“ Referral for Invasive Procedures for Cancer Pain – Assessment Issues” Dr Alison Mitchell Consultant in Palliative Medicine Beatson West of Scotland Cancer Centre, Glasgow

Dr Alison Mitchell

Consultant in Palliative Medicine

Beatson 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

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

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 Society American Academy of Pain Medicine

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

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

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

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

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”

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

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 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

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

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

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.

Inability to tolerate adequate oral radiotherapy

Fear of side effects or addiction.

Receiving aggressive chemotherapy regimens with high toxicity profile.

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

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

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

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

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

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

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

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

Assessment Cancer pain v chronic pain Rapidly changing disease Prognosis www.deathclock.com www.mskcc.org Ask the oncologist!!

Rapidly changing disease

Prognosis

www.deathclock.com

www.mskcc.org

Ask the oncologist!!

Assessment Cancer pain v chronic pain Prognosis Ask oncologist Discussion with patient may be difficult Liase with oncologist/palliative medicine team

Prognosis

Ask oncologist

Discussion with patient may be difficult

Liase with oncologist/palliative medicine team

Assessment Cancer pain v chronic pain Rapidly changing performance status Disease Primary site Distant metastases Treatment Chemotherapy Radiotherapy Surgery

Rapidly changing performance status

Disease

Primary site

Distant metastases

Treatment

Chemotherapy

Radiotherapy

Surgery

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

Concomitant treatment/investigation

Chemotherapy

Frequency

Side effects

Risk of neutropenia

Radiotherapy

Frequency

Side effects

Implantable pump issues

Investigations

MRI

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??

Overall treatment burden

Multiple hospital visits

Frequently uncoordinated

Multiple investigations

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

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

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

Assessment Cancer pain v chronic pain Approaches from other disciplines Interventional Radiology Cementoplasty/Vertebroplasty Surgery Minimally Invasive Transthoracic Splanchectomy (MITS) ‏

Approaches from other disciplines

Interventional Radiology

Cementoplasty/Vertebroplasty

Surgery

Minimally Invasive Transthoracic Splanchectomy (MITS) ‏

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

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 Terminal Care Cancer treatment Palliative treatment Bereavement Palliative Care is appropriate: From diagnosis When treatment is potentially curative

Palliative Care is appropriate:

From diagnosis

When treatment is potentially curative

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

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

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 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

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 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

Referral form

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

Referral form

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

Referral form

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

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

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 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.

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 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.

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

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

TEAM EFFORT

Palliative Medicine

Chronic Pain

Oncology

Primary Care

Pharmacy