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INTERVENTIONAL PAIN MANAGEMENT FOR CANCER PATIENTS

Prof. Krishna Boddu .

MBBS, MD (Anes), DNB, FANZCA, MMEd.

Director, Regional Anaesthesia

Anaesthesia & Pain Medicine

Royal Perth Hospital

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World’s Largest No 1 Cancer Center

Modern Palliative Care IsSupportive Care & Symptom

ControlSays..

(Treats 115,000 patients/year and Employs 19,000)

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Memorial Hermann Hospital

Certified Level I trauma centers in the greater Houston

> 40000 Emergency and trauma care patients a year

Life Flight® air ambulance service – Providing emergency rescue and air transport services

165,000-square-foot HVI for latest innovations in cardiology programs and treatment.

30-story medical office building (Medical Plaza), an Ambulatory Care Center, retail shops, services, restaurants etc

We are proud of our institutions in many ways

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Epidemiology of Cancer & Cancer Pain

>6.35 million new cases / year WHO Estimate: By 2021, 15 million new

cases/ year Only 50% of cases are undergoing treatment > 90% of patients with advanced cancer have

pain.

Portenoy RK, Cancer Pain: Epidemiology and syndromes Cancer 1989; 63:2307 WHO Cancer Pain Relief 1986

70 - 75% Tumor involvement of organic structures

25% Pain due to cancer therapy

10% Past Chronic Pain25%

70-75%

10%

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Non-opioid(Tylenol + NSAID + Tramadol)

Non-Opioids +Codine

Non-Opioids + Opioid

Non-Opioids + Opioid+ Interventional

Cancer Pain After Surgery

Cancer Pain

Where do we stand in providing good pain control

For Cancer Pain Patients? Freedom

From

Cancer Pain

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Some Pain Control Techniques

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Early Intervention Is New Concept

How Can We Justify?Advanced Cancer Rx Prolongation of Life Span

Such Success has an ARTIFACT

Accentuates: Pain & SufferingIncreased Need of Palliative Care Services

Advanced Pain Rx Better Pain Control

Methods Available to Provide Cost Effective

Interventional Pain ReliefMinimize pain and suffering thatincur considerable loss — of time, experience, and sense of self

For the patient who is dying from end-stage terminal illness, such suffering can purloin what time is remaining, and thus diminishes the capacity for meaningful reflection and relational closure with loved ones, and the life-lived, in general

Clearly, Moral Obligation Exists to Relieve Pain & Suffering

When cure is impossible, palliation remains the only viable alternative.

But, Technically Effective Care Must Also Be Rendered

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Common Symptoms Managed in

Cancer Patients Are…

o Paino Fatigueo Dyspneao Anorexia/

Cachexiao Nausea/ Vomitingo Depressiono Anxietyo Constipationo Insomnia

Common Side Effects of Opioid

Management Are….

o Opioid Toleranceo Fatigueo Resp Depressiono Anorexiao Nausea/ Vomitingo Urinary Retentiono Itchingo Constipationo Insomnia/

Hallucinations

Nerve Blocks Catheters in Palliative Care

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Presumed Barriers to InterventionalPain Management in Cancer Patients

1. Claimed Not Worth the Cost

2. Analgesia From Interventional Techniques Is Short Acting for the Cost

when compared with long-term use of systemically administered primary and djunctive/adjuvant analgesics, interventional techniques reveal a very favorable cost:benefit ratio

It is a misconception given that analgesia from neurolytic blocks typically lasts for months

3. Need To Repeat Pain Procedures May Be Unjustifiably Burdensome To Patients At End Of Life, Or Who Require Long-term Care

It is a fact that interventional pain management procedures were originally developed for use in the frail elderly who were unable to tolerate polypharmacologic or surgical interventions

4. Lack of Availability Of Interventional Pain Specialists To Render Treatment Within The Cancer/ Palliative Care Setting Is Limited

All most all urban areas, multispecialist interventional pain specialists can be found

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Benefits and Potential of Interventional Pain Management in Cancer Patients

o Single procedure, the patient can be afforded months of pain relief

o Significant reduction in opioid dose, thereby increasing the response to opioids and/or non-opioid agents

o Often the best, or perhaps the only way to manage certain pain syndromes that are commonly encountered in the cancer care setting

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Interventional Procedures: Opioid Pumps

Opioids : Sub Cu/ Epidural/ SpinalMorphine: 3mg PO=1mg IV =0.1mg Epidural=0.01mg Spinal Refractory Cancer Pain

Life Expectancy < 3mo Life Expectancy > 3mo

Single Shot Intrathecal TrialImplant Pump

Medical Management

>50% Pain Relief

Some Pain Relief

Epidural Catheter Tunneled

IT Catheter Trial

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Nerve BlocksLocal Anaesthetic Nerve Blocks

Neurolytic Nerve Blocks

Diagnostic Nerve Blocks

Therapeutic Nerve Blocks

Alcohol

Phenol RF Cryo

ChemicalHeatCold

Painful/ Not Painful on injection Onset of action variesSeveral Months Relief

To achieve Good Pain Control For Cancer Patients, We need to bridge

the gap between our teams