Diagnosing Neuropathic Pain in Patients with Cancer: Comparative Analysis of Recommendations in National Guidelines from European Countries

A Delphi Study on the Management of Neuropathic Cancer Pain in Spain: The DOLNEO Study

Purpose

The objectives of this project were to assess the current situation and management of cancer-related neuropathic pain (CRNP) in Spain and to provide specific recommendations for the assessment, diagnosis and treatment of CRNP using a Delphi methodology.

Methods

This was a qualitative study that followed a Delphi methodology using a questionnaire with 56 statements that were grouped into 5 areas related to CRNP: prevalence and impact, pathophysiology, assessment and diagnosis, specific syndromes, treatment, and multidisciplinary approach. Based on the responses, the scientific committee prepared an algorithm and a recommended pathway for the management of CRNP.

Results

Seventy-nine physicians attended the meeting and completed the questionnaire. Consensus was reached for all statements relating to the prevalence and impact of CRNP. However, the perceptions of specialists from palliative care of the frequency and impact of CRNP differed from those of other specialists. A high degree of consensus was reached for all statements concerning the assessment and diagnosis of CRNP. Regarding specific syndromes, the only statement with a lack of consensus was that on the frequency of NP in patients undergoing radiotherapy. There were some disagreements regarding the multidisciplinary approach and referral criteria for the management of NP.

Conclusion

Our results show a large degree of agreement on the assessment, diagnosis and treatment of cancer-related neuropathic pain among the specialists involved in its management. There were, however, some disagreements regarding the multidisciplinary approach and referral criteria for the management of neuropathic pain.

Prospective case series of neuropathic cancer pain in patients treated with an EGFR-inhibitor

BACKGROUND

Novel treatments of neuropathic pain are urgently needed. Rapid relief of neuropathic cancer pain in patients treated with epidermal growth factor receptor (EGFR) inhibitors have been reported. Experiments in rodent models confirm the pain relief and reveal novel mechanisms critically involving the EGFR. Clinical pain research is complicated and patients with advanced cancer are heterogeneous, often with complex, deteriorating clinical pictures, hampering feasibility of drug-trial procedures.

ACTUAL CASE

Prospective case series exploring the EGFR inhibition/neuropathic cancer pain association in order to inform planning clinical trials.

POSSIBLE COURSES OF ACTION

Symptom assessment method was tailored to what was ethical, feasible, and clinically relevant for each patient.

FORMULATION OF A PLAN

Patients with neuropathic cancer pain treated off-label with the monoclonal antibody panitumumab were studied to assess feasibility of different measurement tools.

OUTCOME

Fourteen of 20 patients (70%) experienced clinically significant pain relief. There was good concordance in patient and physician-reported outcomes.

LESSONS

Results support panitumumab's potential to be of significant benefit to patients with refractory neuropathic cancer pain. Findings also reinforce the difficulty of using conventional drug trial endpoints and designs in this population.

VIEW

Innovative research methods must be considered for much needed pivotal trials.

A prospective, multicenter, open-label study of the clinical efficacy of tapentadol extended-release in the treatment of cancer-related pain and improvement in the quality of life of opioid-naïve or opioid-resistant patients

Purpose

This study aimed to investigate the clinical efficacy of tapentadol extended-release (ER) on pain control and the quality of life (QoL) of patients with moderate to severe chronic cancer pain in clinical practice in Korea.

Methods

In this prospective, open-label, multicenter trial, patients with sustained cancer pain as well as chronic pain, who were or were not using other analgesics were enrolled. Thirteen centers recorded a total of 752 patients during the 6-month observation period, based on the tapentadol ER dose and tolerability, prior and concomitant analgesic treatment, pain intensity, type of pain, adverse effects, and clinical global impression change (CGI-C). Of those 752 patients, 688 were enrolled, and 650 completed the study for efficacy and adverse drug reactions; among them, 349 were cancer patients.

Results

Tapentadol ER significantly reduced the mean pain intensity including neuropathic pain during the observation period by 2.9 points (from a mean 7 ± 0.87 to 4.1 ± 2.02). Furthermore, QoL was observed to be significantly improved based on the CGI-C, an objective measure.

Conclusion

This study showed that tapentadol ER was effective for treating patients with moderate to severe cancer pain and neuropathic pain, and therefore it significantly improved the patients’ QoL.

WITHDRAWN: Neuropathic Cancer Pain in Patients Treated With an EGFR-Inhibitor

This article has been withdrawn because of a publisher error. It should not have been posted.

Clinical practice guidelines for cancer pain: problems and solutions

PURPOSE OF REVIEW

Clinical practice guidelines (CPGs) should allow practitioners to follow the best evidence-based management for patients. The increasing specialisation of medicine and pain medicine has increased the number of CPGs, but practitioners are still facing contradictory advice that can be difficult to implement and follow.

RECENT FINDINGS

A recent comprehensive metareview of 25 reviews have highlighted that the same issues of quality, barriers to implementation and difficulties in applicability are as prevalent as they were years ago when assessment tools (e.g. AGREE II) and recommendations for CPG development were introduced. There remains a lack of consistency of recommendations and quality of evidence for CPGs in cancer pain that impedes the ability to provide the 'best' management for patients.

SUMMARY

Even the most renowned and apparently high-quality CPGs in many specialities, including cancer pain, still are potentially deficient especially in terms of applicability, implementation, and transparency of conflicts of interest. Despite the increased scrutiny, in part related to the opioid crisis, the situation has not changed. The development of CPGs should engender collaboration with multiple stakeholder groups and focus on transparency and facilitating implementation.

Pain prevalence and treatment in patients with metastatic bone disease

The accomplishment of successful pain treatment requires evaluation, characterization and quantification. The present study characterized pain and survival in a cohort of patients with cancer with bone metastasis who were treated with intravenous bisphosphonates. A total of 84 patients self-completed the Brief Pain Inventory (BPI) and 36-Item Short Form Survey (SF-36), between November 2010 and March 2011 with a 5-year survival follow-up as a surrogate marker of cancer burden. The median age was 62 years old (34–85), 64% of patients were female and 58% of these females had breast cancer. In the population, self-reported pain was 91.6%, with 29 patients (34.5%) reporting severe pain (score 7–10). Among these patients, only 13 (44.8%) presented a similar report to that of their clinical files and 5 were undergoing treatment with strong opioids (17.2%). A total of 45 patients (46%) had not been prescribed analgesic drugs, of these patients, 32 were treated with a weak opioid, and 13 with a strong opioid. An association was observed between pain records and the prescribed analgesic (P=0.031). BPI maximum pain and overall survival data were analyzed, and a significant association was identified between male patients presenting severe pain and decreased survival (P=0.004). Male survival was associated with severe pain, which is consistent with other data. The results revealed a skeletal-related events (SRE)-free survival (time elapsed from diagnosis of the first bone metastasis to the first SRE) of 9 months (4.39–13.73, 95% CI) with a statistically significant difference between subgroups of time since diagnosis of bone metastasis (P=0.005). The added value of the present study is the suggestion that complete and accurate pain narratives are mandatory and may contribute to the optimization of analgesia, and may help to increase survival rates. Optimal pain management for patients with cancer remains an urgent requirement.

Cancer-Related Neuropathic Pain: Review and Selective Topics

Neuropathic pain is the result of neuroplastic and neuroinflammatory changes from trauma or diseases that damage the somatosensory system. Cancer-related neuropathic pain is caused by treatment, cancer, or paraneoplastic reactions to cancer. Approximately 30% of patients with cancer have neuropathic pain, mostly mixed nociceptive and neuropathic pain. History, physical examination, quantitative sensory testing, skin punch biopsies, and functional MRIs help to divide pain into phenotypes that may facilitate analgesic choices. Guidelines for treating cancer-related neuropathic pain are not consistent and are highly dependent on trials in patients without cancer. Combinations of analgesics are promising, whereas evidence for cannabinoids is meager.

Cancer Pain With a Neuropathic Component: A Cross-sectional Study of Its Clinical Characteristics, Associated Psychological Distress, Treatments, and Predictors at Referral to a Cancer Pain Clinic

CONTEXT

In patients with cancer pain, identifying a neuropathic pain component (NPC) may inform the selection of subsequent therapeutic interventions.

OBJECTIVES

The objective of this study was to determine the prevalence, clinical characteristics, associated psychological distress, pre-referral treatment, and predictors of cancer pain with an NPC in patients referred to a cancer pain clinic.

METHODS

Participants had standard assessments and documentation: Brief Pain Inventory ratings, presence of an NPC, based on a Douleur Neuropathique 4 (DN4) (neuropathic pain screening scale) score ≥4 combined with a physician's clinical assessment (blinded to DN4 result), the Hospital Anxiety Depression Scale, and Emotion Thermometer scores. Logistic regression analyses were used to determine predictors associated with an NPC.

RESULTS

Of 371 study participants, 120 (32.3%) had a designated NPC. Overall, psychological distress indices were similar in the NPC and nociceptive pain groups, except for a Hospital Anxiety and Depression Scale >7 score that was proportionately higher (74% vs. 63%, P = 0.03) in the nociceptive group. The final multivariable logistic regression model generated the following NPC predictors and their respective odds ratios (95% CIs): recent chemotherapy, 2.93 (1.63-5.26); recent surgery, 3.65 (2.03-6.59); adjuvant analgesic use, 2.93 (1.66-5.17); episodic incident pain, 2.63 (1.44-4.84); episodic breakthrough pain, 3.67 (2.00-6.73); pain duration three or more months, 2.35 (1.36-4.06); higher pain intensity, 1.47 (1.24-1.74); and pelvic or perineal pain location, 2.75 (1.09-6.96).

CONCLUSION

One in three patients with cancer have an NPC, which is independently associated with recent chemotherapy, surgery, adjuvant analgesic use, episodic incident and breakthrough pain, longer pain duration, higher pain intensity, and pelvic or perineal pain location.

Tapentadol in neuropathic pain cancer patients: a prospective open label study

Many chemotherapy treatments induce peripheral neuropathy (CIPN). These patients often experience neuropathic pain (NP) that reduces the quality of life. The aim of this prospective, open label study was to evaluate the efficacy and tolerability of tapentadol (TP) in patients affected by CIPN. CIPN were consecutively enrolled in a prospective open label study at the Neuro-Oncology Unit of the Regina Elena National Cancer Institute in Rome. During the titration phase, each patient initially received doses of TP 50 mg twice a day. All patients underwent pain intensity (NRS) and DN4. For evaluation of quality of life, patients underwent EORTC QLQ-C30 and EORTC QLQ-CIPN2 QLQ-CIPN20. We enrolled 31 patients, 19 were females with a median age of 60 years. After 3 months of treatment with TP, 22 patients completed the statistical package for social sciences (SPSS). Nineteen patients out of 22 showed a response to treatment (86%). We also observed that TP reduced the NRS and DN4 values from baseline to the last visit in a significant way (p < 0.001, respectively). Seven patients (22.5%) discontinued the TP therapy after the first week of occurrence of side effects. Furthermore, we observed that TP improved also the global health status measured by EORT QLQ-C30. TP is well tolerated and efficacy in the treatment of NP. The important reduction of neuropathic pain, the improvement in NRS and QoL scores after therapy with TP makes it a candidate in the management of patients suffering from neuropathic pain of CIPN also as a first line of therapy.

Prospective study of neuropathic pain after definitive surgery for extremity osteosarcoma in a pediatric population

BACKGROUND

Neuropathic pain (NP) after definitive surgery for extremity osteosarcoma (OS) has not been previously characterized. This study prospectively investigates the incidence, duration, and treatment of NP in limb sparing surgery and amputation groups.

PROCEDURE

In patients treated for OS on a chemotherapy and definitive surgery (limb sparing vs. amputation) protocol (OS08), we prospectively collected the following data: (i) demographical data (age, sex, race); (ii) NP time of onset and duration; and (iii) dose (starting, maximum) and duration of gabapentin, amitriptyline, and methadone treatment.

RESULTS

Thirty-seven patients underwent 38 definitive surgeries: limb sparing (26, 68.4%) or amputations (12, 31.6%). Localization included lower extremity (30, 81%), upper extremity (6, 16%), or pelvis (1, 3%). Thirty patients (81%) developed NP and 26 of them required NP-specific medications (87.7%). The mean [standard deviation (SD)] duration of NP was 6.5 weeks (7.2) (median 4.4, range 0.3-29.9). All 26 patients (27 surgeries) treated with NP medications received gabapentin, either as single therapy (65.4%) (17 patients, 18 surgeries), dual therapy with gabapentin and amitriptyline (five patients), or triple therapy with gabapentin, amitriptyline, and methadone (four patients). The mean starting (maximum) doses of gabapentin, amitriptyline, and methadone (mg/kg/day) were 20.2 (43.8), 0.5 (0.7), and 0.3 (0.3), respectively. The incidence and duration of NP, duration of treatment, and NP-specific dose regimens were similar in the limb sparing and the amputation groups.

CONCLUSIONS

NP after definitive surgery for OS is frequently encountered, can persist for a significant time, and NP outcomes are similar in limb sparing and amputation groups.

Undertreatment of caner pain

Pain is a burdensome symptom that can commonly exist chronically along the cancer trajectory. Uncontrolled pain will impact on cancer patients' quality of life, even further negatively affect cancer survivors' employment. Based on systemic reviews of studies for past 10 years, the paper reported that although there is enormous advancement on the knowledge of cancer pain and pain management, studies still documented undertreatment of cancer pain globally. Additionally, pain distress a significant portion of cancer survivors. The pain in cancer survivors distinct from the pain related with cancer, instead emphasize on pain related with cancer treatment, such as neuropathic pain, muscular syndrome. Evidence-based pain management with common pain problems in cancer survivors is lacking. Further studies are needed to understand the pain in cancer survivors and to develop effective strategies in helping cancer survivors to manage their pain.

The role of screening tools in diagnosing neuropathic pain

SUMMARY: 

Neuropathic pain affects 6–8% of the general adult population. It is reported by 27% of chronic pain patients and 40% of cancer patients, yet there is no standardized diagnostic test for neuropathic pain. A number of screening tools have been developed based on verbal pain descriptors, with or without limited clinical examination, to identify individuals with neuropathic pain. Over the past decade these neuropathic pain screening tools have been validated in a wide range of pain populations, as well as translated into many languages, to discriminate between neuropathic and non-neuropathic pain. We describe here the five most commonly used neuropathic pain screening tools and discuss current assessment guidelines, the use of screening tools in novel clinical contexts and their potential use in personalized therapy.