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Cancer pain
Techniques in Regional Anesthesia and Pain Management (2010) 14, 1-2
Cancer pain The American Cancer Society (ACS) reports that cancer death rate for men and women combined decreased by 1.6% per year during 2001-2006, in keeping with the steady downtrend that started in the early 1990s. New diagnoses for all types of cancer combined also decreased, approximately 1% per year. Men saw greater declines, but overall death and incidence rates still are much higher among men than in women. Rates of the most common cancer types in men (prostate, colorectal, and lung) are falling, but unfortunately others are rising: kidney, liver, esophageal, myeloma, melanoma, and leukemia. Among women, the rates for breast and colorectal cancer have declined, but on the other side rates for lung, thyroid, pancreatic, bladder, kidney, myeloma, melanoma, and leukemia have increased.1 More people surviving cancer often translate to more people having chronic cancer-related pain. Some controversial topics not covered in detail here include the use of paravertebral blocks for cancer surgery and pain relief after vertebro-kyphoplasty. In 2006, Exadaktylos et al2 published a retrospective study that suggested that paravertebral anesthesia and analgesia for breast cancer surgery reduced the risk of recurrence or metastasis during the initial years of follow-up. This report generated a great level of attention and an increase in the procedures getting paravertebral blocks (PVB). I think it is very important to stress the fact that there was a histologic grade difference in both groups, and this could probably lead to the promising results. The general anesthesia group had higher incidence of histologic stage II and III tumors when compared with the PVB block. Moller et al3 did a very nice double blinded study on thoracic paravertebral blocks for breast cancer surgery. They found out that a multilevel paravertebral block with ropivacaine provides good analgesia for breast surgery, but the duration of the analgesia obtained in their study was limited to the first day. This probably translates to being able to discharge the patients quicker from the recovery room. Kairaluoma et al4 did a very important study in which they found that patients who received a T3 PVB with ropivacine before breast surgery had reduced motion-related pain and chronic pain symptoms 12 months after surgery. On the basis of these results, we should probably consider 1084-208X/$ -see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2010.01.001
doing PVB on mastectomies and probably compare it to the use of a high thoracic epidural. In 2009, Kallmes et al5 and Buchbinder et al6 published their results of 2 different randomized trials of vertebroplasty for osteoporotic fractures. In the first study, they found no significant difference at 1 month after the procedure on measures of back pain intensity, functional disability, and quality of life. On the second study, they found no beneficial effect of vertebroplasty over a sham procedure at 1 week, 1, 3, or 6 months among patients with painful osteoporotic vertebral fractures. On the basis of these results, the question arises whether there is any difference in malignant fractures vs osteoporotic fractures. Berenson et al7 presented their interim analysis of results from a phase IV random trial: “Balloon kyphoplasty improves both Roland–Morris disability scores and bone pain among cancer patients with vertebral compression fractures,” at the 50th American Society of Hematology Meeting; December 6-9, 2008, San Francisco, CA. This randomized study showed that patients with cancer-related vertebral compression fractures treated with immediate balloon kyphoplasty showed a marked reduction in back disability and pain at 1 month compared with nonsurgical treatment. Probably based on current published data, the use of vertebro and kyphoplasty should be limited to malignant fractures. We should probably mention the use of peripheral nerve stimulation. Many of our patients have damage to peripheral nerves after surgery which will cause them to develop neuropathic pain. We routinely try a mixture of opioids plus adjuvants (pregabalin, gabapentin, SSRIs, and other drugs), but seldom reach an optimal decrease of pain. In those cases, an option is to implant a spinal cord stimulator in the trajectory of those damaged nerves.8 One good example would be pain in the distribution of the supraorbital nerve or the greater and/or lesser occipital nerve after a craniotomy. In those difficult-totreat cases placing a subcutaneous lead in the trajectory of the damaged nerve can lead to a good response and allow the clinician to decrease the doses of drugs prescribed. New techniques for imaging are being used at some centers. Those include the use of high resolution ultrasound and 3-dimensional CT and fluoroscopy imaging for both diagnosis and
2
Techniques in Regional Anesthesia and Pain Management, Vol 14, No 1, January 2010
therapeutic interventional procedures. These offer better quality of images, reduced exposure to radiation in the case of ultrasound, and most important better accuracy. As technology advances, we will have to learn to use new devices that will allow us provide expert care to our patients. Finally, new novel drugs are being developed to aid in the management of pain, and we anxiously await their release and approval for human use. Rodolfo Gebhardt, MD Guest Editor
References 1. Edwards BK, Ward E, Kohler BA, et al: Annual report to the nation on the status of cancer, in Featuring Colorectal Cancer Trends and Impact of Interventions (Risk Factors, Screening, and Treatment) to Reduce Future Rates: Cancer. Surveillance Research Program, National Cancer Institute, 1975-2006
2. Exadaktylos A, Buggy DJ, Moriarty DC, et al: Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis. Anesthesiology 105:660-664, 2006 3. Moller J, Lone N, Svein A, et al: Thoracic paravertebral block for breast cancer surgery: A randomized double-blind study. Anesth Analg 105: 1848-1851, 2007 4. Kairaluoma P, Bachmann M, Rosenberg P, et al: Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery. Anesth Analg 103:703-708, 2006 5. Kallmes D, Comstock B, Heagerty P, et al: A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 361:569579, 2009 6. Buchbinder R, Osborne RH, Ebeling PR, et al: A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 361:557-568, 2009 7. Berenson JR, Hussein MA, Pflugmacher R, et al: Balloon kyphoplasty improves both Roland–Morris disability scores and bone pain among cancer patients with vertebral compression fractures: Interim analysis of results from a phase IV random trial, in 50th American Society of Hematology Meeting; 6-9 December 2008; San Francisco, CA 8. De Leon-Casasola O: Spinal cord and peripheral nerve stimulation techniques for neuropathic pain. J Pain Symptom Manage 38:S28-S38, 2009 (suppl 2)
Cancer pain The American Cancer Society (ACS) reports that cancer death rate for men and women combined decreased by 1.6% per year during 2001-2006, in keeping with the steady downtrend that started in the early 1990s. New diagnoses for all types of cancer combined also decreased, approximately 1% per year. Men saw greater declines, but overall death and incidence rates still are much higher among men than in women. Rates of the most common cancer types in men (prostate, colorectal, and lung) are falling, but unfortunately others are rising: kidney, liver, esophageal, myeloma, melanoma, and leukemia. Among women, the rates for breast and colorectal cancer have declined, but on the other side rates for lung, thyroid, pancreatic, bladder, kidney, myeloma, melanoma, and leukemia have increased.1 More people surviving cancer often translate to more people having chronic cancer-related pain. Some controversial topics not covered in detail here include the use of paravertebral blocks for cancer surgery and pain relief after vertebro-kyphoplasty. In 2006, Exadaktylos et al2 published a retrospective study that suggested that paravertebral anesthesia and analgesia for breast cancer surgery reduced the risk of recurrence or metastasis during the initial years of follow-up. This report generated a great level of attention and an increase in the procedures getting paravertebral blocks (PVB). I think it is very important to stress the fact that there was a histologic grade difference in both groups, and this could probably lead to the promising results. The general anesthesia group had higher incidence of histologic stage II and III tumors when compared with the PVB block. Moller et al3 did a very nice double blinded study on thoracic paravertebral blocks for breast cancer surgery. They found out that a multilevel paravertebral block with ropivacaine provides good analgesia for breast surgery, but the duration of the analgesia obtained in their study was limited to the first day. This probably translates to being able to discharge the patients quicker from the recovery room. Kairaluoma et al4 did a very important study in which they found that patients who received a T3 PVB with ropivacine before breast surgery had reduced motion-related pain and chronic pain symptoms 12 months after surgery. On the basis of these results, we should probably consider 1084-208X/$ -see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2010.01.001
doing PVB on mastectomies and probably compare it to the use of a high thoracic epidural. In 2009, Kallmes et al5 and Buchbinder et al6 published their results of 2 different randomized trials of vertebroplasty for osteoporotic fractures. In the first study, they found no significant difference at 1 month after the procedure on measures of back pain intensity, functional disability, and quality of life. On the second study, they found no beneficial effect of vertebroplasty over a sham procedure at 1 week, 1, 3, or 6 months among patients with painful osteoporotic vertebral fractures. On the basis of these results, the question arises whether there is any difference in malignant fractures vs osteoporotic fractures. Berenson et al7 presented their interim analysis of results from a phase IV random trial: “Balloon kyphoplasty improves both Roland–Morris disability scores and bone pain among cancer patients with vertebral compression fractures,” at the 50th American Society of Hematology Meeting; December 6-9, 2008, San Francisco, CA. This randomized study showed that patients with cancer-related vertebral compression fractures treated with immediate balloon kyphoplasty showed a marked reduction in back disability and pain at 1 month compared with nonsurgical treatment. Probably based on current published data, the use of vertebro and kyphoplasty should be limited to malignant fractures. We should probably mention the use of peripheral nerve stimulation. Many of our patients have damage to peripheral nerves after surgery which will cause them to develop neuropathic pain. We routinely try a mixture of opioids plus adjuvants (pregabalin, gabapentin, SSRIs, and other drugs), but seldom reach an optimal decrease of pain. In those cases, an option is to implant a spinal cord stimulator in the trajectory of those damaged nerves.8 One good example would be pain in the distribution of the supraorbital nerve or the greater and/or lesser occipital nerve after a craniotomy. In those difficult-totreat cases placing a subcutaneous lead in the trajectory of the damaged nerve can lead to a good response and allow the clinician to decrease the doses of drugs prescribed. New techniques for imaging are being used at some centers. Those include the use of high resolution ultrasound and 3-dimensional CT and fluoroscopy imaging for both diagnosis and
2
Techniques in Regional Anesthesia and Pain Management, Vol 14, No 1, January 2010
therapeutic interventional procedures. These offer better quality of images, reduced exposure to radiation in the case of ultrasound, and most important better accuracy. As technology advances, we will have to learn to use new devices that will allow us provide expert care to our patients. Finally, new novel drugs are being developed to aid in the management of pain, and we anxiously await their release and approval for human use. Rodolfo Gebhardt, MD Guest Editor
References 1. Edwards BK, Ward E, Kohler BA, et al: Annual report to the nation on the status of cancer, in Featuring Colorectal Cancer Trends and Impact of Interventions (Risk Factors, Screening, and Treatment) to Reduce Future Rates: Cancer. Surveillance Research Program, National Cancer Institute, 1975-2006
2. Exadaktylos A, Buggy DJ, Moriarty DC, et al: Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis. Anesthesiology 105:660-664, 2006 3. Moller J, Lone N, Svein A, et al: Thoracic paravertebral block for breast cancer surgery: A randomized double-blind study. Anesth Analg 105: 1848-1851, 2007 4. Kairaluoma P, Bachmann M, Rosenberg P, et al: Preincisional paravertebral block reduces the prevalence of chronic pain after breast surgery. Anesth Analg 103:703-708, 2006 5. Kallmes D, Comstock B, Heagerty P, et al: A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 361:569579, 2009 6. Buchbinder R, Osborne RH, Ebeling PR, et al: A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 361:557-568, 2009 7. Berenson JR, Hussein MA, Pflugmacher R, et al: Balloon kyphoplasty improves both Roland–Morris disability scores and bone pain among cancer patients with vertebral compression fractures: Interim analysis of results from a phase IV random trial, in 50th American Society of Hematology Meeting; 6-9 December 2008; San Francisco, CA 8. De Leon-Casasola O: Spinal cord and peripheral nerve stimulation techniques for neuropathic pain. J Pain Symptom Manage 38:S28-S38, 2009 (suppl 2)