treating pain and neuropathy in metastatic breast cancer
TRANSCRIPT
Treating Pain and Neuropathyin Metastatic Breast Cancer
September 24, 2016 Lida Nabati, MD
CLINICAL MANAGEMENT OF BREAST AND GYNECOLOGIC CANCERS IN SPECIAL POPULATIONS
Goals
• To review basic cancer pain and neuropathy management
Pain
• The body’s way of telling us about damage or perceived damage to tissue.
• Don’t ignore! Report it. • Treating pain is part of treating your cancer.• Subjective, personal
– only you can “measure” your pain
Cancer Pain
Tumor
Surgery
Radiation
Chemotherapy
Treat Cancer
• Radiation Therapy• Surgery• Chemotherapy
PAINED
• Place• Amount • Intensifiers• Nullifiers• Effects • Description
Keep Pain Diary
• Record: – Pain score– Trigger– Medication use – Medication effect (pain score 1 hour after)– Other comments
WHO Step Ladder
Approach To Pain Control1. Thorough assessment by skilled and
knowledgeable clinician.2. What are the goals of care? 3. Investigations: Radiology studies – how
burdensome, will they affect care?4. Treatments: pharmacological and non-
pharmacological, interventional analgesia.5. Ongoing reassessment and review of
options, goals, expectations.
Opioids
• Short-Acting • Oxycodone• Morphine
•Long-acting •Oxycontin •Mscontin •Fentanyl Patch •Methadone
Opioid Side Effects
• Nausea• Sleepiness• Constipation
Opioid Rotation
• If one opioid is not well toelrated, may try another
• Conversion tables do not account for incomplete cross tolerance
• Recommend reduction by 25-50% of calculated equianalgesic dose when rotating opioids.
How Often can one Escalate? Short acting oral__________Each dose interval
Opioid continuous infusion_____Every 8 hours
Long acting oral______________Every 2 days
Methadone_________________Every 3-7 days
TD Fentanyl_________________Every 3 days
Will I become addicted?
• Tolerance and physiologic dependence are expected with chronic opioids, this is not addiction.
• Addiction is misuse of medications with harm resulting. It is not common but can happen – increased risk if personal or family history of addiction
Common reasons for the use of alternate routes
• Severe nausea and/or vomiting• Difficulty swallowing • Complications of the gut• Diminished consciousness
Peripheral Neuropathy
• Results from lesion or disease of nervous system
• Shooting, burning, tingling • Can be associated with numbness, weakness• Can result form tumor, surgery• Many chemotherapies can cause this:
– Taxanes, Platinum based drugs, Eribulin
Neuropathy Treatments
• Gabapentin • Tricyclic antidepressants • Capsaicin • Opioids • Cannabinoids
Pain Treatment
• Genetic, hormonal, and other factors influence one’s perception, experience, of pain.
• There are established genetic variabilities in metabolism of pain medications.
Pain Interventions
• Interventional Radiology – Bone interventions – Cryoablation
• Anesthesia – Nerve blocks– Epidurals
© Pain and Palliative Care ProgramDana-Farber Cancer Institute 2002
Total Pain
Causes of Suffering in Serious Illness
PHYSICAL Pain Dyspnea Delirium Nausea/ vomiting
PSYCHOLOGICAL Anxiety Depression Loss of Meaning Loss of Control Loss of Dignity
SPIRITUAL Uncertainty Fear of disability Fear of death Hopelessness Remorse
SOCIAL Loneliness Functional decline Loss of roles
A Team Approach
“ Caring for the whole person and family requires a caregiver who is whole….
Until one comes along, use a team.” Balfour Mount
Other Modalities
• Acupuncture• Physical Therapy • Reiki• Massage • Meditation • Heat/ice
Summary
• Pain management is an important par t of cancer treatement
• There are many ways your pain can be effectively managed