INTRODUCTION & PRINCIPLES OF CANCER PAIN MANAGEMENT

INTRODUCTION &

PRINCIPLES OF CANCER

PAIN MANAGEMENT

Clinical Practice Guidelines

Management of Cancer Pain

Development Group

1

Epidemiology of Cancer

In Peninsular Malaysia, Age Standardised Incidence Rate = 131.3/100,000 population (annual incidence of cancer in Malaysia estimated 35,000 - 40,000)1

Prevalence estimated at 90,0002

Pain is among the commonest symptoms experienced by cancer patients

1NCR Cancer Incidence Report 20062GCC Lim 2001 2

Cancer Pain Statistics

Paucity of data available in Malaysia

Based on global figures: Cancer pain prevalence = 45,0001 (50% of cancer patients experience pain and 70% of

advanced cancer patients experience pain – Bonica JJ 1985)

Moderate to severe cancer pain prevalence = 15,000 (1/3 of cancer pain patients have moderate to severe pain)2

1Lim R, Oncology, 20082van den Beuken-van Everdingen MH et al., Ann Oncol, 2007 3

15,000 patients with moderate to severe cancer

pain“Have you seen this man?”

4

Unrelieved pain DESTROYS

quality of life for both

the cancer patient & the family

5

““Relief of pain allows the Relief of pain allows the person to live the rest of person to live the rest of his/her life constructively his/her life constructively & productively.& productively.

PALLIATIVE CARE PALLIATIVE CARE USING MORPHINE USING MORPHINE RELIEVES CANCER RELIEVES CANCER PAIN IN 90% OF PAIN IN 90% OF PATIENTS.”PATIENTS.” WHO Cancer & Palliative Care Unit, WHO Cancer & Palliative Care Unit, GenevaGeneva

6

7

2005 Global Consumption of Morphine

0

20

40

60

80

100

120

140

156 Countries

Global mean (5.5708 mg)

Malaysia (0.9230 mg)

International Narcotics Control Board 20078

2005 Global Consumption of Fentanyl

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

147 Countries

Global mean (0.1643 mg)

Malaysia (0.0122 mg)

International Narcotics Control Board 20079

Usage of Opioids in Malaysia 2005

Opioid DDD/1000 population/day

Morphine Total 0.1094

Public 0.0867

Private 0.0227

Fentanyl Total 0.0065

Public 0.0032

Private 0.0033

Oxycodone Total 0.0002

Public <0.0001

Private 0.0002

Malaysian statistics on medicine 200510

Interpretation

If the DDD for morphine of a country is 1 DDD/1000 population/day:

1 person in every 1000 population has 1 person in every 1000 population has received 100 mg of oral morphine dailyreceived 100 mg of oral morphine daily

11

Morphine Usage in Malaysia Total population in Malaysia in 2005 =

26.13 million

1 DDD/1000 population/day = 26,130 people receiving 100 mg of oral morphine daily

26,130 x 0.1094 = 2,858 Malaysians receive an average of 100 mg oral morphine daily

12

Why is a CPG on Cancer Pain Management needed?

It is estimated that <20% of cancer patients in Malaysia who experienced moderate to severe cancer pain received opioid analgesia1

Many healthcare providers are “uncomfortable” & unfamiliar with using opioid analgesia for treating cancer pain adequately

The World Health Organization & the International Association for the Study of Pain have stated that “Pain Relief is a Basic Human Right”

13

1Lim R, Oncology, 2008

Principles of Cancer Pain Management Comprehensive pain assessment prior to

treatment Understanding the concept of ‘total pain’ Reassessment & adjustment of treatment when

indicated Inter-professional collaboration in

multidisciplinary teams Participation of patients & their family

members/carers

14

1.Mehta A et al.., J Hospice & Palliative Nursing, 2008 2Clark, D. “Total pain,” disciplinary power and the body in the work of Cicely Saunders, 1958–1967. Social Science and Medicine, 1999; 49: 727–736

Total Total PainPain

PhysicalPhysical PsychologicalPsychological

SocialSocial SpiritualSpiritual

15

Four-pronged approach1

1. Assess & reduce noxious stimuli. Treat the cancer – RT, Chemo, Surgery

2. Raise threshold to pain – listen to the patient’s story. Reduce anxiety/depression

3. Consider opioid therapy – WHO ladder

4. Consider management of opioid poorly responsive opioid pain – adjuvants, nerve blocks

1Lickiss JN, Eur J Pain, 200116

Multidisciplinary Care & Involvement of Family

Inter-professional collaboration in managing cancer pain has shown:1, level III

o Improvement in mean patient satisfaction (p<0.001)o Less uncertainty & concerns among patients (p=0.047)o Adequacy in pain management (p=0.016)

Involvement of patients & their family carers in the management of cancer pain reduces barriers to analgesic use (p<0.0001) & decreases the worst pain score (p<0.05)2, level I

1San Martin-Rodriguez L et al., Cancer Nurs, 20082Lin CC, et al., Pain, 2006 17

CPG Development CommitteeChairman: Dr. Richard Lim Boon Leong Consultant Palliative Medicine Physician

Dr. Azizul Awaluddin,

Consultant Psychiatrist, Hospital Putrajaya Dr. Azura Deniel, Clinical Oncologist , HKL A/P Dr. Choy Yin Choy, Senior Consultant

Anaesthesiologist , PPUKM Matron Morna Chua Wui Lang, Hospital QE Dr. Eni Juraida Abdul Rahman, Senior

Consultant. Paediatric Haemato-oncologist, HKL Dr. Ismail Aliyas, Consultant Gynae-oncologist,

Hospital Sultanah Bahiyah Datuk Dr. Kuan Geok Lan ,

Senior Consultant Paediatrician, H. Melaka Dr. Lim Zee Nee,

Palliative Medicine Physician, Hospis Malaysia Cik Lee Ai Wei, Pharmacist ,Hosp. Selayang Pn. Lim Khee Li, Physiotherapist ,HKL

Dr. Mary Suma Cardosa, Sen. Consultant Anaesthesiologist & Pain Specialist,H. Slyg

Professor Dr. Marzida Mansor, Senior Consultant Anaesthesiologist, PPUM

Dr. Mohd. Aminuddin Mohd. Yusof, Public Health Physician. MaHTAS

Dr. Ramesh R. Thangaratnam, Consultant Surgeon ,Hospital Serdang

Pn. Rosaniza Zakaria ,

Medical Social Worker , Hospital Selayang Dr. Sinari Salleh, Consultant Clinical

Haematologist, Hospital RPZ II Dr. Sri Wahyu Taher, Consultant Family

Medicine Specialist, KK Bdr Sg. Petani Dr. Yeat Choi Ling , Palliative Medicine

Physician, Hosp. Raja Perempuan Bainun Dr. Zubaidah Jamil ,

Clinical Psychologist, UPM

18

Level of Evidence

Level Study design

I Evidence from at least one properly randomised controlled trial

II -1 Evidence obtained from well-designed controlled trials without randomisation

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or group

II-3 Evidence from multiple time series with or without intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence

III Opinions of respected authorities based on clinical experience; descriptive studies and case reports; or reports of expert committees

SOURCE: US / CANADIAN PREVENTIVE SERVICES TASK FORCE

19

Grades of Recommendations

AAt least one meta analysis, systematic review, or RCT, or evidence rated as good and directly applicable to the target population

B

Evidence from well conducted clinical trials, directly applicable to the target population, and demonstrating overall consistency of results; or evidence extrapolated from meta analysis, systematic review, or RCT

CEvidence from expert committee reports, or opinions and /or clinical experiences of respected authorities; indicates absence of directly applicable clinical studies of good quality

SOURCE: MODIFIED FROM THE SIGNNote: The grades of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation

20

THANK YOU

21