Pain Management In Oncology Research Articles

Early opioid exposure (EOE) and impaired efficacy in patients with advanced NSCLC treated with PD-L1 inhibition: A pooled post hoc analysis of the POPLAR and OAK trials.

2607 Background: Mechanistic evidence suggests opioid signaling to modulate anti-tumor immunity. Whether opioids exposure may affect outcome of patients (pts) treated with immune checkpoint inhibitors is unproven, with clinical evidence being flawed by the negative associative bias between pain and higher burden of disease. Methods: We conducted a post-hoc analysis of the phase 3 OAK (NCT02008227) and phase 2 POPLAR (NCT01903993) trials, which randomized (1:1) pts with advanced NSCLC to receive either atezolizumab or docetaxel. We assessed the differential impact of early opioids exposure (EOE), defined as a minimum of 7 days exposure to any systemic opioids in the time window ranging between -30 to +30 from treatment initiation on efficacy from immunotherapy vs chemotherapy. Pts with ≤30 days survival follow-up were excluded to avoid immortal time bias. Results: After the exclusion of 60 pts, 718 and 686 pts treated with atezolizumab and docetaxel were included, with 341 (47.5%) and 308 (44.9%) pts with EOE respectively (p=0.32) and a median follow-up of 25.5 months (95% CI: 22.8-25.9). Baseline characteristics was balanced across cohorts. In the pooled population, EOE was significantly associated with poorer ECOG-PS (p<0.01) and burden of disease (p<0.01). Univariable analysis showed EOE to be significantly associated with decreased objective response rate (ORR, 11.7% vs 19.8%, p<0.01) and progression free survival (PFS, 1.9 vs 4.2 months, p<0.01) in the atezolizumab cohort, whereas no effect on ORR (17.7% vs 14.4%, p=0.25) and a less pronounced effect on PFS (3.5 vs 4.1 months, p=0.02) was reported for the docetaxel cohort. The pooled multivariable backward stepwise Cox regression used to select variables for validating the results individuated ECOG-PS, histology, tumor burden and race. In multivariable models EOE was associated with decreased ORR (OR 0.58, 95%CI: 0.37-0.92), increased risk of progression (HR 1.47, 95%CI: 1.26-1.72) and death (HR 1.70, 95%CI: 1.42-2.03) in the atezolizumab cohort while no negative impact on ORR/PFS was confirmed among the docetaxel cohort, with a less strong effect on OS (HR 1.44, 95%CI: 1.21-1.72). Multivariable interaction tests confirmed the differential impact of EOE on ORR (p<0.01) and PFS (p<0.01) between treatment modalities (immunotherapy vs chemotherapy). The results were additionally confirmed using IPTW models including all the baseline variables with an optimal distribution (SMD <0.05). Conclusions: EOE is associated with worse response/PFS from immunotherapy but not from chemotherapy exposure, suggesting a possible immune-modulating effect of opioids signaling on anti-tumor immunity. Considering that systemic opioids are the cornerstone of pain management in oncology further research for mitigation strategies, such as the potential use of PAMORAs, is needed. Clinical trial information: NCT02008227 and NCT01903993 .

Challenges in Implementing Guideline on Integrative Oncology and Pain: The Israeli Perspective

Context and objectivesTo explore the feasibility of implementing the joint guideline on integrative medicine for pain management in oncology, published by the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO), for integrative oncology (IO) services in supportive and palliative care. MethodsA qualitative research methodology was co-designed by the SIO-ASCO guideline committee, with the Society for Complementary Medicine, Israel Medical Association (IMA). A questionnaire with five open-ended questions exploring barriers and enablers to implementing the guideline was distributed to chairs and board members of nine IMA-affiliated medical societies; four deans of Israeli medical schools; and nurses from the Israeli Society for Oncology Nursing. Respondent narratives were qualitatively analyzed using ATLAS.Ti software for systematic coding. ResultsQuestionnaires were completed by 52 physicians and nurses from medical oncology, hematology, gynecological oncology, pediatric oncology, palliative medicine, pain, family medicine, internal medicine, and integrative medicine. The SIO-ASCO guidelines were endorsed by nine IMA-affiliated societies. The domains identified included the importance of guideline implementation in clinical practice; barriers and facilitators to implementation; practical aspects required for this implementation (e.g., IO training); clinical indications for referral; budget-related issues; and clinical and administrative models enabling practical implementation of the guideline. ConclusionWe found across-the-board consensus among the nine IMA-affiliated societies supporting the current guideline. This, while identifying potential facilitators and barriers in order to address the implementation of the SIO-ASCO guideline recommendations.

The Benefits of Integrative Medicine for Pain Management in Oncology: A Narrative Review of the Current Evidence.

The aim of this evidence-based study is to narrate and evaluate the current evidence on recommendations for practicing physicians and other healthcare providers regarding integrative approaches to managing pain in patients with cancer. This review will assess the guideline recommendations and analyze the role of integrative medicine in addressing cancer pain in patients. The literature search highlights relevant studies that will inform evidence-based recommendations for practicing physicians, highlighting their relevance and weaknesses. Acupuncture, massage, and hypnosis have intermediate-strength evidence quality and are moderately recommended for various types of cancer pain. Most of the evidence points to acupuncture being recommended for aromatase inhibitor-related joint pain, hypnosis for procedural pain, and massage for palliative care pain. Other practices with lower-quality evidence include yoga and guided imagery with progressive muscle relaxation, mostly recommended for general cancer pain or musculoskeletal pain. Additionally, music therapy is recommended for procedural or surgical pain. Low-quality or inconclusive evidence was found for other mind-body interventions or natural products. Similarly, there is insufficient evidence to provide recommendations for pediatric patients. Further research is required to enhance our understanding of the role of integrative medicine interventions in caring for cancer patients.

Naloxone Training: An Opportunity for Oncology Nurses to Save Lives.

Opioids are commonly prescribed for pain management in oncology; however, there is a growing concern for nonmedical opioid use in patients with cancer. The oncology practice can implement harm-reducing strategies such as prov.

Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline Summary and Q&A.

Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline Summary and Q&A.

Traitement de la douleur cancéreuse : au-delà des approches médicamenteuses conventionnelles

Pain management in oncology is evolving progressively thanks to integrative approaches. In accordance with the type of pain and patient specifics, treatment possibilities are thus multiplied by combining conventional pharmacology, interventional approaches, physical and psychological treatments as well as complementary medicines, in a holistic perspective. International Societies Guidelines and scientific literature lend their support to such treatment plans. This article covers a number of interventional treatments and complementary options that are available. Their relevance is all the more important in view of the necessity to limit secondary effects and long-term opioids, especially in cancer survivors.

New WHO guidelines for cancer pain in adults and adolescents

In this article we performed publication analysis devoted to pain medicine in oncology during anticancer therapy and in palliative setting. Until recently, the main WHO guidelines for pain management in oncology were the recommendations of 1996, which included only pain relievers, as well as adjuvant and symptomatic drugs, which were applied according to the WHO analgesic ladder. These recommendations were based on the collective expert opinion of leading clinicians and scientists. The new WHO clinical guidelines were published in 2019. They are based on the principles of evidence-based medicine, including modern concepts of the etiology and pathogenesis of tumor pain syndrome. This recommendations contain sections on the analgesic efficacy of radiation therapy and antitumor drug therapy. The new WHO recommendations have not yet been published in Russian and are not sufficiently available for a wide range of oncologists and palliative specialists in our country. The purpose of this publication is to present within one volume a concise but complete and comprehensible discussion of the latest trends in pain therapy in oncology, published by WHO experts.

Provider perceptions of the social work role in oncologic pain management.

214 Background: Best practices of cancer care delivery have shifted from medical models to interdisciplinary approaches aimed at holistic care. The social work profession has advanced itself by gaining competence in psycho-oncology, advance care planning, biopsychosocial assessment and intervention, and pain management. While Masters prepared Social Workers (MSW) are widely recognized as experts in most of these areas, it appears that they are underutilized in pain management. This study will examine provider and nursing perceptions about social work expertise and whether those perceptions may limit utilization of social work in multidisciplinary management of cancer pain. Methods: While review of psycho-oncology literature supports the role of social work in pain management, this was not clearly indicated within the medical oncology domain. A survey was created to ascertain the perception of the MSW role in pain management as a supplement to pharmacologic and medically-based care when identifying and treating multidimensional pain. The survey was completed by Physicians, Advanced Practice Providers, and Nurses in outpatient oncology practices in The US Oncology Network. Results: 139 medical professionals responded. As hypothesized, 88% reported they were comfortable with MSWs conducting Advance Care Planning, while 61% reported being comfortable with MSWs educating patients and families about pain management during palliative/end of life care. 95% believed unmet emotional, social, spiritual and existential needs can present as physiological pain, however only 55% indicated they would include Licensed Clinical Social Workers to provide therapeutic interventions as part of pain management. Conclusions: Under half of survey participants reported an understanding of the scope of social work practice, which aligns with the lack of awareness and under-utilization of social work as a vital contributor in oncologic pain management. MSWs have training in evidence-based interventions such as CBT, guided imagery, mindfulness and biofeedback techniques which may diminish the experience of pain. Further research is recommended to identify strategies to promote and integrate social work into multidisciplinary pain management.

An Integrated Review of Cannabis and Cannabinoids in Adult Oncologic Pain Management

ObjectiveThe objective of this paper is to review the available literature regarding the use of cannabis and cannabinoids in adult oncologic pain management. Design and Data SourcesA integrative review was conducted on March 1, 2018 using PubMed, MEDLINE, CINAHL, Embase, and Scopus. A snowball method was used to extract studies included in systematic reviews that were not included in the primary literature search. Review MethodArticles reviewed address the use of cannabinoids or cannabis for pain management in oncology patients, either as stand- alone or adjuvant therapy. ResultsThe final number of articles included is nine articles. Of the nine studies reviewed, eight reviewed the effect of the cannabinoid THC on cancer pain, and one study reviewed the use of medicinally available whole plant cannabis. The following study types were included: multiple multi-center, randomized, placebo- controlled trials and two prospective observational survey studies. Results and ConclusionsOf the eight studies that reviewed the effect of the cannabinoid THC, five found THC to be more effective than placebo, one found THC to be more effective than placebo in American patients but ineffective in patients from other countries, and two found THC to be no more effective than placebo. The study that reviewed the effect of the whole plant cannabis found that there was a significant decrease in pain among those patients smoking cannabis. Nursing Practice ImplicationsThe lack of evidence in this field of research suggests a need to change policy surrounding cannabis research.

Effects of the education program for patients with cancer pain.

193 Background: Caner pain is prevalent, burdensome, and undertreated. Barriers to good cancer pain control exist within patients on lack of knowledge or poor attitudes towards pain and opioid analgesics. The objective of this study was to test the effects of an education program on reducing barriers to pain management in oncology. Methods: Participants completed baseline assessments and were randomly allocated to receive an education program or not in addition to standard care. Education materials for the pain management program included the ‘Guideline on cancer pain management for patients’. The average education time took basically 30 minutes, and CRNs implemented the education program using a booklet for an individual patient. Outcome measures at one week included the Barriers Questionnaire (BQ), Brief Pain Inventory. Adherence of analgesia and daily activity score were assessed. Results: 176 participants were recruited from 5 sites over 3 months. Mean average pain and worst pain score (NRS) improved significantly in patients receiving education program 1.40 and 1.61. The addiction subscale of the BQ score was improved by 1.95 (pre: 3.39, post: 1.44, p < 0.001) for participants receiving pain education. In terms of administration of short-acting analgesics due to breakthrough pain, inpatients showed no large difference before/after education in the use of short-acting analgesics but outpatients exhibited an increase from 25.5% before education to 73.5% after education and the difference was statistically significant. Conclusions: A cancer pain education was effective in reducing patient's barriers to pain management, improving pain score and daily activity score of cancer patients, especially using short-acting analgesics for breakthrough pain control in outpatients.

Therapeutic conducts used in pain management in oncology

OBJETIVO: Identificar as principais modalidades terapêuticas utilizadas pela equipe de enfermagem no tratamento da dor, a coerência de sua utilização e o grau de satisfação dos pacientes oncológicos institucionalizados. MÉTODO: Estudo exploratório-descritivo, realizado em um hospital referência no tratamento de câncer, cuja amostra foi composta de 50 pacientes. Os dados foram obtidos por meio de um questionário e analisados por estatística descritiva e por medidas de associação entre variáveis, utilizando-se o teste qui-quadrado. RESULTADOS: No manejo da dor em oncologia, são implementadas condutas farmacológicas e não farmacológicas, no entanto, os profissionais de enfermagem têm restringido sua prática à administração de analgésicos, sendo descrita pela maioria dos participantes da pesquisa como a conduta mais satisfatória para o alívio da dor. CONCLUSÃO: O controle da dor em oncologia tem sido um desafio para a prática clínica dos profissionais de enfermagem, levando-se em consideração a magnitude do problema e a subjetividade do fenômeno doloroso.

An interdisciplinary process for improving pain management in oncology.

182 Background: Upcoming changes in Medicare reimbursement models take into account HCAHP scores, and over the next 1-3 years, penalties will be enacted towards those institutions falling below a standard on their publicly available HCAHP scores. The HCAHP pain domain can be one of the most challenging to impact directly due to lack of pain management knowledge, proper assessment skills, expertise in managing complex pain syndromes, and the heterogeneity of pain symptomatology reported by advanced cancer patients. Methods: This project identified inpatient oncology units with suboptimal HCAHP scores. The objective was to improve HCAHP pain scores to > 90th percentile. Nursing intervention focused on five primary areas: a) A requirement to attend a mandatory class on malignant pain management; b) making available nursing pain mentors; c) a requirement to address pain during rounds with physicians; d) priority access to medications to address pain; and, e) encouraging event reporting for uncontrolled pain issues. Resident physicians were provided expectations for pain management and attended a mandatory class on malignant pain taught by a palliative medicine attending physician. A palliative medicine physician was also assigned to the unit to evaluate patients with pain scores > 6/10 or complex pain needs. An algorithm for pain control was designed to include a timeline for intervention as well as an escalation process for slow or inadequate physician response. A hand-off report was provided to the charge nurse by the senior resident physician at the end of each day that included a tentative plan for treating any escalating pain. Results: All initiatives were implemented in September 2012. By February 2013, Pain HCAHP scores increased 10% over the entire Taussig Cancer Institute, and increased 20% for the solid tumor oncology unit. This placed all units who received this targeted intervention above the 90th percentile as compared to other hospitals on the HCAHPS pain score. Conclusions: A well-defined collaborative model between physicians and nursing produced measurable improvement in pain outcomes for oncology inpatients. An interdisciplinary approach is essential for the management of complex pain issues in an oncology patient population.

Pain management at the point-of-care

8072 Background: To assure a high level of quality in oncologic pain management, careful assessment of a multitude of clinical parameters and their change over time is necessary, which is usually documented on paper forms. Instead of using a pen and paper-based method, a computer-based method may increase efficiency. However, as pain therapy and its documentation take place at the bedside, a traditional PC application seems not feasible. Our aim was to develop a system which includes a mobile component which would run on PDA computers in addition to PC based software, and assist physicians and other team members to view, enter and assess the condition of the patient's pain and the details of its management. The purpose of this study was to evaluate whether the implementation of this system resulted in improvement of the quality of pain management. Methods: Health care providers using this system have access to several modules. The module on physical examination for example contains various opiate side eff...

Pain management at the point-of-care

8072 Background: To assure a high level of quality in oncologic pain management, careful assessment of a multitude of clinical parameters and their change over time is necessary, which is usually documented on paper forms. Instead of using a pen and paper-based method, a computer-based method may increase efficiency. However, as pain therapy and its documentation take place at the bedside, a traditional PC application seems not feasible. Our aim was to develop a system which includes a mobile component which would run on PDA computers in addition to PC based software, and assist physicians and other team members to view, enter and assess the condition of the patient's pain and the details of its management. The purpose of this study was to evaluate whether the implementation of this system resulted in improvement of the quality of pain management. Methods: Health care providers using this system have access to several modules. The module on physical examination for example contains various opiate side eff...

ANESTHETIC MANAGEMENT OF THE PATIENT WITH CANCER PAIN

Because of a legacy of undertreatment, cancer pain has only been recently recognized as a disease state. Thus, a paucity of data exist relating to the perioperative management of patients withchronic pain syndromes, most of whom are prescribed multiple analgesics and related agents for the control of a myriad of symptoms. Patients are prescribed traditional analgesics (i.e., nonsteroidal anti-inflammatory drugs [NSAIDS] and opioids), often in doses far in excess of those used for the management of acute pain, but patients may also be taking a variety of so-called ”adjuvant” analgesics, drugs developed for alternate purposes and only serendipitously observed to promote analgesia in specific settings (e.g., antidepressants, anticonvulsants, and antiarrhythmics, usually for neuropathic pain). Although a modicum of information exists on potential drug interactions and the perioperative management of patients prescribed adj~vants,’~ there is a dearth of literature on the perioperative management of patients using high-dose opioids. With the recent release of guidelines that endorse more aggressive cancer pain management, the use of opioid analgesics is likely to increase further.l0 In addition, although the chronic use of opioids has traditionally been reserved for oncologic pain management, there is a growing trend toward the use of these agents in patients with chronic nonmalignant pain.’, 47 15, l9 Thus, patients in whom chronic opioid and adjuvant analgesic therapy is an important anesthetic consideration includes not only cancer patients presenting for tumor reduction and other surgery, but also individuals coming for orthopedic, neurologic, and routine surgery. Without careful planning based on a sound knowledge of the pharmacology of chronically administered opioids and an appreciation for basic pain management principles, these patients pose significant perioperative problems to the anesthesiologist and surgeon.