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Bulat E, Crowther JE, Chakravarthy V, Laufer I, Barzilai O, Gulati A. Management of Refractory Cancer Pain with Intrathecal Drug Delivery and Spinal Cord Stimulation. Palliat Med Rep 2024; 5:301-305. [PMID: 39144131 PMCID: PMC11319851 DOI: 10.1089/pmr.2023.0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 08/16/2024] Open
Abstract
Background Intrathecal pumps (ITPs) are indicated for refractory cancer pain and decrease systemic opioid requirements. While not yet indicated for cancer pain, spinal cord stimulators (SCSs) are used off-label for cancer pain, with increasing evidence of their efficacy. Materials and Methods A retrospective chart review was conducted of patients who underwent both ITP and at least SCS trial for cancer pain. Primary outcomes were pain numeric rating scale (NRS) and daily morphine equivalents (MEQs). Results Seventeen patients were identified. Both ITP and SCS were associated with significant decreases in pain ratings at the 3-month follow-up, but this decrease became nonsignificant subsequently. ITP, but not SCS, was associated with a significant decrease in MEQ. Conclusions ITP and SCS may both provide efficacy for cancer pain, but the opioid-sparing effects of SCS may be limited. ITP and SCS may potentially be complementary in their ability to provide relief from cancer-related pain.
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Affiliation(s)
- Evgeny Bulat
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jason E. Crowther
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vikram Chakravarthy
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ilya Laufer
- Department of Neurosurgery, New York University, New York, New York, USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Wang W, Shi Q, Cao Y, Fan B, Yang Y. Intrathecal drug delivery systems for cancer pain: A retrospective analysis at a single tertiary medical center in China. Heliyon 2024; 10:e34522. [PMID: 39114043 PMCID: PMC11305181 DOI: 10.1016/j.heliyon.2024.e34522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/15/2024] [Accepted: 07/10/2024] [Indexed: 08/10/2024] Open
Abstract
Objective Intrathecal drug delivery systems (IDDS) have been clinically applied to treat refractory cancer-related pain for years. In this study, we demonstrate the current clinical practice and outcomes of IDDS for cancer pain management over a 3-year period at a single tertiary medical center in China. Methods Patients who received IDDS implantation for cancer-related pain from 2021 to 2023 were identified. The electronic medical records of all eligible patients were retrospectively reviewed for study data including baseline characteristics, IDDS variables and postoperative clinical outcomes. Results A total of 96 consecutive individuals were identified for analysis and complete follow-up information was available in 72 patients with a follow-up rate of 75 %. Patients were 49.0 % female with a mean age of 62 ± 10 years. The top five cancer types in IDDS population were lung (34.4 %), colorectal (17.7 %), pancreatic (11.5 %), breast (5.2 %) and liver (4.2 %) cancer. The median duration from cancer diagnosis to IDDS implantation was 24 months (interquartile range [IQR] 12-48 months) and from pain onset to IDDS implantation was 6 months (IQR 2-12 months). In addition, the median oral morphine equivalents (OME) daily dose was 290 mg (IQR 100-632 mg). Mean NRS was 7.5 ± 0.8 before implantation and decreased to an average of 3.0 ± 1.1 after IDDS (p < 0.001). Median overall survival after IDDS implantation was 3 months (IQR 2-6 months). Overall, 75 % family members of cancer patients were satisfied with IDDS in relieving cancer pain. Conclusion IDDS therapy is a valuable option for patients suffering from cancer pain. More and more cancer pain patients receive IDDS to treat pain during the 3-year study period.
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Affiliation(s)
- Wen Wang
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Qing Shi
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Yanting Cao
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, China
| | - Bifa Fan
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
| | - Yang Yang
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, China
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Winston GM, Zimering JH, Newman CW, Reiner AS, Manalil N, Kharas N, Gulati A, Rakesh N, Laufer I, Bilsky MH, Barzilai O. Safety and Efficacy of Surgical Implantation of Intrathecal Drug Delivery Pumps in Patients With Cancer With Refractory Pain. Neurosurgery 2024:00006123-990000000-01156. [PMID: 38700319 DOI: 10.1227/neu.0000000000002978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/12/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pain management in patients with cancer is a critical issue in oncology palliative care as clinicians aim to enhance quality of life and mitigate suffering. Most patients with cancer experience cancer-related pain, and 30%-40% of patients experience intractable pain despite maximal medical therapy. Intrathecal pain pumps (ITPs) have emerged as an option for achieving pain control in patients with cancer. Owing to the potential benefits of ITPs, we sought to study the long-term outcomes of this form of pain management at a cancer center. METHODS We retrospectively reviewed medical records of all adult patients with cancer who underwent ITP placement at a tertiary comprehensive cancer center between 2013 and 2021. Baseline characteristics, preoperative and postoperative pain control, and postoperative complication rate data were collected. RESULTS A total of 193 patients were included. We found that the average Numerical Rating Scale (NRS) score decreased significantly by 4.08 points (SD = 2.13, P < .01), from an average NRS of 7.38 (SD = 1.64) to an average NRS of 3.27 (SD = 1.66). Of 185 patients with preoperative and follow-up NRS pain scores, all but 9 experienced a decrease in NRS (95.1%). The median overall survival from time of pump placement was 3.62 months (95% CI: 2.73-4.54). A total of 42 adverse events in 33 patients were reported during the study period. The 1-year cumulative incidence of any complication was 15.6% (95% CI: 10.9%-21.1%) and for severe complication was 5.7% (95% CI: 3.0%-9.7%). Eleven patients required reoperation during the study period, with a 1-year cumulative incidence of 4.2% (95% CI: 2.0%-7.7%). CONCLUSION Our study demonstrates that ITP implantation for the treatment of cancer-related pain is a safe and effective method of pain palliation with a low complication rate. Future prospective studies are required to determine the optimal timing of ITP implantation.
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Affiliation(s)
- Graham M Winston
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Jeffrey H Zimering
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
- Current affiliation: Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York , New York , USA
| | - Christopher W Newman
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Noel Manalil
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Natasha Kharas
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Neal Rakesh
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
- Current affiliation: Department of Neurosurgery, NYU Langone Health, New York , New York , USA
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York , New York , USA
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Minimally Invasive Bleb Surgery for Glaucoma: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2024; 24:1-151. [PMID: 38332948 PMCID: PMC10849035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
Background Glaucoma is the term for a group of eye disorders that causes progressive damage to the optic nerve, which can lead to visual impairment and, potentially, irreversible blindness. Minimally invasive bleb surgery (MIBS) reduces eye pressure through the implantation of a device that creates a new subconjunctival outflow pathway for eye fluid drainage. MIBS is a less invasive alternative to conventional/incisional glaucoma surgery (e.g., trabeculectomy). We conducted a health technology assessment of MIBS for people with glaucoma, which included an evaluation of effectiveness, safety, the budget impact of publicly funding MIBS, and patient preferences and values. Methods We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane Risk of Bias 1.0 tool for randomized controlled trials (RCTs) and the Risk of Bias Assessment tool for Nonrandomized Studies (RoBANS) for comparative observational studies, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We conducted an economic literature search and we estimated the budget impact of publicly funding MIBS in Ontario. We did not conduct a primary economic evaluation due to the limited long-term effectiveness data. We summarized the preferences and values evidence from previous health technology assessments to understand the perspectives and experiences of patients with glaucoma. Results We included 41 studies (2 RCTs and 39 comparative observational studies) in the clinical evidence review. MIBS may reduce intraocular pressure and the number of medications used, but we are uncertain if MIBS results in outcomes similar to trabeculectomy (GRADE: Moderate to Very low). Compared with trabeculectomy, MIBS may result in fewer follow-up visits and interventions, and adverse events (GRADE: Moderate to Very Low). MIBS may also reduce intraocular pressure and the number of antiglaucoma medications used, compared with other glaucoma treatments, but the evidence is uncertain (GRADE: Very low). Our economic evidence review identified two directly applicable studies. The results of these studies indicate that the cost-effectiveness of MIBS is highly uncertain, and the cost of glaucoma interventions are likely to vary across provinces. The annual budget impact of publicly funding MIBS in Ontario ranged from $0.11 million in year 1 to $0.67 million in year 5, for a total 5-year budget impact estimate of $1.93 million. Preferences and values evidence suggests that fear of ultimate blindness and difficulty managing medication for glaucoma led patients to explore other treatment options such as MIBS. Glaucoma patients found minimally invasive glaucoma surgery (MIGS) procedure beneficial, with minimal side effects and recovery time. Conclusions Minimally invasive bleb surgery reduces intraocular eye pressure and the number of antiglaucoma medications needed, but we are uncertain if the outcomes are similar to trabeculectomy (GRADE: Moderate to Very low). However, MIBS may be safer than trabeculectomy (GRADE: Moderate to Very low) and result in fewer follow-ups (GRADE: Moderate to Very low). MIBS may also improve glaucoma symptoms compared with other glaucoma treatments, but the evidence is very uncertain (GRADE: Very low).We estimate that publicly funding MIBS would result in an additional cost of $1.93 million over 5 years. Patients who underwent MIGS procedures found them to be generally successful and beneficial, with minimal side effects and recovery time. We could not draw conclusions about specific MIBS procedures or long-term outcomes.
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Intrathecal Drug Delivery Systems for Cancer Pain: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2024; 24:1-162. [PMID: 38344326 PMCID: PMC10855886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Background Pain is a common and very distressing symptom for adults and children with cancer. Compared with other routes of delivery, infusing pain medication directly into the intrathecal space around the spinal cord may reduce the incidence of systemic side effects and allow for more rapid and effective pain relief. We conducted a health technology assessment of intrathecal drug delivery systems (IDDSs) for adults and children with cancer pain, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding IDDSs, patient preferences and values, and ethical considerations. Methods We performed a systematic literature search of the clinical evidence to retrieve systematic reviews, and we selected and reported results from 2 recent reviews that were relevant to our research questions. We complemented the chosen systematic reviews with a literature search to identify primary studies published after December 2020. We used the Risk of Bias in Systematic Reviews (ROBIS) tool to assess the risk of bias of each included systematic review. We assessed the quality of the body of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-effectiveness analysis comparing IDDSs with standard care (i.e., non-IDDS methods of pain management) from a public payer perspective. We also analyzed the budget impact of publicly funding IDDSs in Ontario. To contextualize the potential value of IDDSs, we spoke with patients with cancer pain and with caregivers of patients with cancer pain. We explored ethical considerations from a review of published literature on the use of IDDSs for the management of cancer pain in adults and children as well as a review of the other components of this health technology assessment to identify ethical considerations relevant to the Ontario context. Results We included 2 systematic reviews (1 on adults and 1 on children) in the clinical evidence review. In adults with cancer pain who have a life expectancy greater than 6 months, intrathecal drug delivery was associated with a significant reduction in pain intensity compared with before implantation up to a 1-year follow-up (GRADE: Moderate to Low). Improved pain management appeared to be maintained beyond a 4-week follow-up. IDDSs likely decrease the use of systemic opioids (GRADE: Moderate to Low). They may also improve health-related quality of life (GRADE: Low), functional outcomes (GRADE: Low), and survival (GRADE: Low to Very low). In children with cancer pain, IDDSs may reduce pain intensity, improve functional outcomes, and improve survival, but the evidence is very uncertain (all GRADEs: Very low). IDDS implantation carries certain rare risks related to mechanical errors, drug-related side effects, and surgical complications. There are inherent limitations in conducting research in patients with refractory cancer pain; therefore, it is unlikely that higher-quality evidence will emerge in the next few years. Our primary economic evaluation found that IDDSs are more effective and more costly than standard care. The incremental cost-effectiveness ratio of IDDSs compared with standard care is $57,314 per quality-adjusted life-year (QALY) gained. The probability of IDDSs being cost-effective versus standard care is 43.46% at a willingness-to-pay of $50,000 per QALY gained and 72.54% at a willingness-to-pay of $100,000 per QALY gained. Publicly funding IDDSs in Ontario would cost an additional $0.27 million per year, for a total of $1.34 million over the next 5 years. The patients with cancer pain and caregivers with whom we spoke described the debilitating nature of cancer pain and the difficulty of finding effective pain management options. Patients with experience of an IDDS spoke of its effectiveness and its positive impact on their quality of life and mental health. Implementing IDDSs for patients with cancer pain raises several ethical and equity considerations related to the experiences and management of cancer pain, how limitations in evidence may entail uncertainties in clinical and health system decision-making, as well as clinical, geographic, and health system access barriers. Conclusions Intrathecal drug delivery likely reduces pain intensity and decreases the use of systemic opioids in adults with cancer pain who have a life expectancy greater than 6 months. It may also improve health-related quality of life, functional outcomes, and survival, although the evidence for survival is very uncertain. The clinical evidence in children with cancer pain is very uncertain. IDDS implantation is reasonably safe. Intrathecal drug delivery is more effective and more costly than standard care. We estimate that funding IDDSs in Ontario will result in additional costs of $0.27 million per year, for a total of $1.34 million over the next 5 years. Considerations related to funding and implementing IDDSs for patients with cancer pain in Ontario will require explicit and focused attention to considerations of equity and access in the diagnosis and management of cancer pain and in the use, clinical uptake, and delivery of IDDS pain management.
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Díaz-Rodríguez D, Fontán-Atalaya IM, Peralta-Espinosa E, Fernández-Torres B. Differences in efficacy and safety between intrathecal infusion devices in cancer pain. Pain Pract 2024; 24:42-51. [PMID: 37493072 DOI: 10.1111/papr.13279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Intrathecal infusion therapy is widely accepted for cancer pain patients when conventional analgesic treatments are not sufficient. There are different types of devices for carrying out this therapy: partially externalized devices (PED), used when life expectancy is under 3 months, and totally implanted devices (TID), when it is larger. Our objective is to compare the efficacy, functionality, and complication rate in both types. METHODS We included 132 patients with mild-severe cancer pain, treated with intrathecal infusion therapy by fixed flow devices, PED, or TID, during the study time. Demographic, physical oncologic, and pain control data of the patients were recorded prior to starting therapy and at months 1, 3, and 6. Functionality status and complications were also collected from the patient's medical records and clinical files. RESULTS Pain control improved after starting therapy, with an overall reduction of 4.75 points in VAS score at 1 month in the both groups, without significant differences between them, keeping it at 3 months and 6. 33.3% of the patients developed complications and were more frequent in the PED group, being catheter dislocation the most common. Patients with TID required more often hospital admission to solve the complication. CONCLUSIONS Intrathecal infusion therapy has been shown to be a very effective and safe therapy for the treatment of moderate to severe oncologic pain. There are no significant differences between PED and TID in terms of degree of pain control, therapeutic success, efficacy on episodic or nocturnal pain, or the presence of serious complications.
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Affiliation(s)
- Diego Díaz-Rodríguez
- Anesthesiology and Reanimation, Pain Unit, Complejo Hospitalario Universitario, A Coruña, Spain
| | | | | | - Bartolomé Fernández-Torres
- Anesthesiology and Reanimation, Hospital Universitario Virgen Macarena, Seville, Spain
- Department of Surgery, Faculty of Medicine, University of Seville, Seville, Spain
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Mahmoud A, Aman MM, Trumbo JL, Paracha U, Langell A, Petersen E. Education and Experience in Intrathecal Drug Delivery Systems (IDDS) During Pain Medicine Fellowships. J Pain Res 2023; 16:4367-4377. [PMID: 38162405 PMCID: PMC10757777 DOI: 10.2147/jpr.s428851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/18/2023] [Indexed: 01/03/2024] Open
Abstract
Objective Targeted drug delivery (TDD) via intrathecal drug delivery systems (IDDS) exposure and clinical adoption remains low despite multiple well-designed trials that demonstrate safety, efficacy, reliability, and cost-saving benefits. This study aims to understand the possible contributing factors starting with Pain Medicine fellowship training. Materials and Methods An internet-based, anonymous pilot survey was distributed to pain medicine fellows enrolled in an Accreditation Council for Graduate Medical Education (ACGME) accredited pain medicine training program during the 2021-2022 academic year. Fellowship programs were identified using published online ACGME accreditation data. The survey was distributed via email to fellowship program directors and coordinators and was made available through pain medicine societies. Results Seventy-one of four hundred and twenty-three pain medicine fellows (17% response rate) completed the survey. Nine percent of respondents evidence-informed opinion coincided with the most recent Polyanalgesic Consensus Conference (PACC) guidelines recommendations for IDDS treatment indications. Fifty-one percent of respondents felt there was an unmet need for IDDS training. About one-third of respondents felt that lack of curriculum, faculty, and cases were barriers to IDDS use, respectively. Thirty-one percent of fellows reported sufficient training for IDDS in their fellowship programs. The majority (70%) of respondents somewhat or strongly support direct training by IDDS manufacturers. Conclusion A wide variability exists surrounding IDDS training during ACGME accredited pain medicine fellowship. Insufficient case exposure and lack of a standardized curriculum may play a role in future therapy adoption. The results from this study call for a more standardized training approach with an emphasis on adequate clinical exposure, utilization of peer reviewed educational curriculum and supplemental material to aid pain medicine fellows' education.
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Affiliation(s)
- Ammar Mahmoud
- Department of Pain Medicine, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | - Mansoor M Aman
- Department of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Jennifer L Trumbo
- Clinical Research Center, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | - Umera Paracha
- Department of Neurology, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | - Ashley Langell
- Department of Pain Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Fernández-Torres B, Fontán-Atalaya IM, Peralta-Espinosa E, Díaz-Rodríguez D. Predictive factors for efficacy and safety of intrathecal infusion devices for oncological pain. Br J Pain 2023; 17:569-578. [PMID: 37974633 PMCID: PMC10642496 DOI: 10.1177/20494637231198231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Introduction In an important percentage of intrathecal infusion therapy, the pain after implantation of a spinal device does not improve. Our objective is to identify factors that can predict therapeutic success and complications, developing a predictive model based on univariate and multivariate analyses. Methods Retrospective observational study, including 132 patients with oncological pain who were implanted with a fixed-flow device for intrathecal infusion. Four time points were established for data collection and, in addition to demographic and anthropometric data, variables related to oncologic pain pathology, initiation of therapy, pain control and complications were collected. Based on univariate and multivariate analyses, we performed predictive models on efficacy and complications. Results The mean baseline pain intensity was VAS 7.78, and when comparing the values before implantation with those at month 1, we observed an overall decrease of 4.75 points, maintained at months 3 and 6. Nocturnal pain progressively decreased in incidence from 50.0% before implantation to 21.8%, 9.1% and 4.3% at 1, 3 and 6 months. Episodic pain was present in 90.1% of the patients before implantation (7.79 episodes/day), and at 6 months the incidence remained at 53.8%. Most of the patients (66.6%) had no complications related to therapy. We constructed a highly significant multivariate model for the efficacy of the therapy with a predictive capacity of 30.2% and composed of factors: absence of nocturnal pain before implantation and clinical improvement on day 2 after implant. Regarding the prediction of complications, it was not possible to achieve a significantly multivariate effective model. Conclusion We identify two factors that predict therapeutic success in a multivariate model: the absence of nocturnal pain before implantation and the improvement of pain on the second day after implantation.
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Affiliation(s)
- Bartolomé Fernández-Torres
- Anesthesiology and Reanimation, Virgen Macarena University Hospital, Sevilla, Spain
- Department of Surgery, Faculty of Medicine, University of Seville, Sevilla, Spain
| | | | | | - Diego Díaz-Rodríguez
- Anesthesiology and Reanimation, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
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Dupoiron D, Autier L, Lebrec N, Seegers V, Folliard C, Patsouris A, Campone M, Augereau P. Intrathecal Catheter for Chemotherapy in Leptomeningeal Carcinomatosis From HER2-Negative Metastatic Breast Cancer. J Breast Cancer 2023; 26:572-581. [PMID: 37704384 PMCID: PMC10761759 DOI: 10.4048/jbc.2023.26.e40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/19/2023] [Accepted: 08/20/2023] [Indexed: 09/15/2023] Open
Abstract
PURPOSE Most oncological treatments for leptomeningeal metastasis (LM) do not cross the blood-brain barrier (BBB). One therapeutic option is intrathecal (IT) chemotherapy. Both the brain-implanted Omaya reservoir and lumbar puncture (LP) are classic routes for IT chemotherapy delivery. An intrathecal catheter (IC) connected to a subcutaneous port is a recently developed option for the management of chemotherapy infusions. It is essential to evaluate the efficacy and safety of chemotherapy infusion using such device. METHODS We conducted a retrospective monocentric study within Institut de cancerologie de l'Ouest at Angers, including all patients with advanced breast cancer (aBC) with LM implanted with an IT device for IT chemotherapy between January 2013 and May 2020. The primary endpoint was overall survival (OS) and secondary endpoints included surgical feasibility, patient safety, and progression-free survival (PFS). The catheter was inserted through an LP, the tip was positioned at the right level and connected to a subcutaneous port implanted under the skin of the anterior thoracic wall. IT chemotherapy is painless and easy for qualified nurses to administer on an outpatient basis. RESULTS Thirty women underwent the implantation. No failures occurred during the procedure. A total of 77% of patients reported no complications after implantation. Only three complications required surgical treatment. The median number of IT chemotherapy courses per patient was 8 (range, 2-27). The tolerance profile for iterative IT chemotherapy was manageable in ambulatory care. With a median follow-up of 76.5 months (95% confidence interval [CI], 11.6-not available), the median OS was 158 days (95% CI, 87-235), and the median PFS was 116 days (95% CI, 58-174). CONCLUSION Infusing chemotherapy using an implanted catheter is an efficient option for managing IT chemotherapy with a good tolerance profile. Patient-reported outcomes for the evaluation of IT chemotherapy toxicity are currently being developed.
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Affiliation(s)
- Denis Dupoiron
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France.
| | - Lila Autier
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France
| | - Nathalie Lebrec
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
| | - Valérie Seegers
- Department of Epidemiology and Biostatistics, Institut de Cancerologie de l'Ouest, Angers, France
| | - Caroline Folliard
- Department of Pharmacy, Institut de Cancerologie de l'Ouest, Angers, France
| | - Anne Patsouris
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France
| | - Mario Campone
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France
| | - Paule Augereau
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France
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Bulat E, Chakravarthy V, Crowther J, Rakesh N, Barzilai O, Gulati A. Exceptional Cases of Spinal Cord Stimulation for the Treatment of Refractory Cancer-Related Pain. Neuromodulation 2023; 26:1051-1058. [PMID: 35941017 PMCID: PMC11256305 DOI: 10.1016/j.neurom.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/05/2022] [Accepted: 06/14/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVES Cancer pain has traditionally been managed with opioids, adjuvant medications, and interventions including injections, neural blockade, and intrathecal pump (ITP). Spinal cord stimulation (SCS), although increasingly used for conditions such as failed back surgery syndrome and complex regional pain syndrome, is not currently recommended for cancer pain. However, patients with cancer-related pain have demonstrated benefit with SCS. We sought to better characterize these patients and the benefit of SCS in exceptional cases of refractory pain secondary to progression of disease or evolving treatment-related complications. MATERIALS AND METHODS This was a single-center, retrospective case series at a tertiary cancer center. Adults ≥18 years old with active cancer and evolving pain secondary to disease progression or treatment, whose symptoms were refractory to systemic opioids, and who underwent SCS trial followed by percutaneous implantation between 2016 and 2021 were included. Descriptive statistics included mean, SD, median, and interquartile range (IQR). RESULTS Eight patients met the inclusion criteria. The average age at SCS trial was 60.0 (SD: ±11.6) years, and 50% were men. Compared with baseline, the median (IQR) change in pain score by numeric rating scale (NRS) after trial was -3 (2). At an average of 14 days after implant, the median (IQR) change in NRS and daily oral morphine equivalents were -2 (3.5) and -126 mg (1095 mg), respectively. At a median of 63 days after implant, the corresponding values were -3 (0.75) and -96 mg (711 mg). There was no significant change in adjuvant therapies after SCS implantation at follow-up. Six patients were discharged within two days after implantation. Two patients were readmitted for pain control within the follow-up period. CONCLUSIONS In patients with cancer-related pain, SCS may significantly relieve pain, reduce systemic daily opioid consumption, and potentially decrease hospital length of stay and readmission for pain control. It may be appropriate to consider an SCS trial before ITP in select cases of cancer-related pain.
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Affiliation(s)
- Evgeny Bulat
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Vikram Chakravarthy
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jason Crowther
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Neal Rakesh
- Pain Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amitabh Gulati
- Pain Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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11
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Ege E, Briggi D, Javed S, Huh A, Huh BK. Risk factors for surgical site infection in advanced neuromodulation pain procedures: a retrospective study. Pain Manag 2023; 13:397-404. [PMID: 37503743 DOI: 10.2217/pmt-2023-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Aim: To assess the effects of diabetes mellitus (DM) and related variables on surgical site infection (SSI) risk in neuromodulation. Methods: This retrospective study followed patients who underwent neuromodulation procedures for at least 9 months to identify postoperative infections. Demographics, clinical characteristics and surgical outcomes were compared. Results: Of 195 cases included, 5 (2.6%) resulted in SSIs. Median HbA1c was significantly higher for the cases with SSIs (8.2 vs 5.6%; p = 0.0044). The rate of SSI was significantly higher among patients with DM (17.9 vs 0%; p = 0.0005), HbA1c≥7% (37.5 vs 0%; p = 0.0009), and perioperative glucose ≥200 mg/dl (40 vs 2.3%; p = 0.0101). Conclusion: DM, elevated HbA1c and perioperative hyperglycemia may all contribute to increased risk of SSIs with neuromodulation procedures.
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Affiliation(s)
- Eliana Ege
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Daniel Briggi
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Saba Javed
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Albert Huh
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Billy K Huh
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA
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12
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Mercadante S. Refractory Cancer Pain and Intrathecal Therapy: Critical Review of a Systematic Review. Pain Ther 2023; 12:645-654. [PMID: 37055698 PMCID: PMC10199986 DOI: 10.1007/s40122-023-00507-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/23/2023] [Indexed: 04/15/2023] Open
Abstract
This critical review assessed the advantages of invasive procedures that were recently included in systematic reviews, to evaluate whether the definition of refractory pain condition was correctly followed to select patients for invasive interventions and to analyze how data were positively interpreted. A total of 21 studies were selected for the purpose of this review. Three were randomized controlled studies, ten were prospective studies, and eight were retrospective studies. Analysis of these studies showed evident lack of proper assessment before implantation for different reasons. These included an optimistic interpretation regarding the outcomes, poor consideration of complications, and inclusion of patients with short survival. Moreover, the indication of intrathecal therapy as a condition in which a patient has failed to respond to multiple therapies provided by a pain or palliative care physician or at sufficient doses for adequate durations, as suggested by a recent research group, has been disregarded. Regretfully, this can discourage the use of intrathecal therapy in patients who are unresponsive to multiple opioid strategies subtrahend a potent means to be used in a very selective population.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90100, Palermo, Italy.
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13
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Whitaker CD, Stone BK, Gregorczyk JA, Alsoof D, Hardacker K, Diebo BG, Daniels A, Basques B. Nonsurgical Interventional Spine Pain Procedures: Outcomes and Complications. JBJS Rev 2023; 11:01874474-202304000-00003. [PMID: 37058581 DOI: 10.2106/jbjs.rvw.22.00235] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
» Nonsurgical interventional spine pain procedures provide an additional treatment option for lower back pain at the traditional bifurcation of conversative vs. operative management. » Transforaminal epidural steroid injections, radiofrequency ablations, intrathecal drug delivery, and spinal cord stimulation were found to be effective and safe techniques when applied to their specific indication. » Thermal annuloplasty and minimally invasive lumbar decompression showed mixed support. » Discography, sacroiliac joint injections, and spinous process spacers lacked sufficient evidence to support efficacy. » Medial branch blocks and facet joint injections were found to be useful diagnostic tools.
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Affiliation(s)
- Colin D Whitaker
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Benjamin K Stone
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Daniel Alsoof
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kyle Hardacker
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Bassel G Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Alan Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Bryce Basques
- Department of Orthopedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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14
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Van Zundert J, Rauck R. Intrathecal drug delivery in the management of chronic pain. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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15
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Zhang Y, Jeske NA. A-kinase anchoring protein 79/150 coordinates α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor sensitization in sensory neurons. Mol Pain 2023; 19:17448069231222406. [PMID: 38073552 PMCID: PMC10722943 DOI: 10.1177/17448069231222406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/30/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
Changes in sensory afferent activity contribute to the transition from acute to chronic pain. However, it is unlikely that a single sensory receptor is entirely responsible for persistent pain. It is more probable that extended changes to multiple receptor proteins expressed by afferent neurons support persistent pain. A-Kinase Anchoring Protein 79/150 (AKAP) is an intracellular scaffolding protein expressed in sensory neurons that spatially and temporally coordinates signaling events. Since AKAP scaffolds biochemical modifications of multiple TRP receptors linked to pain phenotypes, we probed for other ionotropic receptors that may be mediated by AKAP and contribute to persistent pain. Here, we identify a role for AKAP modulation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic Acid Receptor (AMPA-R) functionality in sensory neurons. Pharmacological manipulation of distinct AMPA-R subunits significantly reduces persistent mechanical hypersensitivity observed during hyperalgesic priming. Stimulation of both protein kinases C and A (PKC, PKA, respectively) modulate AMPA-R subunit GluR1 and GluR2 phosphorylation and surface expression in an AKAP-dependent manner in primary cultures of DRG neurons. Furthermore, AKAP knock out reduces sensitized AMPA-R responsivity in DRG neurons. Collectively, these data indicate that AKAP scaffolds AMPA-R subunit organization in DRG neurons that may contribute to the transition from acute-to-chronic pain.
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Affiliation(s)
- Yan Zhang
- Department of Oral and Maxillofacial Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Nathaniel A Jeske
- Department of Oral and Maxillofacial Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
- Department of Pharmacology, University of Texas Health San Antonio, San Antonio, TX, USA
- Department of Physiology, University of Texas Health San Antonio, San Antonio, TX, USA
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16
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Giglio M, Preziosa A, Mele R, Brienza N, Grasso S, Puntillo F. Effects of an Intrathecal Drug Delivery System Connected to a Subcutaneous Port on Pain, Mood and Quality of Life in End Stage Cancer Patients: An Observational Study. Cancer Control 2022; 29:10732748221133752. [PMID: 36281899 PMCID: PMC9607974 DOI: 10.1177/10732748221133752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In cancer patients with limited life expectancy, an implant of an intrathecal (IT) drug delivery system connected to a subcutaneous port (IDDS-SP) has been proposed as a successful strategy, but conflicting results are reported on quality of life (QoL). The aim of this prospective observational study is to report the effects on pain, mood and QoL of an IT combination therapy delivered by an IDDS-SP in malignant refractory pain. METHODS Adult patients in which IT therapy was recommended were recruited. An IT therapy with morphine and levobupivacaine was started: VASPI score, depression and anxiety (evaluated by the Edmonton Symptom Assessment System -ESAS-), the Pittsburgh Sleep Quality Index (PSQI), the 5-level EuroQol 5D version (EQ-5D-5L) and the requirements of breakthrough cancer pain (BTcP) medications were registered, with adverse events rate and the satisfaction of patients scored as Patient Global Impression of Change (PGIC). RESULTS Fifty patients, (16 F/34 M) were enrolled (age 69 ± 12). All had advanced cancer with metastasis. The median daily VASPI score was 75, the median depression score was 6, and the median anxiety score was 4, median PSQI was 16. At 28 days, a significant reduction in VASPI score was registered as well as in depression and anxiety item. Also, PSQI decreased significantly. The EQ-5D-5 L showed a significant improvement in all components at 14 and 28 days. Patient Global Impression of Change scores showed high level of satisfaction. A low incidence of adverse events and a reduction in BTCP episodes were also registered. CONCLUSION Intrathecal combination therapy delivered by an IDDS-SP could ensure adequate control of cancer related symptoms, such as pain, depression, anxiety and sleep disturbances. These effects, with low rate of AEs and reduced BTcP episodes, could explain the improvement in QoL and the overall high levels of patients' satisfaction.
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Affiliation(s)
- Mariateresa Giglio
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Angela Preziosa
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Roberta Mele
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy
| | - Nicola Brienza
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, University of Bari “Aldo Moro”, Bari, Italy
| | - Filomena Puntillo
- Anaesthesia, Intensive Care and Pain Unit, Policlinico Hospital, Bari, Italy,Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy,Filomena Puntillo, Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”. Anaesthesia, Intensive Care and Pain Unit, Piazza G. Cesare 11, 70124 Bari, Italy.
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17
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Lambe T, Duarte R, Eldabe R, Copley S, Kansal A, Black S, Dupoiron D, Eldabe S. Ziconotide for the Management of Cancer Pain: A Budget Impact Analysis. Neuromodulation 2022:S1094-7159(22)01255-7. [PMID: 36202713 DOI: 10.1016/j.neurom.2022.08.458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Recent recommendations on starting dose, smaller dose increments, and longer intervals between dose increase have the potential to increase the safety of ziconotide administration in addition to improving its value for money. Ziconotide is not routinely commissioned in England, with one of the concerns being whether it represents the best use of resources. The aim of this project is to conduct a budget impact analysis to estimate the costs or savings associated with the changes in ziconotide dosage in addition to its use in combination with morphine for the management of cancer pain. MATERIALS AND METHODS An open, Markov-like cohort decision analytic model was developed to estimate the budget impact of ziconotide in combination with morphine (ziconotide combination therapy) vs morphine monotherapy through intrathecal drug delivery (ITDD) for the management of cancer pain. The perspective adopted was that of the UK National Health Service, with a five-year time horizon. Sensitivity analyses were conducted to evaluate different scenarios. RESULTS Ziconotide combination therapy was more expensive than treatment with morphine monotherapy. The total costs of ziconotide combination therapy and morphine monotherapy for the first year were £395,748 and £136,628 respectively. The estimated five-year cumulative budget impact of treatment with ziconotide combination therapy for the five-year time horizon was £2,487,539, whereas that of morphine monotherapy was £913,804. The additional costs in any of the first five years are below the resource impact significance level of £1 million for medical technologies in England. CONCLUSIONS The results of this budget impact analysis suggest that although a combination of intrathecal ziconotide in combination with morphine is associated with higher costs to the health care system in England, the incremental costs are not significant. Routine commissioning of ziconotide alone or in combination with morphine would provide an alternative for a population with limited ITDD treatment options.
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18
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Allam AK, Larkin Michael MB, Shofty B, Viswanathan A. Ablation Procedures. Neurosurg Clin N Am 2022; 33:339-344. [PMID: 35718404 DOI: 10.1016/j.nec.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although ablation has a limited role in the management of chronic noncancer pain, ablation continues to help patients with treatment of refractory cancer-related pain. Interdisciplinary treatment involving supportive care, pain medicine, oncology, and neurosurgery is critical to optimizing the timing and outcome of neurosurgical ablative options for pain management. In this review, 3 targets for ablative surgery-the spinothalamic tract, the dorsal column's visceral pain pathway, and the anterior cingulate cortex-are discussed with a focus on patient selection and key aspects of surgical technique.
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Affiliation(s)
- Anthony Kaspa Allam
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX 77030, USA
| | - M Benjamin Larkin Michael
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX 77030, USA
| | - Ben Shofty
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX 77030, USA
| | - Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX 77030, USA.
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19
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Joseph A, Bendel M, Moeschler S. Infected Intrathecal Pump Exchange with Preservation of Original Catheter in a Cancer Patient. PAIN MEDICINE 2022; 23:1915-1920. [PMID: 35595252 DOI: 10.1093/pm/pnac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/14/2022] [Accepted: 05/11/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Amira Joseph
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Markus Bendel
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan Moeschler
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota
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20
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Ericson T, Singla P, Kohan L. Intrathecal Pumps. Phys Med Rehabil Clin N Am 2022; 33:409-424. [DOI: 10.1016/j.pmr.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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21
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Effectiveness and Safety of Intrathecal Drug Delivery Systems for the Management of Cancer Pain: A Systematic Review and Meta-Analysis. Neuromodulation 2022:S1094-7159(22)00563-3. [PMID: 35422368 DOI: 10.1016/j.neurom.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Intrathecal drug delivery systems (IDDS) and spinal cord stimulation (SCS) have been proposed and assessed for the management of cancer pain; however, such treatments remain underused. We conducted a systematic review to evaluate the effectiveness and safety of IDDS and SCS for cancer pain. MATERIALS AND METHODS Electronic databases MEDLINE, CENTRAL, EMBASE, and WikiStim were searched from 1988 to March 2021. Randomized controlled trials and observational studies of adults with pain related to cancer or its treatment who received an implantable IDDS or SCS were eligible for inclusion. The primary outcome of the review was change in pain intensity from baseline to the last available follow-up, measured using a visual analog scale or numerical rating scale. The protocol for this review is registered on PROSPERO (CRD42021240717). RESULTS A total of 22 studies (24 reports) included a total of 3043 participants who received either IDDS or SCS for cancer pain. Eight studies reporting data for 405 participants with an IDDS could be included in the meta-analysis of pain intensity that showed a statistically significant reduction at the latest posttreatment follow-up time compared with baseline (mean difference [MD], -3.31; 95% CI, -4.18 to -2.45; p < 0.001). Six studies reporting data for 325 participants with an IDDS could be included in the meta-analysis of pain intensity that showed a statistically significant reduction up to one month after treatment compared with baseline (MD, -3.53; 95% CI, -4.06 to -3.00; p < 0.001). A meta-analysis including studies of participants with either an IDDS or an SCS device showed similar results. Improvements in other outcomes following implantation of IDDS also were observed. Postdural puncture headache was the most reported complication, whereas urinary retention, nausea, and vomiting were commonly reported side effects. CONCLUSION Our findings suggest that IDDS is effective in reducing pain intensity for patients with cancer pain when compared with pretreatment.
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22
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Le-Short C, Katragadda K, Nagda N, Farris D, Gelter MH. Interventional Pain Management for the Pediatric Cancer Patient: A Literature Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030389. [PMID: 35327761 PMCID: PMC8947062 DOI: 10.3390/children9030389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/15/2022] [Indexed: 04/08/2023]
Abstract
This literature review examines the use of interventional treatments for pain management in pediatric cancer patients. While interventional procedures may be effective in cancer pain management, these procedures are infrequently employed in pediatric cohorts. This underutilization of interventional procedures may be supported by a deficit in randomized, controlled studies and literature regarding their role in pediatric cancer populations. Particularly because literature on the efficacy of interventional treatments in adult populations may not directly translate to pediatric populations, more research about the role of interventional procedures in managing pediatric cancer pain is necessary for a strengthened understanding of pediatric cancer pain treatment.
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Affiliation(s)
- Christina Le-Short
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.F.); (M.H.G.)
- Correspondence:
| | - Kavya Katragadda
- Institute of Society and Genetics, The University of California, Los Angeles, CA 90095, USA;
| | - Neil Nagda
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA;
| | - David Farris
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.F.); (M.H.G.)
| | - Marianne Halphen Gelter
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.F.); (M.H.G.)
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23
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Du K, Feng X, Xie H, Wu W. To Inadvertent Vascular Placement of an Intrathecal Catheter: A Case Report. A A Pract 2022; 16:e01557. [PMID: 35050904 DOI: 10.1213/xaa.0000000000001557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Intrathecal drug delivery systems (IDDS) are a treatment option for patients with chronic nonmalignant pain and cancer pain. In this case report, we describe a patient in whom an intrathecal catheter was implanted into a blood vessel rather than into the subarachnoid cavity. A contrast agent was administered, and digital subtraction angiography (DSA) imaging suggested that the catheter was inserted into a blood vessel. The anterior spinal arteries and veins were verified on the ventral side of the spinal cord without interruption. To our knowledge, this is the first report of implantation of an IDDS catheter into a blood vessel.
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Affiliation(s)
- Kairong Du
- From the Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China
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24
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Perruchoud C, Dupoiron D, Papi B, Calabrese A, Brogan SE. Management of Cancer-Related Pain With Intrathecal Drug Delivery: A Systematic Review and Meta-Analysis of Clinical Studies. Neuromodulation 2022:S1094-7159(21)06969-5. [PMID: 35088743 DOI: 10.1016/j.neurom.2021.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite increased attention paid to assessment and management, pain continues to be a prevalent and undertreated symptom in patients with cancer. Intrathecal drug delivery (IDD) is a therapeutic option that allows targeted delivery of analgesics to the intrathecal space. OBJECTIVE The aim of this review was to examine the efficacy of managing cancer-related pain with IDD. Secondary objectives included the effects of IDD on systemic opioid use and infection rates. EVIDENCE REVIEW A systematic search of the literature published between 1990 and 2019 was performed to identify studies evaluating the efficacy and/or safety of IDD with external or implanted pumps in patients with cancer-related pain. Data were extracted and meta-analyses performed to determine the mean changes in pain levels at short-, mid-, and long-term intervals; changes in opioid (oral morphine equivalent [OME]) daily dose; and infection rates. Changes were assessed compared with baseline. FINDINGS Pain levels were decreased from baseline: On a 0 to 10 scale, mean differences were -4.34 (95% CI [-4.93 to -3.75], p < 0.001) at 4 to 5 weeks; -4.34 (95% CI [-5.07 to -3.62], p < 0.001) at 6 to 12 weeks; and -3.32 (95% CI [-4.60 to -2.04], p < 0.001) at >6 months. Weighted mean OME consumption was reduced by 308.24 (SE = 22.72) mg/d. Weighted mean infection rates were ∼3% for external and implanted pumps. CONCLUSIONS Meta-analyses show a statistically significant and sustained decrease in cancer pain with IDD, compared with baseline. Systemic opioid consumption was reduced on average by >50% after IDD. Infection rates were comparable with other indications.
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25
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Nelson AM, Jericho BG, Anitescu M. Pump IT Up-Perioperative Care of Patients With Intrathecal Drug Delivery Systems. Anesth Analg 2022; 134:32-34. [PMID: 34908544 DOI: 10.1213/ane.0000000000005821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ariana M Nelson
- From the Department of Anesthesiology and Perioperative Medicine, University of California Irvine School of Medicine, Irvine, California
| | - Barbara G Jericho
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois
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26
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Schultz DM, Abd‐Elsayed A, Calodney A, Stromberg K, Weaver T, Spencer RJ. Targeted Drug Delivery for Chronic Nonmalignant Pain: Longitudinal Data From the Product Surveillance Registry. Neuromodulation 2021; 24:1167-1175. [PMID: 33449428 PMCID: PMC8597001 DOI: 10.1111/ner.13353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/12/2020] [Accepted: 12/07/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To assist in assessment of therapy risks and benefits of targeted drug delivery (TDD) for chronic nonmalignant pain using registry data on product performance, adverse events, and elective device replacement. MATERIALS AND METHODS The Product Surveillance Registry (PSR) (NCT01524276) is an ongoing prospective, long-term, multicenter registry enrolling consented patients implanted with an intrathecal drug delivery system. Patients are followed prospectively with participating investigators providing pump and catheter performance data for events related to the device, procedure, and therapy. Event descriptions include patient symptoms and outcomes. RESULTS Registry data from the 4646 patients (59.7% female) treated with TDD for chronic, nonmalignant pain at 59 registry sites between August 2003 and October 2019, with over 17,000 patient-years (4646 patients with 44 months average follow-up), were analyzed. Registry discontinuation was largely (46.2% of discontinued patients) due to study site closure and patient death; exit due to an adverse or device event was limited to 10.2%. CONCLUSIONS Treating chronic pain with escalating doses of strong systemic opioids often leads to inconsistent pain control, impaired function, untenable side effects, and reduced quality of life and this practice has contributed to the current opioid crisis in the United States. TDD has been an available therapy for these patients for greater than 30 years, and data from this real-world registry offer supporting evidence to the long-term safety of this therapy as an alternative to systemic opioids, as well as insights into patient acceptance and satisfaction.
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Affiliation(s)
| | - Alaa Abd‐Elsayed
- Department of AnesthesiologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWIUSA
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27
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Abstract
Recent decades have demonstrated significant strides in cancer screening, diagnostics and therapeutics. As such there have been dramatic changes in survival following a diagnosis of cancer.
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Affiliation(s)
- Matthew R D Brown
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | | | - David J Magee
- The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK.
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28
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Sindt JE, Odell DW, Tariq R, Presson AP, Zhang C, Brogan SE. Initial Intrathecal Dose Titration and Predictors of Early Dose Escalation in Patients With Cancer Using a 100:1 Oral to Intrathecal Morphine Conversion Ratio. Neuromodulation 2021; 24:1157-1166. [PMID: 34375481 DOI: 10.1111/ner.13517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/26/2021] [Accepted: 07/13/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Pain is common in patients with advanced cancer, and intrathecal drug delivery (IDD) has been successfully used for recalcitrant pain. We report on our experience using a 100:1 oral-to-intrathecal morphine conversion ratio for initial dosing and factors predictive of early dose escalation. MATERIALS AND METHODS Retrospective review of an intrathecal drug delivery system (IDDS) data base at the Huntsman Cancer Institute-University of Utah in cancer patients initiated on IDD with morphine or hydromorphone. Demographic characteristics, preoperative opioid use, and initial and hospital discharge IDD settings were collected. RESULTS A total of 275 patients were identified between June 2014 and May 2020. The median oral-to-intrathecal morphine conversion ratio for initial IDD dosing was 105.5:1 (interquartile range [IQR] 90-120, range 75-150). No serious adverse effects including respiratory depression or sedation were noted and the median length of stay was one night (IQR 1-2, range 1-22). Ninety-six percent of patients discontinued opioids immediately following IDDS implant. Initial IDD dosing was adequate in 42% of patients. Dose reduction was required in 4% prior to discharge due to nausea, patient request, weakness, pruritus, or urinary retention. Dose escalation was required in 54%, with a median dose increase of 66.7% (IQR 33-150%, range 5-1150%). Patients in the highest quartile of dose escalation, ≥70% between IDD initiation and discharge, had associations with younger age, higher preoperative opioid use, and inpatient status. No significant associations were found in patients who required dose reduction as compared to other patients. CONCLUSIONS An oral-to-intrathecal morphine conversion ratio of approximately 100:1 for initiation of IDD in patients with cancer pain was safe and well tolerated and may facilitate rapid elimination of systemic opioids. Dose reduction was rare, while a majority of patients required further dose escalation prior to discharge.
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Affiliation(s)
- Jill E Sindt
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Daniel W Odell
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Rayhan Tariq
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Chong Zhang
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Shane E Brogan
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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Aman MM, Mahmoud A, Deer T, Sayed D, Hagedorn JM, Brogan SE, Singh V, Gulati A, Strand N, Weisbein J, Goree JH, Xing F, Valimahomed A, Pak DJ, El Helou A, Ghosh P, Shah K, Patel V, Escobar A, Schmidt K, Shah J, Varshney V, Rosenberg W, Narang S. The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain. J Pain Res 2021; 14:2139-2164. [PMID: 34295184 PMCID: PMC8292624 DOI: 10.2147/jpr.s315585] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.
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Affiliation(s)
- Mansoor M Aman
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Ammar Mahmoud
- Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vinita Singh
- Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jacqueline Weisbein
- Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Johnathan H Goree
- Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA
| | - Fangfang Xing
- Swedish Pain Services, Swedish Health Services, Seattle, WA, USA
| | - Ali Valimahomed
- Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA
| | - Daniel J Pak
- Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Antonios El Helou
- Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - Krishna Shah
- Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Vishal Patel
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Alexander Escobar
- Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keith Schmidt
- AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Jay Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Vishal Varshney
- Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - William Rosenberg
- Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Pain is the main symptom of pancreatic cancer (pancreatic ductal adenocarcinoma, PDAC). Pain in pancreatic cancer may be visceral, somatic or neuropathic in origin. Pain is produced by tissue damage, inflammation, ductal obstruction and infiltration. Visceral nociceptive signals caused by damage to the upper abdominal viscera are carried along sympathetic fibers, which travel to the celiac plexus nerves and ganglia, which are found at the T12-L2 vertebral levels, anterolateral to the aorta near the celiac trunk. From here, the signals are transmitted through the splanchnic nerves to the T5-T12 dorsal root ganglia and then on to the higher centers of the central nervous system. Somatic and neuropathic pain may arise from tumor extension into the surrounding peritoneum, retroperitoneum and bones and, in the latter case, into the nerves, such as the lumbosacral plexus. It should also be noted that other types of pain might arise because of therapeutic interventions, such as post-chemoradiation syndromes, which cause mucositis and enteritis. Management with non-steroidal anti-inflammatory agents and narcotics was the mainstay of therapy. In recent years, celiac plexus blocks and neurolysis, as well as intrathecal therapies have been used to control severe pain, at times resulting in a decreased need for drugs, avoiding their unwanted side effects. Pain may impair the patient’s quality of life, negatively affecting patient outcome and resulting in increased psychological stress. Even after recognizing the negative effect of cancer pain on patient overall health, studies have shown that cancer pain is still undertreated. This review focuses on neuropathic pain, which is difficult to handle; thus, the most recent literature was reviewed in order to diagnose neuropathic pain and its management.
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Schultz D, Abd-Elsayed A. Response to: "Adverse Events and Complications Associated With Intrathecal Drug Delivery Systems: Insights From the Manufacturer and User Facility Device Experience (MAUDE) Database". Neuromodulation 2021; 24:796-797. [PMID: 34160875 DOI: 10.1111/ner.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- David Schultz
- Medtronic PSR, Minneapolis, Minnesota, USA.,Nura Pain Clinics, Edina, Minnesota, USA
| | - Alaa Abd-Elsayed
- Anesthesiology, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin, USA
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Naseri Kouzehgarani G, Feldsien T, Engelhard HH, Mirakhur KK, Phipps C, Nimmrich V, Clausznitzer D, Lefebvre DR. Harnessing cerebrospinal fluid circulation for drug delivery to brain tissues. Adv Drug Deliv Rev 2021; 173:20-59. [PMID: 33705875 DOI: 10.1016/j.addr.2021.03.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/10/2021] [Accepted: 03/01/2021] [Indexed: 12/31/2022]
Abstract
Initially thought to be useful only to reach tissues in the immediate vicinity of the CSF circulatory system, CSF circulation is now increasingly viewed as a viable pathway to deliver certain therapeutics deeper into brain tissues. There is emerging evidence that this goal is achievable in the case of large therapeutic proteins, provided conditions are met that are described herein. We show how fluid dynamic modeling helps predict infusion rate and duration to overcome high CSF turnover. We posit that despite model limitations and controversies, fluid dynamic models, pharmacokinetic models, preclinical testing, and a qualitative understanding of the glymphatic system circulation can be used to estimate drug penetration in brain tissues. Lastly, in addition to highlighting landmark scientific and medical literature, we provide practical advice on formulation development, device selection, and pharmacokinetic modeling. Our review of clinical studies suggests a growing interest for intra-CSF delivery, particularly for targeted proteins.
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Magee DJ, Schutzer-Weissmann J, Pereira EAC, Brown MRD. Neuromodulation techniques for cancer pain management. Curr Opin Support Palliat Care 2021; 15:77-83. [PMID: 33843762 DOI: 10.1097/spc.0000000000000549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Advanced pain management techniques may be indicated in 5-15% of cancer patients. Despite this, a recent review identified that, over the course of 1 year in England, only 458 patients received a procedure intended to provide analgesia and only 30 patients had intrathecal drug delivery (ITDD) devices implanted. This article describes the emerging evidence for ITDD in cancer pain and provides a narrative review of other neuromodulatory techniques (including spinal cord stimulation, peripheral nerve stimulation and acupuncture), approaches that might be employed to address this area of significant unmet clinical need. RECENT FINDINGS Numerous studies have been published within the last year reporting positive outcomes associated with ITDD in cancer pain management. Neuromodulation represents an important strategy in the management of persistent pain. Whilst the nonmalignant pain evidence-base is rapidly growing, it remains sparse for cancer pain management. The growing cohort of cancer survivors may significantly benefit from neuromodulatory techniques. SUMMARY ITDD and other neuromodulatory techniques for cancer pain management appear underutilised in the UK and offer the prospect of better treatment for cancer patients with refractory pain or intolerable side-effects from systemic analgesics.
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Affiliation(s)
- David J Magee
- Signalling and Cancer Metabolism Team, Division of Cancer Biology, The Institute of Cancer Research
- Pain Medicine Department, The Royal Marsden Hospital
| | | | - Erlick A C Pereira
- Neurosciences Research Centre, Molecular and Clinical Sciences Institute, St George's, University of London
- Department of Neurosurgery, St George's University Hospital
| | - Matthew R D Brown
- Pain Medicine Department, The Royal Marsden Hospital
- Targeted Approaches to Cancer Pain Group, The Institute of Cancer Research, London, UK
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Interventional Therapies for Pain in Cancer Patients: a Narrative Review. Curr Pain Headache Rep 2021; 25:44. [PMID: 33961156 DOI: 10.1007/s11916-021-00963-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population. RECENT FINDINGS A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.
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Tlijani M, Sayadi M, Zribi K, Jbeli F, Zaied S, Daldoul A, Ben Salah Y, Saidani Z, Cherif A. [Pain management in cancer patients in a Tunisian hospital]. Bull Cancer 2021; 108:465-471. [PMID: 33775385 DOI: 10.1016/j.bulcan.2020.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/18/2020] [Accepted: 12/24/2020] [Indexed: 10/21/2022]
Abstract
Pain is a common symptom in cancer patients. It is subjective and difficult to communicate. It continues to be outsourced and often overlooked despite the existence of multiple recommendations. The objective of this study is to describe pain management in cancer patients in a Tunisian hospital. This is a prospective study, conducted over one month at the maternity centre of Monastir by an intern in pharmacy using a questionnaire. Of 128 patients assessed, 50 were algic. Twenty-six percent of algic patients were not treated. The neuropathic component of pain was present in 30 % of cases but under treatment. Relief opioids were prescribed in 43 % of cases to relieve pain. Paracetamol was prescribed in 26 % of cases. Ten percent of patients use paracetamol self-medication. Sixteen percent of patients have tried non-pharmacological means, of which 62 % consume plants. To optimise the management of pain at our centre, the available analgesic sheets have been developed, validated by the medical staff and disseminated in the departments of carcinology and oncohematology. Therapeutic education sessions were also scheduled to warn patients about the risks of self-medication and misuse of medicinal plants. Pain management is complex. It requires respect for international recommendations, but especially for the efforts made by all stakeholders.
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Affiliation(s)
- Marwa Tlijani
- Centre de maternité et de néonatologie de Monastir, service de pharmacie B, Monastir, Tunisie; Faculté de pharmacie de Monastir, Monastir, Tunisie, Tunisie.
| | - Mouna Sayadi
- Centre de maternité et de néonatologie de Monastir, service de pharmacie B, Monastir, Tunisie; Faculté de pharmacie de Monastir, Monastir, Tunisie, Tunisie
| | - Kaouther Zribi
- Centre de maternité et de néonatologie de Monastir, service de pharmacie B, Monastir, Tunisie; Faculté de pharmacie de Monastir, Monastir, Tunisie, Tunisie
| | - Fethi Jbeli
- Centre de maternité et de néonatologie de Monastir, service de réanimation, Monastir, Tunisie
| | - Sonia Zaied
- Centre de maternité et de néonatologie de Monastir, service de carcinologie, Monastir, Tunisie
| | - Amira Daldoul
- Centre de maternité et de néonatologie de Monastir, service de carcinologie, Monastir, Tunisie
| | - Yosra Ben Salah
- Centre de maternité et de néonatologie de Monastir, service de pharmacie B, Monastir, Tunisie
| | - Zahra Saidani
- Centre de maternité et de néonatologie de Monastir, service de gynécologie, Monastir, Tunisie
| | - Ameni Cherif
- Centre de maternité et de néonatologie de Monastir, service de pharmacie B, Monastir, Tunisie; Faculté de pharmacie de Monastir, Monastir, Tunisie, Tunisie
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36
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Odell DW, Albrechtsen RD, Sindt JE, Gole R, Brown S, Parsons MW, Paxton AB, Sarkar V, Lloyd S, Brogan SE, Tao R. The Effect of Measured Radiotherapy Dose on Intrathecal Drug Delivery System Function. Neuromodulation 2021; 24:1204-1208. [PMID: 33624320 DOI: 10.1111/ner.13372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/15/2020] [Accepted: 01/11/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Radiation therapy (RT) and intrathecal drug delivery systems (IDDS) are often used concurrently to optimize pain management in patients with cancer. Concern remains among clinicians regarding the potential for IDDS malfunction in the setting of RT. Here we assessed the frequency of IDDS malfunction in a large cohort of patients treated with RT. MATERIALS AND METHODS Cancer patients with IDDS and subsequent RT at our institution from 2011 to 2019 were eligible for this study. Patients were excluded in the rare event that their IDDS was managed by an outside clinic and follow-up documentation was unavailable. Eighty-eight patients aged 22-88 years old (43% female, 57% male) representing 106 separate courses of RT were retrospectively identified. Patients received varying levels of radiation for treatment of cancer and cumulative dose to the IDDS was calculated. IDDS interrogation was subsequently performed by a pain specialist. Malfunction was recorded as deviation from the expected drug volume and/or device errors reported upon interrogation as defined by the manufacturer. RESULTS Total measured RT dose to the IDDS ranged from 0 to 18.0 Gy (median = 0.2 Gy) with median dose of 0.04 Gy/fraction (range, 0-3.2 Gy/fraction). Ten pumps received a total dose >2 Gy and three received ≥5 Gy. Eighty-two percentage of patients had follow-up with a pain specialist for IDDS interrogation and all patients underwent follow-up with a healthcare provider following RT. There were zero incidences of IDDS malfunction related to RT. No patient had clinical evidence of radiation related pump malfunction at subsequent encounters. CONCLUSIONS We found no evidence that RT in patients with IDDS led to device failure or dysfunction. While radiation oncologists and pain specialists should coordinate patient care, it does not appear that RT dose impacts the function of the IDDS to warrant significant clinical concern.
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Affiliation(s)
- Daniel W Odell
- Department of Anesthesiology, University of Utah, School of Medicine, Salt Lake City, UT, USA
| | | | - Jill E Sindt
- Department of Anesthesiology, University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Ryan Gole
- University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Spencer Brown
- University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Matthew W Parsons
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Adam B Paxton
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Vikren Sarkar
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Shane E Brogan
- Department of Anesthesiology, University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Randa Tao
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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Capozza MA, Triarico S, Mastrangelo S, Attinà G, Maurizi P, Ruggiero A. Narrative review of intrathecal drug delivery (IDD): indications, devices and potential complications. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:186. [PMID: 33569488 PMCID: PMC7867880 DOI: 10.21037/atm-20-3814] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The management of chronic refractory pain (non-neoplastic and cancer-related pain) remains a therapeutic challenge. The continuous intrathecal (IT) administration of drugs may play an important role in the possible management options. Intrathecal drug delivery devices (IDDDs) may be effective for patients with refractory chronic pain. Therefore, they may be adopted for non-oncologic pain in patients with compression fractures, spondylolisthesis, spondylosis, back surgery failure syndrome and spinal stenosis. Oncologic patients can benefit from these treatments in a variable way according to tumor characteristics, prognosis, periprocedural imaging and risk of disease progression. In this review, we describe the most commonly used drugs (opioids and non-opioids), their pharmacokinetic and pharmacodynamic features and indications of use. The most used drugs are morphine, hydromorphone, fentanyl, methadone, bupivacaine, clonidine, and ketamine. Patient evaluation before the device implantation should be based on clinical examination, medical records assessment and psychometric evaluation. The infusion pumps available on the market are both non-programmable (with continuous IT deliver of drugs) and programmable (with variable deliver of drugs according to their flow rate). Moreover, we describe the procedure of implantation and the potential complications of IT drug delivery (such as bleeding, infection, loss of cerebrospinal fluid, wound seroma, loss of catheter pump propellant).
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Affiliation(s)
- Michele Antonio Capozza
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Silvia Triarico
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Stefano Mastrangelo
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giorgio Attinà
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Palma Maurizi
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Ruggiero
- Unità di Oncologia Pediatrica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
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Chou CZ, Hopkins TJ, Badiola I, Gazelka HM, Gohil S, Kitt A, Luke WR, Vaughan CL, Jones CA, Varhabhatla N. Top Ten Tips Palliative Care Clinicians Should Know About Interventional Pain and Procedures. J Palliat Med 2020; 23:1386-1391. [PMID: 32865443 DOI: 10.1089/jpm.2020.0487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pain is a common symptom for patients with advanced illness. Palliative care (PC) clinicians are experts in pharmacologic and nonpharmacologic treatment of pain and other symptoms for these patients. True multimodal pain control should include consideration of interventional procedures and pumps to improve difficult-to-manage pain. This article, written by clinicians with expertise in interventional pain and PC, outlines and explains many of the adjunctive and interventional therapies that can be considered for patients with pain in the setting of serious illness. Only by understanding and considering all available options can we ensure that our patients are receiving optimal care.
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Affiliation(s)
- Claudia Z Chou
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J Hopkins
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina, USA
| | - Ignacio Badiola
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Halena M Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sharmil Gohil
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arthur Kitt
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Whitney R Luke
- Department of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christina L Vaughan
- Department of Neurology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher A Jones
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Narayana Varhabhatla
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Sindt JE, Odell DW, Dalley AP, Brogan SE. Initiation of Intrathecal Drug Delivery Dramatically Reduces Systemic Opioid Use in Patients With Advanced Cancer. Neuromodulation 2020; 23:978-983. [PMID: 32459393 DOI: 10.1111/ner.13175] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/06/2020] [Accepted: 04/22/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Pain is common in cancer, affecting more than 70% of patients with advanced disease. Intrathecal drug delivery systems (IDDS) are a well-established treatment for patients with refractory cancer pain, improving pain control and reducing associated side effects. To date, details of systemic opioid use before and after IDDS implant have not been reported. MATERIALS AND METHODS We conducted a retrospective review of patients at Huntsman Cancer Institute-University of Utah treated with IDDS for cancer pain from May 2014 to May 2018. Oral, transdermal, and parenteral opioid use before IDDS implant was compared to use 30 days postoperatively. RESULTS A total of 173 patients were included, 93% with stage IV disease. The pre-implant median daily oral morphine equivalent (OME) was 240 mg (interquartile range 130-390, range 0-2616 mg). OME doses >200 mg/day were required by 57% of patients, and >500 mg OME by 19% of patients. The post-implant median OME was 0 mg (interquartile range 0-0, range 0-480 mg) and 82.6% of patients discontinued systemic opioids completely. 11.0% of patients used <100 mg OME, and only 1.7% of patients used >200 mg OME. Mean OME decreased by 94% following IDDS implant (p < 0.0001) and all patients who continued to use systemic opioids required a lower OME compared to pre-implant. CONCLUSIONS In the largest cohort of patients with advanced cancer and refractory pain treated with IDDS, implantation was associated with a dramatic reduction in systemic opioid use 30 days postoperatively, with a large majority of patients discontinuing systemic opioids. Those patients that continued systemic opioids utilized significantly lower doses as compared to their pre-implant dose.
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Affiliation(s)
- Jill E Sindt
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Daniel W Odell
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Andrew P Dalley
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Shane E Brogan
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
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Stearns LM. In Response. Anesth Analg 2020; 130:e152. [DOI: 10.1213/ane.0000000000004675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Shane E Brogan
- From the Division of Pain Medicine, Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York
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Wanderer JP, Nathan N. Getting to the (Nerve) Root of It. Anesth Analg 2020; 130:285. [DOI: 10.1213/ane.0000000000004599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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