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P Sylvester (MBBS),D Narinesingh (MBBS ,MMed ,FCRadOnc). The patient with metastatic bone pain: A practical evidenced based approach. Case. 50 year old female Metastatic Left Breast cancer Solitary Liver metastases ER+ PR+ HER2+ Performance status (PS) = 2 Severe lower back pain - PowerPoint PPT Presentation
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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