced solid tumors and using opioids were included, with 82% of them reporting daily pain with 58% having intense pain. Morphine with a mean dose of 49 Morphine Milligram Equivalent were used by 57% of them, and PMI was negative in 34% of the sample. Neuropathic pain was found in 72% of patients. The pain was related to all BPI variables. Despite the substantial negative impact of pain on QOL, no association was found between the clinical factors assessed and QOL itself. This gap can be related to the persistence of high levels of sub-treatment, depression, and neuropathic pain associated with the use of low doses of opiates and adjuvant medications in the sample.

"Fortunately I felt pain, or I would have thought I was on my way out": experiencing pain and negotiating analgesic treatment in the context of cancer

OBJECTIVES

To explore cancer patients' experience of pain and coping strategies as well as beliefs and representations associated with pain, pain management and treatments.

METHOD AND PARTICIPANTS

A qualitative study based on semi-structured interviews was conducted among 16 patients with cancer. The inductive research strategy adopted derived from the Grounded Theory approach and the data transcribed verbatim were gradually analyzed involving researcher triangulation.

FINDINGS

The experience of pain and the coping strategies developed by patients to deal with it are shaped by the experience and representations of cancer associated with death and suffering. Pain acts both as an indication to the patients that they are still alive and as an indicator of the progression of the disease. Cancer also models patients' relationships to analgesic treatments and health care providers, since pain is an area in which patients can take back control of what is happening to them. Patients' expression of reluctance to accept analgesic treatments is also influenced by the significance of opioid treatments in this context, which are perceived as an indication that the end of life is close.

CONCLUSIONS

The contextualization of pain through the particularities of cancer is critical in order to understand cancer patients' experience of pain.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Not only patients' knowledge but also the meaning-making of pain should be incorporated in interventions targeting pain management.

Barriers and Facilitators of Pain Self-Management Among Patients with Cancer: An Integrative Review

BACKGROUND

Defining the main barriers and facilitators of cancer pain self-management are essential to improve patients' overall quality of life.

AIM

The main purpose of this review was to identify the main barriers and facilitators for cancer pain self-management.

METHOD

An integrative review guided by the five-stages framework that was identified by Souza et al. (2010) was used: (1) preparing the guiding question; (2) searching or sampling the literature; (3) data collection; (4) critical analysis of the studies; and (5) discussion of results. A comprehensive literature review was conducted using the electronic databases of PubMed/MEDLINE, CINAHL, Scopus, and Psych INFO.

RESULTS

Twenty-two studies were identified. The main facilitators that foster the process of cancer pain self-management were supportive ambiances including family caregivers as well as health care providers, active participation of patients with cancer in health care including self-discovery and self-awareness, acquiring pain knowledge, and using a pain diary. The main barriers include concerns regarding the use of pain medications, knowledge deficit, negative beliefs and attitudes, unsupportive ambiance, and psychological distress. Some patients' characteristics could be related to these barriers such as age, sex, race, marital status, educational level, level of pain, and presence of comorbidity.

CONCLUSIONS

Patients with cancer pain experience multiple barriers and facilitators when attempting to take on an active role in managing their pain.

Comparison of external system and implanted system in intrathecal therapy for refractory cancer pain in China: A retrospective study

INTRODUCTION

Intrathecal therapy (ITT) via an implanted system was demonstrated for the treatment of refractory cancer pain for decades. Recently, the dissemination of ITT is enhanced in an external system way in Asia for a lower implantation cost. This study compares the efficacy, safety, and cost of the two ITT systems in refractory cancer pain patients in China.

METHODS

One hundred and thirty-nine cancer pain patients who underwent implantation of the ITT system were included. One hundred and three patients received ITT via the external system (external group), while 36 patients received ITT via the implanted system (implanted group). A 1:2 propensity score matching procedure was used to yield a total of 89 patients for the final analysis. Medical records of included patients were retrospectively reviewed and pain scores, incidences of complications, and costs were compared.

RESULTS

ITT via the external system provided pain relief as potent as ITT via the implanted system but was less time-consuming in the implantation phase (13 vs. 19 days, p < .01). Nausea/vomiting and urinary retention were the most frequent adverse events in both external and implanted groups (32.14%, 16.07% vs. 36.36%, 21.21%). No significant difference was found in the incidences of all kinds of complications. Compared to the implanted group, the external group cost less for the initial implantation (7268 vs. 26,275 US dollar [USD], p < .001) but had a significant higher maintenance cost (606.62 vs. 20.23 USD calculated monthly, p < .001).

CONCLUSIONS

ITT via the external system is as effective and safe as that via the implanted system and has the advantage of being cheap in the upfront implantation but costs more during the maintenance process in China.

Bibliometric and visual analysis of research on the links between the gut microbiota and pain from 2002 to 2021

BACKGROUND AND AIMS

The gut microbiota is involved in the regulation of pain, which is proved by plenty of evidence. Although a substantial quantity of research on the link between the gut microbiota and pain has emerged, no study has focused on the bibliometric analysis of this topic. We aim to present a bibliometric review of publications over the past 20 years and predict research hot spots.

METHODS

Relevant publications between 2002 and 2021 were extracted from the Science Citation Index-Expanded (SCI-EXPANDED) of the Web of Science Core Collection (WoSCC) database on April 22, 2022. CiteSpace (version 5.8 R3c), VOSviewer, the Online Analysis Platform of Literature Metrology, and the R package bibliometrix were used to analyze and visualize.

RESULTS

A total of 233 articles have been published between 2002 and 2021. The number of publication outputs increased rapidly since 2016. The collaboration network revealed that the USA, Baylor College of Medicine, and Vassilia Theodorou were the most influential country, institute, and scholar, respectively. Alimentary pharmacology and therapeutics and Gut were the most co-cited journal and Neurogastroenterology and Motility was the most productive journal. Visceral sensitivity, fibromyalgia, gastrointestinal, chronic pain, stress, gut microbiome, LGG, brain-gut axis, SLAB51, and sequencing were the top 10 clusters in co-occurrence cluster analysis. Keyword burst detection indicated that the brain-gut axis and short-chain fatty acid were the current research hot spots.

CONCLUSION

Research on the links between the gut microbiota and pain has increased rapidly since 2016. The current research focused on the brain-gut axis and short-chain fatty acid. Accordingly, the SCFAs-mediated mechanism of pain regulation will be a research direction of great importance on the links between the gut microbiota and pain. This study provided instructive assistance to direct future research efforts on the links between the gut microbiota and pain.

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

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

Unacceptable pain in oncology: The patients' perspective on reasons for absence of pain interventions

Objective

Around 40% of oncology patients receive inadequate pain treatment. A previous study reported pain interventions for only 70% of patients who reported unacceptable pain at the self‐service registration desk. The aim of this study is to gain insight in reasons for the absence of pain intervention among oncology patients who reported unacceptable pain.

Methods

In this mixed methods study, 20 patients visiting the oncology outpatient clinic were selected via patient record assessment and interviewed about their perceived reasons for absence of pain intervention.

Results

The reasons mentioned by the patients for absence of pain intervention included reluctance of the patient to discuss pain, no treatment preferred by the patient, focus of the physician on treatment of the disease, pain treatment difficult or impossible, and the perception that pain is an inevitable consequence of the cancer treatment. Almost 50% of the patients considered the physician responsible for the absence of pain intervention.

Conclusion

In conclusion, a variety of reasons for absence of pain intervention are reported by patients, including patient‐related and health professional‐related reasons. Improvements can be made by promoting regular discussion of pain during hospital visits and empowerment of patients.

Prevalence of chronic postsurgical pain among cancer patients: A cross-sectional study

Background:

Cancer patients accept surgeries as part of their treatment. They may not be aware of the possibility of surgical pain persisting long after the surgery. Understanding chronic postsurgical pain is essential for effective pain management.

Aims:

We aimed to assess the prevalence of chronic postsurgical pain in cancer patients and the associated symptom burden.

Settings and Design:

This study was carried out at a tertiary cancer center. It was a cross-sectional study.

Materials and Methods:

Participants who underwent surgeries were asked to provide feedback on the MD Anderson Symptom Inventory at 3 months.

Statistical Analysis Used:

Descriptive statistics were used. Statistical tests included Kruskal–Wallis test, Chi-square test, Fisher's exact test, and Spearman's correlation. Logistic regression was used to assess the influence of variables on the presence or absence of chronic postsurgical pain.

Results:

Nine hundred and eighteen participants completed the study. Ninety-two percent (n = 840) were asymptomatic. Eight percent (n = 78) had postsurgical pain. Chronic postsurgical pain was influenced by the type of surgery (P = 0.01), specifically orthopedic and thoracic surgeries. Patients who receive epidurals are three times less likely to continue to have pain at 3 months.

Conclusions:

The prevalence of chronic postsurgical pain at 3 months in this study is lower than the rates in the literature. It is still associated with symptom burden that interferes with daily life. The risk of developing chronic postsurgical pain increases with thoracic and orthopedic surgeries. The risk may be lowered with epidural analgesia.

Pain Management in Oncology Patients Amidst the Opioid Epidemic: How To Minimize Non-Medical Opioid Use

The opioid epidemic continues to be a significant public health concern. On the surface, it appears difficult to understate the profound consequences and unnecessary loss of life at the hands of the opioid crisis throughout the 2010s. This reality should not dissuade rigorous attention toward those who have suffered unnecessarily due to an overreaching backlash toward the opioid crisis. Oncology patients have been significantly impacted on both ends of the opioid crisis. Like other populations, cancer patients were first affected during the initial surge of opioid availability, prescription, and use at the beginning of the crisis, where opioid abuse and overdose negatively impacted cancer patient populations at similar rates as the general population. Yet, cancer patients were perhaps even more heavily affected during secondary events after the initial crisis, as opioid restrictions and the stigmatization, undoubtedly beneficial in many spaces, of opioid use became prevalent across the American society. During this second period of the opioid crisis (loosely from 2013 to the present day after the Veterans Health Administration Opioid Safety Initiative started), restrictions on opioids have significantly decreased the use and access of opioids for cancer patients. Management of pain, in general, is a complex topic, and cancer pain is no exception. Cancer patients may experience pain related to the disease itself, its treatment, or other comorbidities. This review aims to clarify the impact of reducing opioid use on cancer patients over the past eight years. We summarize the challenges facing providers as they attempt to manage cancer-related pain. Additionally, we propose tools for best practices to reduce the unnecessary suffering of cancer patients and protect against the overuse and abuse of opioids.

Barriers to cancer pain management from the perspective of patients: A qualitative study

Aim

The aim of this study was to explore the barriers to effective pain management in Iranian people with cancer.

Design

A qualitative descriptive design was used.

Methods

This qualitative descriptive study was performed on 14 people with cancer. Data were collected using semi‐structured interviews and analysed by Graneheim and Lundman's content analysis method.

Results

Four main categories emerged in relation to barriers to pain management from the perspective of people with cancer. Categories included 1) accepting and enduring divine pain, 2) negative attitudes towards the effectiveness of analgesics, 3) patients’ low knowledge of pain self‐management methods and 4) neglected pain management. Barriers to pain management are multidimensional in nature consisting of patients, healthcare providers and system components. Therefore, attempts should be focused on the education of patients and healthcare providers about pain management and eliminating the shortcomings of the healthcare system.

Pain knowledge of patients and family caregivers as predictors of pain management outcomes in cancer patients: a multicenter study in China

PURPOSE

The purposes of this study were to evaluate the current situation of pain management outcomes, patients' pain knowledge, and family caregivers' pain knowledge in China and explore the impact of pain knowledge of patients and family caregivers on pain management outcomes.

METHODS

A total of 410 patient-family caregiver dyads were assessed by Brief Pain Inventory (BPI), the Pain Knowledge subscales of Patient Pain Questionnaire (PPQ), and Family Pain Questionnaire (FPQ). The difference in pain management outcomes was analyzed using bivariate analysis first, and then variables with statistical significance in bivariate analysis were included in multivariable linear regression analysis.

RESULTS

The average patient pain score in the last 24 h was 3.23 (SD = 2.16). The total average scores on pain knowledge of 410 patients and family caregivers were 3.60 ± 1.90 and 3.57 ± 1.76. Multivariable linear regression analysis showed taking strong opioids, patients' perceived moderate health status, patients' pain knowledge, and family caregivers' pain knowledge were the main factors influencing the pain management outcomes.

CONCLUSION

Pain knowledge of patients and family caregivers were important indicators of pain management outcomes, indicating tailored cancer pain education program should be developed.

Impact of Continuing Medical Education for Physicians on the Quality of Cancer Pain Treatment in China

CONTEXT

The management of cancer pain has gained attention in China since the proposal of the three-step analgesic ladder in 1986 and has been further improved after the Chinese Ministry of Health launched the campaign for "Good Pain Management Ward" in 2011. The Beijing Pain Management Center for Quality Control and Improvement was formed with the intent to improve the quality of pain management by various means such as providing continuing medical education (CME) and conducting evaluation in Beijing, the capital of China.

OBJECTIVES

The objective of this study was to investigate the impact of CME on cancer pain treatment in hospitals in Beijing, China.

METHODS

The Beijing Pain Management Center for Quality Control and Improvement carried out annual CME on cancer pain treatment for physicians in Beijing in February from 2016 to 2019. The quality of cancer pain treatment in these hospitals was evaluated in August 2015, 2017 and 2019 by using an evaluation instrument containing eight domains. The evaluation results were retrospectively reviewed to assess the impact of CME.

RESULTS

After annual CME for four successive years, a significant increase in evaluation scores for cancer pain treatment was observed in the participating hospitals. The increased trend varied widely both among the levels of hospitals (secondary and two tiers of tertiary hospitals) and among evaluation domains. These hospitals scored lowest in domains related to opioid tolerance, ongoing care, and risk of nonsteroidal anti-inflammatory drugs in the last evaluation.

CONCLUSION

CME significantly improved the quality of cancer pain treatment in the participating hospitals. Thus, standard CME courses may be adopted to improve the quality of cancer pain treatment by other regions in China and other countries.

Tetrodotoxin, a Potential Drug for Neuropathic and Cancer Pain Relief?

Tetrodotoxin (TTX) is a potent neurotoxin found mainly in puffer fish and other marine and terrestrial animals. TTX blocks voltage-gated sodium channels (VGSCs) which are typically classified as TTX-sensitive or TTX-resistant channels. VGSCs play a key role in pain signaling and some TTX-sensitive VGSCs are highly expressed by adult primary sensory neurons. During pathological pain conditions, such as neuropathic pain, upregulation of some TTX-sensitive VGSCs, including the massive re-expression of the embryonic VGSC subtype Na_V1.3 in adult primary sensory neurons, contribute to painful hypersensitization. In addition, people with loss-of-function mutations in the VGSC subtype Na_V1.7 present congenital insensitive to pain. TTX displays a prominent analgesic effect in several models of neuropathic pain in rodents. According to this promising preclinical evidence, TTX is currently under clinical development for chemo-therapy-induced neuropathic pain and cancer-related pain. This review focuses primarily on the preclinical and clinical evidence that support a potential analgesic role for TTX in these pain states. In addition, we also analyze the main toxic effects that this neurotoxin produces when it is administered at therapeutic doses, and the therapeutic potential to alleviate neuropathic pain of other natural toxins that selectively block TTX-sensitive VGSCs.

Philosophical Assumptions Used in Research on Barriers for Effective Cancer Pain Management: A Scoping Review

Cancer pain is one of the most common symptoms in cancer patients and often has a negative impact on patients' functional status and quality of life. Despite the available guidelines for effective pain management, factors such as barriers to cancer pain management still exist. The lens or philosophical assumptions used to guide cancer pain management research is a crucial but often overlooked component of high-quality research. Therefore, the purpose of this scoping review was to classify and map the available evidence and identify the knowledge gap regarding using a philosophical assumption to address the barriers of pain management among patients with cancer. Absence of clear philosophical assumptions in the qualitative research and generally a theoretical quantitative research may contribute to the slow progress in identifying and addressing barriers to cancer pain management. Therefore, the hermeneutic circle was suggested to address the main barriers of cancer pain management, focusing on the dialectic approach between the participants including researchers, cancer patients, and their family caregivers, health care providers, and policymakers. Understanding and possible solutions of the problem could be obtained through fusion of the horizons; in which the participants past and present horizons emerge. Then the collaborative efforts between the participants may yield effective strategies to overcome cancer pain barriers to improve the quality of cancer pain management.

Conjugates of Curcumin with Graphene and Carbon Nanotubes: A Review on Biomedical Applications

In the last decade, the use of carbon nanotubes and graphenes has been on the rise for various nanobiotechnological applications. Owing to their special characteristics, these two nanostructures of carbon allotropes have been studied for their capacity in the detection and treatment of many diseases. On the other hand, curcumin, a well-known antioxidant and anticancer natural product, is being extensively studied for numerous medicinal applications. Interestingly, many reports have shown great potentials of conjugates of curcumin and carbon nanotubes or graphenes. These conjugates, when properly designed and functionalized with biomolecules, could represent the valuable properties of each component alone while they could be effective in overcoming the poor solubility issues of both curcumin and Carbon Nanomaterials (CNMs). In this case, curcumin conjugates with CNMs seem to be very promising in biosensing applications and the detection of many biomolecules, especially, curcumin has been reported to be very effective with these conjugates. Also, the delivery of curcumin using functionalized SWCNTs was evaluated for its ability to load and release curcumin, to protect curcumin from degradation and to enhance its solubility. It is proposed that other properties of these conjugates are still to be discovered and the interdisciplinary approaches among biology, medicine, chemistry, and material engineering will accelerate the applications of these novel materials. This review aims to summarize the findings on the applications of CNM conjugates of curcumin.

The Effects of Auricular Therapy for Cancer Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

This study aims to systematically assess the efficacy and safety of auricular therapy for cancer pain.

METHODS

A systematic search was conducted using PubMed, EMBASE, Cochrane library databases, CNKI, VIP, WanFang Data, and CBM for randomized controlled trials (RCTs). Review Manager 5.3 was used for meta-analysis.

RESULTS

Of the 275 screened studies, nine RCTs involving 783 patients with cancer pain were systematically reviewed. Compared with drug therapy, auricular therapy plus drug therapy has significant advantages both in the effective rate for pain relief (RR = 1.40; 95% CI 1.22, 1.60; P < 0.00001) and adverse effects rate (RR = 0.46; 95% CI 0.37, 0.58; P < 0.00001). And the result revealed that auricular acupuncture had superior pain-relieving effects as compared with sham auricular acupuncture (SMD = -1.45; 95% CI -2.80, -0.09; P=0.04). However, the analysis indicated no difference on the effective rate for pain relief between auricular therapy and drug therapy (RR = 1.24; 95% CI 0.71, 2.16; P=0.46).

CONCLUSION

Our meta-analysis indicated that auricular therapy is effective and safe for the treatment of cancer pain, and auricular therapy plus drug therapy is more effective than drug therapy alone, whether in terms of pain relief or adverse reactions. However, the included RCTs had some methodological limitations; future large, rigor, and high-quality RCTs are still needed to confirm the benefits of auricular therapy on cancer pain.

Antinociceptive effect of intrathecal injection of miR-9-5p modified mouse bone marrow mesenchymal stem cells on a mouse model of bone cancer pain

Background

A growing body of studies have indicated that bone marrow mesenchymal stem cells (BMSCs) have powerful analgesic effects in animal models of bone cancer pain. Here, we explored the molecular mechanisms underlying how BMSCs alleviate pain sensation in a mouse model of bone cancer pain.

Methods

C3H/HeN adult male mice were used to generate a bone cancer pain model. BMSCs were isolated from mouse bone marrow, modified by transfection with microRNA-9-5p (miR-9-5p), and infused into the spinal cord. Spontaneous flinches, paw withdrawal latency, limb-use score, and weight-bearing score were used to assess pain-related behaviors. ELISA, RT-PCR, western blot, and luciferase assay were used to assess gene expressions.

Results

Our results show that miR-9-5p regulated the expression of both repressor element silencing transcription factor (REST) and μ-opioid receptors (MOR) by targeting REST in primary mouse BMSCs. Overexpression of miR-9-5p reversed the activation of inflammatory pathway in TNF-α- and IL-6-treated BMSCs. In addition, miR-9-5p modified BMSCs alleviated cancer pain in the sarcoma-inoculated mouse model. MiR-9-5p modified BMSCs suppressed cytokine expression in the spinal cord of sarcoma-inoculated mice by suppressing REST gene expression.

Conclusions

Our results indicate that miR-9-5p modified BMSCs can relieve bone cancer pain via modulating neuroinflammation in the central nervous system, suggesting genetically modified BMSCs could be a promising cell therapy in pain management.

European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 2. Treatment

In order to update recommendations on treatment, supportive care, education and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Dermatology Forum, the European Association of Dermato-Oncology and the European Organization of Research and Treatment of Cancer was formed. Recommendations were based on evidence-based literature review, guidelines and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable) and distant metastatic cSCC. For common primary cSCC (the most frequent cSCC type), first-line treatment is surgical excision with postoperative margin assessment or microscopically controlled sugery. Safety margins containing clinical normal-appearing tissue around the tumour during surgical excision and negative margins as reported in the pathology report are necessary to minimise the risk of local recurrence and metastasis. In case of positive margins, a re-excision shall be done, for operable cases. Lymph node dissection is recommended for cSCC with cytologically or histologically confirmed regional nodal involvement. Radiotherapy should be considered as curative treatment for inoperable cSCC, or for non-surgical candidates. Anti-PD-1 antibodies are the first-line systemic treatment for patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiation, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drug Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiation therapy. Multidisciplinary board decisions are mandatory for all patients with advanced disease who require more than surgery. Patients should be engaged with informed decisions on management and be provided with best supportive care to optimise symptom management and improve quality of life. Frequency of follow-up visits and investigations for subsequent new cSCC depend on underlying risk characteristics.

Benefits of using the Brief Pain Inventory in patients with cancer pain: an intervention study conducted in Swedish hospitals

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.

Cancer Pain Management Among Oncology Nurses: Knowledge, Attitude, Related Factors, and Clinical Recommendations: a Systematic Review

The current study evaluated the oncology nurse's knowledge, attitude, related factors of cancer-related pain management (CPM), and clinical recommendations for improving knowledge and attitude. In this systematic review, international databases (PubMed, EMBASE, Web of science (WOS), Science Direct, and Scopus) were searched for relevant studies published in English language from March 30, 2000 to March 30, 2018. The quality of the studies was evaluated using the Hoy instrument. Out of 888 initial studies, 12 studies performed on 3574 participants were included in the final stage of the review. Based on the results, most studies indicated that nurses had a poor (n = 4) or moderate (n = 4) knowledge of CPM. The lowest and the highest knowledge levels were 28.5% and 75%, respectively. According to most studies, nurses had a fair (average) (n = 4) or negative (n = 3) attitude toward CPM. The important factors related to the nurses' knowledge of CPM included previous pain-related education programs (n = 7) and having work experience with cancer patients (n = 4). The most important barrier was the deficit in staff's knowledge of pain (n = 2). The important clinical recommendations for improving nurses' levels of knowledge included the implementation of educational programs (n = 9), training programs (n = 3) on CPM and including CPM topics in nursing curricula (n = 5). This systematic review showed that most nurses had poor knowledge of CPM and a fair attitude toward CPM, indicating the importance of considering the barriers to knowledge, strengthening the positive relevant factors, and using clinical recommendations based on clinical guidelines such as including CPM topics in nursing curricula and implementing educational programs on CPM to improve the knowledge, attitude, and skills of oncology nurses. The results of the present study could be used by policymakers to provide care for cancer patients and manage their pain.

Multimodality palliative treatment with transarterial chemoembolization and high-intensity focused ultrasound for gastric leiomyosarcoma multiple liver metastasis pain: A case report

INTRODUCTION

Gastric leiomyosarcoma (LMS) is a rare malignancy with minimal therapeutic options and has poor prognosis once metastasis develops.

PATIENT CONCERNS

A case of gastric LMS with multiple metastases, pain, and progressive anemia 13 months after the initial diagnosis in a 43-year-old woman.

DIAGNOSIS

Gastric LMS with liver metastases and multiple retroperitoneal lymphatic metastases.

INTERVENTIONS

Minimally invasive therapies of repeated tetrahydropalmatine and oxaliplatin-based transarterial chemoembolization and high-intensity focused ultrasound treatment were performed.

OUTCOMES

The treatments resulted in significant pain relief (numerical rating scale from 8-2 points) after the initial treatment, improvement in performance status and quality of life, and a progression-free survival of 4 months after treatment.

CONCLUSION

This combined modality palliative treatment approach was well tolerated with noticeable pain relief.

[Drug management of cancer-related peripheral neuropathic pain: A systematic review of the literature]

The objective of the present systematic literature review was to provide an update on medical treatment of neuropathic pain in cancer patients. The number of cancer patients is steadily increasing. Pain is frequent in cancer patients. Few studies have focused on medical treatment of pain, and especially of neuropathic pain, in current or former cancer patients. The present systematic review of all studies published between December 2012 and August 2018 was intended to estimate the scale of this lack. In all, 27 articles were identified on a systematic PubMed search and from the authors' personal knowledge, confirming that scant data have been published. The heterogeneity of cancer patients, of cancer, and of pain go some way toward explaining this scarcity. Guidelines, founded mainly on results from non-cancer patients, recommend tricyclic antidepressants and antiepileptic drugs; local treatments have the advantage of good systemic tolerance. Larger-scale studies taking account of the etiology of neuropathic pain, its characteristics (strictly neuropathic or mixed) and patient characteristics (awaiting treatment, under treatment, recent or non-recent survivor, or in terminal phase) along the care pathway are needed to improve knowledge. The results of the present literature analysis can help future research.

Inhibiting STAT3 in a murine model of human breast cancer-induced bone pain delays the onset of nociception

Aggressive breast cancer subtypes utilize system x_c^-, a membrane antiporter, to import cystine for glutathione synthesis and maintenance of redox homeostasis, in turn releasing glutamate as a metabolic pro-nociceptive by-product. Metastatic breast cancers establish themselves at distal sites including bone, where changes in extracellular glutamate levels contribute to cancer-induced bone pain. We previously established that stearically blocking system x_c^- activity with sulfasalazine delays the onset of nociceptive behaviours and that xCT, the functional antiporter subunit, is positively regulated by signal transducer and activator of transcription 3 (STAT3). In the current investigation, a murine xenograft cancer-induced bone pain model was applied to examine whether pharmacological inhibition of phosphorylated STAT3 (pSTAT3) induces changes in nociception. A high glutamate-releasing, xCT/pSTAT3 over-expressing human breast cancer cell line was selected for injection into the distal epiphysis of the right femur of female nude mice. A 14-day regimen of intraperitoneal injections with either vehicle or the novel STAT3 inhibitor DR-1-55 commenced three weeks after initial intrafemoral bone injection. Nociceptive behaviours were temporally monitored by automated von Frey, dynamic weight bearing and open-field testing for the duration of the study, beginning at the baseline. Prior to sacrifice and at ethical end point, tumour-induced osteolytic lesions were radiographically assessed. Treatment with DR-1-55 significantly delayed the onset and severity of spontaneous and induced nociceptive behaviours, also decreasing human SLC7A11 ( xCT) mRNA levels in tumour-bearing limbs without altering osteolysis. In addition, two pro-inflammatory cytokines released by this cell line, interleukin 6 and interleukin 1β, were also down-regulated at the mRNA level in response to DR-1-55 treatment in vivo, with lower human interleukin 6 levels detected in the host circulation. This study demonstrates that targeting pSTAT3 may be a viable therapeutic means to manage cancer-induced bone pain, alone or in combination with stearic system x_c^- blockers.

A clinical approach to the management of cancer-related pain in emergency situations

PURPOSE

Most cancer patients experience many pain episodes depending on disruptive elements, leading them to the emergency room. The objective of the article is to describe common pitfalls that need to be avoided, as well as opportunities to be seized for repositioning patients back on their care pathway.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Most forms of cancer are now chronic, evolving diseases, and patients are treated with high-technology targeted therapies with iatrogenic effects. Moreover, the multimorphic nature of cancer-related pain requires dynamic, interdisciplinary assessments addressing its etiology, its pathophysiology, its dimensions (sensory-discriminatory, cognitive, emotional, and behavioral), and the patient's perception of it, in order to propose the most adapted therapies. However, for most patients, cancer pain remains underestimated, poorly assessed, and under-treated. In this context, the key steps in emergency cancer pain management are as follows: • Quick relief of uncontrolled cancer pain: after eliminating potential medical or surgical emergencies revealed by pain, a brief questioning will make the use of carefully titrated morphine in most situations possible. • Assessment and re-assessment of the pain and the patient, screening specific elements, to better understand the situation and its consequences. • Identification of disruptive elements leading to uncontrolled pain, with an interdisciplinary confrontation to find a mid to long-term approach, involving the appropriate pharmaceutical and/or non-pharmaceutical strategies, possibly including interventions.

CONCLUSIONS

Pain emergencies should be part of the cancer care pathway and, through supportive care, provide an opportunity to help cancer patients both maintain their physical, psychological, and social balance and anticipate further painful episodes.

Comparative Efficacy of Therapeutics for Chronic Cancer Pain: A Bayesian Network Meta-Analysis

PURPOSE

Opioids are the primary choice for managing chronic cancer pain. However, many nonopioid therapies are currently prescribed for chronic cancer pain with little published evidence comparing their efficacy.

METHODS

Electronic databases were searched for randomized controlled trials (RCTs) comparing any systemic pharmaceutical intervention and/or combination thereof in treating chronic cancer pain. The primary outcome was global efficacy reported as an odds ratio (OR). The secondary outcome was change in pain intensity reported as a standardized mean difference (SMD).

RESULTS

We included 81 RCTs consisting of 10,003 patients investigating 11 medication classes. Most RCTs (80%) displayed low risk of bias. The top-ranking classes for global efficacy were nonopioid analgesics (network OR, 0.30; 95% credibility interval [CrI], 0.13 to 0.67), nonsteroidal anti-inflammatory drugs (network OR, 0.44; 95% CrI, 0.22 to 0.90), and opioids (network OR, 0.49; 95% CrI, 0.27 to 0.86), whereas the top-ranked interventions were lidocaine (network OR, 0.04; 95% CrI, 0.01 to 0.18; surface under the cumulative ranking curve analysis [SUCRA] score, 98.1), codeine plus aspirin (network OR, 0.22; 95% CrI, 0.08 to 0.63; SUCRA score, 81.1), and pregabalin (network OR, 0.29; 95% CrI, 0.08 to 0.92; SUCRA score, 73.8). In terms of reducing pain intensity, we found that no class was superior to placebo, whereas the following top-ranked interventions were superior to placebo: ziconotide (network SMD, −24.98; 95% CrI, −32.62 to −17.35; SUCRA score, 99.8), dezocine (network SMD, −13.56; 95% CrI, −23.37 to −3.69; SUCRA score, 93.5), and diclofenac (network SMD, −11.22; 95% CrI, −15.91 to −5.80; SUCRA score, 92.9).

CONCLUSION

There are significant differences in efficacy among current regimens for chronic cancer pain. Our evidence suggests that certain nonopioid analgesics and nonsteroidal anti-inflammatory drugs can serve as effectively as opioids in managing chronic cancer pain.

Cost-Effectiveness of Pain Management Strategies in Advanced Cancer

OBJECTIVES

Uncontrolled pain in advanced cancer is a common problem and has significant impact on individuals' quality of life and use of healthcare resources. Interventions to help manage pain at the end of life are available, but there is limited economic evidence to support their wider implementation. We conducted a case study economic evaluation of two pain self-management interventions (PainCheck and Tackling Cancer Pain Toolkit [TCPT]) compared with usual care.

METHODS

We generated a decision-analytic model to facilitate the evaluation. This modelled the survival of individuals at the end of life as they moved through pain severity categories. Intervention effectiveness was based on published meta-analyses results. The evaluation was conducted from the perspective of the U.K. health service provider and reported cost per quality-adjusted life-year (QALY).

RESULTS

PainCheck and TCPT were cheaper (respective incremental costs -GBP148 [-EUR168.53] and -GBP474 [-EUR539.74]) and more effective (respective incremental QALYs of 0.010 and 0.013) than usual care. There was a 65 percent and 99.5 percent chance of cost-effectiveness for PainCheck and TCPT, respectively. Results were relatively robust to sensitivity analyses. The most important driver of cost-effectiveness was level of pain reduction (intervention effectiveness). Although cost savings were modest per patient, these were considerable when accounting for the number of potential intervention beneficiaries.

CONCLUSIONS

Educational and monitoring/feedback interventions have the potential to be cost-effective. Economic evaluations based on estimates of effectiveness from published meta-analyses and using a decision modeling approach can support commissioning decisions and implementation of pain management strategies.

Efetividade da acupuntura auricular no tratamento da dor oncológica: ensaio clínico randomizado

RESUMO Objetivo: Avaliar a efetividade da acupuntura auricular na dor de pacientes oncológicos em tratamento quimioterápico e possíveis alterações no consumo de analgésicos após a aplicação da intervenção. Método: Ensaio clínico randomizado com portadores de câncer que apresentavam queixa de dor maior ou igual a quatro na Escala Numérica da Dor. Foram criados dois grupos paralelos, um Experimental, o qual recebeu a aplicação da acupuntura auricular em pontos do equilíbrio energético e em pontos indicados para o tratamento da dor, e um Placebo, em que foram aplicados pontos placebos fixos. Ambos os grupos receberam a aplicação de agulhas semipermanentes em oito sessões. Resultados: Participaram 31 portadores de câncer. Depois das oito sessões de acupuntura auricular, houve diferença significativa entre os grupos na redução da intensidade da dor (p < 0,001) e no consumo das medicações (p < 0,05). Conclusão: A acupuntura auricular foi efetiva na redução da dor de pacientes em tratamento quimioterápico. Registro Brasileiro de Ensaios Clínicos: RBR-6k3rqh.

The Association between Patient Characteristics and Opioid Treatment Response in Neuropathic and Nociceptive Pain due to Cancer

BACKGROUND

Cancer pain remains a difficult problem, for which opioids are often necessary. At present it is difficult to predict the effectiveness of opioid therapy.

OBJECTIVES

We aim to assess the association between patient characteristics and opioid treatment response in cancer patients, and develop a model to predict probability of response.

SUBJECTS

We used data from two previously published randomized clinical trials, in which patients with head and neck cancer were treated with fentanyl or methadone (total N = 134).

MEASUREMENTS

Treatment success was defined as ≥50% pain reduction at one and five weeks. We analyzed patient characteristics (age, sex, depression, and anxiety), treatment characteristics (having had chemotherapy, radiotherapy, surgery, methadone, or fentanyl) and pain characteristics (neuropathic and nociceptive).

DESIGN

Based on univariable and multivariable regression analyses determinants of therapy success were assessed. Based on these analyses a prediction model was developed.

RESULTS

Our analyses show that one-week therapy success was associated with methadone (odds ratio [OR] = 5.21), duration of pain in months (OR = 1.12), neuropathic pain (OR = 3.36), and age of the patient in years (OR = 0.95). Inclusion of these four characteristics into our prediction model resulted in an area under the curve of 81.6%.

CONCLUSIONS

Careful analyses of patient attributes, treatment, and pain type of patients with head and neck cancer resulted in a prediction model that allowed to predict short-term pain relief and the opioid treatment response in neuropathic and nociceptive pain owing to cancer.

Neurological Symptoms in Palliative Care Patients

Background

Neurological expertise in palliative care may be required not only for patients with primary neurological disorders but also for patients with non-neurological diseases suffering from burdensome neurological symptoms. The aim of this study was to determine the prevalence of neurological diagnoses and symptoms in palliative care patients, as well as the related burden and impact on everyday life.

Methods

We analyzed retrospectively the medical records of 255 consecutive patients from a tertiary medical center, at the time point of referral to an inpatient palliative care consultation service. In addition, 100 patients prospectively answered a questionnaire which included the assessment of neurological symptoms, as well as numeric rating scales for quality of life, symptom-specific burden, and restrictions in everyday life.

Results

Forty-one patients (16%) suffered from a primary neurological disease. Most decisions regarding the termination of life-sustaining measures concerned this group (20/22, 91%). Neurological symptoms (excluding pain) were documented in 122 patients (48%) with an underlying non-neurological disease. In the questionnaire study, 98/100 patients reported at least one neurological or neuropsychiatric symptom, most frequently sleeping problems (N = 63), difficulty concentrating (N = 55), and sensory symptoms (N = 50). Vertigo/dizziness (N = 19) had the greatest impact on everyday life (7.57/10 ± 2.17) and the highest symptom-specific burden (7.14 ± 2.51). Difficulty concentrating (restrictions in everyday life/burden) and pain intensity were the only symptoms significantly correlated with quality of life (r = -0.36, p = 0.009/r = -0.32; p = 0.04; r = -0.327, p = 0.003).

Conclusion

Neurological diseases and symptoms are frequent among palliative care patients and are often associated with a high symptom burden, which may severely affect the patients' lives. It is thus of paramount importance to implement neurological expertise in palliative care.

Challenges and concerns of persistent opioid use in cancer patients

INTRODUCTION

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

Morphine as a suspect of aiding the propagation of cancer cells

Controlling pain in cancer patients is important for several reasons including patient quality of life (QOL). In moderate-to-severe cancer-pain management, opioid analgesics are indispensable. Among these, morphine is the most representative. Unfortunately, many studies have shown that morphine is potentially associated with cancer growth, recurrence, and metastasis. Specifically, in animal as well as in vivo and in vitro studies, morphine has been demonstrated to have possibly positive effects on cancer progression. However, those effects have not yet been confirmed as entirely harmful, for several reasons: the results of animal and laboratory research have not been subjected to clinical trials; there are as yet no well-designed clinical studies, and indeed, some studies have shown that morphine can have negative, suppression effects on tumor growth. This review paper will present some of the data on the potentially positive relationships between morphine and cancer. It should not be forgotten, though, that such relationships remain controversial, and that pain itself promotes cancer progression.

Going beyond prescription pain relievers to understand the opioid epidemic: the role of illicit fentanyl, new psychoactive substances, and street heroin

The opioid epidemic is associated with morbidity and mortality, and it has taken a vast toll on American society. While prescription opioid abuse is part of the opioid problem, it is by no means the entirety of it. Opioid abuse appears to have entered a technology-driven new world of clandestine labs all over the globe and many new synthetic analog, counterfeit, and adulterated drugs that arrive via the internet faster than the Drug Enforcement Administration (DEA) can catalog and outlaw them. To deal with opioid abuse, it must be recognized that it is more - far more - than a subset of chronic pain patients who become addicted. Indeed, to reduce the opioid epidemic to this population is to misunderstand it. The opioid epidemic involves illicit opioids, counterfeit opioids, new psychoactive substances, diverted opioids, and prescription opioids. The objective of this narrative review is to consider the roles of all substances that contribute to the opioid epidemic in America.