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Treatment outcome in a multidisciplinary cancer pain clinic by Banning et al.
Pain, 47(1991) 127-128
127
~t~ 1991 Elsevier Science Publishers B.V. All rights reserved 0304-3959/91/$03.50
PAIN 01856
Editorial comment
Treatment outcome in a multidisciplinary cancer pain clinic by Banning et al. D w i g h t E. M o u l i n Department of Clinical Neurological Sciences and Oncolo~o,. Unit'ersity of Western Ontario, London, Ont. (Canada) (Received 3 December 1990, accepted 1 March 1991)
Longitudinal studies of treatment outcome in patients with advanced cancer pain are difficult to carry out. This is reflected in the dirth of studies addressing this issue in a prospective manner. In a study of 109 patients, Cohen et al. [4] reported improvement in pain, mood and activity level in the majority of patients followed for up to six clinic visits. A study published in the current issue of this journal provides a more detailed analysis of treatment outcome based on different types of pain and pain syndromes [2]. The authors followed 186 patients who were referred to a multidisciplinary cancer pain clinic. At the time of initial evaluation, 172 patients had pain in motion, 144 had pain at rest and 124 had pain that interrupted sleep. After 1-2 weeks of medical management (primarily analgesic tailoring and non-neurolytic blockade) at least 74% of patients in each group had moderate pain :relief or better. With a median follow-up of 12 weeks, pain relief was maintained in 65 evaluable patients. Subset analysis produced two striking findings. Only 1 patient in 18 with pain in motion due to bone metastases enjoyed complete pain relief. Secondly, pain due to tumour infiltration of nerve was controlled almost as well as pain due to bone metastases (70% vs. 73%, respectively, were pain free at rest). This study by Banning and colleagues provides useful information regarding treatment outcome in patients with advanced cancer pain. Fairly straightforward medical treatment modalities can provide reasonable pain relief in approximately 75% of patients. The authors point out, however, that management is quite labour intensive in that a median of 4 patient contacts with the pain clinic was required in the first 1-2 weeks.
The addition of continuous subcutaneous narcotic infusion [3] and neuroablative procedures such as percutaneous cordotomy would likely further improve the outcome. The observation that bone pain related to movement ('incident pain') was poorly controlled emphasizes the role of incident pain as a major limiting factor in providing quality of life for these patients. In a prospective survey of patients with cancer pain, Portenoy and Hagen [6] reported that breakthrough pain, and more specifically incident pain, was common and of severe or excruciating intensity. Many of these patients have pathological fractures that have not responded to radiation therapy and are not amenable to surgical stabilization. On the other hand, the observation that neuropathic pain was as well controlled as bone pain at rest comes as a surprise. Neuropathic pain generally responds poorly to narcotic analgesics [1] and may not respond to adjuvant analgesics [5]. In a prospective manner, Banning et al. [2] have highlighted the treatment outcome of patients with advanced cancer pain and have drawn attention to our deficiencies in managing pain related to movement. Hopefully, a better understanding of the nature of incident pain at the neurochemical level will provide improved treatment strategies for this distressing problem.
References 1 Arn6r, S. and Myerson, B.A., Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain, Pain, 33 (1988) 11-23.
Correspondence to: D.E. Moulin, M.D., Victoria Hospital, 375 South Street. London, Ont. N6A 4G5, Canada.
2 Banning, A., Sjogren, P. and Henriksen, H., Treatment outcome in a multidisciplinary cancer pain clinic, Pain, 47 (1991) 129-134. 3 Bruera, E., Brenneis, C., Michaud, M. et al. The use of the subcutaneous route for the administration of narcotics in patients with cancer pain, Cancer, 62 (1988) 407-411.
128 4 Cohen, R.S.. Ferrer-Brechner, T.. lhtvlov. A. Prospeclive ewduation of treatment outcome lo a cancer pain center, Clin. J. Pain, 1 (1985) 5 Moulin, D.E. and Foley, K.M., A review of a service, hi: K.M. Foley, J.J. Bonica and V.
and Reading, A.E., in patienls referred 105 I(N. hospital-based pare Ventafridda (Eds.),
Proc. of the 2nd lnl. ('ongl-css on ('ancer Pain, t:lsevicr. ,\mstc~ dam, 199IL pp. 413 427. ~ Portenov, R.K. and Hagen, N.A., Breaklhrough pain: delinilion. prewdcncc and characteristics, Pain, 41 (199(}) 2 7 3 2Sl.
127
~t~ 1991 Elsevier Science Publishers B.V. All rights reserved 0304-3959/91/$03.50
PAIN 01856
Editorial comment
Treatment outcome in a multidisciplinary cancer pain clinic by Banning et al. D w i g h t E. M o u l i n Department of Clinical Neurological Sciences and Oncolo~o,. Unit'ersity of Western Ontario, London, Ont. (Canada) (Received 3 December 1990, accepted 1 March 1991)
Longitudinal studies of treatment outcome in patients with advanced cancer pain are difficult to carry out. This is reflected in the dirth of studies addressing this issue in a prospective manner. In a study of 109 patients, Cohen et al. [4] reported improvement in pain, mood and activity level in the majority of patients followed for up to six clinic visits. A study published in the current issue of this journal provides a more detailed analysis of treatment outcome based on different types of pain and pain syndromes [2]. The authors followed 186 patients who were referred to a multidisciplinary cancer pain clinic. At the time of initial evaluation, 172 patients had pain in motion, 144 had pain at rest and 124 had pain that interrupted sleep. After 1-2 weeks of medical management (primarily analgesic tailoring and non-neurolytic blockade) at least 74% of patients in each group had moderate pain :relief or better. With a median follow-up of 12 weeks, pain relief was maintained in 65 evaluable patients. Subset analysis produced two striking findings. Only 1 patient in 18 with pain in motion due to bone metastases enjoyed complete pain relief. Secondly, pain due to tumour infiltration of nerve was controlled almost as well as pain due to bone metastases (70% vs. 73%, respectively, were pain free at rest). This study by Banning and colleagues provides useful information regarding treatment outcome in patients with advanced cancer pain. Fairly straightforward medical treatment modalities can provide reasonable pain relief in approximately 75% of patients. The authors point out, however, that management is quite labour intensive in that a median of 4 patient contacts with the pain clinic was required in the first 1-2 weeks.
The addition of continuous subcutaneous narcotic infusion [3] and neuroablative procedures such as percutaneous cordotomy would likely further improve the outcome. The observation that bone pain related to movement ('incident pain') was poorly controlled emphasizes the role of incident pain as a major limiting factor in providing quality of life for these patients. In a prospective survey of patients with cancer pain, Portenoy and Hagen [6] reported that breakthrough pain, and more specifically incident pain, was common and of severe or excruciating intensity. Many of these patients have pathological fractures that have not responded to radiation therapy and are not amenable to surgical stabilization. On the other hand, the observation that neuropathic pain was as well controlled as bone pain at rest comes as a surprise. Neuropathic pain generally responds poorly to narcotic analgesics [1] and may not respond to adjuvant analgesics [5]. In a prospective manner, Banning et al. [2] have highlighted the treatment outcome of patients with advanced cancer pain and have drawn attention to our deficiencies in managing pain related to movement. Hopefully, a better understanding of the nature of incident pain at the neurochemical level will provide improved treatment strategies for this distressing problem.
References 1 Arn6r, S. and Myerson, B.A., Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain, Pain, 33 (1988) 11-23.
Correspondence to: D.E. Moulin, M.D., Victoria Hospital, 375 South Street. London, Ont. N6A 4G5, Canada.
2 Banning, A., Sjogren, P. and Henriksen, H., Treatment outcome in a multidisciplinary cancer pain clinic, Pain, 47 (1991) 129-134. 3 Bruera, E., Brenneis, C., Michaud, M. et al. The use of the subcutaneous route for the administration of narcotics in patients with cancer pain, Cancer, 62 (1988) 407-411.
128 4 Cohen, R.S.. Ferrer-Brechner, T.. lhtvlov. A. Prospeclive ewduation of treatment outcome lo a cancer pain center, Clin. J. Pain, 1 (1985) 5 Moulin, D.E. and Foley, K.M., A review of a service, hi: K.M. Foley, J.J. Bonica and V.
and Reading, A.E., in patienls referred 105 I(N. hospital-based pare Ventafridda (Eds.),
Proc. of the 2nd lnl. ('ongl-css on ('ancer Pain, t:lsevicr. ,\mstc~ dam, 199IL pp. 413 427. ~ Portenov, R.K. and Hagen, N.A., Breaklhrough pain: delinilion. prewdcncc and characteristics, Pain, 41 (199(}) 2 7 3 2Sl.