Oncologists practice with opioids in cancer pain

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Background: The majority of cancer patients are mostly under the care of their primary oncologists for both active and symptom management. Pain is the most feared symptom in cancer patients. In general, it is highly prevalent and under treated. Barriers to adequate pain management still exist even among specialized care givers. Improper opioid utilization is one of main factors within those impediments. The pattern of opioid prescription among oncologists in a specialized hospital was examined on referral to a palliative care unit within the same institution. Methods: Over a period of six months (between Dec. 2003 and June 2004) 290 cancer patients were referred to the section of palliative medicine from different medical specialties within the same institution. The medical records of 233 (80%) were analyzed, 116(50%) were referred from oncology specialists (radiation, medical & hematology oncology), 76 referred patients fulfilled the study criteria. On referral; all eligible patients had to be on opioids for pain. The pattern of opioid prescription by oncologists in this group of patients with reference to the currently available guidelines was examined. Results: The following results were found: Pain was inadequately controlled in 71% patients. Although, the majority of the patients 92% were able to utilize the oral route, it was only used in 36% of patients. The first strong regular opioid was the standard morphine in only 46% of patients. Breakthrough opioid was prescribed to most patients (91%). However, dose and interval were outside the general guidelines in 44% & 81% respectively. Laxatives were not prescribed in half of the patients Conclusions: Opioids are the principal effective, relatively simple and practical drugs in pain relief. Yet, within specialized care providers as shown in this study, opioid utilization was unsatisfactory. More understanding of pain assessment, better opioid utilization and more knowledge of opioid pharmacology still warranted.

No significant financial relationships to disclose.

Pulmonary metastatectomy for soft tissue sarcomas: is it valuable?

BACKGROUND

A retrospective study and analysis was performed to determine the value and benefit of pulmonary metastatectomy for soft tissue sarcomas, and which factors predict prognosis following resection.

METHODS

Twenty-three patients underwent resections for pulmonary metastases from a soft tissue sarcoma (STS) at King Faisal Specialist Hospital and Research Center (KFSH&RC), between January 1985 and December 1998. There were 11 male and 12 female patients. Thirteen of 23 patients (57%) had one to three metastases, and 10 (43%) had four or more metastases. A total of 41 thoracic explorations was performed for the 23 evaluable patients. Median sternotomy was used only for three patients and lateral thoracotomy was used for 20 patients as an initial surgical approach. Pulmonary resections performed included one or more wedge resections (n=16), segmentectomy (n=5), and lobectomy (n=2). No one in this series underwent pneumonectomy. The number of resected metastatic nodules ranged from one-six with average three. Eight patients (35%) received various kinds of postoperative adjuvant chemotherapy.

RESULTS

The overall and disease-free survival rate post-metastatectomy at five years was 24% and 21%, respectively. Various prognostic indicators were examined to evaluate their association with improved survival. Age, sex localization of the primary site and histologic type, tumor grade, size of the resected nodules, laterality (unilateral or bilateral), types of resection, adjuvant chemotherapy, and local recurrence did not significantly affect survival. However, patient with disease free interval >6 months, and those with three or fewer metastases showed a trend toward a higher five-year overall survival (p=0.06, 0.07, respectively).

CONCLUSIONS

Surgical excision of lung metastases from soft tissue sarcomas is well accepted and should be considered as a first line of treatment if preoperative evaluation indicated that complete resection of the metastases is possible. Further investigation is needed before chemotherapy can be recommended as additional therapy.