Colette Reid

The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland.

A task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland (APM) was convened to produce some up‐to‐date, evidence‐based, practical, clinical guidelines on the management of cancer‐related breakthrough pain in adults. On the basis of a review of the literature, the task group was unable to make recommendations about any individual interventions, but was able to make a series of 12 recommendations about certain generic strategies. However, most of the aforementioned recommendations are based on limited evidence (i.e., case series, expert opinion). The task group also proposed a definition of breakthrough pain, and some diagnostic criteria for breakthrough pain.

A systematic review of oxycodone in the management of cancer pain

Background: Oxycodone is often used as an opioid analgesic for moderate to severe cancer-related pain, but its use varies across Europe. This systematic literature review forms the basis of guidelines for oxycodone use within the European Palliative Care Research Collaborative opioid guidelines project conducted on behalf of the European Association for Palliative Care. Objectives: The objective of this study was to identify and assess the quality of evidence for the use of oxycodone for cancer pain in adults. Methods: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals. Studies were included if they reported a clinical outcome relevant to the use of oxycodone in adult patients with moderate to severe cancer pain. Any form and route of oxycodone was included except intrathecal. No direct comparator was required for inclusion and studies were excluded if patients had previously switched from another strong opioid because of intolerable adverse effects or poor efficacy. This is a narrative systematic review, using the GRADE approach to assess the quality of studies and to formulate guidelines. Results: Twenty-nine original studies were identified including a meta-analysis and 14 randomized controlled trials. The identified meta-analysis included three trials comparing oxycodone to morphine and one comparing oxycodone to hydromorphone. Four other randomized trials compared oxycodone with other opioids. The remaining randomized controlled trials compared different routes of administration or formulations of oxycodone. No additional studies that would have been suitable for addition to the meta-analysis were identified. Conclusions: There is no evidence from the included trials of a significant difference in analgesia or adverse effects between oxycodone and morphine or hydromorphone. The evidence was graded as high quality on the basis of a well-conducted meta-analysis, with no limitations likely to affect the outcome, in addition to consistency in the results of the other studies. The research was conducted using participants relevant to cancer and palliative care populations. Oxycodone can be recommended as an alternative to morphine or hydromorphone for cancer-related pain.

Contribution to variability in response to opioids

Opioids are the oldest and most effective agents for the short- and long-term control of severe pain, particularly chronic cancer pain palliation. However, morphine and other opioids display wide variations in pharmacological efficacy and tolerability, and a significant number of patients are unable to achieve adequately controlled pain at doses that do not produce intolerable adverse effects. This article reviews factors that affect the efficacy and tolerability of opioid analgesics and clinical strategies for successful pain mangement.

The World Health Organization three-step analgesic ladder comes of age.

Eighteen years ago, the World Health Organization (WHO) published a document entitled Cancer Pain Relief, which set out the principles of cancer pain management based on the use of a ‘three-step analgesic ladder’. The document was derived from consensus guidelines produced some four years earlier. In 1996, the WHO published an updated version of Cancer Pain Relief, which again was based on the use of a ‘three-step analgesic ladder’, and also the principles ‘by mouth’, ‘by the clock’, ‘by the ladder’, ‘for the individual’ and ‘attention to detail’. The updated version of the threestep ladder is shown in Figure 1. Eighteen years is a long time in medicine. Admittedly, the WHO guidelines have been updated during this period, but the second edition is essentially the same as the first edition. Most commentators agree that the original guidelines were appropriate for their time, but some suggest that the current guidelines are less relevant in the new millennium. So, are the WHO guidelines still valid? The WHO guidelines arose from evidence of poor management of cancer pain in both developing and developed countries. One of the reasons, if not the main reason, for this situation was the reluctance of individual health professionals, institutions and governments to use ‘strong’ opioids because of misplaced fears of addiction and tolerance amongst patients, and of illegal use amongst the wider community. Thus, one of the main aims of the WHO guidelines was to legitimize, and so increase, the prescribing of ‘strong’ opioids amongst patients with moderate to severe cancer pain. WHO data suggest that the publication of the guidelines has been associated with an increase in the usage of opioids in many parts of the world. One of the major criticisms of the three-step ladder has been the lack of strong evidence of its effectiveness. In 1995, Jadad and Browman conducted a systematic review of the studies evaluating the WHO guidelines. In the studies included in the review, 69¡/100% of patients achieved ‘adequate analgesia’. However, the authors comment that for methodological reasons ‘the evidence they (the studies) provide is insufficient to estimate confidently the effectiveness of the WHO analgesic ladder’. Their criticisms were that the studies were small, had limited follow-up periods or high dropout rates, and lacked comparator groups. Because of this they conclude, ‘it would be difficult to know whether the WHO ladder has really improved the management of cancer pain’. Jadad and Browman’s criticisms were subsequently addressed and dismissed by some of the developers of the WHO guidelines. ,6 In essence, these authors argued that the guidelines were not suggesting a new treatment, but promoting better use of existing drugs, i.e. opioids for moderate to severe pain, and that the validation studies were setting out to prove that these drugs could be used effectively and safely for cancer-related pain, could be used at any stage of the disease, and could be continued for prolonged periods. Another major criticism of the three-step ladder has been that it is nonspecific. Thus, physicians reviewing the same patient could prescribe different treatment regimens, despite using the same treatment template. A classic example of this phenomenon is the management of patients with neuropathic pain, where some physicians use ‘drugs for neuropathic pain’ (e.g. antidepressants and anticonvulsants) at step one, whilst other physicians only use these drugs at step three. However, we would suggest that this lack of specificity is actually a positive feature, since it promotes the concept of individualised patient management. More recently, a criticism of the three-step ladder has been that it overlooks the benefits of other methods of pain relief, such as disease-modifying therapies, nonpharmacological therapies, and interventional therapies. However, the WHO guidelines do endorse the use of these other treatment modalities, although they do not appear on the illustration of the three-step ladder. Cancer Pain Relief contains much more information than just the three-step ladder, and so it is important that health care professionals refer to the WHO guidelines in their entirety, rather than basing practice on an isolated illustration of the three-step ladder. Ultimately, the use of these other treatment modalities, and also of opioids for moderate to severe pain, depends on their availability, which is likely to vary from country to country. Palliative Medicine 2004; 18: 175¡/176

What do patients with advanced incurable cancer want from the management of their pain? A qualitative study

Background: Pain is one of the most frequent symptoms among patients with metastatic cancer, yet little is known about what patients with advanced cancer want from the management of their pain. Measuring the effectiveness of the management of pain is challenging as it is a subjective phenomenon and a multifaceted process. Determining how we currently define whether a patient with pain due to advanced cancer has controlled pain (or not) is important, particularly from the patient’s perspective. Aim: To explore how patients with advanced cancer describe the control of pain and what they want from management of this pain. Design: Qualitative study using face-to-face interviews. Data were analysed using a constant comparison approach. Setting/participants: Purposive sample of patients with advanced cancer known to palliative care services. Results: Twelve interviews took place until saturation of data was achieved. Four themes emerged: maintaining role, self and independence; compromising/modifying expectations; role of healthcare professionals; and meaning of pain in context of advanced cancer. Conclusion: Patients determined whether their pain was ‘controlled’ by whether or not they were able to perform activities or tasks and maintain relationships with family or friends, which determined themselves as individuals. Numerical rating scales did not appear to be useful for patients in measuring whether they are able to perform these activities or maintain a sense of control and independence. Individualised goal/task/role/activity setting for patients with advanced cancer pain may be useful to allow patients themselves to determine what they want from the ‘management’ of their pain.

Healthcare professionals' perspectives on delivering end-of-life care within acute hospital trusts: a qualitative study

Objective The quality of end-of-life (EOL) care in acute hospitals is variable and interventions to improve this care, such as EOL care pathways, are not always used. The underlying reasons for this variability are not fully understood. We explored healthcare professionals’ views on delivering EOL care within an acute hospital trust in the South West of England. Methods We employed qualitative methods (focus groups, in-depth interviews and questerviews) within a study investigating the impact of a simple EOL tool on the care of dying patients. We invited a range of staff of all grades with experience in caring for dying patients from medicine, surgery and care of the elderly teams to participate. Results Six focus groups, seven interviews and five questerviews were conducted. Two main themes emerged: (a) delays (difficulties and avoidance) in diagnosing dying and (b) the EOL tool supporting staff in caring for the dying. Staff acknowledged that the diagnosis of dying was often made late; this was partly due to prognostic uncertainty but compounded by a culture that did not acknowledge death as a possible outcome until death was imminent. Both the medical and nursing staff found the EOL tool useful as a means of communicating ceilings of care, ensuring appropriate prescribing for EOL symptoms, and giving nurses permission to approach the bedside of a dying patient. Conclusions The culture of avoiding death and dying in acute hospitals remains a significant barrier to providing EOL care, even when EOL tools are available and accepted by staff.

Liverpool care pathway

Chinthapalli’s report broadens the debate on the Liverpool care pathway (LCP).1 Recent negative press coverage has affected end of life care: at University Hospitals Bristol NHS Trust our end of life tool (not LCP) was used in only 37% of patients dying in December 2012 compared with 67% in December 2011. The principles of the LCP are essential to improving …

Contemporary accuracy of death certificates for coding prostate cancer as a cause of death: Is reliance on death certification good enough? A comparison with blinded review by an independent cause of death evaluation committee

Background:Accurate cause of death assignment is crucial for prostate cancer epidemiology and trials reporting prostate cancer-specific mortality outcomes.Methods:We compared death certificate information with independent cause of death evaluation by an expert committee within a prostate cancer trial (2002–2015).Results:Of 1236 deaths assessed, expert committee evaluation attributed 523 (42%) to prostate cancer, agreeing with death certificate cause of death in 1134 cases (92%, 95% CI: 90%, 93%). The sensitivity of death certificates in identifying prostate cancer deaths as classified by the committee was 91% (95% CI: 89%, 94%); specificity was 92% (95% CI: 90%, 94%). Sensitivity and specificity were lower where death occurred within 1 year of diagnosis, and where there was another primary cancer diagnosis.Conclusions:UK death certificates accurately identify cause of death in men with prostate cancer, supporting their use in routine statistics. Possible differential misattribution by trial arm supports independent evaluation in randomised trials.

Vitamin D deficiency as a cause of chronic pain in the palliative medicine clinic: two case reports.

Background: Vitamin D deficiency is common in the general population and has been implicated as a cause of chronic pain. The palliative care population has a number of risk factors for vitamin D deficiency. We present two cases of unexplained pain in patients attending the palliative medicine outpatient clinic that improved after vitamin D replacement. Cases: Case 1 is a 46-year-old man with thalassaemia intermedia and back and leg pain without a clear cause. Case 2 is a 28-year-old woman undergoing treatment for cervical cancer whose initial disease and treatment-related abdominal pain resolved but subsequently reported ongoing non-specific aches and pains. Case management: Both patients were found to have vitamin D levels <50 nmol/L and were treated with vitamin D replacement therapy. Case outcome: Following vitamin D replacement therapy, pain resolved in both patients allowing a reduction in analgesic therapy. Conclusions: The prevalence of vitamin D deficiency in the palliative care population merits further investigation, since these patients are at high risk of deficiency. Having an index of suspicion, particularly in those patients with known risk factors and pain that is not fully explained, may result in better pain control and functional outcomes.

Palliative care is not same as end of life care

Gott and colleagues’ paper resonates with our research findings from focus groups with ward staff caring for dying patients.1 2 We wonder if terminology is a barrier that was not discussed. The provision of palliative care should depend on need not prognosis.3 However, focus group participants considered palliative care as …