Pain Issues inPain Issues inCancer SurvivorsCancer Survivors

Linda Vanni, MSN, RN-BC, ACNS-BC, Linda Vanni, MSN, RN-BC, ACNS-BC, NPNP

Nurse Practitioner, Pain ManagementNurse Practitioner, Pain ManagementProvidence HospitalProvidence Hospital

Southfield, MISouthfield, MI

Conflict of Interest Conflict of Interest DisclosureDisclosure

Author Conflict of Author Conflict of Interest:Interest:-Linda Vanni, No -Linda Vanni, No conflictconflict

ObjectivesObjectives Describe the physiology of cancer Describe the physiology of cancer

survivors’ pain.survivors’ pain. Identify factors that contribute to Identify factors that contribute to

the reluctance of healthcare the reluctance of healthcare providers to manage cancer providers to manage cancer survivors’ pain.survivors’ pain.

Discuss potential solutions Discuss potential solutions regarding cancer survivors, regarding cancer survivors, ability to receive safe, effective ability to receive safe, effective pain management.pain management.

The Scope of the IssueThe Scope of the Issue 66% of 11.7 million people living with a 66% of 11.7 million people living with a

diagnosed cancer in the US at the beginning of diagnosed cancer in the US at the beginning of 2007, are expected to still be alive at least 5 2007, are expected to still be alive at least 5 years after their cancer diagnosis.years after their cancer diagnosis.

By the year 2020, it is estimated that there will By the year 2020, it is estimated that there will be 18.1 million survivors at an annual cost of be 18.1 million survivors at an annual cost of $157.77 billion.$157.77 billion.

As of January 2012, 13.7 million cancer As of January 2012, 13.7 million cancer survivors. survivors.

SEER Stat Fact Sheet, NCI, SEER Stat Fact Sheet, NCI, 1/20121/2012

Mariotto, et al., J.NCI, 2011Mariotto, et al., J.NCI, 2011 NCI, Journal of Cancer NCI, Journal of Cancer

Epidemiology 2013Epidemiology 2013

Based on data from SEER 18 2004-2010. Based on data from SEER 18 2004-2010. Gray figures represent those who have Gray figures represent those who have

died from all cancer sites. Green figures died from all cancer sites. Green figures represent those who have survived represent those who have survived

5 years or more5 years or more

U of M, Lance Armstrong U of M, Lance Armstrong Foundation 2011Foundation 2011

Surveyed 200 U.S. cancer survivorsSurveyed 200 U.S. cancer survivors 43% experienced pain since diagnosis, 20% 43% experienced pain since diagnosis, 20%

suffered chronic, cancer-related pain at least suffered chronic, cancer-related pain at least two years latertwo years later

Women had increased pain, more pain flares Women had increased pain, more pain flares and were more depressed about the painand were more depressed about the pain

Blacks reported higher pain severity and Blacks reported higher pain severity and more treatment side effectsmore treatment side effects

Cancer surgery most significant source of Cancer surgery most significant source of pain (53.8% for whites) and (46.2% for pain (53.8% for whites) and (46.2% for blacks)blacks) Science Daily, Science Daily, 1/13/20111/13/2011

Annals of Oncology, 2009Annals of Oncology, 2009 EPIC, European Pain In Cancer Covering 12 countries, 2006-2007

5084 pts. contacted, 2864 with pain >5 completed survey, 573 completed in-depth survey

30% felt too much pain to care for themselves

4 out of 10, too large of burden to others

Annals of Oncology, cont.Annals of Oncology, cont. 51% pain prevents thinking, 51% pain prevents thinking,

52% pain impacts effectiveness 52% pain impacts effectiveness at workat work

63% inadequate pain control 63% inadequate pain control and/or breakthrough painand/or breakthrough pain

Of the 74% receiving opioids, Of the 74% receiving opioids, 37% experience constipation, 37% experience constipation, 25% not prescribed a laxative by 25% not prescribed a laxative by their cliniciantheir clinician

33% N & V, 20% sedation 33% N & V, 20% sedation

Annals of Oncology cont.Annals of Oncology cont. 50% felt clinicians do not 50% felt clinicians do not

consider their quality of life as consider their quality of life as important aspect of their overall important aspect of their overall care plancare plan

38% felt clinicians would rather 38% felt clinicians would rather treat cancer than pain. What treat cancer than pain. What does this mean for survivors?does this mean for survivors?

26% believed that clinicians do 26% believed that clinicians do not know how to treat moderate not know how to treat moderate to severe painto severe pain

Additional StudiesAdditional Studies Moryl, et al, 2010, Sloan–Kettering: Moryl, et al, 2010, Sloan–Kettering:

Comprehensive information lacking Comprehensive information lacking about the prevalence of persistent about the prevalence of persistent pain, it is known to depend on the pain, it is known to depend on the type of cancer, co-morbid conditions type of cancer, co-morbid conditions and the initial pain management.and the initial pain management.

Burton, et al, 2007, M.D. Anderson: Burton, et al, 2007, M.D. Anderson: Cancer related deaths down 1.1% Cancer related deaths down 1.1% each year from 1993-2002. Blurred each year from 1993-2002. Blurred lines of distinction between lines of distinction between treatment strategies suited for treatment strategies suited for “chronic” versus “malignant” pain. “chronic” versus “malignant” pain.

Glare, P. (et al) (2014) Glare, P. (et al) (2014) Pain inPain in

Cancer SurvivorsCancer Survivors Pain is common in first few years after Pain is common in first few years after

treatmenttreatment 5 to 10% experience severe pain that 5 to 10% experience severe pain that

interferes with functioninginterferes with functioning Pharmaco therapy is principle treatmentPharmaco therapy is principle treatment 40% of cancer survivors live longer than 40% of cancer survivors live longer than

10 years What are the concerns over 10 years What are the concerns over extended opioid use?extended opioid use?

Aim should be restoring functionAim should be restoring function

Northwestern Medicine Northwestern Medicine Study 2011Study 2011

Robert H. Lurie CCC in ChicagoRobert H. Lurie CCC in Chicago Lynne Wagner, MD, Co-investigatorLynne Wagner, MD, Co-investigator Presented 2011 American Society of Clinical Presented 2011 American Society of Clinical

Oncology Annual MeetingOncology Annual Meeting Most common symptoms reported by survivors:Most common symptoms reported by survivors:

Fatigue (16%), Disturbed Sleep (15%), Cognitive Fatigue (16%), Disturbed Sleep (15%), Cognitive Difficulties (13%), Difficulties (13%), Pain (13%)Pain (13%)

““It is acceptable for someone actively going It is acceptable for someone actively going through cancer treatment to have pain through cancer treatment to have pain medications, but when they transition to being medications, but when they transition to being survivors, that acceptance goes away. If they survivors, that acceptance goes away. If they ask for pain medication again, doctors may ask for pain medication again, doctors may worry that they are getting addicted.” Wagner worry that they are getting addicted.” Wagner Science Daily, Science Daily, 6/3/20116/3/2011

Causes of Persistent Causes of Persistent Cancer PainCancer Pain

Chemotherapy induced peripheral Chemotherapy induced peripheral neuropathy (CIPN)neuropathy (CIPN)

Radiation-induced painRadiation-induced pain Hormone therapy-induced arthralgiaHormone therapy-induced arthralgia Graft vs Host Disease (GVHD)-related Graft vs Host Disease (GVHD)-related

painpain Surgery-related painSurgery-related pain

Stokowski, L.A. (2011), Stokowski, L.A. (2011), MedscapeMedscape

ChemotherapyChemotherapyNeuropathies, peripheralNeuropathies, peripheral

Difficultly walking, Difficultly walking, potential for falls. potential for falls. Difficulty with cold Difficulty with cold weatherweather

Altered tastes and smellAltered tastes and smell

Appetite issuesAppetite issues

Radiation Radiation TherapyTherapy

Plexopathies-Plexopathies-

delayed onset, delayed onset,

months to yearsmonths to years

Altered sensationsAltered sensationsStricturesStrictures Used with permissionUsed with permission

Hormone Related PainHormone Related PainAromatase InhibitorsAromatase Inhibitors

Approximately 50% of breast Approximately 50% of breast

cancer patients taking adjuvant AIs for cancer patients taking adjuvant AIs for

their cancer report new or worsening their cancer report new or worsening

musculoskeletal pain musculoskeletal pain

Clinical Pain Medicine Clinical Pain Medicine

ISSUE: OCTOBER 2012 | VOLUME: 10:10ISSUE: OCTOBER 2012 | VOLUME: 10:10

(J Clin Oncol 2010;28:4120-4128)

Issues with long term opioid Issues with long term opioid therapytherapy

Now that the disease is stable, who is going Now that the disease is stable, who is going to write the scripts, and for how long?to write the scripts, and for how long?

Does survivor pain management fall to the Does survivor pain management fall to the PCP?PCP?

Chronic side effectsChronic side effects ToleranceTolerance Going back to work, employee drug screensGoing back to work, employee drug screens MoneyMoney Stigma, worry about addictionStigma, worry about addiction Driving, drinkingDriving, drinking Keeping the medication safe, diversionKeeping the medication safe, diversion Sexual dysfunctionSexual dysfunction

Sexual/Intimacy IssuesSexual/Intimacy Issues “ “If You Don’t Ask Me . . . If You Don’t Ask Me . . . Don’t Expect me to Tell”Don’t Expect me to Tell”

JHPN Sept/Oct. 2009JHPN Sept/Oct. 2009 Pilot Study of the Sexual Pilot Study of the Sexual Health of Hospice PatientsHealth of Hospice Patients

Qualitative data, nurses Qualitative data, nurses often feel uncomfortableoften feel uncomfortable

Sexual/Intimacy Issues cont.Sexual/Intimacy Issues cont. Assessment of sexual issues vitalAssessment of sexual issues vital Illicit the conversationIllicit the conversation Don’t assume the patient is too illDon’t assume the patient is too ill Different definition of sexual healthDifferent definition of sexual health Pt’s may feel their body is a source Pt’s may feel their body is a source

of disappointment, disgust and painof disappointment, disgust and pain Facilitating sexual health during Facilitating sexual health during

illness can replace bodily pain with illness can replace bodily pain with pleasurepleasure

GVHD PainGVHD Pain

Chronic graft-versus-host disease following allogeneic stem cell transplantation may resemble various autoimmune conditions. The patient above exhibits symptoms of scleroderma: thickening of the skin on the hands with fascial involvement OncoLog, April 2013, Vol. 58, No. 4

Surgical PainSurgical Pain Post-mastectomy Pain Syndrome (PMP)Post-mastectomy Pain Syndrome (PMP) Post-thoracotomy painPost-thoracotomy pain Phantom limb/breastPhantom limb/breast Neuropathic Neuropathic Dysphasia (62.5%), Head and neck Dysphasia (62.5%), Head and neck

Post-Mastectomy Pain Post-Mastectomy Pain SyndromeSyndrome

Paraesthesia (47%), Chronic Pain (29%), Paraesthesia (47%), Chronic Pain (29%), arm & arm & shoulder shoulder swelling (25%), Phantom swelling (25%), Phantom Sensation (19%), Allodynia (15%)Sensation (19%), Allodynia (15%)

Mejdahl et al Mejdahl et al BMJBMJ2013:346:f18652013:346:f1865

Already known: after Already known: after treatment for treatment for breast breast cancer 25-60% of women experience cancer 25-60% of women experience persistent pain. What study added: Pain persistent pain. What study added: Pain not static. 1/3 of women with pain 2 years not static. 1/3 of women with pain 2 years after treatment, reported no pain six years after treatment, reported no pain six years after treatment. Young age & lymph node after treatment. Young age & lymph node high riskhigh risk

Phantom Limb PainPhantom Limb Pain

2015 Patient Cost 2015 Patient Cost by by

Type of ServiceType of Service

Individually Tailored Individually Tailored CombinationsCombinations

OpioidsOpioids CoanalgesicsCoanalgesics Physical TherapyPhysical Therapy Interventional ProceduresInterventional Procedures Psychosocial InterventionsPsychosocial Interventions Integrative TherapiesIntegrative Therapies Alternative ModalitiesAlternative Modalities

Cannabinoid & Opioid Synergism

Combination cannabinoid-opioid therapy maybe effective for neuropathic pain

The two systems may work synergistically in converging brain pathways.

The cannabinoids have a distinct mechanism of action, targeting ubiquitous cannabinoid (CB) receptors in the central nervous system and periphery

Opioid analgesics less effective for neuropathic pain

Who is responsible?Who is responsible? Opioid issuesOpioid issues Is the knowledge base there for the PCP Is the knowledge base there for the PCP

or other practitioners to treat survivor or other practitioners to treat survivor pain?pain?

Visits to the oncologist are now less Visits to the oncologist are now less frequentfrequent

Are we talking about the need for Are we talking about the need for surveillance and monitoring?surveillance and monitoring?

Is this a role for the pain specialist?Is this a role for the pain specialist? The volumes will continue to increaseThe volumes will continue to increase

Journal of Clinical Journal of Clinical Oncology, 4/21/14Oncology, 4/21/14

Survey of 1,130 oncologists and 1,020 PCPs to Survey of 1,130 oncologists and 1,020 PCPs to assess the practice of survivorship care for assess the practice of survivorship care for cancer patientscancer patients

64% of oncologists discussed survivor plan with 64% of oncologists discussed survivor plan with patientspatients

12% of PCPs12% of PCPs Oncologists stated they had received detailed Oncologists stated they had received detailed

training about late and long-term effects of training about late and long-term effects of cancer survivorscancer survivors

Oncologists also had written care plansOncologists also had written care plans If PCPs received survivorship plans from If PCPs received survivorship plans from

oncologists reported they were more likely to oncologists reported they were more likely to discuss survivorship with patientsdiscuss survivorship with patients

NCCN Survivorship: PainNCCN Survivorship: Pain 2014 Version2014 Version Template for treatment of survivorship Template for treatment of survivorship

pain pain Highlighting functionalityHighlighting functionality Guidelines are EBP to be utilized by Guidelines are EBP to be utilized by

different disciplinesdifferent disciplines Uses a multi-modal, multidisciplinary Uses a multi-modal, multidisciplinary

approachapproach Addresses long-term survivor opioid useAddresses long-term survivor opioid use Empowerment tool for patientsEmpowerment tool for patients

Thank you very Thank you very much!much!

QuestionsQuestions??????