Effectiveness of the World Health Organization cancer pain relief guidelines: an integrative review

The WHO guidelines: the new and the old

PURPOSE OF THE REVIEW

The original World Health Organisation (WHO) cancer pain guidelines were published in 1986 and used globally. Updated guidance was released in 2018. This review compares the 'old' with the 'new' with a closer look at the relevance of the WHO analgesic ladder in the current climate.

RECENT FINDINGS

The new guidelines provide a more evidence based, rigorously developed document including recommendations relating to radiotherapeutic management. There is a more detailed focus on safe opioid prescribing, opioid stewardship and the importance of integrating pain management expertise early on in the cancer journey. There remains a lack of evidence for certain therapies despite their widespread use particularly in relation to adjuvants. The pitfalls of the original renowned analgesic ladder are highlighted including a recognition that omitting 'step 2' is safe, feasible and cost effective.

SUMMARY

The new guidelines offer more detailed recommendations relevant to clinical practice with a strong focus on safety of opioid prescribing making it relevant in the current climate. The original WHO analgesic ladder is no longer recommended as a strict protocol for cancer pain management.

Effects of Exercise in Adults With Cancer Pain: A Systematic Review and Network Meta-Analysis

CONTEXT

Pain is one of the most common symptoms of cancer patients, affecting the patient's physical, psychological, behavioral, social relations and other aspects. Previous studies have demonstrated that exercise is effective for cancer pain, and the optimal exercise is still unknown.

OBJECTIVES

This study aimed to compare the effects of different exercise interventions on cancer pain in adults.

METHODS

Randomized control trials identified from medical literature databases that reported effects of exercise in adults with cancer pain were included in this study. Literature screening and data extraction were conducted independently by 2 researchers. Cochrane Bias Assessment 2.0 was used to assess the quality of the literature, and Stata 15.0 software was used for Network meta-analysis.

RESULTS

Forty-one studies were included, involving 3537 patients with cancer pain. The types of exercise involved included aerobic exercise, medium intensity continuous training, high-intensity interval training, resistance exercise, mind-body exercise and comprehensive exercise program (CEP). The results suggested that CEP was more effective than the usual care in relieving pain intensity in cancer patients [SMD = -1.96,95% CI (-3.47, -0.44)] (SUCRA = 97.9%). Mind-body exercise outperformed usual care in reducing pain interference in cancer patients [SMD = -0.65, 95% CI (-1.21, -0.09)] (SUCRA = 83.8%).

CONCLUSION

Current evidence shows that CEP is the best way to relieve the pain intensity of cancer patients, and mind-body exercise is the best way to reduce pain interference of cancer patients. Due to the limited number and quality of the included studies, the above conclusions need to be further verified by more high-quality studies.

Attitudes and Beliefs Regarding Pain Medicine: Results of a National Palliative Physician Survey

CONTEXT

Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists.

OBJECTIVES

To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness.

METHODS

A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs.

RESULTS

The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians.

CONCLUSION

This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.

Potential role of cannabis in ameliorating observed racialized disparities in cancer pain management

Cancer-related pain affects a large proportion of all patients with cancer yet remains inadequately managed, particularly among patients from certain racialized backgrounds. Recently, there has been increased research and clinical interest in the use of medical cannabis for cancer pain management, including its potential to ameliorate race-based disparities in cancer pain control. Although medical cannabis is not currently a US Food and Drug Administration-approved treatment option for cancer-related pain, many oncologists discuss and recommend its use with their patients, underscoring the need for researchers and clinicians to proactively identify barriers to cannabis for cancer pain management that may disproportionately affect patients from certain racial groups. In this commentary, we highlight challenges that patients from racialized backgrounds may face when incorporating cannabis into their palliative care regimens and discuss opportunities for researchers and clinicians to address these challenges should medical cannabis become a recommended treatment option for cancer pain management. In particular, we identify challenges at the structural (eg, lack of insurance coverage), clinician (eg, racialized stereotypes regarding addiction and pain), and individual (eg, internalized stigma) levels and emphasize the importance of multilevel approaches in combating these challenges as the evidence base regarding medical cannabis and its potential harms and therapeutic benefits continues to accumulate.

Initial Experiences With Integration of Palliative Medicine and Specialist Pain Services in a Tertiary Cancer Care Center in India

Pain management constitutes a pivotal aspect of palliative care. Certain instances of distressing pain are significantly relieved through interventional pain methodologies, demanding the expertise of pain specialists. Our perspective revolves around the integration of these 2 facets, envisaging a symbiotic relationship that could enhance patient outcomes. A prospective assessment was carried out within a collaborative clinic, uniting the realms of pain management and palliative medicine. Anonymized patient information was scrutinized to grasp the advantages of this amalgamation and identify strategies to address any inherent deficiencies. Furthermore, an illustrative case study was delineated, spotlighting the collaborative dynamics at a systemic level. During the period spanning from November 2020 to June 2021, a total of 43 patients received consultations at this collaborative clinic. Each patient was exposed to a comprehensive pain management regimen, with the most frequently conducted procedure being an intercostal nerve block, which was administered in 9.30% of cases. For the provision of effective pain relief within the palliative care context, the confluence of joint consultations from cancer pain specialists emerges as a requisite measure. This approach carries the promise of optimizing pain control and augmenting the quality of palliative care.

Effectiveness of epidural morphine for the treatment of cancer pain in patients with gastrointestinal neoplasm-a systematic review

One-third of cancer pain patients do not experience adequate pain relief using analgesic ladder by the World Health Organization. Interventional procedures, such as epidural morphine, have been considered. This study aimed to review the literature comparing the effects of epidural administration of morphine with the oral route. This systematic review included randomized controlled trials (RCTs) conducted with patients with gastrointestinal neoplasm. A search was conducted on PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and CINAHL databases to identify studies published up to May 2023. The retrieved study was evaluated using the Risk of Bias 2 (RoB 2) tool and qualitatively synthesized. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Prospero: CRD42021264728). Only one RCT, a crossover trial, was included in this systematic review. The study was conducted with ten participants (one withdrawal) and reported a statistically significant difference between both subcutaneous and epidural morphine solutions and oral morphine. The adverse events were not described. The included study presents some concerns of bias and low certainty of evidence on the effectiveness and security of epidural morphine administration. The available literature does not suffice to elucidate whether morphine administration via the epidural route is more effective than other routes. Further RCTs are necessary to improve the level of evidence on the effectiveness and risk-benefit of epidural morphine in the management of cancer pain in gastrointestinal neoplasm patients.

Efficacy of aerobic and resistance exercises on cancer pain: A meta-analysis of randomised controlled trials

Purpose

To evaluate effects of aerobic and resistance exercises for cancer-related pain in adults with and surviving cancer. Secondary objectives were to a) evaluate the effect of exercise on fatigue, psychological function, physical function, b) assess fidelity to exercise.

Design

A systematic search of MEDLINE, EMBASE, AMED, CINAHL and Cochrane Central Register of Controlled Trials was conducted to identify randomised controlled trials (RCTs) comparing aerobic and/or resistance exercise to control groups. The primary endpoint were changes in cancer-related pain intensity from baseline to post intervention. Meta-regression analysis evaluated predictors for heterogeneity between study findings. Tolerability was defined as reporting of exercise-induced adverse events while fidelity evaluated by reported intervention dropout.

Results

Twenty-three RCTs including 1954 patients (age 58 ± 8.5 years; 78 % women); 1087 (56 %) and 867 (44 %) allocated to aerobic/resistance exercise therapy and control group, respectively. Exercise therapy was associated with small to moderate decreases in cancer-related pain compared to controls (SMD = 0.38, 95 % CI: 0.17, 0.58). Although there was significant heterogeneity between individual and pooled study effects (Q = 205.25, p < 0.0001), there was no publication bias. Meta-regression including supervision, age, duration and exercise type as moderators showed no significant differences in reported outcomes. Analysis of secondary outcomes revealed a moderate effect for improvements in physical function, fatigue and psychological symptoms.

Conclusions

Aerobic and resistance exercises are tolerable and effective adjunct therapies to reduce cancer-related pain while also improving physical function, fatigue and mood. Future RCTs of dose, frequency, compliance and exercise type in specific cancer settings are required.

External treatment of traditional Chinese medicine for cancer pain: A systematic review and network meta-analysis

BACKGROUND

Cancer pain is one of the most intolerable and frightening symptoms of cancer patients. However, the clinical effect of the three-step analgesic ladder method (TSAL) is not satisfactory. The combination of external treatment of traditional Chinese medicine (TCM) can improve the clinical effect.

OBJECTIVE

This study used network meta-analysis to compare the effects of different external treatment methods of TCM combined with TSAL on cancer pain.

METHODS

Databases searched by our team included Google Scholar, Web of Science, Scopus, Embase, PubMed, and Cochrane Library. Randomized controlled trials related to the external treatment of TCM combined with TSAL for cancer pain were screened from the establishment of the database till now. The above literature extracted clinical efficacy, NRS score, KPS score, analgesic onset time, and duration as the main results after the screening. The 95% confidence interval (95% CI) of OR value and SMD value was used as the effect index to compare the difference in efficacy of different interventions, and the ranking was conducted. STATA 17.0 software was used for the statistical analysis of the above data.

RESULTS

A total of 78 studies were included, including 8 interventions and 5742 participants. Based on ranking probability, the clinical effective rate of manual acupuncture combined with TSAL was the best when the intervention time was set at 4 weeks [OR = 5.42, 95% CI (1.99,14.81)], and the improvement effect on KPS score was also the best [SMD = 0.97, 95% CI (0.61, 1.33)]. Acupoint external application was the best intervention in reducing NRS score [SMD = -1.14, 95% CI (-1.90, -0.93)]. Acupoint moxibustion combined with TSAL was considered to be the most effective intervention to prolong the duration of analgesia [SMD = 1.69, 95% CI (0.84, 2.54)] and shortening the onset time of analgesia [SMD = -3.00, 95% CI (-4.54, -1.47)].

CONCLUSIONS

TSAL combined with manual acupuncture is the best in terms of clinical efficacy and improvement of patients' functional activity status. With the extension of treatment time, the intervention of this kind of treatment on the clinical effect is more pronounced. Acupoint external application also has a unique advantage in reducing the pain level of patients. From the point of view of analgesic duration and duration of analgesia, combined acupoint moxibustion has the best effect.

Management of pain in cancer patients- lessons from practices during the COVID-19: a qualitative study of cancer care providers' perspectives

BACKGROUND

The ongoing COVID-19 pandemic has impacted health systems globally and affected managing many chronic conditions, including cancer. This study aimed to explore the perceptions of multi-disciplinary cancer care providers on how cancer pain management was affected by the COVID-19 pandemic.

METHODS

Participants were eligible if they were cancer care providers of any specialty and discipline from two tertiary hospitals in Australia. Data were collected using semi-structured interviews to explore cancer care providers' perspectives on cancer pain management within COVID-19. Thematic analysis of interview transcripts used an integrated approach that started with inductive coding before coding deductively against a behaviour framework called the COM-B Model, which proposes that 'capability', 'motivation' and 'opportunity' are requisites for any behaviour.

RESULTS

Twenty-three providers participated. Five themes were developed and interpreted from the analysis of data, namely: "Telehealth enables remote access to cancer pain management but also created a digital divide", "Access to cancer pain management in the community is compromised due to the pandemic", "COVID-19 negatively impacts hospital resource allocation", "Patients were required to trade off cancer pain management against other health priorities" and "Hospital restrictions result in decreased social and psychological support for patients with cancer pain".

CONCLUSIONS

The landscape of cancer pain management in the Australian health system underwent substantial shifts during the COVID-19 pandemic, with lasting impacts. Cancer care providers perceived the pandemic to have significant adverse effects on pain management across multiple levels, with repercussions for patients experiencing cancer-related pain. A more adaptive health system model needs to be established in the future to accommodate vulnerable cancer patients.

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

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

Morphine-induced osteolysis and hypersensitivity is mediated through toll-like receptor-4 in a murine model of metastatic breast cancer

ABSTRACT

The propensity for breast cancer to metastasize to bone is coupled to the most common complaint among breast cancer patients: bone pain. Classically, this type of pain is treated using escalating doses of opioids, which lack long-term efficacy due to analgesic tolerance, opioid-induced hypersensitivity, and have recently been linked to enhanced bone loss. To date, the molecular mechanisms underlying these adverse effects have not been fully explored. Using an immunocompetent murine model of metastatic breast cancer, we demonstrated that sustained morphine infusion induced a significant increase in osteolysis and hypersensitivity within the ipsilateral femur through the activation of toll-like receptor-4 (TLR4). Pharmacological blockade with TAK242 (resatorvid) as well as the use of a TLR4 genetic knockout ameliorated the chronic morphine-induced osteolysis and hypersensitivity. Genetic MOR knockout did not mitigate chronic morphine hypersensitivity or bone loss. In vitro studies using RAW264.7 murine macrophages precursor cells demonstrated morphine-enhanced osteoclastogenesis that was inhibited by the TLR4 antagonist. Together, these data indicate that morphine induces osteolysis and hypersensitivity that are mediated, in part, through a TLR4 receptor mechanism.

Exploring the challenges and roles of nurses in delivering palliative care for cancer patients and co-morbidities in Ghana

BACKGROUND

Patients suffering from chronic and life-threatening diseases receive inadequate palliative care in low-income countries, eventually leading to poor quality of life for these patients. Little is known about the experience of delivering palliative care in a low-resource country such as Ghana in comparison to higher-income countries. This study, therefore, aimed to assess the roles and challenges of nurses providing palliative care services for patients with cancer and life-limiting conditions at tertiary Hospitals in Ghana.

METHODS

Thirty oncology nurses at a tertiary Hospital in Ghana participated. All nurses were providing end-of-life care to patients with cancer. A qualitative exploratory-descriptive design and a semi-structured interview guide developed by the researchers were used. Interviews lasted on average forty minutes to 1 h were audio-recorded, and transcribed verbatim. Content analysis was carried out to generate themes and sub-themes.

FINDINGS

Participants were between the ages of 25 and 40 years. A higher percentage of females (n = 17, 57%) participated in the study than males (n = 13, 43%). Two main themes were generated which were the delivery of palliative care and the provision of home care services. The current roles of nurses were centered around pain management, home care services, spiritual needs, and psychological care. Challenges that hindered the implementation of palliative care included distress over expected and unexpected patient mortality, difficulty delivering bad news to patients and families, and frustration with health system resource shortages that negatively impacted patient care.

CONCLUSION

Palliative care is one of the essential services provided for patients with life-limiting conditions, and nurses play an active role in the provision of this care. Further research is needed to determine the most effective ways to deliver this care, particularly in developing nations like Ghana.

Identifying risk factors for opioid-induced neurotoxicity in cancer patients receiving oxycodone

PURPOSE

The aim of this study was to determine the frequency of opioid-induced neurotoxicity (OIN) in cancer patients receiving oral controlled-release oxycodone and to define risk factors for OIN.

METHODS

This was a single-center, retrospective study of hospitalized adult cancer patients receiving oral controlled-release oxycodone between April 1, 2013, and April, 30, 2020. The onset of OIN within 30 days after oxycodone initiation in the study patients was investigated. OIN was defined as any of the following: delirium, hallucinations (visual or auditory), seizure, myoclonus, hyperesthesia, and excessive somnolence. Multivariate logistic regression analysis was performed to identify risk factors for OIN in patients receiving oxycodone.

RESULTS

In total, 520 patients were included in this study. The number of patients with OIN was 65 (12.5%). The median time until onset of OIN after oxycodone initiation was 7.5 days. Multivariate logistic regression analysis revealed that age ≥ 65 years (OR = 2.74, 95% CI [1.30-5.78], p = 0.008), total bilirubin ≥ 1.3 mg/dL (OR = 4.85, 95% CI [2.13-11.0], p < 0.001), and concomitant use of pregabalin or mirogabalin (OR = 3.11, 95% CI [1.47-6.61], p = 0.003) were significant independent risk factors for OIN.

CONCLUSION

Age ≥ 65 years, liver dysfunction, and concomitant use of pregabalin or mirogabalin were independent risk factors for OIN in patients receiving oxycodone. Patients with these risk factors who are receiving oxycodone should be monitored for OIN, especially early in the administration of oxycodone.

Mechanisms of cancer pain

Personalised and targeted interventions have revolutionised cancer treatment and dramatically improved survival rates in recent decades. Nonetheless, effective pain management remains a problem for patients diagnosed with cancer, who continue to suffer from the painful side effects of cancer itself, as well as treatments for the disease. This problem of cancer pain will continue to grow with an ageing population and the rapid advent of more effective therapeutics to treat the disease. Current pain management guidelines from the World Health Organisation are generalised for different pain severities, but fail to address the heterogeneity of mechanisms in patients with varying cancer types, stages of disease and treatment plans. Pain is the most common complaint leading to emergency unit visits by patients with cancer and over one-third of patients that have been diagnosed with cancer will experience under-treated pain. This review summarises preclinical models of cancer pain states, with a particular focus on cancer-induced bone pain and chemotherapy-associated pain. We provide an overview of how preclinical models can recapitulate aspects of pain and sensory dysfunction that is observed in patients with persistent cancer-induced bone pain or neuropathic pain following chemotherapy. Peripheral and central nervous system mechanisms of cancer pain are discussed, along with key cellular and molecular mediators that have been highlighted in animal models of cancer pain. These include interactions between neuronal cells, cancer cells and non-neuronal cells in the tumour microenvironment. Therapeutic targets beyond opioid-based management are reviewed for the treatment of cancer pain.

Inoperable Bowel Obstruction in Ovarian Cancer: Prevalence, Impact and Management Challenges

Malignant bowel obstruction (MBO) is one of the most severe complications in patients with advanced ovarian cancer, with an estimated incidence up to 50%. Its presence is related to poor prognosis and a life expectancy measured in weeks for inoperable cases. Symptoms are usually difficult to manage and often require hospitalization, which carries a high burden on patients, caregivers and the healthcare system. Management is complex and requires a multidisciplinary approach to improve clinical outcomes. Patients with inoperable MBO are treated medically with analgesics, antiemetics, steroids and antisecretory agents. Parenteral nutrition and gut decompression with nasogastric tube, venting gastrostomy or stenting may be used as supportive therapy. Treatment decision-making is challenging and often based on clinical expertise and local policies, with lack of high-quality evidence to optimally standardize management. The present review summarizes current literature on inoperable bowel obstruction in ovarian cancer, focusing on epidemiology, prognostic factors, clinical outcomes, medical management, multidisciplinary interventions and quality of life.

Breathing Exercises for Pain Management in Cancer Survivors: A Systematic Review

OBJECTIVES

Unmanaged pain significantly affects cancer survivors' quality of life. Nurses should play a significant role in pain management through non-pharmacological interventions. This review aims to explore the efficacy and safety of breathing exercises for pain management in all cancer survivors.

DESIGN

A systematic review.

DATA SOURCES

Thirteen databases, including PubMed, EMBase, CENTRAL, MEDLINE, CINAHL, JBI, Science Direct, Scopus, SocINDEX, Web of Science, PsycINFO, CNKI, and Wan Fang, were searched from inception to May, 2021.

REVIEW/ANALYSIS METHODS

Studies that focused on the efficacy of breathing exercises for pain management, regardless of the age of the cancer survivors, were included. Cochrane tools were used for the quality appraisal of the included studies. Because of the limited number of studies, descriptive data analysis was used to summarize the results.

RESULTS

Ten studies were included. Slow pursed lip breathing showed benefits for post-surgical pain. Contradictory findings were identified in the Enhanced Recovery After Surgery for post-surgical pain. Slow deep breathing and Hey-Hu regular breathing techniques were effective for pain management in pediatric cancer patients. The Active Cycle of Breathing Technique and five-minute mindful breathing did not have any statistically significant effects on pain relief. Quality of life was measured in three studies, with some improvement. Only one study addressed adverse events and reported that no adverse events occurred.

CONCLUSIONS

Breathing exercises may be a promising approach to pain relief in cancer survivors. However, more rigorously designed studies are required to establish the evidence.

Feasibility and potential effects of breathing exercise for chronic pain management in breast cancer survivors: study protocol of a phase II randomised controlled trial

INTRODUCTION

Chronic pain is a common symptom significantly affecting the quality of life of breast cancer survivors. Despite the achievement of pharmacological interventions, the barriers associated with this approach such as inaccessibility, misuse and side effects drive research into effective non-pharmacological interventions to improve chronic pain management, quality of life, anxiety and depression. Breathing exercise (BE) can be a promising option, but research evidence is sparse. This pilot study aims to examine the feasibility and preliminary effect of using an evidence-based BE intervention for chronic pain management in breast cancer survivors.

METHOD AND ANALYSIS

This study will be a two-parallel-arm, open-labelled, phase II randomised controlled trial with 1:1 allocation. Seventy-two participants will be recruited from a tertiary hospital in China and randomly allocated to either a BE intervention group (n=36) or a control group (n=36). The participants in the intervention group will receive the usual care, a pain information booklet and a 4-week self-administered BE intervention; the participants in the control group will receive the usual care and the pain information booklet only. The assessment will be conducted at three time points: baseline (week 0), immediately after the intervention completion (week 5) and 4 weeks after the intervention completion (week 9). The primary outcomes will be the acceptability and feasibility assessment of the study protocol and methodological procedures. The secondary outcomes will be the effects of BE on pain, quality of life, anxiety and depression in breast cancer survivors. Descriptive statistics will be applied to present the primary outcomes and the Generalised Estimating Equation Model will be utilised to analyse the clinical outcomes.

ETHICS AND DISSEMINATION

This study has received ethical approvals from the Human Research Ethics Committee at Charles Darwin University (H21089) and the Clinical Trial Ethics Committee at the Affiliated Hospital of Southwest Medical University (KY2022107). Findings from this study will be presented at academic conferences and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT05257876.

Efficacy and safety of strong opioids for chronic noncancer pain and chronic low back pain: a systematic review and meta-analyses

ABSTRACT

In recent years, long-term prescribing and use of strong opioids for chronic noncancer pain (CNCP) has increased in high-income countries. Yet existing uncertainties, controversies, and differing recommendations make the rationale for prolonged opioid use in CNCP unclear. This systematic review and meta-analyses compared the efficacy, safety, and tolerability of strong opioids with placebo or nonopioid therapy in CNCP, with a special focus on chronic low back pain (CLBP). Systematic literature searches were performed in 4 electronic databases (MEDLINE, Web of Science, Cochrane Library, and CINAHL) in July 2019 and updated by regular alerts until December 2020. We included 16 placebo-controlled randomized controlled trials for CLBP and 5 studies (2 randomized controlled trials and 3 nonrandomized studies) of opioids vs nonopioids for CNCP in the quantitative and qualitative synthesis. Random effects pairwise meta-analyses were performed for efficacy, safety, and tolerability outcomes and subgroup analyses for treatment duration, study design, and opioid experience status. Very low to low certainty findings suggest that 4 to 15 weeks (short or intermediate term) opioid therapy in CLBP (compared with placebo) may cause clinically relevant reductions in pain but also more gastrointestinal and nervous system adverse events, with likely no effect on disability. By contrast, long-term opioid therapy (≥6 months) in CNCP may not be superior to nonopioids in improving pain or disability or pain-related function but seems to be associated with more adverse events, opioid abuse or dependence, and possibly an increase in all-cause mortality. Our findings also underline the importance and need for well-designed trials assessing long-term efficacy and safety of opioids for CNCP and CLBP.

Oncology clinical practice guidelines usage among physicians in Nepal

OBJECTIVE

Oncology clinical practice guidelines (OCPGs) are systematically developed evidence-based recommendations aimed to guide practitioners in decision making during the diagnosis, management, and treatment of cancer patients under specific circumstances, thereby optimizing clinical outcomes. However, little is known about the implementation of those guidelines in low and middle-income countries including Nepal. This research aimed to identify the type of OCPGs used by Nepalese physicians working in oncology departments and to explore barriers and facilitators affecting their use.

METHODS

Using the total population sampling technique, we conducted an online cross-sectional survey from June 2020 to January 2021 among physicians working in the oncology departments of Nepal. Descriptive analyses were conducted to summarize the research findings.

RESULTS

Out of 171 physicians approached for the study, 102 (59.6%) responded to the questionnaire. The sizable proportions of the participants were a senior group of physicians with 27.5% being consultants, 14.7% senior consultants, and 16.7% professors. The most commonly used guideline was the National Comprehensive Cancer Network guideline of the United States (75.5%) followed by the American Society of Clinical Oncology guideline (44.7%). While only 22.6% of physicians reported using OCPGs every time, more than half (56.9%) highlighted that OCPGs are not feasible to implement in Nepal. Insufficient facilities/equipment, physicians' unwillingness to change their usual practice, inability to discuss research with knowledgeable colleagues, and lack of time were commonly cited barriers.

CONCLUSION

Findings of our study highlighted that the OCPGs developed in high-income countries may not be feasible for low resource settings like Nepal. Comprehensive local OCPGs should be developed considering the available resources, feasibility, and financial constraints of patients. Furthermore, a constant sharing and learning environment should be created to enhance the knowledge of practicing physicians and to promote the proper implementation of evidence-based findings.

Clinical implications of chemotherapeutic agent organ toxicity on perioperative care

Cancer is the second most common cause of death in the United States and is a challenging disease to treat. The treatment options for various cancers include but are not limited to surgery, radiation, and chemotherapy. The mechanism behind chemotherapy is intended to promote cellular damage to cells that are proliferating uncontrollably. Unfortunately for the recipients, most chemotherapeutic agents cannot differentiate between malignant cells and healthy cells and tissues. Thus, chemotherapy-induced toxicities are often observed in once-healthy organs. These effects can be acute and self-limiting or chronic, appearing long after chemotherapy is completed. Cancer survivors can then present for non-cancer related surgeries later in life, due to this toxicity. Furthermore, the administration of chemotherapeutic agents can profoundly impact the anesthetic management of patients who are undergoing surgery. This review discusses how chemotherapy-induced organ toxicity can occur in multiple organ systems and what drugs should be avoided if prior toxicity exists in these organ systems.

Knowledge, Practices, and Perceived Barriers in Cancer Pain Management at Oncology Units: A Cross-Sectional Survey of Medical Staff in China

Background

Patients and Methods

Results

Conclusion

Changes in Plasma Beta-Endorphin Levels in Stage III–IV Nasopharyngeal Carcinoma Patients Post World Health Organization 3-Step Analgesic Ladder Therapy

Introduction Nasopharyngeal carcinoma (NPC) is the most common malignancy in the field of otorhinolaryngology, and chronic pain is identical with this malignancy. Pain therapy according to World Health Organization (WHO) recommendations is WHO 3-step analgesic ladder. Pain is subjective and related to the function of beta-endorphin hormone.

Objective Analyzing the relationship between the degree of pain and plasma endorphin levels in stage III–IV NPC patients before and after the administration of WHO 3-step analgesic ladder.

Materials and Methods The study design used pretest and posttest without control design. Participants were given WHO 3-step analgesic ladder therapy for 3 days. The participants then rated the pain scale using the visual analog scale (VAS) and plasma beta-endorphin levels in venous blood. The statistical test used the dependent t-test, Wilcoxon test, and Spearman test with p < 0.05, confidence interval: 95%.

Results There were 14 stage-III NPC patients with moderate pain (78.57%) and 31 stage-IV NPC participants had moderate pain (83.87%; p = 0.071). The VAS value in the moderate pain group before and after therapy was 82.22 and 66.67%, respectively (p < 0.001). The values of plasma beta-endorphin levels before and after therapy were 74.89 ± 69.12 and 72.49 ± 75.53 pg/mL, respectively (p = 0.647). Plasma beta-endorphin levels were −19.20 ± 37.72 pg/mL (mild pain), −4.76 ± 35.30 pg/mL (moderate pain), and −21.67 ± 6.27 pg/mL (severe pain; p = 0.717).

Conclusion Pain levels in advanced NPC patients have decreased after the therapy, but plasma beta-endorphin levels have no significant difference.

Current management of cancer pain in Italy: Expert opinion paper

Introduction

Chronic pain and breakthrough cancer pain (BTcP) have a high prevalence in all cancer types and cancer stages, combined with a significant physical, psychological, and economic burden. Despite efforts to improve appropriate management of cancer pain, a poor assessment and guilty undertreatment are still reported in many countries. The purpose of this expert opinion paper is to contribute to reduce and clarify these issues with a multidisciplinary perspective in order to share virtuous paths of care.

Methods

Common questions about cancer pain assessment and treatment were submitted to a multidisciplinary pool of Italian clinicians and the results were subsequently discussed and compared with the findings of the published literature.

Conclusion

Despite a dedicated law in Italy and effective treatments available, a low percentage of specialists assess pain and BTcP, defining the intensity with validated tools. Moreover, in accordance with the findings of the literature in many countries, the undertreatment of cancer pain is still prevalent. A multidisciplinary approach, more training programs for clinicians, personalised therapy drug formulations, and virtuous care pathways will be essential to improve cancer pain management.

Evolving pancreatic cancer treatment: From diagnosis to healthcare management

The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.

A Randomized Controlled Trial Evaluating the Analgesic Effect of the Combination of Methadone With Morphine for Cancer Related Pain

CONTEXT AND OBJECTIVES

Although opioids play an indispensable role in the management of cancer-related pain, inadequate pain relief still occurs. The primary objective of this study was to evaluate whether the combination of a low dose of methadone with morphine promotes a reduction in opioid consumption; the secondary objectives were if the association promotes lower pain intensity, and adverse effects (AEs).

MATERIALS AND METHODS

A sample if 41 patients with cancer-related pain in palliative setting were included. Patients were starting the third step of the analgesic ladder, and 1 group (n=21) achieve methadone (2.5 mg/12 h) in combination with morphine/methadone, and another group (n=20) received morphine alone. Both groups could use morphine (5 mg) as needed to maintain pain intensity <4, and adjuvant in stable dose. The following outcomes were evaluated: total morphine dose, pain intensity, and AEs.

RESULTS

There was no difference in the number of adjuvants, and the dose of morphine used. Pain intensity was significantly lower in the morphine/methadone group after 2 weeks, with no statistically significant difference at other timepoints. There was no difference between groups in the AEs.

CONCLUSION

Low dose of methadone in combination with morphine provided faster pain control as compared with morphine alone, and although this study was not powered to show differences in AEs, we did not notice a difference.

The Effectiveness of Cancer Pain Management in a Tertiary Hospital Outpatient Pain Clinic in Thailand: A Prospective Observational Study

Objectives

The objective was to examine the effectiveness of the updated approach.

Methods

With IRB approval, outpatients with cancer were enrolled from January to December 2018. Assessments were recorded at baseline and three consecutive visits (BL, FU1, FU2, and FU3), including Numerical Rating Scale (NRS), the Brief Pain Inventory (BPI), the Edmonton Symptom Assessment System (ESAS), side effects, and analgesic use. The primary outcome was a favorable response, defined as an NRS decrease more than 30% or NRS <4. Secondary outcomes included trends over time in BPI, ESAS, side effects, and analgesic use. Pain response predictors at FU3 were analyzed using logistic regression.

Results

Among 150 patients, 72 (48%) completed follow-ups. Of these, 61% achieved a favorable response at FU3. Pain interference diminished at all visits relative to baseline (p < 0.05). Median morphine equivalent daily dosage (MEDD) at BL was 20 mg/day, with a statistically significant, but clinically modest increase to 26.4 mg/day at FU3. Radiation therapy during pain care was a predictor of pain responders.

Conclusion

The current Siriraj multidisciplinary approach provided effective relief of pain and stabilization of other cancer-related symptoms. Radiation therapy during pain care can be used to predict pain outcomes. Ongoing improvement domains were identified and considered in the context of cultural, economic, and geographic factors.

Neuromodulation techniques for cancer pain management

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.

Clinical Evidence for the Effects of Manual Therapy on Cancer Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

This meta-analysis aimed to evaluate the effects of manual therapy (MT) on cancer pain, so as to provide clinical evidence for application.

METHODS

Five English and Chinese databases were searched until February 29, 2020, for randomized controlled trials (RCTs) of MT for cancer pain. Articles published in the English or Chinese language were included. Two authors independently reviewed all articles and extracted the data, and any disagreements in the above process were discussed with other reviewers until the authors reached consensus. Review Manager 5.3 was used to calculate the effect size and 95% confidence intervals. This review was registered in PROSPERO, number CRD42020172053.

RESULTS

The intensity of cancer pain is our primary outcome measure, and compared with standard care, MT can significantly relieve the pain of patients with cancer (SMD, 0.63; 95% CI [0.18, 1.08]; P=0.006 < 0.01); the effects of MT plus active activity were significantly different from AT alone (SMD, 0.79; 95% CI [0.28, 1.30]; P=0.002 < 0.01); there was no statistical difference in the efficacy of MT and AT alone (SMD, -0.24; 95% CI [-1.09, 0.62]; P=0.53 > 0.05). In other related symptoms, the above evidence cannot support that MT had a good effect on fatigue (SMD, 0.77; 95% CI [-0.09, 1.63]; P=0.08 > 0.05), nausea (SMD, 0.24; 95% CI [-0.00, 0.48]; P=0.05), anxiety (SMD, 0.76; 95 % CI [-0.32, 1.84]; P=0.17 > 0.05), and depression (SMD, 0.67; 95 % CI [-0.28, 1.62]; P=0.17 > 0.05); however, MT intervention can improve physical function (n = 271; SMD, 0.35; 95 % CI [-0.04, 0.74]; P=0.04 < 0.05) and global well-being (SMD, 0.50; 95 % CI [0.02, 0.98]; P=0.04 < 0.05). In addition, MT had a significant effect on pain relief (SMD, 0.52; 95% CI [0.03, 1.01]; P=0.04 < 0.05) and improvement of physical function (SMD, 0.28; 95% CI [0.02, 0.53]; P=0.03 < 0.05) even after a period of time after treatment.

CONCLUSION

MT was an effective intervention, which may have immediate effect on cancer pain and may improve physical function and global well-being. In the view of follow-up effects, MT had good effects for the reduction of pain and the recovery of physical function. However, because of limitations, the seemingly promising results should be interpreted with caution.

Oncologic emergency in patients with skeletal metastasis of unknown primary

Aim

Patients with skeletal metastasis from prediagnosed primary malignancy sometimes have concurrent oncologic emergency (OE) during the first visit. This study aims to investigate the types of OEs and treatment outcome in such patients.

Methods

We have experienced 359 patients with skeletal metastasis from unknown primary malignancy. Among them, 130 patients required immediate admission for OE treatment (OE group), 229 patients had no OE and did not required immediate admission (non‐OE group).

Results

The recognized types of OE were spinal cord compression in 60 patients, cancer pain in 30, hypercalcemia in 19, delirium in 16, deep vein thrombosis in 13, acute renal failure in 6, respiratory failure in 3, gastrointestinal hemorrhage in 3, and disseminated intravascular coagulation in 1. The overall 5‐year survival rates were 28% and 37% in the OE and non‐OE groups, respectively (P < 0.001). The multivariate analysis revealed that delirium (hazard ratio 4.2; 95% confidence interval, 1.6–12.5; P < 0.005) and respiratory failure (hazard ratio 22.6; 95% confidence interval, 4.5–92.8; P < 0.001) were significant prognostic factors in patients with OEs, whereas other OEs did not confer a significant risk for patient outcomes.

Conclusion

In this study, OE was observed in as many as 36% of patients with skeletal metastasis from unknown primary malignancy. Delirium and respiratory failure were only two significant prognostic risk factors, which suggest that many of the OEs in untreated advanced cancer patients have probable chance to resolve. Early detection followed by appropriate treatment of such OEs is recommended.

Non-opioid Analgesics and Emerging Therapies

Pain is a common and debilitating symptom of cancer. Cancer-related pain can occur at any point along the continuum from diagnosis to treatment to survivorship¹. A systematic review published in 2016 estimated the prevalence of cancer pain to be 55% in those undergoing antineoplastic treatment, 66.4% in advanced cancer, and 39.3% in the post-treatment population. Thirty-eight percent of cancer patients in this pooled analysis experienced moderate to severe pain².

Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis

Question

Is the use of acupuncture and acupressure associated with improved cancer pain management compared with sham intervention and/or analgesic therapy alone?

Findings

In this systematic review of 17 randomized clinical trials and meta-analysis of 14 trials in the current English-language and Chinese-language literature, a significant association was found between real (compared with sham) acupuncture and reduced pain, and acupuncture combined with analgesic therapy was associated with decreased analgesic use. However, heterogeneity lowered the level of certainty of the evidence.

Meaning

This study found a moderate level of evidence that acupuncture and/or acupressure was significantly associated with lower pain intensity in patients with cancer compared with a sham control, which suggests a potential for a combination of acupuncture and acupressure to help reduce opioid doses in patients with cancer.

Importance

Research into acupuncture and acupressure and their application for cancer pain has been growing, but the findings have been inconsistent.

Objective

To evaluate the existing randomized clinical trials (RCTs) for evidence of the association of acupuncture and acupressure with reduction in cancer pain.

Data Sources

Three English-language databases (PubMed, Embase, and CINAHL) and 4 Chinese-language biomedical databases (Chinese Biomedical Literature Database, VIP Database for Chinese Technical Periodicals, China National Knowledge Infrastructure, and Wanfang) were searched for RCTs published from database inception through March 31, 2019.

Study Selection

Randomized clinical trials that compared acupuncture and acupressure with a sham control, analgesic therapy, or usual care for managing cancer pain were included.

Data Extraction and Synthesis

Data were screened and extracted independently using predesigned forms. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. Random-effects modeling was used to calculate the effect sizes of included RCTs. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach.

Main Outcomes and Measures

The primary outcome was pain intensity measured by the Brief Pain Inventory, Numerical Rating Scale, Visual Analog Scale, or Verbal Rating Scale.

Results

A total of 17 RCTs (with 1111 patients) were included in the systematic review, and data from 14 RCTs (with 920 patients) were used in the meta-analysis. Seven sham-controlled RCTs (35%) were notable for their high quality, being judged to have a low risk of bias for all of their domains, and showed that real (compared with sham) acupuncture was associated with reduced pain intensity (mean difference [MD], −1.38 points; 95% CI, −2.13 to −0.64 points; I² = 81%). A favorable association was also seen when acupuncture and acupressure were combined with analgesic therapy in 6 RCTs for reducing pain intensity (MD, −1.44 points; 95% CI, −1.98 to −0.89; I² = 92%) and in 2 RCTs for reducing opioid dose (MD, −30.00 mg morphine equivalent daily dose; 95% CI, −37.5 mg to −22.5 mg). The evidence grade was moderate because of the substantial heterogeneity among studies.

Conclusions and Relevance

This systematic review and meta-analysis found that acupuncture and/or acupressure was significantly associated with reduced cancer pain and decreased use of analgesics, although the evidence level was moderate. This finding suggests that more rigorous trials are needed to identify the association of acupuncture and acupressure with specific types of cancer pain and to integrate such evidence into clinical care to reduce opioid use.

Sensitization of Cutaneous Primary Afferents in Bone Cancer Revealed by In Vivo Calcium Imaging

Simple Summary

Cancer-induced bone pain severely impairs the quality of life of cancer patients, many of whom suffer from inadequate pain relief. The development of new analgesic therapies depends on the identification of the cells and mechanisms involved in cancer-induced bone pain. Bone marrow innervating sensory neurons have been proposed to contribute to this debilitating disease, but their role remains unexplored. Here we used in vivo calcium imaging to determine the functional role of bone innervating and skin innervating neurons in contributing to pain at an advanced stage of bone cancer. Our results indicate increased excitability of skin innervating neurons, while those innervating bone are unaffected. Our data suggests skin-innervating neurons become hyperexcitable in cancer-induced bone pain and are a potential target for pain relief.

Abstract

Cancer-induced bone pain (CIBP) is a complex condition, comprising components of inflammatory and neuropathic processes, but changes in the physiological response profiles of bone-innervating and cutaneous afferents remain poorly understood. We used a combination of retrograde labelling and in vivo calcium imaging of bone marrow-innervating dorsal root ganglia (DRG) neurons to determine the contribution of these cells in the maintenance of CIBP. We found a majority of femoral bone afferent cell bodies in L3 dorsal root ganglia (DRG) that also express the sodium channel subtype Na_v1.8—a marker of nociceptive neurons—and lack expression of parvalbumin—a marker for proprioceptive primary afferents. Surprisingly, the response properties of bone marrow afferents to both increased intraosseous pressure and acid were unchanged by the presence of cancer. On the other hand, we found increased excitability and polymodality of cutaneous afferents innervating the ipsilateral paw in cancer bearing animals, as well as a behavioural phenotype that suggests changes at the level of the DRG contribute to secondary hypersensitivity. This study demonstrates that cutaneous afferents at distant sites from the tumour bearing tissue contribute to mechanical hypersensitivity, highlighting these cells as targets for analgesia.

Clinical evidence of acupuncture and related therapy in patients with cancer-pain: A protocol for systematic review and meta-analysis

BACKGROUND

Cancer pain (CP) is one of the common complications of cancer. During the treatment, oral medication, radiotherapy and chemotherapy bring certain adverse reactions to patients with CP; a safe way to treat this disease is necessary. Acupuncture and related therapies for CP with few side effects have been gradually accepted. But at present the evidence is insufficient, the related research is not thorough enough. The purpose of this study was to investigate the efficacy and safety of acupuncture and related therapies for CP.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines were used to design this protocol. The final study will also be conducted under the PRISMA guidelines for systematic reviews and meta-analysis. An electronic search will be conducted in Medline, Embase, and the Cochrane Central Register of Controlled Trials databases through January 2020. The search will be conducted in English. Risk of bias will be assessed by the Cochrane Collaboration tool and the collected evidence will be nar-ratively synthesized. We will also perform a meta-analysis to pool estimates from studies considered to be homogenous. Subgroup analyses will be based on intervention or overall bias. The strength of evidence will be evaluated by the Grading of Recommendations, Assessment, Development and Evaluation scale.

RESULTS

This systematic review will summarize high quality clinical evidence to assess and appraise the effectiveness and safety of acupuncture and related therapies for CP patients.

CONCLUSION

The meta-analysis will assess evidence from randomized controlled trials of acupuncture and related therapies and CP types.

INPLASY REGISTRATION NUMBER

INPLASY202040129.

[Radiosurgical hypophysectomy in cancer pain treatment. Literature review and clinical case]

Cancer pain is one of the main problem in modern medicine. According European Society for Medical Oncology data, cancer pain prevalence is 64% among patient with terminal stage of disease and in 46% standard pain therapy was ineffective. Radiosurgical hypophysectomy is one of the important and perspective method in cancer pain treatment. This method could be offered patient with chronic disease. According literature review, endocrinology complications were very rare and occurred 10 months after therapy. Value of analgesic effect was 70-90%. In some trials, procedure was effective not only nociceptive, but also in neuropathic pain. More trials require for determination of indications and mechanism of action. The case of successful relief of resistant pain in patient with pancreatic cancer by means of radiosurgical hypophysectomy is described.

Top Ten Tips Palliative Care Clinicians Should Know About Opioid Use Disorder

Since the prevalence of substance use disorders, and opioid use disorder (OUD) specifically, remains high and represents a public health crisis, it is critical that palliative care (PC) providers have a broad understanding of this class of chronic, yet treatable, diseases. Conceptualizing stigma associated with OUD, treatment modalities available, and educational opportunities are key factors in providing patient-centered care. A solid foundation of knowledge about OUD in the setting of serious illness is also crucial as PC providers often recommend or prescribe opioids for symptom management in patients who also have OUD. Furthermore, the PC interdisciplinary team is particularly well poised to care for patients suffering from OUD due to the inherently holistic approach already present in the specialty of PC. This article offers PC teams a framework for understanding the diagnosis and treatment of OUD, methods for performing risk stratification and monitoring, and an overview of opportunities to enhance our care of PC patients with OUD.

Long-Term Influence of the Practice of Physical Activity on the Self-Perceived Quality of Life of Women with Breast Cancer: A Randomized Controlled Trial

Background: There is still no consensus on the most suitable interventions for exercise practice in breast cancer survivors. Therefore, the aim of this study was to evaluate the effect of a two-year physical activity intervention (strength, aqua fitness and aerobic exercise programs) on the self-perceived quality of life and physical functionality of female breast cancer survivors. Methods: A randomized, controlled, experimental trial with a sample of 316 women (63 ± 7 years), who had been diagnosed with breast cancer. The evaluations were performed using the Rikli & Jones Senior Fitness Test, and the Short Form 12 Health Survey (SF-12). Results: The participants in the strength program showed statistically significant improvements in all the items of the SF-12. The aqua fitness program obtained significant improvements in Physical Functioning and Limitations, Pain and Emotional Limitations, General Health, Vitality, Social Functioning and the physical and mental components of the SF-12. The participants in the aerobic program showed a progressive deterioration of Vitality and Mental Health. Conclusion: When assigning breast cancer survivors to an exercise program, the preferential or predominant activity should include strength exercises. On the other hand, as the second choice, those patients with particularly low levels of Vitality or Physical Limitations will show greater improvement with an aqua fitness program.

Feasibility study of MR-guided pancreas ablation using high-intensity focused ultrasound in a healthy swine model

Purpose: Pancreatic cancer is typically diagnosed in a late stage with limited therapeutic options. For those patients, ultrasound-guided high-intensity focused ultrasound (US-HIFU) can improve local control and alleviate pain. However, MRI-guided HIFU (MR-HIFU) has not yet been studied extensively in this context. To facilitate related research and accelerate clinical translation, we report a workflow for the in vivo HIFU ablation of the porcine pancreas under MRI guidance.Materials and methods: The pancreases of five healthy German landrace pigs (35-58 kg) were sonicated using a clinical MR-HIFU system. Acoustic access to the pancreas was supported by a specialized diet and a hydrogel compression device for bowel displacement. Organ motion was suspended using periods of apnea. The size of the resulting thermal lesions was assessed using the thermal threshold- and dose profiles, non-perfused volume, and gross examination. The effect of the compression device on beam path length was assessed using MRI imaging.Results: Eight of ten treatments resulted in clearly visible damage in the target tissue upon gross examination. Five treatments resulted in coagulative necrosis. Good agreement between the four metrics for lesion size and a clear correlation between the delivered energy dose and the resulting lesion size were found. The compression device notably shortened the intra-abdominal beam path.Conclusions: We demonstrated a workflow for HIFU treatment of the porcine pancreas in-vivo under MRI-guidance. This development bears significance for the development of MR-guided HIFU interventions on the pancreas as the pig is the preferred animal model for the translation of pre-clinical research into clinical application.

Oxycodone versus morphine for cancer pain titration: A systematic review and pharmacoeconomic evaluation

Objective

To evaluate the efficacy, safety and cost-effectiveness of Oxycodone Hydrochloride Controlled-release Tablets (CR oxycodone) and Morphine Sulfate Sustained-release Tablets (SR morphine) for moderate to severe cancer pain titration.

Methods

Randomized controlled trials meeting the inclusion criteria were searched through Medline, Cochrane Library, Pubmed, EMbase, CNKI,VIP and WanFang database from the data of their establishment to June 2019. The efficacy and safety data were extracted from the included literature. The pain control rate was calculated to eatimate efficacy. Meta-analysis was conducted by Revman5.1.4. A decision tree model was built to simulate cancer pain titration process. The initial dose of CR oxycodone and SR morphine group were 20mg and 30mg respectively. Oral immediate-release morphine was administered to treat break-out pain. The incremental cost-effectiveness ratio was performed with TreeAge Pro 2019.

Results

19 studies (1680 patients)were included in this study. Meta-analysis showed that the pain control rate of CR oxycodone and SR morphine were 86% and 82.98% respectively. The costs of CR oxycodone and SR morphine were $23.27 and $13.31. The incremental cost-effectiveness ratio per unit was approximate $329.76. At the willingness-to-pay threshold of $8836, CR oxycodone was cost-effective, while the corresponding probability of being cost-effective at the willingness-to-pay threshold of $300 was 31.6%. One-way sensitivity analysis confirmed robustness of results.

Conclusions

CR oxycodone could be a cost-effective option compared with SR morphine for moderate to severe cancer pain titration in China, according to the threshold defined by the WHO.

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

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

Mu Opioid Receptor 1 (MOR-1) Expression in Colorectal Cancer and Oncological Long-Term Outcomes: A Five-Year Retrospective Longitudinal Cohort Study

Preclinical evidence has shown increased expression of mu opioid receptor 1 (MOR-1) in colorectal cancer although its association with disease-free and overall survival (DFS and OS) has not been investigated. We hypothesized that MOR-1 was overexpressed in tumor samples compared to normal tissue and this was associated with decreased DFS and OS. We carried out a retrospective study assessing the association of MOR-1 tumor expression with long-term outcomes by immunohistochemistry in normal and tumor samples from 174 colorectal cancer patients. The primary endpoint was five years of DFS. Secondary endpoints were five years of OS, the difference in MOR-1 expression between normal and tumor tissue and the occurrence of postoperative complications. Multivariable Cox regression showed no significant association between MOR-1 expression and DFS (HR 0.791, 95% CI 0.603–1.039, p = 0.092). MOR-1 expression was higher in tumor tissue compared to non-tumor tissue. No associations were found between MOR-1 expression and OS or postoperative complications. These findings suggest that although MOR-1 is over-expressed in colorectal cancer samples there is no association to increased risk of recurrence or mortality. Future studies are warranted to elucidate the role of cancer stage, genetic polymorphism, and quantitative assessment of MOR-1 over-expression on long-term outcomes in colorectal cancer.

A rapid positive influence of S-ketamine on the anxiety of patients in palliative care: a retrospective pilot study

BACKGROUND

Patients in palliative care need rapid-acting pharmacological options for psychological distress. N-methyl-D-aspartate antagonist ketamine is known to have a fast onset of anti-depressant and anxiolytic action. Its S-enantiomer S-ketamine (or esketamine) is an analgesic used as a routine treatment for refractory pain as an intravenous infusion (0.25 mg/kg over 45 min). This study investigates whether S-ketamine pain therapy has a positive impact on psychological distress caused by anxiety and depression in palliative care.

METHODS

Patient routine data from a palliative care unit of a tertiary care hospital were used in a retrospective analysis after positive ethics approval. Eight patients, who received analgesic S-ketamine treatment, were compared to a control group matched by gender and age. The main analysis was conducted using three-way mixed MANOVA followed by two-way mixed ANOVA. Target variables were the values for anxiety and depression in the state-trait anxiety-depression inventory STADI. The predictor variables were the time of measurement before (T1) and after (T2) S-ketamine application and group membership.

RESULTS

Comparison of the S-ketamine group (n = 8; 4 male, 4 female; average age 52 years) with the control group (n = 8; 3 male, 5 female; average age 55 years) revealed a significant multivariate effect on anxiety and depression F(1, 14) = 4.78; p = 0.046; r = 0.50. The univariate comparisons showed a significant reduction of the anxiety scores from T1 to T2 in the S-ketamine group compared to the control group F(1, 14) = 10.14; p = 0.007; r = 0.65. With regard to depression, there was no significant reduction from T1 to T2 in the group comparison F(1, 14) = 1.60; p = 0.23; r = 0.32. No long-lasting effects on pain were found.

CONCLUSIONS

Our findings show that psychological distress of patients in palliative care may improve after a single administration of S-ketamine, which mainly alleviates anxiety in those patients. Limitations of this study arise from non-randomization, retrospective analysis and low sample size. Therefore, further prospective and ideally randomized studies are necessary.

Pancreatic cancer-A disease in need: Optimizing and integrating supportive care

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that continues to be challenging to treat. PDAC has the lowest 5-year relative survival rate compared with all other solid tumor malignancies and is expected to become the second-leading cause of cancer-related death in the United States by 2030. Given the high mortality, there is an increasing role for concurrent anticancer and supportive care in the management of patients with PDAC with the aims of maximizing length of life, quality of life, and symptom control. Emerging trends in supportive care that can be integrated into the clinical management of patients with PDAC include standardized supportive care screening, early integration of supportive care into routine cancer care, early implementation of outpatient-based advance care planning, and utilization of electronic patient-reported outcomes for improved symptom management and quality of life. The most common symptoms experienced are nausea, constipation, weight loss, diarrhea, anorexia, and abdominal and back pain. This review article includes current supportive management strategies for these and others. Common disease-related complications include biliary and duodenal obstruction requiring endoscopic procedures and venous thromboembolic events. Patients with PDAC continue to have a poor prognosis. Systemic therapy options are able to palliate the high symptom burden but have a modest impact on overall survival. Early integration of supportive care can lead to improved outcomes.

Managing Pain in the Older Cancer Patient

PURPOSE OF REVIEW

This paper aims to give the specialist and non-specialist alike an overview of the considerations involved in the management of cancer-related pain in the older population.

RECENT FINDINGS

Comprehensive guidelines on cancer pain management have been published recently by expert bodies. Cancer pain differs in many respects to other pain conditions and we are likely to encounter it more frequently in older patients in the future. The elderly are more sensitive to the effects of many analgesic medications. The elderly patient with cancer pain presents a unique challenge to the treating physician. The biological effects of ageing impact on the efficacy of many pain management strategies as well as its diagnosis and assessment. Treatment options can be broadly divided into pharmacological, non-pharmacological and interventional. A multidisciplinary approach and frequent re-assessment are essential in achieving favourable outcomes in this patient group.

A multicentre survey of pain management in cancer patients and physicians attending radiotherapy clinics in Shandong Province, China

Objective

To obtain a better understanding of the prevalence and management of pain in patients undergoing radiotherapy for cancer in Shandong Province, China.

Methods

This cross-sectional study used a questionnaire during face-to-face interviews to collect data from physicians and patients regarding the recognition, prevalence and treatment of pain during the waiting period before commencement of radiotherapy and during the radiotherapy period. Physicians and patients were recruited from 10 tertiary Class A hospitals across Shandong Province, China.

Results

A total of 184 patients and 87 physicians were recruited to the study. During the waiting period, pain was reported by the physicians according to their experience to affect 26.0% of patients, which almost agreed with the patients’ data (36.5%; 160 of 438). During the radiotherapy period, there was a significant difference in the reported prevalence of pain during the radiotherapy period between the physicians’ data (23.0%) based on their experience and the patients’ data (84.1%; 169 of 201 patients). The majority of physicians (98.9%; 86 of 87) agreed to the use opioids for pain management and 90.8% (79 of 87) were satisfied with the analgesic effect, but more than half of the patients who received pain treatment reported inadequate analgesia.

Conclusion

There was a high incidence of cancer pain, but insufficient assessment, inadequate treatment and inadequate education about pain in both the waiting and radiotherapy periods.

Opioid prescription patterns in Germany and the global opioid epidemic: Systematic review of available evidence

Introduction

Opioids are one of the most important and effective drug classes in pain medicine with a key role in most medical fields. The increase of opioid prescription over time has led to higher numbers of prescription opioid misuse, abuse and opioid-related deaths in most developed OECD (Organisation for Economic Co-operation and Development) countries around the world. Whilst reliable data on the prevalence of opioid treatment is accessible for many countries, data on Germany specifically is still scarce. Considering Germany being the largest country in the European Union, the lack of evidence-based strategies from long-term studies is crucial. The aim of this work is to review and summarise relevant published literature on the prevalence of opioid prescription in Germany to adequately inform health policy strategies.

Methods

A systematic review of the epidemiology of opioid prescription in Germany was conducted, searching PubMed and Web of Science. Eligibility criteria were defined prior to conducting the search. Literature concerning Germany, published in English and German was included and the search was replicated by three independent researchers. Two levels of screening were employed. Disagreement was resolved by face-to-face discussion, leading to a consensus judgement.

Results

Our electronic search yielded 735 articles. Reviewing titles and abstracts yielded 19 relevant articles. Three authors examined each article’s full text more closely and determined that twelve papers should be included. Of the twelve identified studies—with publication dates ranging from 1985 to 2016—six were retrospective cross-sectional studies and six were retrospective repeated-measures cross-sectional studies. Sample sizes ranged from 92,842 to ≈ 11,000,000 participants. Data sources of included studies showed vast heterogeneity. The reviewed literature suggested an increase in the number of patients with opioid prescriptions and defined daily doses of opioids per recipient in Germany over time. The majority of opioid prescriptions was used for patients with non-cancer pain. Opioid use was more common in older people, women and in the north of Germany. Fentanyl was shown to be the most prescribed strong opioid in outpatient settings in Germany, despite not being the first-line choice for chronic pain conditions. All data published before 2000—but none of the more recent studies—suggested an insufficient treatment of pain using opioids. There were no signs for a current opioid epidemic in Germany.

Conclusions

Despite some limitations of the review and the heterogeneity of studies, it can be stated that the number of opioid prescriptions overall as well as the number of people receiving opioid treatment have increased over time. Most prescriptions were found to be for strong opioids and patients with non-cancer pain. Even though patterns of opioid prescription follow trends observed in other developed countries, there are no signs of an opioid epidemic in Germany. Therefore, this review could currently not find a need for urgent health policy interventions regarding opioid prescription practices. However, critical gaps in the literature remain and more research is needed to make more reliable judgements.