Patient-reported outcome measures (PROMS) are extremely important for the understanding and management of pain. PROMS must be combined with the objective description, diagnosis, and clinical data, in an attempt to try to help patients dealing with pain. It is important to initially identify pain problems and classify them correctly. Moreover, there are various types of populations that need to be differentiated – current cancer patients, survivors of cancer, patients in need of palliative care and others. It is also required to identify and connect with all the members of the care network of each patient. This network includes the oncologist, the surgeon, the pain specialist, the family physician, nurses, and the entire team caring for the patient, and his family.
The prevalence of moderate to severe pain among cancer patients is quite high. After curative treatment, approximately 27.6% of patients complain of moderate-severe pain, 32.4% complain of this magnitude of pain during anti-cancer treatment, and 51.9% report it during advanced, metastatic or terminal disease.1
In a large Spanish study, the authors attempted to analyze the patterns of pain among cancer patients. A total of 8,615 patients were analyzed. Overall, 30% of them had pain with 33% of them having neuropathic pain according to their clinician, 19% had neuropathic pain according to DN4 (Douleur Neuropathique en 4 Questions, which is a screening tool for neuropathic pain consisting of interview questions and physical tests). In a total of 43% of patients with neuropathic pain, it was found to be due to their treatment.2
In patients that have been cured, pain is also reported. This includes postsurgical neuropathic pain, post chemotherapy neuropathic pain, and post-medical treatment. In patients with active ongoing cancer, pain management should be concurrent with antineoplastic treatment, and with the palliative care. This issue of pain and its management should come up in every visit with one of their treating physicians.
Dr. Caraceni quoted his own unpublished data, stating that the patients that are usually referred at an early stage to the palliative care clinics for pain management, include those with advanced disease stage (in all types of cancer), patients with a high grading of pain severity, patients with chronic worsening cough, and patients with brain metastases.
The European Association for palliative care and ESMO have published their recommendations and guidelines on the use of opioid analgesics in the treatment of cancer pain3,4.
Some of the other analyzed, and possible new treatments include testosterone, etoricoxib, calcitonin, and vitamin D, O3FA, and Duloxetine. When analyzing the impact of physical exercise, there has been only one positive trial.5 There have been many reports on many heterogenous intentions in the form of physical exercise, but no definitive evidence on its added benefit currently exists.
Another interesting study published in JAMA analyzed the effect of acupuncture on pain reduction. This was a randomized study that compared Acupuncture to sham acupuncture and or waitlist control (placebo).6 This was a positive trial demonstrating an improvement of 2 pain points with acupuncture (58%) compared to sham acupuncture (33%) and compared with a waiting list (31%).
Duloxetine is s thiophene derivative and a selective neurotransmitter reuptake inhibitor for serotonin, norepinephrine, and to a lesser degree of dopamine. It belongs to a class of heterocyclic antidepressants known as serotonin-norepinephrine reuptake inhibitors (SNRIs). A randomized study published this year, compared duloxetine 60 mg to placebo for 11 weeks.7 This study demonstrated a significant improvement with duloxetine with a significant difference in pain score of 0.82, p=0.0002, with no significant difference in the side effect- profile.
Figure1 – Duloxetine compared to placebo in a randomized trial, showing a clear benefit in favor of duloxetine.
Dr. Caraceni concluded his talk stating that physicians, surgeons, and oncologists should be more involved in the management of pain in their patients and should strive to include pain management in every patient visit.
Presented by: Augusto Caraceni, IRCCS Foundation National Cancer Institute of Milan Milan Institute of Tumors, Palliative care, Pain Therapy, and Rehabilitation, Milano Italy
References:
1. Van den Beuken-Van Everdingen M J et al. Pain Sympt Manage 2016
2. Garcia de Paredes et al. Ann Oncol 2011
3. Caraceni A et al. Lancet Oncol 2012
4. Marie Fallon et al. Ann Oncol 2018 ESMO CLINICAL PRACTICE GUIDELINES.
5. Irwin et al. JCO 2015
6. Hershman D et al. JAMA 2018
7. Henry NL et al. JCO 2018
Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 European Society for Medical Oncology Congress (#ESMO18), October 19-23, 2018, Munich Germany