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      The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain

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          Abstract

          Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.

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          Most cited references 183

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          Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC.

          Here we provide the updated version of the guidelines of the European Association for Palliative Care (EAPC) on the use of opioids for the treatment of cancer pain. The update was undertaken by the European Palliative Care Research Collaborative. Previous EAPC guidelines were reviewed and compared with other currently available guidelines, and consensus recommendations were created by formal international expert panel. The content of the guidelines was defined according to several topics, each of which was assigned to collaborators who developed systematic literature reviews with a common methodology. The recommendations were developed by a writing committee that combined the evidence derived from the systematic reviews with the panellists' evaluations in a co-authored process, and were endorsed by the EAPC Board of Directors. The guidelines are presented as a list of 16 evidence-based recommendations developed according to the Grading of Recommendations Assessment, Development and Evaluation system. Copyright © 2012 Elsevier Ltd. All rights reserved.
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            Novel 10-kHz High-frequency Therapy (HF10 Therapy) Is Superior to Traditional Low-frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain: The SENZA-RCT Randomized Controlled Trial.

            Current treatments for chronic pain have limited effectiveness and commonly known side effects. Given the prevalence and burden of intractable pain, additional therapeutic approaches are desired. Spinal cord stimulation (SCS) delivered at 10 kHz (as in HF10 therapy) may provide pain relief without the paresthesias typical of traditional low-frequency SCS. The objective of this randomized, parallel-arm, noninferiority study was to compare long-term safety and efficacy of SCS therapies in patients with back and leg pain.
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              Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases.

              Radiation therapy is effective in palliating pain from bone metastases. We investigated whether 8 Gy delivered in a single treatment fraction provides pain and narcotic relief that is equivalent to that of the standard treatment course of 30 Gy delivered in 10 treatment fractions over 2 weeks. A prospective, phase III randomized study of palliative radiation therapy was conducted for patients with breast or prostate cancer who had one to three sites of painful bone metastases and moderate to severe pain. Patients were randomly assigned to 8 Gy in one treatment fraction (8-Gy arm) or to 30 Gy in 10 treatment fractions (30-Gy arm). Pain relief at 3 months after randomization was evaluated with the Brief Pain Inventory. The Wilcoxon-Mann-Whitney test was used to compare response to treatment in terms of pain and narcotic relief between the two arms and for each stratification variable. All statistical comparisons were two-sided. There were 455 patients in the 8-Gy arm and 443 in the 30-Gy arm; pretreatment characteristics were equally balanced between arms. Grade 2-4 acute toxicity was more frequent in the 30-Gy arm (17%) than in the 8-Gy arm (10%) (difference = 7%, 95% CI = 3% to 12%; P = .002). Late toxicity was rare (4%) in both arms. The overall response rate was 66%. Complete and partial response rates were 15% and 50%, respectively, in the 8-Gy arm compared with 18% and 48% in the 30-Gy arm (P = .6). At 3 months, 33% of all patients no longer required narcotic medications. The incidence of subsequent pathologic fracture was 5% for the 8-Gy arm and 4% for the 30-Gy arm. The retreatment rate was statistically significantly higher in the 8-Gy arm (18%) than in the 30-Gy arm (9%) (P < .001). Both regimens were equivalent in terms of pain and narcotic relief at 3 months and were well tolerated with few adverse effects. The 8-Gy arm had a higher rate of re-treatment but had less acute toxicity than the 30-Gy arm.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                jpr
                jpainres
                Journal of Pain Research
                Dove
                1178-7090
                16 July 2021
                2021
                : 14
                : 2139-2164
                Affiliations
                [1 ]Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health , Oshkosh, WI, USA
                [2 ]Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center , Bangor, ME, USA
                [3 ]The Spine and Nerve Center of the Virginias , Charleston, WV, USA
                [4 ]Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center , Kansas City, KS, USA
                [5 ]Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic , Rochester, MN, USA
                [6 ]Department of Anesthesiology, Division of Pain Medicine, University of Utah , Salt Lake City, UT, USA
                [7 ]Department of Anesthesiology, Division of Pain Medicine, Emory University , Atlanta, GA, USA
                [8 ]Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center , New York, NY, USA
                [9 ]Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic , Phoenix, AZ, USA
                [10 ]Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences , Little Rock, AR, USA
                [11 ]Interventional Pain Medicine, Napa Valley Orthopedic Medical Group , Napa, CA, USA
                [12 ]Swedish Pain Services, Swedish Health Services , Seattle, WA, USA
                [13 ]Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute , Freehold, NJ, USA
                [14 ]Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College , New York, NY, USA
                [15 ]Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University , Halifax, NS, Canada
                [16 ]Remedy Medical Group , San Francisco, CA, USA
                [17 ]Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine , Houston, TX, USA
                [18 ]Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center , Toledo, OH, USA
                [19 ]AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center , Hoffman Estates, IL, USA
                [20 ]SamWell Institute for Pain Management , Colonia, NJ, USA
                [21 ]Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia , Vancouver, BC, Canada
                [22 ]Center for the Relief of Pain, Midwest Neurosurgery Associates , Kansas City, Missouri, USA
                [23 ]Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School , Boston, MA, USA
                Author notes
                Correspondence: Mansoor M Aman Interventional Pain Medicine, Department of Anesthesiology, Advocate Aurora Health , Oshkosh, WI, 54904, USATel +1 920-456-7715 Email aman.mansoorm@gmail.com
                Article
                315585
                10.2147/JPR.S315585
                8292624
                34295184
                © 2021 Aman et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 1, Tables: 11, References: 187, Pages: 26
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