PATIENT CASE Module 1 Date of preparation: June 2015 HQ/EFF/15/0024h.
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Transcript of PATIENT CASE Module 1 Date of preparation: June 2015 HQ/EFF/15/0024h.
Pain caused by cancer and cancer therapy
Dr Carla Ida RipamontiOncologist / pharmacologist specialised expert in pain, palliative and supportive careFondazione IRCCS, Istituto Nazionale Tumori, Milano, IT
Routine care
Patient history
Female, 66-years-old, retired school teacher, divorced, 2 sons, lives alone, no medical problem before 2004
2004: DIAGNOSIS OF invasive ductal carcinoma G3, pT1c, pNo, ER 95%, PgR 90%, Ki-67 52%, HER2 2+ (gene non-amplified according to FISH)THERAPY: quadrantectomy dx + BLS + intraoperative RT + tamoxifene for 5 years
2014: DIAGNOSIS OF left breast nodule retroareolar, invasive ductal carcinoma and lobular component pT1c (2 cm), G3, diameter 2 cm, IV (>3 vessels involved), ER 95%, PgR 0%, HER2 1+, Ki-67 40%. Axilla sx 1/12 nodes; Axilla dx 9/22 nodes with massive mtsTHERAPY: Mastectomy sx + axilla dissection sx and dx + reconstruction with expander + adjuvant chemotherapy adriamycin + paclitaxel → CMF → RT supraclavicular dx → aromatase inhibitors
No comorbidities
PAIN DUE TO CANCER THERAPY
Patients refears pain in the hands and feet due to chemotherapyThe pain is described as tingling, ringing, numbness and 2-3 times a day;stabbing
The pain is of suspected neuropathic origin and the patient presents both neuropathy in the hands and feet because hands are weak and she has difficulties in holding a glass; she does not feel the presence of or painful neuropathy
Stabbing pain arises sudden with an intensity of 10/10 on a NRS anda duration of 1-2 minutes
PAIN DUE TO CANCER
2015 February: Evaluated for the presence of osteopenia or osteoporosis. Osteopenia was confirmed at the femoural level and osteoporosis at the lumbar level
February: Bone scan showed the presence of litic lesion (mts)at D7. The patient refered pain at rest and on moving at D7. • Pain on moving is a type of predictable episodic pain
Current pain/illnesses
As the patient presented sleeping problems and anxiety, she accepted the intervention of the psychologist and did not want drugs
February 2015 At the first visit in my office she was on codeine + paracetamol t.i.d + gabapentin 100 mg t.i.d.The oncologist/chemotherapist sent the patient to me to assess and treat pain and to start with denosumab 120 mg IV every monthThe patient with sent for consultation to radiotherapist
Clinical examination and pain assessment
Blood pressure: normal 120/80 mmHg
Cardiovascular examination: normal limits
Sensory examination: present of dysesthesia and paresthesia at the hands and feet + reduction in sensitivity at the fingers on the hand and feet
ESAS administered to assess pain and other physical and emotional symptoms
No specific tools used to assess for neuropathic pan
Clinical judgment
By ESAS, pain at rest at D7 is 4/10, pain on moving is 7/10
Fatigue 6, nausea 0, depression 2, anxiety 3, drowsiness 0, short of breath 0, appetite 3, sleeping 8, feeling of well-being 5• Diagnosis of neuropathic pain was done with patient descriptions and physical
examination• Breakthrough cancer pain without a neuropathic component was present on
moving due to bone metastases. The BTP with a neuropathic component (stabbing pain) was so sudden; the duration of 1-2 minutes made it impossible to consider
Ripamonti CI, et al. Support Care Cancer. 2014;22(3):783-93.
Edmonton Symtom Assessment System (ESAS)Please circle the number that best describes:
No Pain
No Fatigue
No Nausea
No Depression
No Anxiety
No Dowsiness
No ShortnessOf Breath
Best Appetite
Best Sleep
Best FeelingOf Well-being
Worst Feelingof Well-beingImaginable
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Worst SleepImaginable
Worst AppetiteImaginable
Worst Shortnessof Breath Imaginable
Worst Anxiety Imaginable
Worst DowsinessImaginable
Worst Depression Imaginable
Worst NauseaImaginable
Worst FatigueImaginable
Worst PainImaginable
Therapeutic approach
Drugs for background pain changed from codeine to oxycontin 10 mg every 8 hours with a reduction of background pain to 2/10 and a reduction in neuropathic pain in the hands and feet by 30%Breakthrough pain medication: buccal fentanyl started at 100 mcg ,as needed200 mcg occasionally with reduction or absence of pain during movement, although somnolence reported• Non-pharmacologic treatment: placed an orthopaedic brace (only when she had to
travel) + psychological intervention for other symptoms (sleeping and anxiety)
Follow-up
Pharmacological treatment for nociceptive pain (bone mets) and neuropathic pain (due to chemotherapy)• Interval after initial consultation/change in pain meds, 2 weeks• No complaint of AEs (after a laxative was added)• Says medication alleviates most pain• Says now able to sleep better because pain is under control and because the
anxiety is reduced thanks to psychological intervention with no drugs
Conclusions
Buccal fentanyl was effective in reducing breakthrough cancer pain and was well tolerated
Collaboration between a palliative care specialist and a pain specialist was beneficial for proper therapy