BEST OF CANCER PAIN 2019 El amplio panorama

BEST OF CANCER PAIN 2019 El amplio panorama de la analgesia al alcance del onco logo me dico Dr. Javier Pe rez Altozano. H. Virgen de los Lirios, Alcoy (Alicante) #SEOM 2019

EAPC 2019 16 th World Congress of the European Association for Palliative Care 23 – 25 May, Berlin #SEOM 2019

Free Communications Hospital Care - A Risk Factor for Dying with Unrelieved Pain Klint A et al. Institute for Palliative Medicine, Lund University, Lund, Sweden • • • Data from the 161, 762 expected deaths during 2011 - 2015. 68% of the total population reported pain during the last week of life, for 25% of these the pain remained unrelieved, despite prescription of opioids “as needed” in 97% of the cases. Significant risk factors for unrelieved pain included hospital death, not having had an end-of-life conversation and cancer/metastases in bones and lung. Association between Quality of Life (Qo. L) and Survival Time in 28, 264 Danish Cancer Patients. Hansen et al. Department of Palliative Medicine, Bispebjerg, Copenhagen • • • Danish Palliative Care Database: 28, 264 cancer patients who died in 2010 -2017 and who completed EORTC QLQ- C 15 -PAL at admission. Test if the basic variables and Qo. L domains (pain, dyspnea, sleeplessness, appetite loss, constipation, fatigue, nausea/ vomiting, emotional function, physical function and Qo. L) were associated with survival time. Except for constipation and nausea in hospice and overall Qo. L in both settings, all Qo. L domains were significantly associated with survival time (all p< 0. 05). #SEOM 2019

Quality and Safety in Prescribing at the End of Life Exploring Opioid Errors in Australian, Inpatient Palliative Care Services: A Mixed Methods Study Heneka N et al. University of Notre Dame Australia • • Identify opioid error incidence, patient impact, error contributing factors, barriers and facilitators to safe opioid delivery processes in inpatient palliative care services. Opioid errors accounted for 32% of all reported medication errors Opioid administration errors comprised 76% of reported opioid errors, 33% of which were omitted dose errors. 53% of opioid errors required a clinical intervention to preclude or manage patient harm. For 57% of patients, opioid errors resulted in opioid under-dose Effects of Corticosteroids on Quality of Life in Cancer Patients with Advanced Disease and Short Life Expectancy Paulsen Ø et al. Palliative Care Unit, Telemark Hospital Trust, Norway • • • 49 patients were included in the trial with a mean Karnofsky Performance score of 67. Compare the analgesic effects of methyl-prednisolone 16 mg twice daily or placebo for 7 days in advanced cancer patients. CS administration for seven days improved global health and role function in addition to appetite and fatigue in cancer patients with metastatic disease. Pain improved by 14. 7 (p=0. 05). #SEOM 2019

Posters Can a Care Using Virtual Reality Be Efficacious for Terminal Cancer Patients to Improve Various Symptom Burden? A Preliminary Study Niki K et al 1 Department of Clinical Pharmacy Research and Education, Osaka, Japan • • Verify whether simulated travel using virtual reality has impact on patient symptom burden and satisfaction. 20 patients. Significant improvements were observed for pain, tiredness, drowsiness, dyspnea, depression, anxiety, and well-being scores. The Electronic Medical Record Can Be Used to Measure Palliative Care Team Impact on Pain Scores Burns B et al. Hospice and Palliative Medicine, Ohio. Health, Columbus, US • • Measure the change in pain scores for patients seen by specialist palliative care teams in general community hospitals. 11 hospitals with an aggregate of 2, 000 beds serving a population of 3. 5 million people uses the EPIC elec- tronic medical record in 2015 (recorded by nursing for all hospitalized patients seen by a palliative care team). The first mean pain score was 5 and the last mean pain score was 3 (n = 2, 984, p < 0. 0001). When the analysis was repeated for patients with pain score � 6, the first mean pain score was 8 and the last mean pain score 5 (n=1, 315, p < 0. 0001). The electronic medical record showed a 40% improvement in mean pain scores. #SEOM 2019

A Case Series of Rotation from Tapentadol to Morphine Sulphate in Cancer Patients Ni Nualla in A et al St. Luke’s Radiation Oncology Centre Rathgar, Dublin, Ireland • • • The recommended conversion ratio of Morphine Sulphate to Tapentadol is 1: 3, 3. Little research exists on the use of Tapentadol for cancer pain, and even less on Tapentadol switching. Due to a dual mode of action, the equi-analgesic effect of Tapentadol can be difficult to determine. Morphine Sulphate to Tapentadol conversion ratios in our patients were 1: 10 and 1: 15 respectively; considerably less than recommended conversion ratios Potential risk of opioid toxicity when rotating from Tapentadol to Morphine Sulphate in cancer patients. A Randomized, Double-blind, Non-inferiority Study of Hydromorphone Hydrochloride Sustained-release Tablets versus Oxycodone Hydrochloride Sustained-release Tablets for Cancer Pain: Efficacy and Safety in Japanese Cancer Patients Hydromorphone Hydrochloride Injection for Management of Cancer Pain: An Open. Label, Multi-Center Study for Japanese Cancer Patients Saito Y et al. Faculty of Medicine, Anesthesiology, Shimane University, Shimane, Japan #SEOM 2019

Inpatient Methadone Rotation for the Relief of Cancer Pain in a Singapore Hospital: An Observational Study Wong J. et al Palliative Medicine, Tan Tock Seng Hospital, Singapore • • • Protocol combining the “Stop-and-go” for low morphine equivalent daily doses (MEDD) and a 3 -day rotation method for higher MEDD, utilizing an equianalgesic ratio of 10: 1. A retrospective review of patients initiated on methadone for cancer pain from June 2015 to June 2018 will be conducted. Reasons for methadone rotation, the initial and final conversion MEDD: methadone ratio achieved in our patients, the time to achieve improvement in pain control (defined as a decrease in pain score of � 1 or a pain score of � 3 in 3 consecutive reviews), as well as the adverse effects encountered with methadone use. Ketamine in Context of Oncologic Palliative Care - A Challenge Experience of a Palliative Care Service Martins Cunha O. et al. Faculty of Medicine of Porto University, Porto, Portugal • • • Retrospective study for 30 months in an oncologic adult palliative careservice of 20 patients undergoing treatment with ketamine. The average dose of ketamine was 85 mg/day in continuous IV or SC infusion in 90% of patients. They were treated with high doses of opioids- equivalent to 480, 5 mg /day of oral morphine. The dose of opioid decreased in 12% and the rescue opioid dose in 53%. In 70% the pain was relieved. Improvement in pain was found in an average of 4, 8 days. #SEOM 2019

Profile of Patients Undergoing Palliative Radiotherapy: A Single-institute Study from a Tertiary Care Oncology Center Mariam L. Nat. Inst. of Cancer Research and Hospital, Radiation Oncology, Dhaka, Bangladesh • • • Retrospective observational study in a tertiary care government institute. 100 patients were included in the study over 6 months who received PRT to control of symptoms in advance primary site and metastatic site. The most common indication for PRT was to relief pain from painful bone metastases cases. PRT forms an integral and important aspect of palliative care to the major number of patients with metastatic disease who need treatment for symptomatic relief. Short course of PRT in outdoor setting with minimum expenditure is a preferred mode of treatment and improves the quality of life of these distressed patients. #SEOM 2019

Tailored Treatment for Breakthrough Cancer Pain (BTc. P): Is it an Open Issue? Magnani C et al. Research Department, Antea Palliative Care Unit, Rome, Italy • • Assess any relationship between some variables (setting of assistance, BTc. P characteristics, oral mucositis etc. ) and BTc. P pharmacological treatment in a sample of 149 terminal cancer patients. Oral mucositis was not considered as a discriminating factor when choosing the formulation for BTc. P. Outpatients received more frequently Short-Acting Oral Morphine, this might be due to difficulties in Transmucosal Immediate-Release Fentanyl titration. Patients’ self-ability to take medications influenced the clinicians’ decision. Prevalence of Breakthrough Cancer Pain and its impact on Qo. L in Cancer Patients at Regional Cancer Centre, India: A Cross-sectional Study Choudhary et al. Onco-Anesthesia and Palliative Medicine, New Delhi, India • • • A total of 400 patients were recruited in this study, out of which 156 (39%) patient had BTc. P. Most common location of Bt. CP was abdomen (31%) followed by low back pain (18%). 38% of patient had at least 1 -2 times breakthrough pain per day. Overall quality of life score was 1. 8, showing very poor quality of life in patients having breakthrough pain. Quality of life domains showed lower scores, meaning patient with Bt. CP experience poor Qo. L not only affecting their physical health but also psychological, social and environmental. #SEOM 2019

Coordination: Integral Oncological Support Team / Clinic of Pain Management Priorization Rodriguez Mesa D et al. Oncology, Hospital Sant Joan, Reus, Spain • • Pain integral valoration comitee composed by: an anestesiologist, a palliativist, a nurse, a psycooncologist; and it meets weekly. A retrospective analyse has been done, from January to June 2017 (6 months). 87 patients have been evaluated, 57% women, age ranged between 30 -89 years old. 62 patients (71%) received some interventionist technique. 90% of the patients experimented pain control improvement, making possible an opioid and/or coanalgesics diminuisement of dose. Palliative nursing followed all the patients (control of toxicity, efficacy. . . ). What Do Palliative Cancer Patients Want in Regard to the Management of their Pain Pascual Pla et al. Fundacio n Instituto Valenciano de Oncologi a, Valencia, Spain. • • • Explore how palliative cancer patients describe pain control and what they want in the management of their pain. Qualitative study using direct interviews in a sample of 56 patients with advanced cancer treated in the Emergency Department. Patients developed better with fentanyl and tapentadol than with morphine and anti-inflammatories Patients determined if their pain was controlled, ‘in case they could or could not perform different activities and maintain relationships with family or friends’. The numerical scale does not seem to be useful for patients to measure whether they are able to perform these activities or maintain a sense of control and / or independence. #SEOM 2019

ASCO 2019 American Society of Clinical Oncology Anual Meeting May 31 - June 04, Chicago #SEOM 2019

Oral Abstract Session Impact of darolutamide (DARO) on pain and quality of life (Qo. L) in patients (Pts) with nonmetastatic castrate-resistant prostate cancer (nm. CRPC). Fizazi et al. Institut Gustave Roussy, University of Paris-Sud, Villejuif, France • DARO is a structurally distinct androgen receptor antagonist • 1509 pts were randomized 2: 1 to DARO 600 mg (two 300 mg tablets) twice daily (n = 955) or PBO (n = 554) while continuing androgen deprivation therapy (ADT). Primary endpoint was MFS. Secondary endpoints included OS and time to pain progression (assessed by Brief Pain Inventory Short Form). • • • DARO significantly delayed pain progression vs PBO (40. 3 vs 25. 4 mo; HR 0. 65; 95% CI 0. 53– 0. 79; P < 0. 001); this was maintained beyond end of study treatment. Time to deterioration of EORTC-QLQ-PR 25 outcomes showed statistically and clinically significant delays with DARO vs PBO for urinary symptoms #SEOM 2019

Clinical Science Symposium A randomized controlled trial of a novel artificial intelligence-based smartphone application to optimize the management of cancer-related pain. Kamdar M et al. Massachusetts General Hospital, Boston, US • e. PAL is a smartphone application that utilizes patient-reported outcomes (PROs) and artificial intelligence (AI) to optimize cancer pain management. • Patients with pain from metastatic solid tumors (n = 112) undergoing treatment in a palliative care clinic were randomized to either a control group (n = 56) that received usual care or an intervention group (n = 56) that received e. PAL in addition to usual care for 8 weeks. • Measures of pain severity (Brief Pain Inventory), attitudes towards cancer treatment (Barriers Questionnaire II) and anxiety (General Anxiety Disorder-7) were assessed. • Pain severity (BPI) and negative attitudes toward cancer treatment (BQ-II) decreased significantly for those assigned to e. PAL compared to controls. Patients assigned to e. PAL reported higher anxiety scores compared to controls. Patients assigned to e. PAL had significantly fewer pain-related hospital admissions and fewer pain-related admissions through the Emergency Department. • • #SEOM 2019

Abstracts - Publication only Navigating care to reduce emergency room (ER) visits in cancer patients using opioids. Pinto CF et al. Instituto de Oncologia do Vale, São Jose Dos Campos, Brazil • • Navigation System based on Kanban (board and visual signals - KNS) for managing treatment plan. The pain KNS comprises a set of standardized procedures and successive checks for patients using opioids based on three procedures: (a) standardized prescription and use of analgesics using WHO’s Pain Ladder (b) standardized follow up in 24 and 48 hours, 1, 2 and 4 weeks (c) manage side effects of opioids or other emerging problem (constipation, confusion, etc). Once pain is adequately controlled, the frequency of checks become wider up to once a month if no toxicity is identified. Any new condition will restart the 24 -48 hours loop. • The KNS is managed by oncology nurses using phone or video calls, messaging, and appointments; Mon-Sat from 6 AM to 10 PM. • Pain represented 20% of ER visits (33. 65 UCL and 6. 7 LCL); in pilot phase 15% of ER visits (27. 34 UCL and 3. 70 LCL); and now 4% of ER visits ( 8. 46 UCL and 0 LCL), an 80% reduction in pain related ER visits. • #SEOM 2019

Posters Effect on pain outcomes in patients treated for painful bone metastases with biopolar RFA: The OPu. S One study. Bagla et al. Vascular Institute of Virginia, Woodbridge, US • Prospective, nonrandomized, multicenter study of the Osteo. Cool Radiofrequency Ablation system used for the palliative treatment of patients with painful bone metastases. • • 37 subjects at 8 US centers underwent RFA. The most common histology was adenocarcinoma. Breast (32%) and lung (24%) were reported as the most common primary cancer. Thirty-one subjects (84%) were treated for lesions involving the thoracolumbar spine. • Rapid pain improvement at 1 week and sustained long-term relief through 3 months #SEOM 2019

Risk factors for opioid abuse/dependence in hospitalized cancer patients in the United States. Bakalov et al. Department of Internal Medicine, Pittsburgh, US • • • Nationwide Inpatient Sample for the years of 2011 -2015: 524, 624 patients. Rate of opioid abuse/dependence was highest in: • Patients with Medicaid insurance • Patients with liver cancer followed by head and neck cancer. • Substance abuse, mental disease and nutrition. Inhospital mortality rate, total cost of hospitalization and length of stay were significantly higher in patients with opioid abuse/dependence. #SEOM 2019

Conclusiones • Era de la tecnología: VR, AI, App … Gran potencial pero grandes riesgos • Optimización de recursos, circuitos y necesidad de protocolización. • Unificación de criterios en DIO y dolor neuropático. • Intervencionismo, RFA y Comités/Unidades del Dolor. • Desigualdades económicas, de acceso y formativas entre países y regiones. • Llegarán nuevos fármacos, combinaciones y presentaciones, pero lo que realmente necesitamos es visitar y reevaluar al paciente repetidamente con tiempo. #SEOM 2019