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Referral For Invasive Procedures For Cancer Pain Dr Alison Mitchell

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Lecture given to the North British Pain Association on 16th May 2008 by Dr Alison Mitchell. In this talk, Dr Mitchell discusses the indications for referral of patients with cancer pain for invasive …

Lecture given to the North British Pain Association on 16th May 2008 by Dr Alison Mitchell. In this talk, Dr Mitchell discusses the indications for referral of patients with cancer pain for invasive procedures. She describes the new interventional cancer pain service being set up in Glasgow. www.nbpa.org.uk

Published in: Health & Medicine, Technology

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  • Cancer is one of the most fatal diseases. To fight this cancer, the cancer patients undergo several cancer therapies and these therapies may create severe side effects. These side effects of the chemotherapy may again cause various troubles for the patients suffering from fatal disease like cancer. Maximum patients undergoing Chemotherapy suffer from problems like vomiting and nausea. Cachexia and anorexia are conditions which affect several people with cancer.

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  • 1. “ Referral for Invasive Procedures for Cancer Pain – Assessment Issues”
      • Dr Alison Mitchell
      • Consultant in Palliative Medicine
      • Beatson West of Scotland Cancer Centre, Glasgow
  • 2. 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
  • 3. 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
  • 4. 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 Society
    • American Academy of Pain Medicine
  • 5. Assessment- Patient
    • British 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
  • 6. 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
  • 7. Assessment- system
    • British Pain Society – Executive Summary
    • “ A multi-professional infrastructure must be provided for continuing care”
  • 8. 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
  • 9. Literature Search Cancer Pain
    • Individualised approach to each patient
    • considering –
    • 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
  • 10. 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 dose Toxicity or dependency CLINICAL SCENARIOS GOAL UNDERLYING CONCERN J. Supportive Oncol 2005 Vol 3, No 6
  • 11. 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 Drug
    • Delivery and for Chronic Pain: A National Survey” Ahmed et al. Neuromodulation Vol 8, No 2, 2005 112-120
  • 12.
    • 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 undergo
    • psychological evaluation.
    • 25% requested psychological evaluation for most of their
    • own patients.
    • “ Patient Selection and Trial Methods for Intraspinal Drug
    • Delivery and for Chronic Pain: A National Survey” Ahmed et al. Neuromodulation Vol 8, No 2, 2005 112-120
    Literature search- CP and Cancer Pain
  • 13.
    • 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 Drug
    • Delivery and for Chronic Pain: A National Survey” Ahmed et al. Neuromodulation Vol 8, No 2, 2005 112-120
    Literature search- CP and Cancer Pain
  • 14. Assessment Cancer 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
  • 15. Assessment Cancer pain v chronic pain
    • Rapidly changing disease
      • Prognosis
      • www.deathclock.com
      • www.mskcc.org
      • Ask the oncologist!!
  • 16. Assessment Cancer pain v chronic pain
    • Prognosis
      • Ask oncologist
      • Discussion with patient may be difficult
      • Liase with oncologist/palliative medicine team
  • 17. Assessment Cancer pain v chronic pain
    • Rapidly changing performance status
      • Disease
        • Primary site
        • Distant metastases
      • Treatment
        • Chemotherapy
        • Radiotherapy
        • Surgery
  • 18. Assessment Cancer pain v chronic pain
    • Concomitant treatment/investigation
      • Chemotherapy
        • Frequency
        • Side effects
        • Risk of neutropenia
      • Radiotherapy
        • Frequency
        • Side effects
        • Implantable pump issues
      • Investigations
        • MRI
  • 19. Assessment Cancer pain v chronic pain
    • Overall treatment burden
      • Multiple hospital visits
      • Frequently uncoordinated
      • Multiple investigations
    • Can interventional chronic pain approach be coordinated with other disciplines??
  • 20. Assessment Cancer 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
  • 21. Assessment Cancer pain v chronic pain
    • Approaches from other disciplines
      • Interventional Radiology
      • Cementoplasty/Vertebroplasty
      • Surgery
      • Minimally Invasive Transthoracic Splanchectomy (MITS) ‏
  • 22. Assessment Cancer 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
  • 23. Palliative Care 20 years ago Cancer Treatment Palliative/ Terminal Care Bereavement Patient Journey
  • 24. Palliative Care Now Terminal Care Cancer treatment Palliative treatment Bereavement
    • Palliative Care is appropriate:
    • From diagnosis
    • When treatment is potentially curative
  • 25. Palliative Care 2008 Condition specific care Diagnosis Investigations Treatment Follow-up Palliative Care Assessment Prevention Rehabilitation Supportive Care Bereavement Diagnosis Death Patient journey Relapse of disease Disease free
  • 26. ITDD Service for GG and C Pilot 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
  • 27. ITDD Service for GG and C Pilot 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
  • 28. Patient Assessment GGC ITDD Service
    • Referral form
    Yes / No Unknown Brain metastases (please circle)‏ Location of metastases Tumour type and location Date of diagnosis Physician/Surgeon And hospital base Oncologist Diagnosis
  • 29. Patient Assessment GGC 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
  • 30. Patient Assessment GGC 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 No Is Patient on anticoagulants? If Yes – give details PT/APPT/INR Comprehensive list of all other medication Previously Tried Analgesia Current Analgesia List
  • 31. Patient Suitability Check List GGC ITDD Service Signed ____________________________________ (Referring Palliative Medicine Consultant) Date____________________ Signed ______________________________________(Chronic Pain Consultant)‏ Date___________________ 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 Clinic Please date and sign Referring Palliative Medicine Consultant
  • 32. Patient Assessment GGC 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
  • 33. ITDD Service for GG and C Implications 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.
  • 34. ITDD Service for GG and C Implications 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.
  • 35. 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
  • 36. Patient Assessment for Invasive Procedures for Cancer Pain
    • TEAM EFFORT
      • Palliative Medicine
      • Chronic Pain
      • Oncology
      • Primary Care
      • Pharmacy