The use of oral transmucosal fentanyl citrate during high-dose-rate gynecologic brachytherapy

Pain in High-Dose-Rate Brachytherapy for Cervical Cancer: A Retrospective Cohort Study

High-dose-rate brachytherapy (HDR) is part of the main treatment for locally advanced uterine cervical cancer. Our aim was to evaluate the incidence and intensity of pain and patients' satisfaction during HDR. Risk factors for suffering pain were also analyzed. A retrospective study was carried out by extracting data from patients who had received HDR treatment for five years. Postoperative analgesia had been administered using pre-established analgesic protocols for 48 h. Pain assessment was collected according to a protocol by the acute pain unit. Analgesic assessment was compared according to analgesic protocol administered, number of needles implanted, and type of anesthesia performed during the procedure. From 172 patients treated, data from 247 treatments were analyzed. Pain was considered moderate in 18.2% of the patients, and 43.3% of the patients required at least one analgesic rescue. Patients receiving major opioids reported worse pain control. No differences were found regarding the analgesic management according to the intraprocedural anesthesia used or the patients' characteristics. The number of inserted needles did not influence the postoperative analgesic assessment. Continuous intravenous infusion of tramadol and metamizole made peri-procedural pain during HDR mild in most cases. Many patients still suffered from moderate pain.

Breakthrough cancer pain in the radiotherapy setting: a systematic and critical review

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.

Effect of Foot Reflexology and Aromatherapy on Anxiety and Pain During Brachytherapy for Cervical Cancer

OBJECTIVES

To determine if the addition of aromatherapy and foot reflexology to the standard of care improves pain and anxiety in patients receiving brachytherapy for cervical cancer.

SAMPLE & SETTING

41 women with locally advanced cervical cancer who received intracavitary brachytherapy as part of their treatment.

METHODS & VARIABLES

Participants were randomized to either the control group, which received the standard-of-care management during brachytherapy, or the intervention group, which received the addition of aromatherapy and foot reflexology to standard of care. Participants rated their pain on a numeric rating scale and anxiety on the State-Trait Anxiety Inventory (STAI) and a numeric rating scale at five different time points.

RESULTS

All average pain and anxiety scores were equal or lower at each key time point for the intervention group. Statistically significant differences were found for the intervention group for anxiety on the numeric rating scale and on the STAI, but only post-reflexology.

IMPLICATIONS FOR NURSING

Nurses and other healthcare providers can be trained to provide reflexology during painful, anxiety-producing procedures to increase patient tolerance of these treatments and overall quality of life.

The experiences of women receiving brachytherapy for cervical cancer: A systematic literature review

OBJECTIVES

To determine women's experiences of brachytherapy for cervical cancer.

KEY FINDINGS

Nineteen studies were included for data extraction/synthesis. Twelve studies focussed on psychological issues, seven on pharmacological aspects of women's experiences. Themes of anxiety, distress, pain, informational needs and non-pharmacological interventions were found. Nine out of ten psychological studies described brachytherapy as a distressing experience causing anxiety and distress for most women. Non-pharmacological interventions were found to be effective and inexpensive adjuncts. Peri and post-operative pharmacological management was variable, but duration of procedure was an important factor.

CONCLUSION

Brachytherapy for gynaecological cancer causes varying levels of pain, anxiety and distress. To improve women's experiences there needs to be better pain management, patient information and the development of non-pharmacological interventions. Future recommendations are to develop clinical support guidelines, audit the quality of services and develop effective interventions to improve women's experiences of brachytherapy for locally advanced cervical cancer.

A phase II study on the efficacy and safety of procedural analgesia with fentanyl buccal tablet in cancer patients for the placement of indwelling central venous access systems

Background

Pain in cancer patients is often related to oncologic therapies and diagnostic procedures. The placement of fully implantable venous access systems is a very common procedure in oncology patients. Local anaesthesia is the method most commonly used to overcome pain related to this surgical procedure, but the local anaesthetic may be unable to completely eradicate all pain. This study investigates the effectiveness and safety of fentanyl buccal tablet (FBT), administered by OraVescent® technology, in reducing procedural pain related to the placement of indwelling central venous access systems (Ports) in opioid-naïve cancer patients.

Methods

Inpatients who required an indwelling vascular access (Port) were preoperatively assessed with a self-assessment questionnaire on anxiety and pain. A 100 μg FBT was administered 10 min before preparation of the operating field. A self-assessment scale for pain experienced during the procedure was administered at the end of the procedure. Vital signs and the presence of any side effects or bothersome symptoms were monitored during the procedure, at the end, and 4 h later.

Results

From October 2012 to June 2014, 65 patients were enrolled in the study. A total of 61 (93.9 %) patients perceived no or a little pain during the procedure. Four patients (6.2 %) reported a lot of pain. No patient reported very severe pain. This data is significant in terms of the lower than expected presence of pain (Fisher test p = 0.0018) as assessed in our previous experience without procedural analgesia. The most common side effects of FBT was drowsiness, experienced by 28 patients at the end of the procedure (43.1 %), significantly reduced (p < 0.01) to 8 patients after 4 h (12.5 %). Nausea was present in 6 cases at the end of the procedure (9.2 %) and in 7 cases 4 h later (10.9 %). Vomiting was present in 3 cases at the end (4.7 %) and in 2 other patients after 4 h (7.8 %). No significant change of vital parameters was observed between the baseline and the subsequent measurements in all patients studied.

Conclusions

The significant improvement in the number of patients experiencing little or no pain, accompanied by a lower number of non-severe side effects, suggests that FBT is a valid, practical and safe method of procedural analgesia. It will be necessary to perform further studies, taking into account the need for standard antiemetic pre-medication to minimise the incidence of nausea and vomiting.

Pain and symptom assessment during multiple fractions of gynecologic high-dose-rate brachytherapy

PURPOSE

A prospective assessment of tolerability of gynecologic brachytherapy was completed to determine adequacy of analgesia and symptom control for patients undergoing CT-guided brachytherapy, with multiple fractions delivered during a single applicator insertion.

METHODS AND MATERIALS

Seventeen patients receiving high-dose-rate brachytherapy for gynecologic cancer (other than vaginal vault) completed ratings of pain intensity, anxiety, and nausea at five key time points before, during, and after brachytherapy. Symptoms were assessed with patient-reported scores using an 11-point numeric rating scale. The patient population included cervical (n=12), endometrial (n=3), and vulvar-vaginal (n=2) malignancies. Patients underwent general anesthesia for applicator placement. Analgesia consisted of subcutaneous route opioid, and oral opioid and/or nonopioid as needed for the duration of the treatment planning and delivery.

RESULTS

The mean scores for pain were highest after patients were transferred to the CT scanner, 3.3±2.6, compared with baseline scores of 0.9±1.7. Pain scores were 2.3±2.3 during the remainder of the procedure, and 2.7±2.1 after the removal of the applicator. The highest mean anxiety scores occurred before the brachytherapy procedure, 4.3±3.4, with resolution of anxiety during the procedure to 1.3±1.6. The mode of nausea scoring during the procedure was 0.

CONCLUSION

For most of the patients, the delivery of multiple fractions of image-guided high-dose-rate brachytherapy is well tolerated with maximum scores of mild-moderate pain and distress, and no significant nausea. This can be accomplished with applicator placement under general anesthesia and standard medical management.