WELCOME to the Second Annual Duke Cancer Pain Symposium

2. WELCOMEto theSecond AnnualDuke Cancer Pain Symposium Sponsored by Duke Cancer Care Research Program

3. VISION Cancer care that… • treats the patient as a whole person, in mind, body, and spirit; • helps the patient travel the full journey of cancer (diagnosis through survivorship or end of life); • incorporates the best of medical care into a comprehensive, longitudinal, personalized care plan; and • optimizes the patient’s well-being, quality of life, and outcomes.

4. Why talk about cancer pain? • 1/6 of cancer patients at diagnosis • 1/3 of cancer patients undergoing active therapy • 60-90% of patients with advanced disease • >80% of cancer patients with pain have 2 or more sites of pain

5. Who is at risk? Risk of cancer-related pain is related to: • type and stage of tumor • age • race and gender • therapy, especially side effects of chemotherapy • lack of belief in the patient’s pain complaint Abernethy AP, Samsa GP, and Matchar DB. Am J Managed Care 2003; 9: 121-134. Cleeland CS et. al. NEJM 1994; 330:592-596.

6. Is cancer pain unique? • Comprises nocioception + subjective perception • Presents unique qualities associated with cancer • Meaning • Association with cancer, death, punishment, challenge, enemy, • Existential suffering • Co-occurring noxious symptoms • Anticipated progression • Caused, or relieved, by anti-neoplastic therapies • Low risk of addiction

7. Physical TOTAL PAIN Psychological Existential Social

8. Etiologies and experiences of pain are highly individual.

9. Cancer pain management = Foundation +Individualized Care

10. WHO Analgesic Ladder

11. Cancer pain management in practice • analgesic ladder as foundation of care • individualized therapy • round-the-clock dosing • breakthrough dosing • by mouth, whenever possible • side effects treated expectantly Basic principles:

12. Do guidelines work? Du Pen SL et al. Implementing Guidelines for Cancer Pain Management: Results of a Randomized Controlled Trial. JCO 17:361-370, 1999. Worst Pain, p=.2 BPI Pain Intensity Usual Pain, p <0.02

13. When don’t the guidelines work? • More appropriate prescribing of adjuvant drugs for algorithm patients (p<0.001) • Common errors in both groups: • Prescribing prn dosing only • Underdosing of rescue medication • Failure to escalate scheduled dose in face of escalating pain Du Pen SL et al. Implementing Guidelines for Cancer Pain Management: Results of a Randomized Controlled Trial. JCO 17:361-370, 1999.

14. anticonvulsants antidepressants benzodiazepines antihistamines steroids antibiotics radiation bisphosphonates chemotherapy surgery neurolytic blocks and neurosurgery acupuncture relaxation techniques exercise other Adjuvant therapies Side effect management

15. Agenda • Lee Jones - exercise • TJ Gan - acupuncture • Amy Abernethy – neuropathic pain • Holly Forester-Miller – medical hypnosis • Alexandra DuPont – e/Tablets for assessment • Lydia Mis – side effect management • Tracy Gosselin – survivorship concerns • Yousuf Zafar – topic opiates • Krista Rowe – concluding remarks

16. A sincere thank you to our speakers As well as the DCCRP team including Laura Criscione and Laura Roe And thank you to our audience – we wouldn’t be here if it weren’t for you and the patients that we serve