How does disease modifying treatment fit into future cancer pain management guidelines?
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1 How does disease modifying treatment fit into future cancer pain management guidelines? Peter Lawlor Elisabeth Bruyère & University of Ottawa 5/06/2012 EAPC Preconf P7 1 Case Example: 62yo fem with MCRC in PCU..1 Dx Oct 2007, localized disease Neoadjuvant RT, Laparoscopic Ant Resection + colostomy Jan 2008 Adjuvant ChemoTx with FOLFOX x 2 cycles LBO in midst of 1st cycle, Rx laparotomy adhesions divided Coronary spasm in 2 nd cycle? due to 5FU Dx 2009 vaginal met, July 2010 Rx Irinotecan ChemoTx ARF, febrile neutropenia, flank pain, Nephrostomy drain initially then Nephroureterostomy in Dec 2010 Oct 2011: Pre sacral mass on MRI invading S1 and S2 RadioTx, & Pain Team referral Nov 2011 Rx Panitumumab Switched to Ralitrexed (Tomudex) because of skin toxicity 5/06/2012 EAPC Preconf P7 2 1
2 Case Example: 62yo fem with MCRC in PCU..2 May 2012: admitted to PCU for Methadone switch Severe incident pain Unable to tolerate Methadone / Fentanyl prn Intrathecal administration of opioid /local anaesthetic Points to note: Patients personality Many surgical/radiological interventions Chemotherapy treatments: benefit vs burden Late palliative care referral Radiation Rx Monoclonal Rx Methadone unsuccessful, next step: intrathecal analgesia 5/06/2012 EAPC Preconf P7 3 Objectives To evaluate the impact of cancer disease modifying therapies on cancer pain [Why?] To explore how best to incorporate cancer disease modifying therapies in cancer pain guidelines [What & How?] 5/06/2012 EAPC Preconf P7 4 2
3 Tumour directed therapy 1 Cytotoxic chemotherapy Hormonal therapy Bisphosphonates Monoclonals Others 5/06/2012 EAPC Preconf P7 5 Tumour directed therapy..2 EB Radiation therapy Stereotactic Radiopharmaceuticals Sr Sm Re Surgical Excision / Debulking Stenting / Drainage Other Laser Embolisation RF Ablation 5/06/2012 EAPC Preconf P7 6 3
4 Survival Risk /Benefit Pain / HRQoL Oncol / Phys Advice re DMT EB Survival EB HRQoL Pain Personalised Care Family Preference Goals Expectations Patient Preference Goals Expectations DMT Accessibility Institutional Factors Cost Effectiveness Tumour biology Financial 5/06/2012 EAPC Preconf P7 7 An evolving story Developments in Cancer Care Disease modification RCTs: strong evidence base Survival data vs HRQoL data Symptom control / Supportive & Palliative Care / Hospice Care Developing evidence base QoL: Pall & Hospice Care 5/06/2012 EAPC Preconf P7 8 4
5 Table 3 Binary Logistic Regression Model Adj Odds Ratios 2007 vs % CIs P Value Central Line Use Peripheral Line Use < Bisphosphonate iv Antibiotics iv < Chemotherapy Feeding oral vs other Out of Hospice Trip A red cell transfusion Adjusted for age, admission duration, gender and referral location Lawlor et al MASCC Rome /06/2012 EAPC Preconf P7 10 5
6 5/06/2012 EAPC Preconf P7 11 Medline (R) without Revision 1996 to 2012 (May Week 3) Hits 1 Antibodies monoclonal (MeSH) or targeted therapy, 131,419 (tw) 2 Neoplasms (MeSH) or cancer, (tw) 626, ,353 4 Pain (MeSH) or pain, (tw) 263, Limits: year > 2000, English, abstract available 153 5/06/2012 EAPC Preconf P7 12 6
7 5/06/2012 EAPC Preconf P7 13 5/06/2012 EAPC Preconf P7 14 7
8 5/06/2012 EAPC Preconf P7 15 5/06/2012 EAPC Preconf P7 16 8
9 5/06/2012 EAPC Preconf P7 17 5/06/2012 EAPC Preconf P7 18 9
10 5/06/2012 EAPC Preconf P7 19 5/06/2012 EAPC Preconf P
11 5/06/2012 EAPC Preconf P7 21 5/06/2012 EAPC Preconf P
12 Swetz KM and Smith TJ, Ca Journal 2010;16: /06/2012 EAPC Preconf P7 23 5/06/2012 EAPC Preconf P
13 5/06/2012 EAPC Preconf P7 25 5/06/2012 EAPC Preconf P
14 5/06/2012 EAPC Preconf P7 27 5/06/
15 5/06/2012 EAPC Preconf P7 29 Interactive Web of Decision Making Healthcare Personnel Institutional issues Cost and Access to Rx Communication Cancer Illness Evidence Base Experience - bias Communication Patient Preferences Perceived Prognosis Hope/Denial/Coping Communication GOALS OF CARE Family Preferences Perceived Prognosis Hope/Denial/Coping DECISION 30 15
16 5/06/2012 EAPC Preconf P7 31 Advanced Breast Ca Pts Perceptions of Decision Making for Palliative ChemoTx Grunfeld et al JCO 2006;24: N=102 with advanced Br Ca 15 closed fixed choice Qs & 6 open-ended 1 st Line CT: N=70 and 2 nd Line CT: N= mins interview with Res Nurse mean of 20/7 and 13/7 post key consult Recall of key clinical decision-making consult Perceptions re info disclosure Perceptions of clinical decision-making process 5/06/2012 EAPC Preconf P
17 5/06/2012 EAPC Preconf P7 33 5/06/2012 EAPC Preconf P
18 [38%] [15%] [47%] 5/06/2012 EAPC Preconf P
19 5/06/2012 EAPC Preconf P7 37 5/06/2012 EAPC Preconf P
20 K M Estimates of Survival According to Study Group. Temel JS et al. N Engl J Med 2010;363: /06/2012 EAPC Preconf P7 39 5/06/2012 EAPC Preconf P
21 5/06/2012 EAPC Preconf P7 41 5/06/2012 EAPC Preconf P
22 5/06/2012 EAPC Preconf P7 43 Conclusions Decision-making re DMT is complex: individualized approach and further studies needed Trend towards more aggressive use of DMTs? reflecting advances: need to evaluate PROs Increasing evidence that Pall Care referral / integrated care is associated with better coping, QoL, decision-making and even survival Tactful communication time and training Guidelines / MDT conferences / Decision Aids help Cost is an arbiter in relation to decisions regarding newer therapies (? PALYs vs QUALYs) 5/06/2012 EAPC Preconf P
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