PATIENT CASE

Module 1

Date of preparation: June 2015 HQ/EFF/15/0024h

Pain caused by cancer and cancer therapy

Dr Carla Ida RipamontiOncologist / pharmacologist specialised expert in pain, palliative and supportive careFondazione IRCCS, Istituto Nazionale Tumori, Milano, IT

Routine care

Patient history

Female, 66-years-old, retired school teacher, divorced, 2 sons, lives alone, no medical problem before 2004

2004: DIAGNOSIS OF invasive ductal carcinoma G3, pT1c, pNo, ER 95%, PgR 90%, Ki-67 52%, HER2 2+ (gene non-amplified according to FISH)THERAPY: quadrantectomy dx + BLS + intraoperative RT + tamoxifene for 5 years

2014: DIAGNOSIS OF left breast nodule retroareolar, invasive ductal carcinoma and lobular component pT1c (2 cm), G3, diameter 2 cm, IV (>3 vessels involved), ER 95%, PgR 0%, HER2 1+, Ki-67 40%. Axilla sx 1/12 nodes; Axilla dx 9/22 nodes with massive mtsTHERAPY: Mastectomy sx + axilla dissection sx and dx + reconstruction with expander + adjuvant chemotherapy adriamycin + paclitaxel → CMF → RT supraclavicular dx → aromatase inhibitors

No comorbidities

PAIN DUE TO CANCER THERAPY

Patients refears pain in the hands and feet due to chemotherapyThe pain is described as tingling, ringing, numbness and 2-3 times a day;stabbing

The pain is of suspected neuropathic origin and the patient presents both neuropathy in the hands and feet because hands are weak and she has difficulties in holding a glass; she does not feel the presence of or painful neuropathy

Stabbing pain arises sudden with an intensity of 10/10 on a NRS anda duration of 1-2 minutes

PAIN DUE TO CANCER

2015 February: Evaluated for the presence of osteopenia or osteoporosis. Osteopenia was confirmed at the femoural level and osteoporosis at the lumbar level

February: Bone scan showed the presence of litic lesion (mts)at D7. The patient refered pain at rest and on moving at D7. • Pain on moving is a type of predictable episodic pain

Current pain/illnesses

As the patient presented sleeping problems and anxiety, she accepted the intervention of the psychologist and did not want drugs

February 2015 At the first visit in my office she was on codeine + paracetamol t.i.d + gabapentin 100 mg t.i.d.The oncologist/chemotherapist sent the patient to me to assess and treat pain and to start with denosumab 120 mg IV every monthThe patient with sent for consultation to radiotherapist

Clinical examination and pain assessment

Blood pressure: normal 120/80 mmHg

Cardiovascular examination: normal limits

Sensory examination: present of dysesthesia and paresthesia at the hands and feet + reduction in sensitivity at the fingers on the hand and feet

ESAS administered to assess pain and other physical and emotional symptoms

No specific tools used to assess for neuropathic pan

Clinical judgment

By ESAS, pain at rest at D7 is 4/10, pain on moving is 7/10

Fatigue 6, nausea 0, depression 2, anxiety 3, drowsiness 0, short of breath 0, appetite 3, sleeping 8, feeling of well-being 5• Diagnosis of neuropathic pain was done with patient descriptions and physical

examination• Breakthrough cancer pain without a neuropathic component was present on

moving due to bone metastases. The BTP with a neuropathic component (stabbing pain) was so sudden; the duration of 1-2 minutes made it impossible to consider

Ripamonti CI, et al. Support Care Cancer. 2014;22(3):783-93.

Edmonton Symtom Assessment System (ESAS)Please circle the number that best describes:

No Pain

No Fatigue

No Nausea

No Depression

No Anxiety

No Dowsiness

No ShortnessOf Breath

Best Appetite

Best Sleep

Best FeelingOf Well-being

Worst Feelingof Well-beingImaginable

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

Worst SleepImaginable

Worst AppetiteImaginable

Worst Shortnessof Breath Imaginable

Worst Anxiety Imaginable

Worst DowsinessImaginable

Worst Depression Imaginable

Worst NauseaImaginable

Worst FatigueImaginable

Worst PainImaginable

Therapeutic approach

Drugs for background pain changed from codeine to oxycontin 10 mg every 8 hours with a reduction of background pain to 2/10 and a reduction in neuropathic pain in the hands and feet by 30%Breakthrough pain medication: buccal fentanyl started at 100 mcg ,as needed200 mcg occasionally with reduction or absence of pain during movement, although somnolence reported• Non-pharmacologic treatment: placed an orthopaedic brace (only when she had to

travel) + psychological intervention for other symptoms (sleeping and anxiety)

Follow-up

Pharmacological treatment for nociceptive pain (bone mets) and neuropathic pain (due to chemotherapy)• Interval after initial consultation/change in pain meds, 2 weeks• No complaint of AEs (after a laxative was added)• Says medication alleviates most pain• Says now able to sleep better because pain is under control and because the

anxiety is reduced thanks to psychological intervention with no drugs

Conclusions

Buccal fentanyl was effective in reducing breakthrough cancer pain and was well tolerated

Collaboration between a palliative care specialist and a pain specialist was beneficial for proper therapy

Thank you