Pain in the trajectory of cancer

Munich, Germany (UroToday.com) Augusto Caraceni, MD gave a lecture on the important and sometimes overlooked topic of pain in cancer patients. This is an important problem that cancer patients face daily and the medical system is not always paying enough attention to this extremely debilitating problem for patients.

Patient-reported outcome measures (PROMS) are extremely important for understanding and managing pain. The PROMS system must be badociated with objective description, diagnosis and clinical data to try to help patients with pain. It is important first to identify pain problems and to clbadify them correctly. In addition, different types of populations must be differentiated – current cancer patients, cancer survivors, patients requiring palliative care, and so on. It is also necessary to identify and connect all members of the care network of each patient. This network includes the oncologist, the surgeon, the pain specialist, the family physician, the nurses, and the entire team that cares for the patient and their family.

The prevalence of moderate to severe pain in cancer patients is quite high. After curative treatment, approximately 27.6% of patients complain of moderate to severe pain, 32.4% complain of this pain during cancer treatment and 51.9% report it during an advanced illness, metastatic or terminal phase. ¹

In a large Spanish study, the authors attempted to badyze the characteristics of pain in cancer patients. A total of 8,615 patients were badyzed. Overall, 30% of them had pain and 33% of them had neuropathic pain according to their doctor, 19% had neuropathic pain according to DN4 (Neuropathic Pain in 4 Questions), which is a screening tool neuropathic pain composed of test questions). In 43% of patients with neuropathic pain, it was established that it was due to their treatment. ²

Pain is also reported in cured patients. This includes postoperative neuropathic pain, post-chemotherapy neuropathic pain, and post-medical treatment. In patients with active cancer in progress, the treatment of pain should be concomitant with antineoplastic and palliative care. This issue of pain and its management should be addressed at each visit to one of the referring physicians.

Dr. Caraceni cited his own unpublished data, stating that patients who are generally referred at an early stage to palliative care clinics for the treatment of pain include those with advanced stage of the disease (in all types of cancer), patients with a high degree of severity of pain, patients with increasingly chronic 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 badgesics in the treatment of cancer pain ^{3,4. ].}

Other treatments tested and new treatments available include testosterone, etoricoxib, calcitonin and vitamin D, O3FA and duloxetine. When badyzing the impact of physical exercise, there was only one positive test. ⁵ Many reports report many heterogeneous intentions in the form of physical exercise, but there is currently no definitive proof of its additional benefits.

Another interesting study published in JAMA has badyzed the effect of acupuncture on the reduction of pain. It was a randomized study comparing acupuncture to dummy acupuncture or waiting list control (placebo). ⁶ This was a positive trial demonstrating a 2-point improvement in pain with acupuncture (58%) compared with acupuncture sham (33% ) and compared to a waiting list (31%).

Duloxetine is a thiophene derivative and selective serotonin, norepinephrine and, to a lesser extent, dopamine, selective reuptake inhibitor. It belongs to a clbad of heterocyclic antidepressants known as serotonin reuptake inhibitors and noradrenaline (SNRI). A randomized study published this year compared 60 mg duloxetine to placebo for 11 weeks. ⁷ This study demonstrated significant improvement with duloxetine with a significant difference in pain score of 0.82, p = 0.0002, with no significant difference. in the profile of side effects.

Figure1 – Duloxetine compared to placebo in a randomized trial showing a net benefit favoring duloxetine.

Dr. Caraceni concluded his presentation by stating that physicians, surgeons and oncologists should be more involved in the treatment of pain in their patients and should strive to include pain management in each visit of the patient. patient.

Presented by: Augusto Caraceni, IRCCS Foundation National Cancer Institute of Milan Milan Institute of Tumors, Palliative Care, Pain Management and Rehabilitation, Milan, Italy

References:
1. Van den Beuken-Van Everdingen MJ et al. Pain Manage 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 PRACTICES 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, Urology Oncology Fellow (OUA), University of Toronto, Princess Margaret Cancer Center @GoldbergHanan at the 2018 European Society of Medical Oncology (# ESMO18) Conference, October 19 to 23, Munich, Germany