A Q&A with Kevin Sevarino, MD, PhD, President-elect of the American Academy of Addiction Psychiatry and Consulting Psychiatrist at Gaylord Hospital in Wallingford, CT
Q: Opioid abuse, addiction, and overdose are huge American problems right now. Many cancer patents experience chronic pain. What is the best way to use opioids to manage chronic pain?
[Note: The views expressed below represent the opinion of the author, and do not necessarily reflect the views of the American Academy of Addiction Psychiatry nor those of Gaylord Hospital.]
A. We live in amazing times. Targeted immunotherapies, stem cell transplants of transfected cells, identification of unique molecular targets in cancer cells through differential gene expression profiling—all promise to expand survival rates (or cures!) with diminished adverse effects compared to the “blunt hammer” approach of chemotherapy, radiation treatments, and more. Continue reading…
“Early-stage breast cancer patients receiving a shorter course of whole breast radiation with higher radiation doses per fraction reported equivalent cosmetic, functional and pain outcomes over time as those receiving a longer, lower-dose per fraction course of treatment, according to researchers from The University of Texas MD Anderson Cancer Center.
“Their study, published in Cancer, found patient-reported functional status and breast pain improved significantly following both radiation schedules, and there were no significant differences in physician-reported cosmetic evaluations. With a more convenient treatment schedule and equivalent outcomes, the authors suggest the shorter course as the preferred option for patients.”
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“Despite what many believe, not all radiopharmaceuticals are just for pain palliation, says Phillip J. Koo, MD, a radiologist of Memorial Hospital and University of Colorado Hospital.
“The ALSYMPCA trial, which was the basis for the 2013 FDA approval of radium-223 dichloride (Xofigo) showed a median overall survival (OS) of 14 months with radium-223 versus 11.2 months with placebo (HR, 0.70; P = .00185) in patients with metastatic castration-resistant prostate cancer (mCRPC).
“Despite the fact that it has been 3 years since the pivotal ALSYMPCA trial and the coinciding FDA approval, many oncologists still need to be educated regarding radium-223’s benefits, says Koo.”
“Almost half of patients with advanced lung cancer receive more than the recommended number of radiation treatments to reduce their pain, according to a new study published in the Journal of the National Cancer Institute.
“Radiation therapy that is palliative, or not intended to cure, can reduce the pain from lung tumors and improve quality of life. But unnecessary treatments add to costs and require needless trips to the hospital—and can lead to radiation toxicity and difficulty in swallowing.
“Guidelines developed from clinical trials recommend no more than 15 radiation treatments be given for pain in stage 4 lung cancer. The guidelines recommend that patients not receive chemotherapy at the same time, to reduce the risk of toxicity.”
“I could hear the anxiety in my sister’s voice. A week after her double mastectomy and breast reconstruction for breast cancer, she had developed a burning sensation under her right arm where her surgeon had removed several dozen lymph nodes for a postoperative biopsy. The throbbing and itching were so intense it felt ‘like poison ivy lit by a blowtorch.’ ”
“The physician assistant at her reconstructive surgeon’s office told her it was probably “neuropathic in origin” — probably arising from nerve damage during surgery — and that the condition, known as postmastectomy pain syndrome, or PMPS, would subside over time. And luckily for my sister, five weeks out from surgery, the pain began to wane.
“But for many of the estimated 20 to 50 percent of women who develop pain after a mastectomy, it may never go away.”
“The addition of trametinib to dabrafenib improved health-related quality of life and reduced pain in patients with BRAF V600-mutated metastatic melanoma, according to results of a randomized phase 3 study.
“The combination of dabrafenib (Tafinlar, GlaxoSmithKline) and trametinib (Mekinist, GlaxoSmithKline) received accelerated approval from the FDA in 2014 based on the results of a phase 1/2 study that compared the combination with dabrafenib monotherapy. Results from a phase 3 trial later demonstrated significantly improved PFS and objective rate response with the combination vs. dabrafenib monotherapy in patients with BRAF V600 metastatic melanoma.
“In the current analysis, Dirk Schadendorf, MD, of the department of dermatology at the University Hospital Essen in Germany, and colleagues sought to evaluate the effect of the combination on health-related quality of life among patients treated in the phase 3 study.”
“Women with breast cancer who follow a physical exercise program during their chemotherapy treatment experience less side effects like fatigue, reduced physical fitness, nausea and pain. It is also less often necessary to adjust the dosage of their chemotherapy. This is shown by a study supervised by Neil Aaronson of the Netherlands Cancer Institute (NKI).
“Chemotherapy can be very burdensome for patients. Because of the side effects, not all patients are able to complete their chemotherapy as originally planned, but require a dose adjustment. There are some indications that physical exercise might help reduce these side effects. Neil Aaronson of the NKI was interested in determining which type of physical exercise programs are most effective, and whether such programs can also help patients better tolerate their chemotherapy. He investigated these issues in a group of women with breast cancer who received adjuvant chemotherapy. The research project, nicknamed PACES, was for a large part carried out by PhD student Hanna van Waart of Aaronson’s research group, in close collaboration with the Physical Therapy department of the NKI. The results of the project are now published in the Journal of Clinical Oncology.
“Aaronson and Van Waart randomly divided 230 breast cancer patients into three groups. The first group followed a moderately intensive aerobic and strength exercise program, under supervision of a trained physiotherapist. Women in the second group were assigned to a low intensity aerobic exercise program that they could follow at home, which was coached by a trained nurse or nurse practitioner. The third group did not follow any exercise program. The results of the study were clear. Both groups of women who followed an exercise program experienced less fatigue, loss of fitness, nausea and pain during their chemotherapy treatment. This effect was most pronounced in the group of women who followed the supervised, moderately intensive program. The women in this group were also the ones who endured their chemotherapy best; only twelve percent of them required a dose adjustment. In the control group, 34 percent of the women could not tolerate the chemotherapy and needed a dose adjustment.”
“A team of researchers from The University of Texas at Arlington and the University of Central Florida have determined that years after going into remission, many adult cancer survivors still encounter challenges arising from their disease and its treatment.
“From anxiety about a cancer recurrence to physical problems such as chronic pain, survivors aren’t quite done battling the effects of cancer even 2, 5, and 10 years after treatment for the disease.
“The study, ‘Current unmet needs of cancer survivors: Analysis of open-ended responses to the American Cancer Society Study of Cancer Survivors II,’ is published online and in the February issue of Cancer, a journal of the American Cancer Society.
” ‘So often, the expectation is that a cancer survivor should be grateful for having survived a diagnosis of cancer. And while this may be true, those survivors with debilitating, lingering effects of cancer and its treatment are not always acknowledged within healthcare systems as needing continued care based on their cancer survivor status,’ said Gail Adorno, assistant professor in the UT Arlington School of Social Work and co-principal investigator on the study.”
“One in every three women undergoing a mastectomy could potentially be spared chronic post-operative pain if anesthesiologists used a regional anesthetic technique in combination with standard care, according to a new study.
“Standard care for mastectomies is a general anesthetic, whereby anesthesiologists use gas to keep the patient asleep and narcotics to control pain. Up to 60 per cent of women may experience chronic pain three months after they’ve had the surgery and at least half of those will still suffer from this pain one year later
” ‘Sadly, the pain these women experience can be so severely debilitating that it may require treatment by a pain specialist and pain killers,’ said Dr. Faraj Abdallah, lead author of the study and an anesthesiologist at St. Michael’s Hospital.
“The regional anesthetic technique Dr. Abdallah examined when added to standard care -called ultrasound-guided paravertebral blocks- is similar to a dental freeze. Trained anesthesiologists use a local anesthetic to freeze nerves in the breast area. Paravertebral blocks allow excellent pain control immediately after surgery and help with long-term pain reduction.”