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Interventional Therapies for Cancer Pain Management: Important Adjuvants to Systemic Analgesics

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Interventional Therapies for Cancer Pain Management: Important Adjuvants to Systemic Analgesics JN058_Jrnl_50806Swarc.qxd 10/3/07 2:16 PM Page 851 851 Original Article Interventional Therapies for Cancer Pain Management: Important Adjuvants to Systemic Analgesics Anthony Eidelman, MD; Traci White, MD; and Robert A. Swarm, MD, St. Louis, Missouri Key Words functional status, diminished appetite, insomnia, depres- Cancer pain, pain management, chronic pain, palliative care sion, anxiety, and loss of control or hope.1 Without ad- equate pain control, those with cancer not only Abstract experience the anguish of poorly controlled pain but also Optimized use of systemic analgesics fails to adequately control have greatly diminished quality of life and may even pain in some patients with cancer. Commonly used analgesics, have reduced life expectancy. Moreover, in the past 2 including opioids, nonopioids (acetaminophen and non-steroidal decades, as the mortality rates from certain malignan- anti-inflammatory drugs), and adjuvant analgesics (anticonvulsants and antidepressants), have limited analgesic efficacy, and their use cies have declined, the population of cancer survivors is often associated with adverse effects. Without adequate pain facing the hardship of chronic pain has increased. Cancer control, patients with cancer not only experience the anguish of patients who have poorly controlled pain during the poorly controlled pain but also have greatly diminished quality of acute disease phase are at increased risk for developing life and may even have reduced life expectancy. Interventional pain chronic pain.2 Fortunately, multiple modalities exist to therapies are a diverse set of procedural techniques for controlling pain that may be useful when systemic analgesics fail to provide manage cancer pain, including direct antineoplastic ther- adequate control of cancer pain or when the adverse effects of apies, systemic analgesics, interventional pain proce- systemic analgesics cannot be managed reasonably. Commonly used dures, and cognitive behavioral therapies. In most cases, interventional therapies for cancer pain include neurolytic neural the management of cancer pain begins with readily avail- blockade, spinal administration of analgesics, and vertebroplasty. able analgesics, as outlined by the World Health Compared with systemic analgesics, which generally have broad 3 indications for control of pain, individual interventional therapies Organization’s analgesic ladder (see steps 1–3 in Table 1). generally have specific, narrow indications. When appropriately Although systemic analgesics are effective in most can- selected and implemented, interventional pain therapies are cer patients, up to 21% of patients continue to have in- important components of broad, multimodal cancer pain manage- adequately controlled pain despite undergoing optimized ment that significantly increases the proportion of patients able treatment with systemic analgesics.4,5 When systemic to experience adequate pain control. (JNCCN 2007;5:851–858) analgesics are inadequate or when the risk/benefit ratio is favorable, various interventional procedures, includ- Inadequately controlled pain produces immense phys- ing peripheral nerve blocks, spinal analgesics, and ver- ical and psychological suffering, including decreased tebroplasty, may play an important role in cancer pain management (see step 4 in Table 1). From the Division of Pain Management, Department of In certain circumstances, including vertebroplasty Anesthesiology, Washington University School of Medicine, for compression fracture or celiac plexus block for pan- St. Louis, Missouri. Submitted April 18, 2007; accepted for publication May 16, 2007. creatic cancer, intervention should not be delayed for ex- The authors have no financial interest, arrangement, or affiliation tensive trials of conservative therapy. Unnecessarily with the manufacturers of any products discussed in the article or their competitors. delaying interventional techniques may result in diffi- Correspondence: Anthony Eidelman, MD, Division of Pain cultly accomplishing specific interventions when ad- Management, Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 South Euclid vanced care is necessary but the patient’s performance Avenue, St. Louis, MO 63110. E-mail: [email protected] status has declined. © Journal of the National Comprehensive Cancer Network Volume 5 Number 8 September 2007 JN058_Jrnl_50806Swarc.qxd 10/3/07 2:16 PM Page 852 852 Original Article Eidelman et al. Table 1 Modified Analgesic Ladder for Cancer has a narrow risk/benefit ratio and the potential to Pain Management cause significant untoward effects; therefore, neural destruction is generally considered when conserva- Step 1. Mild pain Use nonopioid analgesics (nonsteroidal anti-inflammatory tive modalities are exhausted. Neurolytic blockade of drugs or acetaminophen) somatic nerves may be complicated by postneurolysis Step 2. Moderate pain Use a “weak” opioid (codeine, neuritic pain or the development of deafferentation hydrocodone, oxycodone) pain, which may typically develop several weeks to along with nonopioid agents months after neurolysis. Concern for neuritic and deaf- Step 3. Severe pain Use a “strong” opioid (morphine, hydromorphone, oxycodone) ferentation pain generally restricts use of neurolytic along with nonopioid agents blockade of somatic nerves to patients with advanced Step 4. Pain not Interventional pain therapies malignancies or those with short life expectancy. controlled by systemic including neurolytic injections, Interventional pain procedures should be per- analgesics* vertebroplasty, and spinal formed by clinicians with the skill, training, and ex- analgesics (with continuation of systemic analgesics when pertise to safely perform these procedures and manage needed) potential complications. This is especially important in cancer pain management because unique chal- Adjuvant drugs, including antidepressants, corticosteroids, lenges are present when these interventions are per- or anticonvulsants, are recommended for each step of the ladder, when needed. formed in the setting of malignancy. Extensive *Earlier use advocated when risk/benefit ratio is favorable. surgery, radiation therapy, or tumor mass may alter anatomy, necessitating technique modification. Special attention to technique is required because When considering the use of interventional pain this population may have increased risk for infection therapies for cancer pain, an accurate clinical and ra- because of immunosuppression from chemotherapy, diologic assessment of the specific pain in question is steroids, or general debilitation. Furthermore, cancer essential to guide technique selection and implemen- patients are often opioid-tolerant and therefore, if tation.6 Localized cancer pain may be controlled by procedural sedation is required, significantly greater destroying peripheral nerves or plexuses using chem- doses may be required. ical or thermal modalities; however, diffuse, general- The goals of interventional pain therapies include ized cancer pain is unlikely to be controlled with 1) reduced pain intensity, 2) decreased requirement of selective peripheral neurolysis. Spinal analgesics, es- systemic analgesics to allow reduction in analgesic as- pecially when based on epidural or subarachnoid ad- sociated adverse effects, and 3) improved quality of ministration of combination analgesics involving life and functional status. Some studies suggest that, opioid, local anesthetic, or clonidine, are an especially through improving patients’ dietary intake and general potent tool for managing appropriate cancer-related function, interventional pain procedures may increase pain. Vertebroplasty plays a unique role in managing the survival of patients with cancer pain.7,8 However, pain from pathologic vertebral compression fractures other trials do not support this finding.9 Although an caused by osteoporosis, metastasis, or myeloma. association between pain control and survival is a Because many interventional therapies have a spe- possibility that needs further evaluation, the urgent cific anatomic site of action, whereas patients with need of cancer patients with inadequate pain control metastatic cancer may have multiple anatomic sites of from systemic analgesics should lead to more consis- pain,6 interventional pain procedures may not elimi- tent and timely use of interventional pain therapies. nate all pain but are best used as a component of mul- Furthermore, opioid-induced hyperalgesia may be seen timodal management of cancer pain. in cancer patients, especially during rapid dose esca- In the context of interventional cancer pain man- lation. In extreme cases, a paradoxical increase in pain agement, neuroablation is often accomplished through may occur in response to increasing doses of opioid. chemical neurolysis, also known as neurolytic neural With opioid-induced hyperalgesia, increased sensitiv- blockade. Nerve blocks with local anesthetic are of- ity to pain stimuli and pain that becomes more dif- ten performed before chemical neurolysis for both di- fuse seem to occur, extending beyond the distribution agnostic and prognostic purposes. Neurolytic blockade of pre-existing pain.10 Interventional therapies may © Journal of the National Comprehensive Cancer Network Volume 5 Number 8 September 2007 JN058_Jrnl_50806Swarc.qxd 10/3/07 2:16 PM Page 853 Original Article 853 Interventional Therapies for Cancer Pain Management be especially indicated in management of cancer pain pain, with similar
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