Management of pain in the treatment of cancer patients
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Transcript of Management of pain in the treatment of cancer patients
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MANAGEMENT OF PAIN IN THE TREATMENT OF
CANCER PATIENTS
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TREATMENT OPTIONS
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Chemotherapy Radiotherapy Hormonal Therapy Surgery
Systemic Localized
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BASIC PRINCIPLES APPLY
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WHO ANALGESIC LADDER
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DIFFERENT PATHOPHYSIOLOGIES OF PAIN
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CHOOSING THE APPROPRIATE FORMULATION AND AVAILABLE DRUG
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CHEMOTHERAPY
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COMMON DETERMINANTS OF PAIN Chemotherapy drug and regimen Co existing pain Age Nutritional status Prior chemotherapy and radiation
treatments Cognitive, physiological,
psychological and behavioral factors
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COMMON SIDE EFFECTS Mucositis Neuropathic pain Hand foot syndrome Arthralgia
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Case 1 68 year old male with colon cancer with extensive
lung and liver metastases On 5 FU based palliative chemotherapy ECOG performance status 3 His 67 year old wife takes care of him He now has pain in the mouth, is not able to eat
well and finds it difficult to swallow his analgesics Examination:
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MUCOSITIS
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MUCOSITIS Mucositis can affect all mucous membrane-covered
surfaces from the mouth to the rectum (Camp-Sorrell 2000)
Most common condition requiring systemic analgesics during cancer therapy (Epstein and Schubert 1999)
Oral mucositis affects approximately 40% of patients undergoing chemotherapy
Cancer treatment-induced mucositis causes acute pain, which is the result of sloughing of the epithelium, inflammation of the mucosa and ulceration (Camp-Sorrell 2000)
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MUCOSITIS WHO grading
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MUCOSITIS
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MUCOSITIS
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MUCOSITIS: mouth care Rinse mouth with water frequently (every 2
hrs while awake & when awake during the night). May add salt or baking soda (1/2 to 1 teaspoon in 8 ounces of water)
Use soft-bristle toothbrush (can soften even more by placing brush in very warm water), cotton swabs, mouth swabs (popsicle stick covered with gauze) to clean teeth after each meal and at bedtime
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MUCOSITIS: pain control Topical or local agents such as Orajel Combination mouth wash can be made
(ingredients may require prescription). Use equal parts: xylocaine viscous solution, benadryl, sucralfate and Maalox® taking 2 teaspoons every 2-4 hours as needed (swish around mouth and spit out)
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MUCOSITIS: healing Apply Vitamin E (puncture cap 400IU and
squeeze onto swab. Gently place swab on open area(s)
Take an antacid 1/2-1 ounce every 3-4 hours as needed to decrease burning sensation
Maintain good nutrition focusing on high protein and high calorie foods which are soft and/or semi liquid (i.e. scrambled eggs, puddings, blenderized or pureed foods). May use liquid supplements (i.e. Ensure®, Boost®, etc.)
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MUCOSITIS: avoidance Hot, spicy, coarse or rough textured
foods Very hot or cold beverages and foods Citric juices or foods containing citric
acid (tomatoes, oranges, lemon, etc.) Alcoholic beverages or tobacco products Liquid medication containing alcohol
(e.g. mouth wash) if not essential
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Case 2 34 year old mother with metastatic breast cancer
(lung, bone and liver) Performance status 2 Takes care of her 8 month old On capecitabine Develops pain in her hands and feet and she is
unable to care for her baby. She is emotionally distressed.
Examination:
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HAND AND FOOT SYNDROME
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HAND FOOT SYNDROME Uncomfortable and relatively frequent
dermatologic toxic reaction to certain chemotherapeutic agents (NCI)
Can be caused by: 5-Fluoruracil, capecitabine, vinorelbine, liposomal doxorubicin, docetaxel, sorafenib, sunitinib and high-dose Interleukin-2 (De Vita)
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HAND FOOT SYNDROME From managing CRC:
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HAND FOOT SYNDROME: prevention Preventative measures can help to decrease
the severity of symptoms should they develop
Modifying some of the normal daily activities of the patient to reduce friction and heat exposure to his/her hands and feet for a period of time following treatment
Avoiding long exposure of the hands and feet to hot water such as long showers or tub baths
Avoiding increased pressure on the soles of the feet or palms of hands
Minimizing long walks
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HAND FOOT SYNDROME: management Stop the chemotherapy agent once the
syndrome has started Emollients such as Aveeno®, Lubriderm®,
Aqueous cream provide excellent moisturizing
Analgesics, cold compresses, cushioning and elevating the limb area
Oral and topical steroids as well as Vitamin E have been used with limited success
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RADIOTHERAPY
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FACTORS AFFECTING PAIN AT RADIATION SITE
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FACTORS Site of radiation Extent of disease Total dose Dose per fraction Comorbid conditions Physiological factors
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COMMON SITES FOR PAIN Head and neck area Skin Groin
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Case 3 A 68 year old female with extensive
cutaneous metastases from a recurrent breast cancer
She is having short course palliative radiotherapy with electrons for pain and bleeding
She has moist desquamation and has difficulty with dressing and sleeping
Performance status 2
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MANAGEMENT OF DESQUAMATION Topical treatment may offer symptomatic relief and may
help skin healing. Different areas of skin may require different treatment approaches
Drying pastes may be appropriate for use within skin folds, where skin reactions remain moist
Gels can be useful in seborrhoeic areas Creams can be used in areas outside skin folds and
seborrhoeic areas Hydrophilic dressings may also be useful in moist areas.
These are placed over the cleaned, dried wound and some can absorb wound exudate. They can be soothing for the patient and can help skin healing
Greasy topical products should be avoided because they inhibit the absorption of wound exudate and promote superinfection
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PREVENTION OF DESQUAMATION The irradiated area should be kept clean to
minimize the risk of infection
Patients should wash the area with a gentle cleanser and dry it with a soft, clean towel
Loose-fitting clothing should be worn over the irradiated area to prevent friction injuries
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SURGERY
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SURGERY Not commonly used modality
Can be used in cases to aid with bleeding, obstruction and fracture
Pain is usually at the post surgical wound site
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HORMONAL THERAPY
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A SMALL CATEGORY Breast cancer patients on aromatase
inhibitors can experience joint pain
Can worsen quality of life especially in those with pre-existing joint pain