MANAGEMENT OF PAIN IN THE TREATMENT OF

CANCER PATIENTS

TREATMENT OPTIONS

Chemotherapy Radiotherapy Hormonal Therapy Surgery

Systemic Localized

BASIC PRINCIPLES APPLY

WHO ANALGESIC LADDER

DIFFERENT PATHOPHYSIOLOGIES OF PAIN

CHOOSING THE APPROPRIATE FORMULATION AND AVAILABLE DRUG

CHEMOTHERAPY

COMMON DETERMINANTS OF PAIN Chemotherapy drug and regimen Co existing pain Age Nutritional status Prior chemotherapy and radiation

treatments Cognitive, physiological,

psychological and behavioral factors

COMMON SIDE EFFECTS Mucositis Neuropathic pain Hand foot syndrome Arthralgia

Case 1 68 year old male with colon cancer with extensive

lung and liver metastases On 5 FU based palliative chemotherapy ECOG performance status 3 His 67 year old wife takes care of him He now has pain in the mouth, is not able to eat

well and finds it difficult to swallow his analgesics Examination:

MUCOSITIS

MUCOSITIS Mucositis can affect all mucous membrane-covered

surfaces from the mouth to the rectum (Camp-Sorrell 2000)

Most common condition requiring systemic analgesics during cancer therapy (Epstein and Schubert 1999)

Oral mucositis affects approximately 40% of patients undergoing chemotherapy

Cancer treatment-induced mucositis causes acute pain, which is the result of sloughing of the epithelium, inflammation of the mucosa and ulceration (Camp-Sorrell 2000)

MUCOSITIS WHO grading

MUCOSITIS

MUCOSITIS

MUCOSITIS: mouth care Rinse mouth with water frequently (every 2

hrs while awake & when awake during the night). May add salt or baking soda (1/2 to 1 teaspoon in 8 ounces of water)

Use soft-bristle toothbrush (can soften even more by placing brush in very warm water), cotton swabs, mouth swabs (popsicle stick covered with gauze) to clean teeth after each meal and at bedtime

MUCOSITIS: pain control Topical or local agents such as Orajel Combination mouth wash can be made

(ingredients may require prescription). Use equal parts: xylocaine viscous solution, benadryl, sucralfate and Maalox® taking 2 teaspoons every 2-4 hours as needed (swish around mouth and spit out)

MUCOSITIS: healing Apply Vitamin E (puncture cap 400IU and

squeeze onto swab. Gently place swab on open area(s)

Take an antacid 1/2-1 ounce every 3-4 hours as needed to decrease burning sensation

Maintain good nutrition focusing on high protein and high calorie foods which are soft and/or semi liquid (i.e. scrambled eggs, puddings, blenderized or pureed foods). May use liquid supplements (i.e. Ensure®, Boost®, etc.)

MUCOSITIS: avoidance Hot, spicy, coarse or rough textured

foods Very hot or cold beverages and foods Citric juices or foods containing citric

acid (tomatoes, oranges, lemon, etc.) Alcoholic beverages or tobacco products Liquid medication containing alcohol

(e.g. mouth wash) if not essential

Case 2 34 year old mother with metastatic breast cancer

(lung, bone and liver) Performance status 2 Takes care of her 8 month old On capecitabine Develops pain in her hands and feet and she is

unable to care for her baby. She is emotionally distressed.

Examination:

HAND AND FOOT SYNDROME

HAND FOOT SYNDROME Uncomfortable and relatively frequent

dermatologic toxic reaction to certain chemotherapeutic agents (NCI)

Can be caused by: 5-Fluoruracil, capecitabine, vinorelbine, liposomal doxorubicin, docetaxel, sorafenib, sunitinib and high-dose Interleukin-2 (De Vita)

HAND FOOT SYNDROME From managing CRC:

HAND FOOT SYNDROME: prevention Preventative measures can help to decrease

the severity of symptoms should they develop

Modifying some of the normal daily activities of the patient to reduce friction and heat exposure to his/her hands and feet for a period of time following treatment

Avoiding long exposure of the hands and feet to hot water such as long showers or tub baths

Avoiding increased pressure on the soles of the feet or palms of hands

Minimizing long walks

HAND FOOT SYNDROME: management Stop the chemotherapy agent once the

syndrome has started Emollients such as Aveeno®, Lubriderm®,

Aqueous cream provide excellent moisturizing

Analgesics, cold compresses, cushioning and elevating the limb area

Oral and topical steroids as well as Vitamin E have been used with limited success

RADIOTHERAPY

FACTORS AFFECTING PAIN AT RADIATION SITE

FACTORS Site of radiation Extent of disease Total dose Dose per fraction Comorbid conditions Physiological factors

COMMON SITES FOR PAIN Head and neck area Skin Groin

Case 3 A 68 year old female with extensive

cutaneous metastases from a recurrent breast cancer

She is having short course palliative radiotherapy with electrons for pain and bleeding

She has moist desquamation and has difficulty with dressing and sleeping

Performance status 2

MANAGEMENT OF DESQUAMATION Topical treatment may offer symptomatic relief and may

help skin healing. Different areas of skin may require different treatment approaches

Drying pastes may be appropriate for use within skin folds, where skin reactions remain moist

Gels can be useful in seborrhoeic areas Creams can be used in areas outside skin folds and

seborrhoeic areas Hydrophilic dressings may also be useful in moist areas.

These are placed over the cleaned, dried wound and some can absorb wound exudate. They can be soothing for the patient and can help skin healing

Greasy topical products should be avoided because they inhibit the absorption of wound exudate and promote superinfection

PREVENTION OF DESQUAMATION The irradiated area should be kept clean to

minimize the risk of infection

Patients should wash the area with a gentle cleanser and dry it with a soft, clean towel

Loose-fitting clothing should be worn over the irradiated area to prevent friction injuries

SURGERY

SURGERY Not commonly used modality

Can be used in cases to aid with bleeding, obstruction and fracture

Pain is usually at the post surgical wound site

HORMONAL THERAPY

A SMALL CATEGORY Breast cancer patients on aromatase

inhibitors can experience joint pain

Can worsen quality of life especially in those with pre-existing joint pain