treating pain and neuropathy in metastatic breast cancer
TRANSCRIPT
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Treating Pain and Neuropathyin Metastatic Breast Cancer
September 24, 2016 Lida Nabati, MD
CLINICAL MANAGEMENT OF BREAST AND GYNECOLOGIC CANCERS IN SPECIAL POPULATIONS
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Goals
• To review basic cancer pain and neuropathy management
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Pain
• The body’s way of telling us about damage or perceived damage to tissue.
• Don’t ignore! Report it. • Treating pain is part of treating your cancer.• Subjective, personal
– only you can “measure” your pain
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Cancer Pain
Tumor
Surgery
Radiation
Chemotherapy
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Treat Cancer
• Radiation Therapy• Surgery• Chemotherapy
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PAINED
• Place• Amount • Intensifiers• Nullifiers• Effects • Description
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Keep Pain Diary
• Record: – Pain score– Trigger– Medication use – Medication effect (pain score 1 hour after)– Other comments
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WHO Step Ladder
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Approach To Pain Control1. Thorough assessment by skilled and
knowledgeable clinician.2. What are the goals of care? 3. Investigations: Radiology studies – how
burdensome, will they affect care?4. Treatments: pharmacological and non-
pharmacological, interventional analgesia.5. Ongoing reassessment and review of
options, goals, expectations.
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Opioids
• Short-Acting • Oxycodone• Morphine
•Long-acting •Oxycontin •Mscontin •Fentanyl Patch •Methadone
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Opioid Side Effects
• Nausea• Sleepiness• Constipation
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Opioid Rotation
• If one opioid is not well toelrated, may try another
• Conversion tables do not account for incomplete cross tolerance
• Recommend reduction by 25-50% of calculated equianalgesic dose when rotating opioids.
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How Often can one Escalate? Short acting oral__________Each dose interval
Opioid continuous infusion_____Every 8 hours
Long acting oral______________Every 2 days
Methadone_________________Every 3-7 days
TD Fentanyl_________________Every 3 days
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Will I become addicted?
• Tolerance and physiologic dependence are expected with chronic opioids, this is not addiction.
• Addiction is misuse of medications with harm resulting. It is not common but can happen – increased risk if personal or family history of addiction
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Common reasons for the use of alternate routes
• Severe nausea and/or vomiting• Difficulty swallowing • Complications of the gut• Diminished consciousness
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Peripheral Neuropathy
• Results from lesion or disease of nervous system
• Shooting, burning, tingling • Can be associated with numbness, weakness• Can result form tumor, surgery• Many chemotherapies can cause this:
– Taxanes, Platinum based drugs, Eribulin
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Neuropathy Treatments
• Gabapentin • Tricyclic antidepressants • Capsaicin • Opioids • Cannabinoids
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Pain Treatment
• Genetic, hormonal, and other factors influence one’s perception, experience, of pain.
• There are established genetic variabilities in metabolism of pain medications.
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Pain Interventions
• Interventional Radiology – Bone interventions – Cryoablation
• Anesthesia – Nerve blocks– Epidurals
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© Pain and Palliative Care ProgramDana-Farber Cancer Institute 2002
Total Pain
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Causes of Suffering in Serious Illness
PHYSICAL Pain Dyspnea Delirium Nausea/ vomiting
PSYCHOLOGICAL Anxiety Depression Loss of Meaning Loss of Control Loss of Dignity
SPIRITUAL Uncertainty Fear of disability Fear of death Hopelessness Remorse
SOCIAL Loneliness Functional decline Loss of roles
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A Team Approach
“ Caring for the whole person and family requires a caregiver who is whole….
Until one comes along, use a team.” Balfour Mount
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Other Modalities
• Acupuncture• Physical Therapy • Reiki• Massage • Meditation • Heat/ice
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Summary
• Pain management is an important par t of cancer treatement
• There are many ways your pain can be effectively managed