Palliative Care and Cancer

Dr Anne Boyle Assistant Clinical Professor Division of Palliative Care McMaster University Palliative Care Physician St Joseph’s Healthcare Slides in conjunction with Dr Nadia Platch

MF4 McMaster – June 07, 2013 • I have no conflict of interest and no association with companies or business associated with pharmaceutical or other commercial industries Learning Objectives

• Describe Palliative Care • Describe elements of good pain history • Assess pain severity using validated tools • Identify causes of - acute & chronic • Differentiate pain - nociceptive vs neuropathic • Pharmacotherapy: multimodal analgesia WHO Definition of Palliative Care

• Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative Care

• provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten or postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; offers a support system to help the family cope during the patients illness and in their own bereavement; • uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated

• will enhance quality of life, and may also positively influence the course of illness • is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. • http://www.who.int/cancer/palliative/definition/en/ Early Palliative Care for Patients with Metastatic Non-Small Cell Temel,J et al NEJM 363;8 August 19 2010 733-42

• This study shows the effect of palliative care when it is provided throughout the continuum of care for advanced lung cancer. Early integration of palliative care with standard oncologic care in patients with metastatic non–small-cell lung cancer resulted in survival that was prolonged by approximately 2 months and clinically meaningful improvements in quality of life and mood. Moreover, this care model resulted in greater documentation of resuscitation preferences in the outpatient electronic medical record, as well as less aggressive care at the end of life. Less aggressive end-of-life care did not adversely affect survival. Rather, patients receiving early palliative care, as compared with those receiving standard care alone, had improved survival. Case Scenario John is 55 yr old - lung cancer Partial pneumonectomy 2 yrs ago...“we got it all” Admitted with severe back pain & leg weakness Past Medical History Chronic back pain – injured at work 10 yrs ago Smokes, hypertension Social History Construction worker – disability (WSIB) Divorced then remarried 5 yrs ago A son & daughter from first marriage No drug plan outside of meds covered by WSIB • 3 days ago patient admitted due to increased back and leg pain • Urgent MRI revealed tumor involving the lumbar spine and cord • Patient treated with steroids and urgent radiation • Patient was seen by Ortho for consideration of decompression and instrumentation. Cancer Pain

• Pain – often most distressing symptom experienced by patient with cancer • Need to ask patient “what pain means” to them • Many factors contribute to experience of pain -physical sensation only one of them • Concept of “total pain” should be considered

Jovey R. Managing Pain 2002. Cancer Pain. Chapter 13.p 129-135 “Total Pain”

Physical

Culture & Emotions & Social Factors Personality

Spiritual Patient Assessment: Cancer pain

• Pain history • Physical exam • Lab and tests • Diagnosis The Pain History

• Onset • Effect on daily living • Pattern/Location • Aggravating factors • Quality Relieving factors • Radiation • Past medications • Severity • Fears about • Timing/Duration medication • Understanding • Meaning of the pain • Value Concurrent Pain & Symptoms

• Description and impact of cancer pain – Document baseline pain severity to gauge response to therapy • Pre-existing pain syndromes (OA, LBP, etc) • Other symptoms associated with cancer • Concurrent medical problems

Jovey R. Managing Pain 2002. Cancer Pain. Chapter 13.p 129-135 Analgesic History

• Past experience with analgesics: – Efficacy • Inter-individual differences in analgesic effect • Metabolism: 10% +of population is unable to convert codeine to morphine –Adverse effects –“Allergy” to opioids is rare (mistaken S/E) –Patient preferences (fear of narcotics)

Chen ZR. Br J Clin Pharmacol 1991 Psycho-social Issues • Relevance of pain to patient & family • Impact on quality of life • Social supports • Cognitive function (geriatrics, advanced disease) • Alcohol and drug use history – Tolerance issues – Assess risk of misuse Jovey R. Managing Pain 2002. Cancer Pain. Chapter 13.p 129-135 Whitcomb LA, Kirsh KL, Passik SD. Substance abuse issues in cancer pain. Curr Pain Headache Rep 2002;6:183-90 Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 1: Prevalence and diagnosis. Oncology 1998;12:517-21. Pain History-Addiction

• Traditionally less of societal concern in cancer pain than chronic non-cancer pain – (7-10%) risk of addiction/abuse in CNCP patients • Family members (or patients) can take pills or siphon pain pumps for personal use or sale “Have any family members had problems with drugs or alcohol?” “Have you ever had any problems with drug or alcohol use?” “Have you ever had problems with prescription drug overuse?” Assessing Pain – Validated Tools

Validated scales document pain severity as well as efficacy of treatment: • Unidimensional Pain Scales - short & easy • Brief Pain Inventory - more detailed • Edmonton Symptom Assessment Scale (ESAS) – multi-dimensional: pain & other symptoms Descriptive, Numeric, Analog Pain Rating Scales

No Pain Mild Pain Moderate Severe Very Worst Pain Pain Severe Possible Pain Pain

No Distressing Unbearable Pain Pain Pain

0 1 2 3 4 5 6 7 8 9 10

No Pain Pain as Bad as it Could Possibly Be FACES Pain Scale - Revised

“These faces show how much something can hurt. This face [point to left-most face] shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to right-most face] - it shows very much pain. Point to the face that shows how much you hurt [right now]”

Hicks e t al 2001 ESAS Case Study

• John is upset about likely recurrence of his cancer • Unable to sleep, anxious, poor appetite, slow to mobilize due to pain • Referral made to Palliative Care team (MD, RN, SW) – Assesss his pain & symptoms (ESAS scores) – Arrange a family meeting to address psychosocial needs – Provide psychological and emotional support – Goal setting for future care plans Co-morbidities of Unrelieved Pain

• Associated stress & negative consequences lead to: – Inadequate sleep – Anxiety – Depression • Negative impact on functionality & quality of life • Require assessment & treatment using a multimodal and inter-disciplinary approach

Argoff CE. Clin J Pain 2007; 23(1):15-22. Nicholson B et al. Pain Medicine 2004; 5(S1):S9-S27. Cleeland CS et al. Ann Acad Med Singapore 1994; 23:129-38. Breitbart W et al. Pain 1996; 68:315-21. Current Functioning and Future Goals • The longer and more complex the pain problem, the more helpful an inter-disciplinary team approach is (PT, OT, psych, chaplain…) • Goal is to improve quality of life – Improving function & relieving pain – Combine pharmacological & physical therapies – Coping strategies (psychological & spiritual) Assessment of Cancer Pain

• Pain history • Physical exam • Lab and tests • Diagnosis Physical Exam & Laboratory Testing in Cancer Pain

Assessment should consider “goals of care” • Less advanced stages: assess source of pain, ensuring pain control maintained throughout • Advanced cancer: investigations may cause more pain & discomfort, without improving outcome – may not need to clarify cause - just treat the pain

Cherny NI, Portenoy RK. The management of cancer pain. CA Cancer J Clin (1994) 44:262-303 Jovey R. Managing Pain (2002) Cancer Pain. Chapter 13.p 16;129-135 Goals of Exam & Tests in CA Pain

• Identify the source of pain(s): –Acuteversus chronic pain (CA & CNCP) – Differentiate nociceptive vs • Initiate pain treatment while awaiting test results – Important to control severe CA-related pain ASAP – Fully assess cause - after pain under control – Document source, type of pain & recent treatments

Cherny NI, Portenoy RK. The management of cancer pain. CA Cancer J Clin 1994;44:262-303. Jovey R. Managing Pain 2002. Cancer Pain. Chapter 13.p 16;129-135 Differential Diagnosis of CA Pain

• Pain history • Physical exam • Lab and tests • Diagnosis Role of Diagnosis in Cancer Pain

• Identify the causes of pain (often >3) – reverse the underlying cause, if possible • Intermittent or constant pain? – analgesia “round the clock” or PRN • Treat pain aggressively to avoid chronic pain – neuropathology…more resistant to analgesia Characteristics of Acute CA Pain

• Recent onset and/or transient • Typically accompanied by: – Overt behaviours (moaning, grimacing, splinting) – Anxiety – Generalized sympathetic hyperactivity(sweating, hypertension, tachycardia etc)

Cherny NI, Portenoy RK. The management of cancer pain. CA Cancer J Clin 1994;44:262-303. Causes of Acute Cancer Pain

• Tumor-related acute pain: – pathological fracture – acute obstruction of bowel or – acute hemorrhage into tumor • Diagnostic & therapeutic interventions: – biopsies of tissue / bone marrow – lab investigations / – surgery, catheter insertion, chemotherapy, radiation

Jovey R. Managing Pain 2002. Cancer Pain. Chapter 13.p 16;129-135 Chronic Cancer Pain

• Persistent over time, unremitting or recurrent • Gradual onset, increases with tumor growth and cancer progression – may subside with tumor shrinkage (chemo, radiation) • Often accompanied by: – anxiety/depression – vegetative symptoms

Cherny NI, Portenoy RK. The management of cancer pain. CA Cancer J Clin 1994;44:262-303. Causes of Chronic CA Pain • Usually from tumor itself – invasion of bone and/or nerves – obstruction or ulceration – CA-induced syndromes (pressure sores, constipation)

• Diagnostic & therapeutic interventions - procedures/post-op/radiation/chemotherapy - adverse S/Es of therapy 15-25% of discomfort

• May be unrelated to disease/treatment

Jovey R. Managing Pain 2002. Cancer Pain. Chapter 13.p 16;129-135 Cherny NI, Portenoy RK. The management of cancer pain. CA Cancer J Clin 1994;44:262-303. Case Study

• John’s back pain is constant (8/10) • Aggravated by activities eg. physiotherapy (10/10) • Radiates down his legs “shooting & burning” • Analgesic effective for about 3 hours, only Breakthrough Pain in Cancer

Occurs in both acute and chronic pain 1. Sudden increase in pain (incident pain) • movement or activities • micturition and/or defecation • cough • bowel distention 2. “End of dose” analgesic failure

Cherny NI, Portenoy RK. The management of cancer pain. CA Cancer J Clin 1994;44:262-303. Questions

• How will you manage John’s pain(s)?

– Route of analgesic administration?

– Best choice of analgesic? Parenteral Options

Intravenous/PCA Subcutaneous Injections

Ambulatory Pump Fentanyl Patch Parenteral Analgesic Options

• IM - never • Intravenous – PCA infusions or bolus • Subcutaneous – Intermittent injections (butterfly needle) – Continuous infusions - ambulatory pumps • Buccal/Sublingual – Morphine/hydromorphone – likely swallowed – Fentanyl good transmucosal absorption* *Protocols: SL & intranasal fentanyl Routes of Analgesics cont’d

• Transdermal fentanyl – Delayed onset – Route for breakthrough analgesia still needed – Never use in opioid naïve patient

• Rectal – Least favourable – Rolling patient to insert meds may be painful – Preparations increasingly unavailable What orders would you write for John?

“Choice of the right drug in the right dose at the right time” “WHO Analgesic Ladder”

Severe Pain Moderate Pain

Mild Morphine Pain Hydromorphone Fentanyl Codeine Methadone Oxycodone (+/- non opioid) Tramadol (+/- adjuvants) Acetaminophen (+/- non opioid) ASA (+/- adjuvants) NSAIDs/COXIBs (+/- adjuvants) Adapted from The WHO 3 Step Analgesic Ladder, Cancer Pain Relief, 2nd Edition, World Health Organization Leppert W, Luczak J. The role of tramadol in cancer pain management – a review. Support Care Cancer 2005;13:5-17. Relative Potencies of Opioids

• Hydromorphone Morphine Codeine 5 x 10 x

• Routes: parenteral oral 2 x Case Study

• John’s PCA total 24hr dose morphine: 60mg IV • Converted to morphine 10mg sc q4h – Breakthrough dose: morphine 5mg sc q2h prn • Oral dose: 20mg po q4h + 10mg po q2h prn • Morphine CR 60mg BID

• Back pain relieved (2/10) but persisting “burning and stabbing pain radiating into legs”….. (6/10) Classification of Pain

Mechanism: anatomical & physiological pathology Diagnosis: based on clinical history & physical exam +/- selective investigations

• NOCICEPTIVE (somatic & visceral) • NEUROPATHIC (peripheral & central) • MIXED PAIN SYNDROMES Nociceptive Pain

Somatic Pain

• Bone mets are the most common cause in cancer • Constant, aching or gnawing – well localized • Worse on weight bearing (pelvis, hip, leg) • May be referred: (eg. skull mets cause facial pain, T1 mets cause back & shoulder pain) Nociceptive Pain

Visceral Pain

• Constant deep aching - difficult to localize

• Often referred to somatic areas supplied by the same nerve root (eg. capsule to shoulder area, gallbladder to mid-back)

• If intense, may be sharp & penetrating pain (eg. peritonitis & pleuritic pain) Neuropathic Pain

Nerve Compression • Pain can precede sensory & motor changes • Constant ache to intermittent, sharp lancinating • Pain referred to specific dermatomes

Dysaesthetic Pain • Progressive damage may lead to superficial burning tingling & numbness or hyperalgesia • Peripheral nerve, root/plexus, or central neural injury Diagnostic Formulation of CA Pain

• Mechanism of pain (nociceptive/neuropathic) – choice of analgesics and co-analgesics • Contributing physical factors – deconditioning, neurological deficits, atrophy • Contributing psychosocial factors – mood, catastrophizing, environment, addiction risk Pharmacotherapy

Nociceptive pain: – Mild/moderate: acetaminophen / NSAIDs / Coxibs – Severe pain: opioid analgesics in combination with acetaminophen / NSAIDs / Coxibs

Neuropathic pain: – Severe pain: titrate with opioid analgesics until 30-50% reduction in pain levels – Add co-analgesics early (tricyclics, anticonvulsants) – Consider special procedures where indicated Case Study

• John’s neuropathic pain improved with the addition of Amitriptyline (4/10) – Sleep and mood also improved • Persisting “stabbing pain” eventually subsided with the addition of Gabapentin (2/10) • Able to participate more in physiotherapy • Discharged a week later with added CCAC services and equipment in home Take Home Pearls

• Assessment requires evaluation of “total pain” • Diagnosis of cancer pain (acute & chronic): based on good history & physical exam • Differentiation of nociceptive vs neuropathic pain important for planning treatment • Severe pain should be treated without delay and efficacy evaluated using validated tools • Multimodal & inter-disciplinary approach References

• As per individual slides as well as • Cancer Care Ontario www.cancercare.on.ca • Learning Essential Approaches to Palliative and End of Life Care The Pallium Project • Canadian Society of Palliative Care Physicians www.cspcp.ca • The Canadian Virtual Hospice www.virtualhospice.ca • HOT SPOT Newsletter of the Rapid Response Radiotherapy Program, Odette Cancer Centre Sunnybrook Health Sciences Toronto, ON www.sunnybrook.ca • Please do your evaluation☺ Thank you