Cancer Pain

[bgabes]

For personal reasons I'm interested in interventional pain mgt of cancer-related pain...would it be feasible to tailor an interventional pain med practice to emphasize t/x of cancer pain (even if this meant only practicing pain part-time), anybody have any experience or anecodotes related to this?

Thanks,

Brian

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[drrinoo]

Speak with Dr. Burton at MD Anderson...great guy and very friendly!

However, if you are not affiliated with a cancer center (i.e, visible to the oncologists on a daily basis...on rounds...in the hospital), it is tough to consistently get referrals from them.

Any outpatient based interventionalist that has cultivated this referral network...kudos to you. Please share your secrets.

In any case, interventional based pain management for cancer pain is arguably one of the most gratifying aspects of our field.

 

[Aether2000]

I completely agree! The oncology community believes in " Til Death Do Us Part" with their cancer patients, even if it means gorking them with high dose oral or rectal narcotics, and even if there are other proven ways to successfully deliver pain control without having a patient comatose for 4 weeks or having the hospice nurses knock them off as a mercy killing.
Many of us in pain medicine, esp interverventional pain, have attempted to cultivate relationships for years with this obstinate group of physicians to provide another tool to control the pain of the 50% of cancer patients who do not have adequate pain control without major side effects. But the prevailing attitude is that they have a bond with their patients and will be with them (or their surrogates, the hospice programs) until the end. It appears the patients and their families are not given an array of pain options- instead they are told the patient will die and the oncologists will give them whatever they need to control their pain.
I do not buy the line that the majority of cancer patients need $20,000 implantable programmable pump systems, but there are many other ablative techniques and infusion techniques available.

 

[paz5559]

I do not buy the line that the majority of cancer patients need $20,000 implantable programmable pump systems, but there are many other ablative techniques and infusion techniques available.

Having just had this very discussion with both my dad (a practicing orthopaedist) and my colleagues here at Emory, let me play devil's advocate - it is my job to take care of my patient and to optimize his/her pain care - it is the insurance company, and the government's role to figure out how to allocate limited health care resources.

The patient who tirggered this discussion was an 85 y/o man c prostate ca, mets throughout his spine, and phenotypically he is 65 and spry. He has failed/is intolerant to conservative meqasures, and anything stronger than Lortab 5 makes him woozy. ESIs of several varietites have not touched his pain, nor have RFAs.

It is true that his life expectancy is less than yours or mine. But is it our role to limit his options? I believe my role is to make him as comfortable, as active, and as functional as he can be, whether he lives another 6 months, or 5 years. That being said, a stimulator or a pump may well be the option that best suits his needs, and who am I to make the determination that it is an excessively expensive choice? If medicare, or comerdcial insurance denies him that choice, then it is on them to explain the cost-benefit analysis to the patient. I see our role as to offer the best available choices to all patients, and leave number crunching, bean counting, and public policy determinations to others.

 

[bbbmd]

For personal reasons I'm interested in interventional pain mgt of cancer-related pain...would it be feasible to tailor an interventional pain med practice to emphasize t/x of cancer pain (even if this meant only practicing pain part-time), anybody have any experience or anecodotes related to this?

Ill be starting fellowship at MDACC in a couple of months. I have the same interest as you and loved the fellowship/institution when I rotated and interviewed there. If you want to tailor your pain practice to cancer, this would be the best place for you as well! End of life, malignant pain management is very gratifying, but I think you need a certain personality for it!

I agree that Dr Burton is a great person for you to speak with! Ill be happy to share my experiences as a fellow once I get more experience under my belt!

I think there is a huge role for narcotics for this population, but like what algos said, there are limitations due to side effects. I think that multidisciplinary management, including Rehab, Psychologic, Social and interventional management is the key to successful pain control. Although MDACC is aggressive in interventional and pharmacologic management, the multidisciplinary, or should I say "interdisciplinary", approach to management is the model that they follow. I know that this model of pain management is EXPENSIVE and I am not sure if it could be practiced outside of a tertiary cancer hospital--> However, its would be pretty tough to deny this service to those in the terminal stage of their lives.

B

 

[Aether2000]

With health care costs rising an average of 9-12% a year over the past 15 years, we will eventually reach a point of financial unsustainability. It would be nice in an ideal world if we could offer the best to everyone, but in our country not everyone can afford to drive a BMW...some drive Fords, some take the bus, some walk. For instance, I do not offer pumps to Medicaid patients because in my state, Medicaid pays around $600 to the hospital for a $20,000 system. It is not reasonable for me to even consider implanting in such a situation.
But PAZ has an excellent point that ultimately the insurers and governments will decide on what therapies are to be permitted via payment vehicles of control. It would be interesting to look in a crystal ball and determine would the government look more favorable at an expensive therapy that was adopted for widespread use (eg pumps in most terminal cancer patients) or will inadequate use cause the government to consider pumps in cancer patients frivolous?

 

[drrinoo]

Medicaid has a carve out for duragesic...a fairly expensive drug, approx 700/month...the intrathecal drug cost for a patient with a limited life expectancy would be substantially less....40 cc pump with 2-3 refills

additionally, the cost of the pump is artificially high.....

the technology is over 20 years old/and minimal design changes....I'm sure the manufacturing processes have paid for themselves by now. So, the company has to only worry about the variable costs of the pump components and the expenses of running the factory....so, why does it still cost 20, 000 dollars? I would wager that a price of 1000-1500/pump would still be profitable for the company; then factor in OR time....then compare these costs to untreated pain/repeat hospitalizations for standard opioids

so if costs were realistic, pumps could be competitively priced

as far as interventional pain for cancer, there is a widespread belief that some procedures may prolong life...there was a paper out of Hopkins by Lillemoe (intra-op celiac plexus) in the early 1990s...I believe in interventional pain for cancer./life prolongation (my bias out in the open)..but we must pay respect to arguably the best RCT in interventional pain by GY Wong, which debunks this myth....yet again, EBM is the party pooper. I will still offer the NCPB for this population of patients, barring contraindications.

Don't get depressed....but, if the holy grail (NCPB for pancreatic cancer) of interventional pain can't beat EBM...I don't know what will be in store for us

Vol. 291 No. 9, March 3, 2004 Featured Link
Effect of Neurolytic Celiac Plexus Block on Pain Relief, Quality of Life, and Survival in Patients With Unresectable Pancreatic Cancer
A Randomized Controlled Trial

Gilbert Y. Wong, MD; Darrell R. Schroeder, MS; Paul E. Carns, MD; Jack L. Wilson, MD; David P. Martin, MD, PhD; Michelle O. Kinney, MD; Carlos B. Mantilla, MD, PhD; David O. Warner, MD


JAMA. 2004;291:1092-1099.

Context Pancreatic cancer is an aggressive tumor associated with high mortality. Optimal pain control may improve quality of life (QOL) for these patients.

Objective To test the hypothesis that neurolytic celiac plexus block (NCPB) vs opioids alone improves pain relief, QOL, and survival in patients with unresectable pancreatic cancer.

Design, Setting, and Patients Double-blind, randomized clinical trial conducted at Mayo Clinic, Rochester, Minn. Enrolled (October 1997 and January 2001) were 100 eligible patients with unresectable pancreatic cancer experiencing pain. Patients were followed up for at least 1 year or until death.

Intervention Patients were randomly assigned to receive either NCPB or systemic analgesic therapy alone with a sham injection. All patients could receive additional opioids managed by a clinician blinded to the treatment assignment.

Main Outcome Measures Pain intensity (0-10 numerical rating scale), QOL, opioid consumption and related adverse effects, and survival time were assessed weekly by a blinded observer.

Results Mean (SD) baseline pain was 4.4 (1.7) for NCPB vs 4.1 (1.8) for opioids alone. The first week after randomization, pain intensity and QOL scores were improved (pain intensity, P.01 for both groups; QOL, P<.001 for both groups), with a larger decrease in pain for the NCPB group (P = .005). From repeated measures analysis, pain was also lower for NCPB over time (P = .01). However, opioid consumption (P = .93), frequency of opioid adverse effects (all P>.10), and QOL (P = .46) were not significantly different between groups. In the first 6 weeks, fewer NCPB patients reported moderate or severe pain (pain intensity rating of 5/10) vs opioid-only patients (14% vs 40%, P = .005). At 1 year, 16% of NCPB patients and 6% of opioid-only patients were alive. However, survival did not differ significantly between groups (P = .26, proportional hazards regression).

Conclusion Although NCPB improves pain relief in patients with pancreatic cancer vs optimized systemic analgesic therapy alone, it does not affect QOL or survival.