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M.J. Johnson



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    E12 - Symptom Control - Pain, Dyspnoea and Fatigue (ID 12)

    • Event: WCLC 2013
    • Type: Educational Session
    • Track: Supportive Care
    • Presentations: 1
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      E12.2 - Pain (ID 429)

      14:30 - 14:55  |  Author(s): M.J. Johnson

      • Abstract
      • Presentation
      • Slides

      Abstract
      Pain in lung cancer Lung cancer is the most common cancer globally with 1.6 million people diagnosed with the disease during 2008; over half of them in the developing world. Nearly 90% are due to smoking, or passively smoking, tobacco. The mortality to incidence ratio is 0.86, reflecting dismal survival [http//:globocan.iarc.fr/factsheet.asp] . Therefore, the focus of care remains one of palliation despite increased options for cancer directed treatment. Optimal symptom relief must play a central role. A systematic review of pain in people in with lung cancer found an overall weighted mean prevalence of pain in 47% patients (6 – 100%); the wide variation reflecting the different patient settings (1). However, for studies in general hospitals, just over one third of lung cancer patients had pain, and the weighted mean prevalence in a cancer treatment centre was 65%. Most pain is attributed to the cancer, either directly, or due to treatment (weighted mean prevalence; 13%). Pain is most common in the chest, then, pain in the spine. Patients may have multiple sites of pain, with other symptoms such as breathlessness, cough, and fatigue; pain considered to be one of the top three most distressing. Severe pain is associated with reduced survival, and interferes with function, enjoyment of life, mood and work(2). According to surviving relatives, of the 85% patients who had pain in the last year of life, over 50% found it very distressing(3). Management Assessment. All symptom management should start with a full assessment which extends beyond physical concerns into psychosocial and spiritual domains, and treatments (and involvement of relevant team members) tailored to the needs of the individual, remembering the effect on their family and friends. There are many extensive pain assessment tools which are not easy to use in daily clinical practice. Systematic assessment of every patient attending clinic, or admitted to hospital is often overlooked, but simple aide memoirs for the busy clinician are available and effective(4), or simple screening patient report scales. Where patient reported symptoms have been embedded in oncology clinical practice and linked to symptom management protocols, outcomes have improved(5-7). Symptom monitoring should be related to factors that patients rate as important such as effect on function and relationships with family and friends rather than a score(8). The linking of assessment to education (clinician and patient) and clinical guidance is important and shown to be more effective than education alone(9). Interventions for pain control Radiotherapy. Most pain is from the primary tumour, often with haemoptysis and cough. Palliative radiotherapy is effective but not extensively documented. One RCT study in non-small cell lung cancer shows improvement in pain in three quarters. Other symptoms also improved, along with function and wellbeing(10). Bony metastases are common in lung cancer, if present over 55% lead to one or more skeletal related events. Palliative radiotherapy is the most effective treatment. Onset of relief is between a few days and 1 month, and lasts between 3 to 6 months(11;12). A Cochrane review in 2000 calculated a number needed to treat to give complete relief in one patient at one month as 4.2 (95% CI 3.7 – 4.7)(13). A single fraction of 8Gy is as effective as higher multi-fractionated doses for the acute relief of pain, although of shorter duration(14). Opioids and other analgesics. The WHO analgesic ladder remains the standard approach to analgesic use in cancer pain with morphine still the most cost-effective first line strong opioid; cheaper than the equally effective oxycodone(15;16). In the presence of significant renal dysfunction, fentanyl, alfentanil and methadone are the least likely to cause harm (17). A systematic review confirms a small further benefit with the addition of a non-steroidal anti-inflammatory drug (NSAID), although the contributory studies were too small to comment on toxicity(18). Given the recent data on cardiovascular toxicity of NSAIDS, naproxen and low dose ibuprofen appear to be the safest in this group(19). Incident pain due to bone metastases is difficult to manage with analgesics alone because the direct relationship to periods of activity; the average duration of incident pain is 60 minutes and so may be improving before oral morphine may be fully absorbed. The newer transmucosal fentanyl preparations may be more helpful, with an onset of action of 10 minutes(20). Neuropathic pain often contributes to difficult to manage cancer pain. Opioids may provide benefit and a trial should be given. Standard adjuvant analgesics such as tricyclic antidepressants (duloxetine, amitriptyline) and anticonvulsants (gabapentin and pregabalin) and topical agents (capsaicin and lidocaine) may help but good quality trials in cancer pain are lacking(21). A recent RCT of ketamine for the palliation of refractory cancer pain found no benefit with ketamine(22). Another in patients with better performance status and where neuropathic pain is deemed to be the primary aetiology is almost closed to recruitment [ClinicalTrials.gov Identifier: NCT01316744]. Corticosteroids are commonly used for cancer pain although the evidence base is scant; a systematic review only found “low level evidence” for benefit (23). Bisphosphonates. Bisphosphonates are not routinely used for patients with lung cancer. A recent systematic review of bisphosphonate use in small cell lung cancer demonstrated improved pain control (RR 1.18; 95% CI 1.0 – 1.4), reduced skeletal related events (RR 0.81; 95% CIs 0.67 – 0.97) (24). However, many of the studies were of poor quality. Toxicity is usually restricted to transient flu-like or gastro-intestinal symptoms, but 15% of those with zoledronic acid developed renal dysfunction and 5% the distressing side-effect of osteonecrosis of the jaw. Newer agents such as denosumab may be tolerated better, but comparative trials in lung cancer are awaited. For the future In spite of these options, cancer pain, in general, is under-treated even where there is good access. Barriers include fear of, and poor education about, opioids in both patients and clinicians with consequent respective poor compliance and prescribing, and a lack of systematic screening of patient symptoms with full assessment if needed. Until assessment and management of pain is embedded into daily clinical practice, this feared symptom will remain a problem.

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