“Referral for Invasive Procedures for Cancer

Pain – Assessment Issues”Dr Alison Mitchell

Consultant in Palliative MedicineBeatson West of Scotland Cancer Centre,

Glasgow

Assessment of Cancer Patients for Interventional Procedures

• INTRATHECAL

• What Guidelines exist?• Literature search • Differences between cancer pain

population and chronic pain population• What are we doing in GG and C?• Patient assessment and system

assessment

Assessment of Cancer Pain Patients• Patient and System• Professional guidelines

– British Pain Society– IASP– American Academy of Pain Medicine– American Pain Society– SIGN 44– NICE– HDL (2006) Guidance on Safe Handling

of Non Cytotoxic Intrathecal and Intraventricular Injections

• Literature search• Current Practice

Assessment

British Pain Society “Intrathecal drug delivery for the

management of pain and spasticity in adults .

Recommendations for best clinical practice”

(Provisional) 2006

IASP American Pain SocietyAmerican Academy of Pain Medicine

Assessment- PatientBritish Pain Society Guidelines • Multi-professional assessment of symptoms

disease psychological factors social factors treatment options

• Trial of IT therapy should be performed• Malignant disease should be fully investigated • IT preferable if catheter duration > 3 weeks• Indications include failure of conventional

analgesic and/or dose limiting side effects. • ITDD underused in UK

Assessment- patient

• British Pain Society Guidelines• Patient must be fit for surgery and

anaesthesia• Planned discontinuation of systemic

analgesia• No evidence justifying antibiotic

prophylaxis• Anticoagulant and antiplatelet

treatment should be stopped for the procedure

Assessment- system

• British Pain Society – Executive Summary

“ A multi-professional infrastructure must be provided for continuing care”

Assessment- system

• British Pain Society• Refills must be planned taking drug

stability into account• Post op care should be on a ward

where nursing staff have developed appropriate skills in care of ITDD

• Adequate arrangements must be in place for ongoing care- including programme changes and refill attendances

• Clear pathway for dealing with complications both in and out of hospital

Literature SearchCancer Pain

Individualised approach to each patientconsidering – • Nature and severity of symptoms that

interfere with patients activities of daily life (ADLs)

• Response to previous treatment• Disease status• Physical and psychological status of

patient• Patient preference

Seminars in Pain Medicine Vol 1 No 1 2003

Literature search-Cancer Pain

Patient selection for Intrathecal Drug Delivery System

• Pain refractory to oral regimens• Presence of visceral tumours of autonomic dysfunction• Severe neuropathic pain• Impending spinal cord paralysis • Acute, unstable pathological fractures•Complex regional pain syndromes secondary to surgery, chemotherapy or radiation treatment.

Provide more effective pain treatment options

Disease or treatment related refractory, worsening or severe pain

• Inability to tolerate adequate oral radiotherapy • Fear of side effects or addiction.• Receiving aggressive chemotherapy regimens with high toxicity profile.

Reduce doseToxicity or dependency

CLINICAL SCENARIOSGOALUNDERLYING CONCERN

J. Supportive Oncol 2005 Vol 3, No 6

Literature search- CP and Cancer Pain

• Survey of 1500 interventional pain physicians in USA examining patient selection, drug choice, trial techniques and efficacy assessment for ITDD.

• All types of indications – non cancer and cancer• 205/1500 questionnaire returned • Four major areas surveyed

- patient selection criteria assessment- choice of medication for pre-implantation

trials - preferred trial techniques

- assessment of trial efficacy to select candidates for permanent implants

“Patient Selection and Trial Methods for Intraspinal DrugDelivery and for Chronic Pain: A National Survey” Ahmed et al.

Neuromodulation Vol 8, No 2, 2005 112-120

• Patient Selection Criteria – Respondents rated importance of various factors in decision making as to whether to go ahead or not:– Reduction of side effects (74%)– Obtaining more than 50% pain relief (64%)– Enabling patients to de household work (33%)– Realistic expectations (92%)

43% of respondents required patients to undergopsychological evaluation.

25% requested psychological evaluation for most of theirown patients.

“Patient Selection and Trial Methods for Intraspinal DrugDelivery and for Chronic Pain: A National Survey” Ahmed et al. Neuromodulation Vol

8, No 2, 2005 112-120

Literature search- CP and Cancer Pain

Psychosocial issues that discouraged IT insertion: • Current alcohol or substance abuse (96%)• Repeated history of opioid contract violation (92%)• Significant secondary gain (89%)• Significant history of non-compliance with

medication (87%)• Satisfaction with current level of functioning (74%)• Psychiatric conditions

Most respondents did not have separate trial protocols for cancer and non-cancer pain.

The 47 respondents who did cited:• Shorter life expectancy (83%)• Clear aetiology of pain (66%)• Relatively few psychosocial issues (64%)• Well defined outcomes (49%)As reasons for a separate protocol

“Patient Selection and Trial Methods for Intraspinal DrugDelivery and for Chronic Pain: A National Survey” Ahmed et al.

Neuromodulation Vol 8, No 2, 2005 112-120

Literature search- CP and Cancer Pain

AssessmentCancer pain v chronic pain

• Rapidly changing disease– prognosis

• Rapidly changing performance status– Opioid side effects

• Concomitant treatment/investigations

• Overall treatment burden• Litigation/secondary gain• Approaches from other disciplines• Usually known to Palliative

Medicine Consultant

AssessmentCancer pain v chronic pain

• Rapidly changing disease– Prognosis– www.deathclock.com

– www.mskcc.org

– Ask the oncologist!!

AssessmentCancer pain v chronic pain

• Prognosis– Ask oncologist– Discussion with patient may be

difficult– Liase with oncologist/palliative

medicine team

AssessmentCancer pain v chronic pain

• Rapidly changing performance status– Disease

•Primary site•Distant metastases

– Treatment•Chemotherapy•Radiotherapy•Surgery

AssessmentCancer pain v chronic pain• Concomitant

treatment/investigation– Chemotherapy

•Frequency•Side effects•Risk of neutropenia

– Radiotherapy•Frequency•Side effects•Implantable pump issues

– Investigations•MRI

AssessmentCancer pain v chronic pain

• Overall treatment burden– Multiple hospital visits– Frequently uncoordinated– Multiple investigations

• Can interventional chronic pain approach be coordinated with other disciplines??

AssessmentCancer pain v chronic pain

• Litigation– Not such an issue in cancer pain– Usually related to perceived

delay in diagnosis– Frequently perceived diagnosis

delays are not pursued

• Secondary gain– Not an issue

AssessmentCancer pain v chronic pain• Approaches from other disciplines

– Interventional Radiology– Cementoplasty/Vertebroplasty

– Surgery– Minimally Invasive Transthoracic

Splanchectomy (MITS)

AssessmentCancer pain v chronic pain

• Usually known to a Palliative Medicine Team– Pain– Other symptoms– Psychological issues– Social issues– Spiritual issues– Can be involved much earlier in

disease pathway

Palliative Care 20 years ago

Cancer Treatment

Palliative/

Terminal Care

Bereavement

Patient Journey

Palliative Care Now

TerminalCare

Cancertreatment

Palliativetreatment

Bereavement

Palliative Care is appropriate:

1. From diagnosis

2. When treatment is potentially curative

Palliative Care 2008

Condition specific care

DiagnosisInvestigations

TreatmentFollow-up

Palliative Care

AssessmentPrevention

RehabilitationSupportive Care

Bereavement

Diagnosis

Death

PatientPatientjourneyjourney

Relapseofdisease

Disease free

ITDD Service for GG and CPilot Service

• Patients referred by Palliative Medicine Consultants throughout GGC

• Integrated OP Clinic in BWof SCC– 4 Chronic Pain Consultants– Palliative Medicine Consultant

• Admitted to BWof SCC for trial• Converted to implantable pump• Follow up by referring Palliative

Medicine Team

ITDD Service for GG and CPilot Service

• Patient assessment– Referral form information– Integrated Clinic assessment– Information from GP/DNs

• System assessment• Implications of HDL ( 2006) Guidance

on Safe Handling of Non Cytotoxic Intrathecal and Intraventricular Injections

Patient AssessmentGGC ITDD Service

• Referral form

Yes / No Unknown

Brain metastases (please circle)

Location of metastases

Tumour type and location

Date of diagnosis

Physician/SurgeonAnd hospital base

Oncologist

Diagnosis

Patient AssessmentGGC ITDD Service• Referral form

Details of Oncological Treatment

Proposed treatment in the future

Current treatment

Completed treatment to date

Prognosis (Please discuss potential ITDD with oncologist to check both prognosis and planned oncological treatment schedule)

Prognosis

Patient AssessmentGGC ITDD Service• Referral form

Pain History (please include any relevant chronic pain or spinal surgery past medical history)

Comprehensive analgesia list including all medications tried to date

Yes NoIs Patient on anticoagulants?If Yes – give details PT/APPT/INR

Comprehensive list of all other medication

Previously Tried Analgesia

Current Analgesia List

Signed ____________________________________ (Referring Palliative Medicine Consultant) Date____________________Signed ______________________________________(Chronic Pain Consultant)Date___________________

Patient Suitability Check List GGC ITDD Service

Beatson West of Scotland Cancer Centre Palliative Medicine Cover for titration period

ITDD has been discussed with the oncologist

Patient understands and consents to intervention

Chronic Pain on-call cover

There will be 24/7 referring palliative care team consultant cover

Referring palliative care team are willing to participate in refill programme

Letter to community team (GP and DN), informing them of the possibility of ITDD, has been sent at the same time as patient referral made

Patient has someone at home 24/7

Integrated ClinicPlease date and sign

Referring Palliative Medicine Consultant

Patient AssessmentGGC ITDD Service

• Tailored assessment– Prognosis– Performance status– Information from Pall Med, Oncology and Primary Care

• Brief Pain Inventory ( short form)• Current analgesic regimen• Previously tried analgesia• Pain history

– Side effects from opioids

• Patient’s/carers assessment of pain• Limitations to ADLs• Patient expectations from proposed procedure• Investigations focussed and timeous

ITDD Service for GG and CImplications of HDL• HDL ( 2006) Guidance on Safe

Handling of Non Cytotoxic Intrathecal and Intraventricular Injections– Nominated lead for IT service– Local protocol for training,

prescribing, preparation, labelling, storage and administration of Intrathecal Medicines

– Register of Medical, Nursing and Pharmacy personnel authorised to train/prescribe/prepare/administer IT injections.

ITDD Service for GG and CImplications of HDL• All staff involved in delivering IT non

cytotoxic medication must receive appropriate education and training.

• Written protocols• Specific IT prescription form• Preparation should be in pharmacy

aseptic dept., separate from preparation of cytotoxic IT drugs.

Assessment of Cancer Patients for Interventional Procedures

• INTRATHECAL

• What Guidelines exist?• Literature search • Differences between cancer pain

population and chronic pain population• What are we doing in GG and C?• Patient assessment and system

assessment

Patient Assessment for Invasive Procedures for Cancer Pain

• TEAM EFFORT– Palliative Medicine– Chronic Pain– Oncology– Primary Care– Pharmacy