THE PATIENT WITH METASTATIC BONE PAIN:

A PRACTICAL EVIDENCED BASED APPROACH

P Sylvester (MBBS),D Narinesingh (MBBS ,MMed ,FCRadOnc)

Case

50 year old female Metastatic Left Breast cancer

Solitary Liver metastasesER+ PR+ HER2+Performance status (PS) = 2

Severe lower back pain Numerical pain score = 8Bone scan and MRI revealed bone

metastases to vertebra L5

Bone Pain

WHO Analgesic Ladder

Radiotherapy BMA

Bone pain

Affects quality of life (Mental + Physical) Nociceptive somatic pain Assessment of pain by :

0-10 Numeric pain scaleFaces pain rating scale

Three intensities:Mild pain(1-3); Moderate(4-6); Severe (7-10)

Psychosocial support and Patient education

NCCN guidelines Version 1.2012 , Adult Cancer Pain

WHO Analgesic Ladder

http://pharmacologycorner.com/wp-content/uploads/2009/03/image.png

Commonly Selected Analgesics

Non opiodAcetaminophenIbuprofenDiclofenac Arcoxia/ Celebrex

Combined ( Weak Opioid + Non opioid) Panadeine Tramacet

Opioids Morphine sulphate oralMorphine parenteral

Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v257-v260, 2010

Opioid Scheduling and titration

Goal Rapid pain relief Initial dose regime 5-7.5mg sc q 4hr “Breakthrough dose”transient

exacerbations of pain = 10-15% of total daily dose

Revision of analgesic regimemore than 4 “breakthrough” doses per day

are administered dose titration

Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v257-v260, 2010

Co analgesics for neuropathic pain Antiepileptic

CarbamazepinePregabalin

Antidepressant FluoxetineAmitryptiline

Neuroleptic HaloperidolChlorpromazine

Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v257-v260, 2010

Bone modifying agents (BMA’s)[1]

Adjunctive therapy for pain control Zoledronic acid/Donesumab Donesumab superior in terms of delaying

SRE[2]

Calcium and Vitamin D supplementation Monitor creatinine clearance for intravenous

bisphosphonates Monitor calcium levels Dental exam and preventive dentistry before

using a BMA[1]Van Poznak CH, Temin S, Yee GC, et al: American Society of Clinical Oncology Executive Summary of the Clinical Practice Guideline Update on the role of Bone-Modifying Agents in Metastatic Breast Cancer. J Clin Oncol 29:1221-1227, 2011[2] Stopeck A, et al. J Clin Oncol. 2010;28:5132-5139.

Palliative radiotherapy Specific and Critical efficacy in pain relief[1]

Clinical mark upAreas of maximal pain intensityWhole pelvis radiationRadiation to spine

Doses (tailored to Performance Status) 8Gy in 1# / 30Gy in 10# / 20Gy in 5#Studies show 8Gy in 1# = 30Gy in 10# [2]

Bone targeted radioisotopesE.g.Strontium-89

[1] Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v257-v260, 2010[2]  Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005;97:798-804.

Case Management Initial Bone Pain Management

Zoledronic acid 4mg iv q 4weeksOral Morphine

Mild relief after initial management Also developed BL Lower limb paresthesiae 2o

tumor infiltration Palliative RT to L5 (30Gy in10#) Had good pain relief after RT

Now on Pregabalin After one year of BMA therapy

○ Pain score = 1○ PS = 0

IN SUMMARY

Mild to

Moderat

e

•Non opioids ± weak opioids

•Zoledronic acid

Severe

•Opioids

•Zoledronic acid

Refractory

pain

•Palliative RT

•Reassess pain