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      Pain Management in Pancreatic Cancer

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          Abstract

          A majority of pancreatic cancer patients present with pain at the time of diagnosis. Pain management can be challenging in light of the aggressive nature of this cancer. Apart from conventional pharmacotherapy, timely treatment with neurolytic celiac plexus block (NCPB) has been shown to be of benefit. NCPB has demonstrated efficacious pain control in high quality studies with analgesic effects lasting one to two months. NCPB has also shown to decrease the requirements of narcotics, and thus decrease opioid related side effects. Another option for the control of moderate to severe pain is intrathecal therapy (IT). Delivery of analgesic medications intrathecally allows for lower dosages of medications and thus reduced toxicity. Both of the above mentioned interventional procedures have been shown to have low complication rates, and be safe and effective. Ultimately, comprehensive pancreatic cancer pain management necessitates understanding of pain mechanisms and delivery of sequential validated therapeutic interventions within a multidisciplinary patient care model.

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          Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival.

          Eric Buchser, Peter Staats, … (2002)
          Implantable intrathecal drug delivery systems (IDDSs) have been used to manage refractory cancer pain, but there are no randomized clinical trial (RCT) data comparing them with comprehensive medical management (CMM). We enrolled 202 patients on an RCT of CMM versus IDDS plus CMM. Entry criteria included unrelieved pain (visual analog scale [VAS] pain scores >/= 5 on a 0 to 10 scale). Clinical success was defined as >/= 20% reduction in VAS scores, or equal scores with >/= 20% reduction in toxicity. The main outcome measure was pain control combined with change of toxicity, as measured by the National Cancer Institute Common Toxicity Criteria, 4 weeks after randomization. Sixty of 71 IDDS patients (84.5%) achieved clinical success compared with 51 of 72 CMM patients (70.8%, P =.05). IDDS patients more often achieved >/= 20% reduction in both pain VAS and toxicity (57.7% [41 of 71] v 37.5% [27 of 72], P =.02). The mean CMM VAS score fell from 7.81 to 4.76 (39% reduction); for the IDDS group, the scores fell from 7.57 to 3.67 (52% reduction, P =.055). The mean CMM toxicity scores fell from 6.36 to 5.27 (17% reduction); for the IDDS group, the toxicity scores fell from 7.22 to 3.59 (50% reduction, P =.004). The IDDS group had significant reductions in fatigue and depressed level of consciousness (P <.05). IDDS patients had improved survival, with 53.9% alive at 6 months compared with 37.2% of the CMM group (P =.06). IDDSs improved clinical success in pain control, reduced pain, significantly relieved common drug toxicities, and improved survival in patients with refractory cancer pain.
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            Systems to rate the strength of scientific evidence.

            Christopher Carey, N McKoy, K Löhr … (2002)
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              Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial.

              Darrell Schroeder, Carlos B Mantilla, Mandy L. Wilson … (2004)
              Pancreatic cancer is an aggressive tumor associated with high mortality. Optimal pain control may improve quality of life (QOL) for these patients. To test the hypothesis that neurolytic celiac plexus block (NCPB) vs opioids alone improves pain relief, QOL, and survival in patients with unresectable pancreatic cancer. Double-blind, randomized clinical trial conducted at Mayo Clinic, Rochester, Minn. Enrolled (October 1997 and January 2001) were 100 eligible patients with unresectable pancreatic cancer experiencing pain. Patients were followed up for at least 1 year or until death. Patients were randomly assigned to receive either NCPB or systemic analgesic therapy alone with a sham injection. All patients could receive additional opioids managed by a clinician blinded to the treatment assignment. Pain intensity (0-10 numerical rating scale), QOL, opioid consumption and related adverse effects, and survival time were assessed weekly by a blinded observer. Mean (SD) baseline pain was 4.4 (1.7) for NCPB vs 4.1 (1.8) for opioids alone. The first week after randomization, pain intensity and QOL scores were improved (pain intensity, P .10), and QOL (P =.46) were not significantly different between groups. In the first 6 weeks, fewer NCPB patients reported moderate or severe pain (pain intensity rating of > or =5/10) vs opioid-only patients (14% vs 40%, P =.005). At 1 year, 16% of NCPB patients and 6% of opioid-only patients were alive. However, survival did not differ significantly between groups (P =.26, proportional hazards regression). Although NCPB improves pain relief in patients with pancreatic cancer vs optimized systemic analgesic therapy alone, it does not affect QOL or survival.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cancers (Basel)
                Journal ID (iso-abbrev): Cancers (Basel)
                Journal ID (publisher-id): Cancers
                Title: Cancers
                Publisher: Molecular Diversity Preservation International (MDPI)
                ISSN (Electronic): 2072-6694
                Publication date Collection: March 2011
                Publication date (Electronic): 24 December 2010
                Volume: 3
                Issue: 1
                Pages: 43-60
                Affiliations
                [1 ] Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, 600 N. Wolfe St., Phipps 160, Baltimore, MD 21287, USA; E-Mails: mhameed1@ 123456jhmi.edu (M.H.); hhameed1@ 123456jhmi.edu (H.H.)
                [2 ] Division of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University, School of Medicine, 550 North Broadway St., Suite 301, Baltimore, MD 21205, USA
                Author notes
                [* ] Author to whom correspondence should be addressed; E-Mail: merdek@ 123456jhmi.edu (M.E.); Tel.: +1-410-502-7388; Fax: +1-410-502-6730.
                Article
                Publisher ID: cancers-03-00043
                DOI: 10.3390/cancers3010043
                PMC ID: 3756348
                PubMed ID: 24212605
                SO-VID: b648ba9b-38ef-4a7c-b1fd-a9e6aa0045fe
                Copyright © © 2010 by the authors; licensee MDPI, Basel, Switzerland.
                License:

                This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license ( http://creativecommons.org/licenses/by/3.0/).

                History
                Date received : 01 November 2010
                Date revision received : 25 November 2010
                Date accepted : 20 December 2010
                Categories
                Subject: Review

                Keywords: pancreatic cancer,neurolytic celiac plexus block,intrathecal therapy,opioids,pain
                Data availability:
                Keywords: pancreatic cancer, neurolytic celiac plexus block, intrathecal therapy, opioids, pain

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