Palliative

care
Supportive care
Pain Management in Cancer Patients

Prof Banjin
20.11.2019.
 ESO 2000:

Palliative care is the person- centered attention to physical

symptoms and to psychological, social and existential
distress and cultural needs in patients with limited
prognosis, in order to optimize the quality of life of
patients and their families or friends.
 ASCO
• ASCO recommends that all patients with
advanced cancer receive palliative care early
on and along with cancer treatment.
• For those newly diagnosed with advanced
cancer, the recommendation is that palliative
care should be offered within 8 weeks after
diagnosis.
• In addition to treating physical issues, such as
pain, nausea, and fatigue, palliative care also
focuses on supporting of patients emotional,
spiritual, and practical needs. It also supports the
needs of family and caregivers.
• Palliative care is given at every step of the
treatment process. It provides an extra layer of
support for people with any stage of cancer.
Hospice care is a specific type of palliative care. It
is only provided to people with advanced cancer
who are expected to live six months or less.
• Each year, 10 million people worldwide are
diagnosed with cancer and 6 million die from the
disease.
• Global cancer rates will increase by50%, from 10
million in 2002 to 15 million cases in 2020.
• 50% of the world’s new cancer cases occur in
developing countries; in 80% of these cases, disease
is incurable at the time of diagnosis and most
patients will die within 1 year.
•
• According to WHO definition, palliative care
(PC) is an approach that improves the quality
of life of patients and their families facing the
problems 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 vs Hospice
• Palliative care is given at every step of the
treatment process. It provides an extra layer
of support for people with any stage of cancer.
• Hospice care is a specific type of palliative
care. It is only provided to people with
advanced cancer who are expected to live six
months or less.
 What is palliative care?

• Cancer often causes symptoms, and any

treatment for cancer may cause side effects.
An important part of cancer care, regardless of
diagnosis, is preventing or relieving these
symptoms and side effects.
• Doing this helps keep patients as comfortable
as possible while maintaining the best
possible quality of life from diagnosis through
treatment and beyond.
• Seeks to manage the symptoms of advanced and
terminal illness
• Views people as a whole individual rather than a
disease process to be treated
– Body/Physical
– Mind/psychological
– Heart/social
– Soul/spiritual
• Delivers holistic care through multidisciplinary
team working
•
 Palliative care team
• Oncologist.
• Palliative medicine physician.
• Nurses and advanced practice nurses.
• Social worker
• Pain specialist.
• Chaplain.
• Dietitian.
• Physical and occupational therapists.
• Child life specialist.
• Volunteers.
• Grief and bereavement coordinator.
 TYPES OF PC SERVICES
• 1. Community home care
• 2. Day center
• 3. Outpatient care
• 4. Inpatient care –  PC wards/dept. –  hospices
• 5. Hospital PC teams
 Palliative Care Is NOT:
• “giving up” on a patient
• a substitute for curative or life-prolonging care
• the same as hospice
 Different paradigms
CURATIVE CARE
• Patient-disease focus
• Provider cultur centered
• Death is failure
• Suffering is expected
• Multi-specialty involvement
(multi-plan)
• Special expertise required
PALLIATIVE CARE
• Person-family focus
• Person culture centered
• Death is part of life
• Moral obligation to relieve
suffering
• Interdisciplinary team
involvement (uni-plan)
• Special expertise required
 Supportive care
• ESMO: “care that aims to optimize the comfort, function and
social support of the patients and their family at all stages of
the illness”.

• National Cancer Institute (NCI): “care given to improve

the quality of life of patients who have a serious or life-
threatening disease”

• The prevention and management of the adverse effects of

cancer and its treatment.
• This includes management of physical and psychological
symptoms and side effects across the continuum of the cancer
experience from diagnosis through anticancer treatment to
post-treatment care.
 SUPPORTIVE CARE (SC)

•  Supportive Care:
–  alleviates symptoms and complications of cancer
–  reduces or prevents toxicities of treatment
–  supports communication with patients about their
disease and prognosis
–  allows patients to tolerate and benefit from active
therapy more easily
–  eases emotional burden of patients and care givers
–  helps cancer survivors with psychological and social
problems.
 Managing symptoms and side effects

• Physical symptoms of cancer, such as pain,

fatigue, breathlessness, insomnia, and weight
changes, vary widely from person to person.
 Pain Management in Cancer Patients

Types:
• Nociceptive : pain signals from nerve endings
• Neuropathic : damage to nerve fibres.
 Descripatientive pain rating scales
• Numerical rating scale:
-Verbal: “What number describes your pain
from 0 (no pain) to 10 (worst pain you can
imagine)”?
- Written: “Circle the number that describes
your pain”
0 1 2 3 4 5 6 7 8 9 10
no pain worst pain you can imagine
 Cancer Pain
• Nociceptive Somatic: intermittent to constant
sharp, knife-like, localized e.g. soft tissue
infiltration
• Nociceptive Visceral: constant/intermittent
crampy/squeezing poorly localized, referred
e.g. intra-abdominal mets
• Nociceptive Bony: constant, dull ache
localized, may have neuropathic features e.g.
vertebral metastasis pathologic fractures
 Cancer Pain
• Neuropathic -Destruction/infiltration of nerves
a) dysesthetic: burning/tingling constant, radiates e.g.
post-herpetic neuralgia
b) neuralgic: shooting/stabbing shock-like/lancinating
paroxysmal e.g. trigeminal neuralgia
c) Chemotherapy induced Neuropathies :
Cisplatin,Oxaliplatin • Paclitaxel,Thalidomide •
Vincristine,Vinblastine
d) Surgical Neuropathies : Phantom Limb pain • Post
mastectomy syndrome • Post thoracotomy syndrome
 Breakthrough “Incidental” pain

• Severe transitory increase in pain on baseline

of moderate intensity or less
• Caused by movement, positioning, cough,
wound dressing, etc Often associated with
bony metastasis
 New adaptation of analgetic ladder
• Acute pain/ chronic pain without control/acute
crisis of chronic pain
• Step1-Nonopioid analgesics/ NSAIDS
• Step2-Weak opioids
• Step3-Strong opioids/Methadone/Oral
administration/Transdermal patch
• Step4-Nerve block/Epidurals/PCA pump/Neurolytic
block therapy/Spinal stimulators
 Pain Management

Nociceptive Agent
Opioids
Soft Tissue
Steroids
Visceral Surgery
Radiation Treatment
 Opioid receptors
• Classically, opioids active on CNS receptors
mu (µ) kappa (κ) delta (δ) receptors
• Now found on:
• Peripheral Neurons
• Immune Cells
• Inflammed Tissue
• Respiratory Tissue
• GI Tract
 Opioid Side Effects
Common Uncommon
• Constipation • Bad Dreams / Hallucinations
• Dry Mouth • Dysphoria / Delirium
• Nausea / Vomiting • Myoclonus / Seizures
• Sedation • Pruritus / Urticaria
• Sweats • Respiratory Depression
• Urinary Retention
Opioid-Induced Neurotoxicity (OIN)
• Neuropsychiatric syndrome
• Cognitive dysfunction
• Delirium
• Hallucinations
• Myoclonus/seizures
• Hyperalgesia/allodynia
 BONE PAIN
PHARMACOLOGIC TREATMENT

• Opioids
• NSAIDs/steroids/Cox-2
inhibitors
• Bisphosphonates
-Pamidronate
-Clodronate
- Zoledronate
 BONE PAIN
RADIATION TREATMENT
• 1. Single treatment (800 cGy)
• 2. Multiple fraction (200 cGy x 3-5)
• 3. Effective immediately
• 4. Maximal effect 4 - 6 weeks
• 5. 60-80% patients get relief
 BONE PAIN
SURGICAL OPATIENTIONS
• 1. Pathologic # (splint, cast, ORIF)
• 2. Intramedullary support
• 3. Spinal cord decompression
• 4. Vertebral reconstruction
 ADJUVANTS
NSAIDs
• Anti-inflammatory, anti-PEG
• S/E: gastritis/ulcer, renal failure
• ↑ K+ , platelet dysfunction
• Ibuprofen, naproxen

• Don’t use both steroids & NSAIDs!

 ADJUVANTS
COX-2 INHIBITORS
• Anti-inftinflammatory ; Anti-prostaglandin
• S/E: less gastritis ; no platelet dysf’n; renal
failure still a problem; OD dosing; expensive

• Celecoxib
• Rofecoxib
• Meloxicam
• Valdecoxib
 ADJUVANTS
STEROIDS
• ↓ inflammation
• ↓ edema
• ↓ spontaneous nerve depolarization
• Multipurpose
 ADJUVANTS
ANTICONVULSANTS
• Gabapentin
• Lamotrigine
• Carbamazepine
• Valproic acid
 ADJUVANTS
ANTIDEPRESSANTS
• Amitriptyline
• Nortriptyline
• Desipramine
• SSRIs: results disappointing
 ADJUVANTS
NMDA RECEPTOR ANTAGONISTS
(N-methyl-D-aspartate)

• Ketamine
• Dextromethorphan
• Methadone
 NEUROPATHIC PAIN
NON-PHARMACOLOGIC
• Radiation treatment

• Anaesthetic treatment
• Nerve Block
• Epidural Block
 NEUROPATHIC PAIN
PHARMACOLOGIC TREATMENT
• Opioids
• Steroids
• Anticonvulsants
• TCAs (dysesthetic)
• NMDA receptor antagonists
• Anaesthetics
 Key Points
• Current, accurate information
• Use available resources
• Involve family & caregivers
• Know patient knowledge base
• Address patient priorities first
• Small doses of useful info (e.g., S/E)
• Individualize to patient (social, education level
 Conclusion
• Cancer pain can be from the cancer itself, or
from cancer-related treatments
• Can be somatic, visceral, or neuropathic
• Negative effects of cancer-related pain can
effect QOL, mortality
• Ask the patient about pain and REASSESS!
 Conclusion
• Choose non-opioid / adjuvants carefully
paying close attention to side effect profile
• Use WHO ladder guidelines when titrating
pain medications
• Use long-acting opioids for chronic cancer
pain
• Recognize “4th step” in WHO ladder and
utilize your multidisciplinary resources
 New adaptation of analgetic ladder
• Acute pain/ chronic pain without control/acute
crisis of chronic pain
• Step1-Nonopioid analgesics/ NSAIDS
• Step2-Weak opioids
• Step3-Strong opioids/Methadone/Oral
administration/Transdermal patch
• Step4-Nerve block/Epidurals/PCA pump/Neurolytic
block therapy/Spinal stimulators