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Management of pain in the treatment of cancer patients

Management of pain in the treatment of cancer patients. Treatment Options. Chemotherapy Radiotherapy Hormonal Therapy Surgery Systemic Localized . BASIC PRINCIPLES APPLY. WHO ANALGESIC LADDER. DIFFERENT PATHOPHYSIOLOGIES OF PAIN. CHOOSING THE APPROPRIATE FORMULATION AND AVAILABLE DRUG.

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Management of pain in the treatment of cancer patients

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  1. Management of pain in the treatment of cancer patients

  2. Treatment Options

  3. Chemotherapy • Radiotherapy • Hormonal Therapy • Surgery • Systemic • Localized

  4. BASIC PRINCIPLES APPLY

  5. WHO ANALGESIC LADDER

  6. DIFFERENT PATHOPHYSIOLOGIES OF PAIN

  7. CHOOSING THE APPROPRIATE FORMULATION AND AVAILABLE DRUG

  8. Chemotherapy

  9. Common determinants of pain • Chemotherapy drug and regimen • Co existing pain • Age • Nutritional status • Prior chemotherapy and radiation treatments • Cognitive, physiological, psychological and behavioral factors

  10. COMMON SIDE EFFECTS • Mucositis • Neuropathic pain • Hand foot syndrome • Arthralgia

  11. Case 1 • 68 year old male with colon cancer with extensive lung and liver metastases • On 5 FU based palliative chemotherapy • ECOG performance status 3 • His 67 year old wife takes care of him • He now has pain in the mouth, is not able to eat well and finds it difficult to swallow his analgesics • Examination:

  12. MUCOSITIS

  13. MUCOSITIS • Mucositis can affect all mucous membrane-covered surfaces from the mouth to the rectum (Camp-Sorrell 2000) • Most common condition requiring systemic analgesics during cancer therapy (Epstein and Schubert 1999) • Oral mucositis affects approximately 40% of patients undergoing chemotherapy • Cancer treatment-induced mucositis causes acute pain, which is the result of sloughing of the epithelium, inflammation of the mucosa and ulceration (Camp-Sorrell 2000)

  14. Mucositis • WHO grading

  15. Mucositis

  16. Mucositis

  17. Mucositis: mouth care • Rinse mouth with water frequently (every 2 hrs while awake & when awake during the night). May add salt or baking soda (1/2 to 1 teaspoon in 8 ounces of water) • Use soft-bristle toothbrush (can soften even more by placing brush in very warm water), cotton swabs, mouth swabs (popsicle stick covered with gauze) to clean teeth after each meal and at bedtime

  18. Mucositis: pain control • Topical or local agents such as Orajel • Combination mouth wash can be made (ingredients may require prescription). Use equal parts: xylocaine viscous solution, benadryl, sucralfateand Maalox® taking 2 teaspoons every 2-4 hours as needed (swish around mouth and spit out)

  19. Mucositis: healing • Apply Vitamin E (puncture cap 400IU and squeeze onto swab. Gently place swab on open area(s) • Take an antacid 1/2-1 ounce every 3-4 hours as needed to decrease burning sensation • Maintain good nutrition focusing on high protein and high calorie foods which are soft and/or semi liquid (i.e. scrambled eggs, puddings, blenderized or pureed foods). May use liquid supplements (i.e. Ensure®, Boost®, etc.)

  20. Mucositis: avoidance • Hot, spicy, coarseor rough textured foods • Very hot or cold beverages and foods • Citric juices or foods containing citric acid (tomatoes, oranges, lemon, etc.) • Alcoholic beverages ortobaccoproducts • Liquid medication containing alcohol (e.g. mouth wash) if not essential

  21. Case 2 • 34 year old mother with metastatic breast cancer (lung, bone and liver) • Performance status 2 • Takes care of her 8 month old • On capecitabine • Develops pain in her hands and feet and she is unable to care for her baby. She is emotionally distressed. • Examination:

  22. Hand and foot syndrome

  23. Hand foot syndrome • Uncomfortable and relatively frequent dermatologic toxic reaction to certain chemotherapeutic agents (NCI) • Can be caused by: 5-Fluoruracil, capecitabine, vinorelbine, liposomal doxorubicin, docetaxel, sorafenib, sunitinib and high-dose Interleukin-2 (De Vita)

  24. Hand foot syndrome • From managing CRC:

  25. Hand foot syndrome: prevention • Preventative measures can help to decrease the severity of symptoms should they develop • Modifying some of the normal daily activities of the patient to reduce friction and heat exposure to his/her hands and feet for a period of time following treatment • Avoiding long exposure of the hands and feet to hot water such as long showers or tub baths • Avoiding increased pressure on the soles of the feet or palms of hands • Minimizing long walks

  26. Hand foot syndrome: management • Stop the chemotherapy agent once the syndrome has started • Emollientssuch as Aveeno®, Lubriderm®, Aqueous cream provide excellent moisturizing • Analgesics, cold compresses, cushioning and elevating the limb area • Oral and topical steroids as well as Vitamin E have been used with limited success

  27. Radiotherapy

  28. Factors affecting pain at radiation site

  29. Factors • Site of radiation • Extent of disease • Total dose • Dose per fraction • Comorbid conditions • Physiological factors

  30. Common sites for pain • Head and neck area • Skin • Groin

  31. Case 3 • A 68 year old female with extensive cutaneous metastases from a recurrent breast cancer • She is having short course palliative radiotherapy with electrons for pain and bleeding • She has moist desquamation and has difficulty with dressing and sleeping • Performance status 2

  32. Management of desquamation • Topical treatment may offer symptomatic relief and may help skin healing. Different areas of skin may require different treatment approaches • Drying pastes may be appropriate for use within skin folds, where skin reactions remain moist • Gels can be useful in seborrhoeicareas • Creams can be used in areas outside skin folds and seborrhoeicareas • Hydrophilic dressings may also be useful in moist areas. These are placed over the cleaned, dried wound and some can absorb wound exudate. They can be soothing for the patient and can help skin healing • Greasy topical products should be avoided because they inhibit the absorption of wound exudate and promote superinfection

  33. Prevention of desquamation • The irradiated area should be kept clean to minimize the risk of infection • Patients should wash the area with a gentle cleanser and dry it with a soft, clean towel • Loose-fitting clothing should be worn over the irradiated area to prevent friction injuries

  34. surgery

  35. Surgery • Not commonly used modality • Can be used in cases to aid with bleeding, obstruction and fracture • Pain is usually at the post surgical wound site

  36. Hormonal therapy

  37. A small category • Breast cancer patients on aromatase inhibitors can experience joint pain • Can worsen quality of life especially in those with pre-existing joint pain

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