Does pain intensity predict a poor opioid response in cancer patients?
Abstract Aim The aim of this study was to test the hypothesis that initial pain intensity is not a predictive factor of poor opioid response in advanced cancer patients, as suggested by a recent work. Methods A secondary analysis of one-hundred-sixty-seven patients referred for treatment of cancer-related pain was conducted. Pain intensity at admission was recorded and patients were divided in three categories of pain intensity: mild, moderate and severe. Patients were offered a treatment with opioid dose titration, according to department policy. Data regarding opioid doses and pain intensity were collected after dose titration was completed. Four levels of opioid response were considered:…
Emergencies in patients with advanced cancer followed at home.
Abstract CONTEXT: Patients with advanced cancer stay at home for most of their time, and acute problems may occur during home care. Caregivers may call medical services for an emergency, which can result in patients being admitted to the hospital. No data exist on emergencies in patients followed by a home care team. OBJECTIVES: The aim of this multicenter prospective study was to assess the frequency, reasons for, and subsequent course of emergency calls for patients followed at home by a palliative care team. METHODS: A consecutive sample of patients admitted to home care programs was surveyed for a period of seven months. Epidemiological data, and characteristics of emergency calls and o…
Breakthrough pain in oncology: A longitudinal study
Abstract Context Existing studies on breakthrough pain (BP) have reported different prevalence rates because of different settings, populations, and assessment methods. These studies have used cross-sectional designs, and the relationship of BP with analgesic treatment has not been evaluated. Objectives The aim of this study was to longitudinally assess BP in cancer patients admitted to oncology units. Methods A consecutive sample of patients admitted to oncology centers was selected. At admission (T0), three months after admission (T3), and six months after admission (T6), data on background pain and BP were recorded. BP was assessed in terms of its intensity, duration, number of episodes,…
Relationship between background cancer pain, breakthrough pain, and analgesic treatment: a preliminary study for a better interpretation of epidemiological and clinical studies
Abstract Abstract Background: The different operational definitions of breakthrough cancer pain (BTcP) has generated unclear epidemiological data. Methods: A consecutive sample of patients was categorized on the basis of their background pain intensity, background analgesic treatment, and the presence of BTcP. Results: A total of 265 patients were surveyed; 117 patients had background pain and 91 patients presented peaks of pain intensity distinguishable from background pain. Of 117 patients with background pain, 49 patients were re-assessed after optimization of background analgesia (T1) within a mean of 8.2 days. Pain intensity significantly decreased in comparison with values recorded at…
Spinal analgesia for advanced cancer patients: An update
In the nineties, spinal analgesia has been described as an useful means to control pain in advanced cancer patients. The aim of this review was to update this information with a systematic analysis of studies performed in the last 10 years. 27 papers pertinent with the topic selected for review were collected according to selection criteria. Few studies added further information on spinal analgesia in last decade. Despite a lack of a clinical evidence, spinal analgesia with a combination of opioids, principally morphine, and local anesthetics may allow to achieve analgesia in patients who had been intensively treated unsuccessfully with different trials of opioids. Some adjuvant drugs such …
Palliative sedation in advanced cancer patients followed at home: A retrospective analysis
Abstract CONTEXT: Data regarding palliative sedation at home in dying patients are lacking. OBJECTIVES: To describe the frequency, indication, and modality of palliative sedation (PS) in patients followed at home. METHODS: A retrospective analysis of home care cancer patients was performed. Patients who received PS before dying were selected and information about epidemiologic characteristics, indications, duration, drugs, and outcomes was collected. RESULTS: Of 370 medical charts of patients who died at home, 49 patients received PS before dying. PS was proposed by the team, relatives, or both in 63.3%, 4.1%, and 32.6% of cases, respectively. Delirium alone or in combination with other sym…
Fentanyl Buccal Tablet vs. Oral Morphine in Doses Proportional to the Basal Opioid Regimen for the Management of Breakthrough Cancer Pain: A Randomized, Crossover, Comparison Study
Fentanyl products have shown superiority to oral opioids for the management of breakthrough cancer pain (BTcP). However, these studies did not use appropriate patient selection, and drugs have been compared by using different rationales.The aim of this randomized, crossover, controlled study was to compare efficacy and safety of fentanyl buccal tablets (FBTs) and oral morphine (OM), given in doses proportional to opioid daily doses.Cancer patients with pain receiving ≥60 mg or more of oral morphine equivalents per day and presenting with ≤3 episodes of BTcP per day were included. In a randomized, crossover manner, patients received FBT or OM at doses proportional to the daily opioid regimen…
Octreotide for malignant bowel obstruction: Twenty years after
Malignant bowel obstruction (MBO) is a challenging complication of advanced cancer. Conservative treatment of inoperable MBO in terminal cancer patients has been found to be effective in controlling the distressing symptoms caused by this complication in inoperable cancer patients. Twenty years ago, octreotide was proposed to treat symptoms related to malignant bowel obstruction. Since then several reports have confirmed the efficacy of octreotide in the management of gastrointestinal symptoms of MBO. Fifteen randomized controlled trials or observational reports with a significant number of patients treated with octreotide have been reviewed; 281 patients were surveyed. Authors reported a t…
Palliative Care in Advanced Cancer Patients: How and When? And Where?
Eduardo Bruera et al. [1] recently published an exhaustive paper in which they underscore the importance of the integration between oncology and palliative care, suggesting how and when to provide palliative care in advanced cancer patients. We agree that this integrative model allows prompt evaluation and treatment of symptoms, a reduction in costs resulting from inappropriate hospitalization, and better survival outcomes. In their conclusion, Bruera et al. [1] affirm that the two most important resources for palliative care delivery are outpatient palliative care centers and inpatient palliative care units. Although we are on the same wavelength as Bruera et al. [1], we would like to poin…
Tapentadol at medium to high doses in patients previously receiving strong opioids for the management of cancer pain.
Abstract Abstract Objective: The aim of this study was to assess the efficacy and tolerability of tapentadol (TP) for a period of 4 weeks in patients who were already treated by opioids. Methods: A convenience sample of 30 patients was selected for a prospective observational cohort study. Cancer patients who were receiving at least 60 mg of oral morphine equivalents were selected. Patients discontinued their previous opioid analgesics before starting TP, in doses calculated according the previous opioid consumption (1:3.3 ratio with oral morphine equivalents). The subsequent doses were changed according to the patients' needs for a period of 4 weeks. Oral morphine was offered as a breakthr…
The use of fentanyl buccal tablets for breakthrough pain by using doses proportional to opioid basal regimen in a home care setting.
Abstract The dose of rapid onset opioids to be given for breakthrough cancer pain (BTcP) is controversial. Dose proportional to the basal opioid regimen seem to be safe and effective in hospital units. However, data in other less protected settings, like home care, are lacking. The aim of this open-label study was to assess the efficacy and safety in a group of patients with BTcP followed at home, after giving a dose of fentanyl buccal tablets (FBT) proportional to the opioid basal regimen, skipping the steps for dose titration. Consecutive patients admitted to a home care program presenting BTcP episodes and receiving stable doses of opioids for background pain were selected. Data from fou…
Pain intensity as prognostic factor in cancer pain management
Aim The aim of this study was to prospectively assess the prognostic value of initial pain intensity and its duration in advanced cancer patients. Methods A prospective study was conducted in a sample of patients with cancer requiring pain control. Patients underwent standard analgesic strategies used in our palliative care units. Pain intensity was measured at admission (T0) and after successful dose titration or opioid/route switching within a week (Ts). Patients were also asked about their pain intensity reported 15 days before admission (T-15). Doses of opioids and duration of opioid use were recorded. Patients were also assessed for the presence of incident pain, neuropathic pain, alco…
Pattern of symptoms and symptomatic treatment in adults and the aged population: a retrospective analysis of advanced cancer patients followed at home.
Context Data regarding symptom burden and symptomatic drugs in palliative population in different classes of age are lacking. Objective The aim of this retrospective study was to assess the symptom burden, and the profile of symptomatic drugs in the last four weeks of life in adults and older cancer patients followed at home. Methods Charts of 412 patients were retrospectively analyzed by using a backward analysis. Patients were divided into three groups: adults (<65 years, A), old (65-74 years, O1), very old (75-84 years, O2), and the oldest (≥85 years, O3). Results At -4W Karnofsky status was significantly lower for older people (p = 0.03). No significant effect of age on the vector of sy…
Opioid switching in patients with advanced cancer followed at home. A retrospective analysis.
Abstract CONTEXT: Opioid switching has been found to improve opioid responsiveness in different conditions. However, data on opioid switching performed at home are almost nonexistent, despite the fact that most patients are followed at home. OBJECTIVES: The aim of this retrospective survey was to determine frequency, indications, usefulness, and safety of opioid switching when treating advanced cancer-related pain in patients followed at home. METHODS: A retrospective review of data from patients with advanced cancer followed at home by three home care teams for a period of two years was performed. Patients who had their opioids switched were selected. Reasons for switching opioid doses and…
Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study
Abstract Context Home care programs in Italy. Objectives The aim of this study was to assess a protocol for palliative sedation (PS) performed at home. Methods A total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam. Results A total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P = 0.012). The principal reasons to start PS were agitated delirium (n = 20) and dyspnea (n = 4).…
Tapentadol in cancer pain management: a prospective open-label study.
OBJECTIVES: The aim of this prospective, open-label study was to evaluate the efficacy and tolerability of tapentadol (TP) in the management of cancer pain. METHODS: A 4 weeks' prospective study was carried out in 50 opioid-naive cancer patients with moderate-severe pain. Each patient initially received twice-daily doses of slow-release TP 50 mg. Doses were then managed to maintain adequate relief or dose-limiting toxicity, on the basis of the clinical response. The following parameters were recorded at weekly intervals for 4 weeks: pain and opioid-related adverse effects, quality of life measured with the Spitzer score, TP escalation index percent (TPEI%) and TP escalation index in mg (TPE…
Dosing fentanyl buccal tablet for breakthrough cancer pain: dose titration versus proportional doses.
Abstract OBJECTIVES: The aim of this study was to compare the efficacy and safety of doses of fentanyl buccal tablet (FBT) proportional to doses of opioids used for background analgesia versus dose titration starting with the minimal dose for the management of breakthrough cancer pain (BTcP). METHODS: A total of 82 cancer patients with BTcP who were receiving strong opioids in doses of at least 60 mg of oral morphine equivalents and having acceptable background analgesia, were selected for a multicenter unblinded study. Forty-one patients were randomized to receive FBT in doses proportional to the daily opioid doses for four consecutive episodes of BTcP (group P). Forty-one patients underwe…
Sleep Disturbances in Patients with Advanced Cancer in Different Palliative Care Settings.
Abstract Context Information regarding sleep disturbances in the population with advanced cancer is meager. Objectives To assess the prevalence of sleep disturbances and possible correlations with associated factors in a large number of patients with advanced cancer admitted to different palliative care settings. Methods This was an observational study performed in different settings of palliative care. A consecutive sample of patients with advanced cancer was prospectively assessed for a period of six months. Epidemiological and clinical data, treatments received in the last month, Karnofsky status, Edmonton Symptom Assessment System scores, and concomitant medical treatment were recorded.…
Sustained-release oral morphine versus transdermal fentanyl and oral methadone in cancer pain management.
The aim of this study was to compare the analgesic and adverse effects, doses, as well as cost of opioid drugs, supportive drug therapy and other analgesic drugs in patients treated with oral sustained-release morphine, transdermal fentanyl, and oral methadone.One hundred and eight cancer patients, no longer responsive to opioids for moderate pain, were selected to randomly receive initial daily doses of 60 mg of oral sustained-release morphine, 15 mg of oral methadone, or 0.6 mg (25 microg/h) of transdermal fentanyl. Oral morphine was used as breakthrough pain medication during opioid titration. Opioid doses, pain intensity, adverse effects, symptomatic drugs, were recorded at week interva…
Safety and effectiveness of intravenous morphine for episodic breakthrough pain in patients receiving transdermal buprenorphine.
Supplemental dosing of an opioid is the main treatment suggested to manage breakthrough pain in cancer patients. The intravenous route has been proven to be safe and effective, providing rapid analgesia in patients receiving oral morphine. Transdermal buprenorphine (TTS-BUP) is increasingly used in cancer pain management, but this drug has been labeled as a difficult drug to use in combination with other opioids. The aim of this open-label study was to verify the safety and effectiveness of intravenous morphine (IV-MO) for the treatment of episodic pain in cancer patients receiving TTS-BUP. A consecutive sample of 29 cancer patients, who were treated with TTS-BUP, reported an acceptable bas…
The frequency of alcoholism in patients with advanced cancer admitted to an acute palliative care unit and a home care program
Abstract Context Cancer patients with a history of alcoholism may be problematic. The frequency of alcoholism among patients with advanced cancer has never been reported in Italy or other European countries. Objectives The aim of this prospective study was to determine the frequency of alcoholism, assessed with a simple and validated instrument, among patients with advanced cancer who were referred to two different palliative care settings: an acute inpatient palliative care unit (PCU) of a comprehensive cancer center in a metropolitan area and a home care program (HCP) in a territorial district, localized in the mountains of Italy. Methods A consecutive sample of patients admitted to an in…
Evaluation of Second-line Anti-VEGF after First-line Anti-EGFR Based Therapy in RAS Wild-Type Metastatic Colorectal Cancer: The Multicenter “SLAVE” Study
: Background: The optimal anti-angiogenic strategy as second-line treatment in RAS wild-type metastatic colorectal cancer (mCRC) treated with anti-EGFR (Epidermal Growth Factor Receptor) based first-line treatment is still debated. Methods: This multicenter, real-world, retrospective study is aimed at evaluating the effectiveness of second-line Bevacizumab- and Aflibercept-based treatments after an anti-EGFR based first-line regimen. Clinical outcomes measured were: objective response rate (ORR), progression free survival (PFS), overall survival (OS) and adverse events (AEs) profiles. Results: From February 2011 to October 2019, 277 consecutive mCRC patients received Bevacizumab-based (228,…
Switching from Transdermal Drugs: An Observational "N of 1" Study of Fentanyl and Buprenorphine
The aim of this study was to confirm that the concomitant presence of transdermal fentanyl (TTS FE) and buprenorphine (TTS BU) may be feasible without important consequences, using doses presumed to be equianalgesic. A prospective "N of 1" study was carried out in a sample of volunteers with cancer pain receiving stable doses of TTS FE or TTS BU, with adequate pain and symptom control. In the study design, each patient provided data before and after a switch from one opioid to the other and then back to the previous one. Sixteen patients receiving daily stable doses of 0.6 or 1.2 mg of TTS FE were switched to TTS BU using an FE-BU ratio of 0.6-0.8. After three days, the TTS BU patch was rem…
The effects of low doses of pregabalin on morphine analgesia in advanced cancer patients
Abstract OBJECTIVES: The aim of this study was to evaluate the opioid response in patients receiving morphine and pregabalin, independently from the presumed pain mechanisms, in comparison with patients receiving morphine treatment only. METHODS: A multicenter prospective randomized controlled study was carried out in a sample of 70 advanced cancer patients with pain requiring strong opioids. Thirty-five patients (group MO) were randomized to receive sustained-release morphine using initial doses of 60 mg/day. Thirty-five patients (group MO-PR) were randomized to start the same morphine doses and pregabalin in increasing doses, starting with 25 mg/day up to 150 mg/day in one week. The follo…
Opioid switching from and to tapentadol extended release in cancer patients: conversion ratio with other opioids
Objectives: The aim of this exploratory study was to assess the conversion ratios between tapentadol and other opioids in patients requiring an opioid switching. Methods: A prospective study was carried out in a convenience sample of consecutive patients admitted to an acute palliative care unit and a home care unit for a period of 1 year. Patients who were switched from/to tapentadol were selected. The initial ratio between tapentadol and other opioids, expressed as oral morphine equivalents was 1:3.3. The subsequent doses were flexible and were changed to fit the patients’ needs. Pain intensity and distress score were recorded until opioid doses were stable. In all, 37 patients were exami…
Post-Induction Management in Patients With Left-Sided RAS and BRAF Wild-Type Metastatic Colorectal Cancer Treated With First-Line Anti-EGFR-Based Doublet Regimens: A Multicentre Study
BackgroundFew data regarding post-induction management following first-line anti-epidermal growth factor receptor (EGFR)-based doublet regimens in patients with left-sided RAS/BRAF wild-type metastatic colorectal cancer (mCRC) are available.MethodsThis multicenter, retrospective study aimed at evaluating clinicians’ attitude, and the safety and effectiveness of post-induction strategies in consecutive patients affected by left-sided RAS/BRAF wild-type mCRC treated with doublet chemotherapy plus anti-EGFR as first-line regimen, who did not experience disease progression within 6 months from induction initiation, at 21 Italian and 1 Spanish Institutions. The measured clinical outcomes were: p…
Tools for identifying cancer pain of predominantly neuropathic origin and opioid responsiveness in cancer patients.
Neuropathic pain (NP) is a difficult issue, particularly in cancer which is a dynamic condition where multiple pain etiologies are concomitantly present. Cancer pain is often labeled as mixed mechanism pain and is not easily classified as exclusively nociceptive or NP. The aim of this study was to explore the value of evaluation tools such as Neuropathic Pain Questionnaire (NPQ), complete and short form (NPQ-SF), Leeds Assessment of Neuropathic Signs and Symptoms (LANSS) and Neuropathic Pain Symptom Inventory (NPSI). The secondary outcome was to evaluate the response to opioid titration, according to the hierarchical classification of definite, possible and unlikely NP. A consecutive sample…
Palliative sedation in patients with advanced cancer followed at home: A systematic review
Abstract Context Patients with advanced cancer who are near the end of life may experience intolerable suffering refractory to targeted palliative therapies. Palliative sedation (PS) is considered to be an effective treatment modality for these refractory symptoms when aggressive efforts fail to provide relief. Objectives The aim of this study was to systematically review articles regarding PS performed at home in patients with intractable symptoms. Methods Literature databases searched included MedLine, PubMed, and EMBASE. The text words and MeSH/EMTREE terms "home care" and "sedation" were used for electronic database searches. Results Six articles met the inclusion criteria for research …
Prognostic factors of survival in patients with advanced cancer admitted to home care
Abstract CONTEXT: Data regarding prognostication of life expectancy in patients with advanced cancer are of paramount importance to patients, families, and clinicians. However, data regarding patients followed at home are lacking. OBJECTIVES: The aim of this study was to evaluate the correlation between various factors recorded at the beginning of home care assistance and survival. METHODS: A sample of consecutive patients admitted to two home care programs was surveyed. A preliminary consensus was achieved as to the possible variables easy to be recorded at home. These included age at the time of home care admission, gender, residence, marital status, primary cancer diagnosis, Karnofsky Pe…
Orphan symptoms in advanced cancer patients followed at home
Abstract Orphan symptoms are rarely assessed, particularly at home. The aim of this multicenter prospective study was to assess the prevalence of these symptoms and eventual factors possibly associated in advanced cancer patients at admission of a home care program. A prospective study was performed at three home care programs in Italy. Patients' data were collected, including age, sex, diagnosis, and Karnofsky status. Possible contributing factors were analyzed; preexisting neurological diseases, cerebral metastases, hyperthermia, diabetes, a state of dehydration clinically evident and/or oliguria, possible biochemical parameters when available, data regarding recent chemotherapy, opioids …
Epidemiology and Characteristics of Episodic Breathlessness in Advanced Cancer Patients. An Observational Study
Abstract Context Episodic breathlessness is a relevant aspect in patients with advanced cancer. Objectives The aim of this study was to assess the different aspects of this clinical phenomenon. Methods A consecutive sample of patients with advanced cancer admitted to different settings for a period of six months was surveyed. The presence of background breathlessness and episodic breathlessness, their intensity (numerical scale 0–10), and drugs used for treatment were collected. Factors inducing episodic breathlessness and its influence on daily activities were investigated. Results Of 921 patients, 29.3% ( n = 269) had breathlessness and 134 patients (49.8%) were receiving drugs for backg…