Struggling With Severe Cancer Pain In The Middle Of Night? - Removemypain

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Learn More About Breakthrough Pain In Cancer

Medical advancement has transitioned cancer from being a rapidly fatal disease to a chronic disease. Cancer pain, however, still remains a major problem affecting 30–40% at the time of diagnosis, and 75% of those with advanced cancer. Although it may not always be possible to relieve the cancer-related pain completely but fortunately it can be effectively managed in most individuals with appropriate therapy. Effective pain control has been shown to improve the quality of life in all stages of the disease. Breakthrough pain is one pain which troubles even those cancer patients whose pain is otherwise well controlled. Its management requires careful evaluation by specialists with attention to detail. In the subsequent section we discuss more about the breakthrough pain and commonly asked questions.

What is breakthrough pain?

Breakthrough cancer pain (BTcP) is a transient exacerbation of pain superimposed on the background of controlled persistent pain. In simple words it refers to the sudden, relatively short lasting severe pain episodes one experiences from time to time, often catching one unprepared, despite having background pain well controlled.

Here are a few characteristics of breakthrough pain

• Pain is of moderate to severe intensity (between 4-10/10, average score 7/10)
• Onset is rapid (between 3 to 5 minutes) or in some cases more gradual reaching peak intensity within a few minutes. In about two thirds of the patients time to maximum pain intensity is less than 10 minutes
• Duration of an untreated episode can be between 1 min and 4 h (average 30 min)
• Multiple, predictable (in one third of patients) or unpredictable episodes throughout the day

Effective pain management requires assessment of responsible factors and having a management plan rather than trying to reach out for emergency services during unsocial hours in a panic mode. 

How common is breakthrough pain and what causes this pain?

BTcP is a common problem with studies reporting the incidence as approx. 50% to 75%. This is despite using strong painkillers to control the baseline pain. Patients with the severe persisting pain, advanced cancer disease, and aggressive anticancer treatments are more likely to experience breakthrough pain. 

BTcP may result from the cancer itself (70–80% of cases) or the anticancer treatment (10–20% of cases) and is seen more commonly is association with certain cancers like head and neck cancer (70%), gastrointestinal (59%), lung (55%) and breast cancer (52%). Common examples of BTcP include mouth pain on swallowing due to inflammation of mouth lining (mucositis) or bone pain due to movement. 

BTcP can originate from numerous sources (somatic, visceral, or neuropathic) and the cause may be different from the sources of persisting background pain. It may be associated with 

• Voluntary movements like sitting, standing
• Involuntary movements like intestinal distension or
• May occur spontaneously

This distinction is relevant as it may encourage more targeted treatment approaches. Up to half of the patients may experience two or more types of BTcP. Sometimes the term episodic pain is used synonymously with breakthrough pain although some researchers ascribe a different meaning to this term.

Another type of BTcP which one commonly encounters is the increased pain that can occur when the effect of painkillers is wearing off, just before the next dose is due. This is addressed as the “end of dose failure.” Some studies include this as a type of breakthrough pain whereas others do not.

Why do we need to treat breakthrough pain?

Breakthrough cancer pain is a common problem and can be associated with a variety of physical, psychological and social complications. Persisting pain often robs the sufferers of their independence and their ability to perform routine tasks, adversely affecting the quality of life. Besides causing suffering, the severity and unpredictability of breakthrough pain can adversely impact one’s confidence level, emotional health and social interactions. Moreover, it is associated with increased utilisation of healthcare and social care services with obvious financial implications.

How do we address this type of pain?

All cancer pain patients should be specifically assessed for the presence of BTcP. A standard pain management & palliative care practice is to prescribe medications for the constant background pain and a separate on-demand dose of pain relieving measures for breakthrough pain. In BTcP there is no one treatment which works universally and the treatment needs to be individualised. 

Selecting the right option requires a fair amount of expertise and familiarity with all the available options. There are a number of factors which need to be taken in to account when deciding on the treatment and these include

• The underlying cause of pain
• Type of pain (nerve pain, nociceptive, mixed)
• Pain characteristics (onset, duration, severity)
• Predictable or unpredictable
• Previous response to pain relieving medications including opioids (efficacy, tolerability)
• Background analgesic medications (may need to be adjusted) and drug interactions
• Patient-related factors including age, other organ function, stage of the cancer and individual preferences
• Cost, availability and safety aspects

Opioids (morphine-like drugs) are considered the preferred medications for treating BTcP. The profile of the drug selected to treat the BTcP needs to mirror the pain profile one is experiencing. For example, in cases of sudden onset short-lasting pain episodes, drugs like oral morphine may prove to be ineffective as they take 30 to 45 minutes to work. In such a situation rapidly acting drugs are more likely to be useful. A mismatch between pain profile and drug selected is likely to produce poor relief and/or more side effects 

The route of drug administration is important as it controls how quickly the pain relieving effects are apparent. Drugs given directly into the veins have a rapid effect although it requires an intravenous cannula to be present. Alternative routes such as through the nose or by intraoral route (sucking on tablets) of the rightly chosen drugs work within 5 -15 min. The dose of ‘rescue medication’ is determined by individual titration to ensure maximum relief with minimal side effects and may be subject to change over time.

A predictable episode of BTcP triggered by known factors for example, eating can be managed by a planned administration of medicine prior to the activity taking into account the time taken for the medication to work. Some patients choose to restrict activity to reduce the number of  BTcP episodes.

Once the trial medication has been started, dose titration and regular reassessments are essential. All patients with new BTcP medications should be reevaluated within 48–72 h. Patient education regarding the correct and appropriate use of medications is essential as research evidence demonstrates incorrect usage, misuse/abuse, and underuse in a significant proportion. 

Other non-opioid drugs are also useful in the management of BCP. Examples include anti-inflammatories, benzodiazepines, paracetamol, etc. Preventing and treating BTcP is not just about medications as interventional techniques and non-pharmacological methods are other options that can be helpful.

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Struggling With Pain After Breast Cancer Surgery? Learn More About Post Mastectomy Pain

Breast cancer is a common cancer among women worldwide. A variety of problems can occur during treatment, and persisting pain after surgery is one such issue. It can affect 20% to 50% of women after mastectomy (operation involving removal of breast) and is defined as pain in the chest, armpit, upper arm, and shoulder persisting for more than 3 months post-surgery. Treating this pain is important as persisting pain besides causing suffering, can negatively impact on mood, sleep, activities of daily living, social interactions, and overall quality of life. Reduced working ability and financial implications are obvious consequences as shown in one study where 54% of individuals reported reducing their workload to part-time as a direct result of pain. As survivorship is increasing, enabled by the technological advancements in medicine, the focus needs to be equally on quality of life and reducing suffering. Phantom breast sensation (where one feels that the removed breast is still present) has an even higher incidence (60-80% of patients). The actual problem and pain may be underreported due to reasons such as worries about cancer reoccurrence, barriers in discussing personal issues, fear of being misconstrued, etc.

Another subgroup of patients undergoing mastectomy are those who want to reduce their risk of developing breast cancer such as those with gene mutations (e.g., BRCA1, BRCA2) and strong family history. Advances in surgical treatment like breast-conserving approaches have enabled patients to really consider this option.

Who are at risk of developing persisting pain?

Some factors associated with increased risk of persisting pain include:

Type of surgery: Nerve preservation approaches are associated with a reduced incidence of sensory deficits (53 % vs. 84 %) but may not be possible in all cases.

Different breast cancer surgery options include

• Radical mastectomy – involves removing the breast, skin, fat, chest muscles (pectoralis major and minor), and all the lymph nodes of the affected side.
• Modified radical mastectomy spares the chest (pectoral) muscles when compared to the surgery mentioned previously.
• Lumpectomy with axillary node dissection involves removal of the tumor with a surrounding margin of normal tissue and the axillary (armpit) lymph nodes.
• Breast-conserving surgery (lumpectomy) also known as breast preservation, conservative breast surgery, wide local excision, partial mastectomy is generally used in early breast cancer  and involves removal of the tumour and a margin of normal tissue.
• Lumpectomy with sentinel lymph node biopsy involves removal and examination of the first axillary node (sentinel node) receiving drainage from the breast. The node is identified by injection of a special dye/ radiolabeled substance prior to the operation. If this node is free of disease, axillary dissection is not required.

Axillary nodes dissection leads to increased chances of lymphedema (arm swelling due to inadequate drainage) and poses risks to one of the nerves (intercostobrachial nerve) which is responsible for the sensation of the inner aspect of the upper arm. Both of these factors can become a source of persisting pain. The wide variation in the size, location, and branching patterns of the nerve makes it more vulnerable to injury. Damage may occur as a result of stretching during surgery or direct nerve injury, presenting with numbness and pain in the area supplied by the nerve. As per one study women with axillary node dissection are 3.1 times more likely to experience moderate-to-severe pain at rest.

Other nerves in the area are also at risk of injury and can become a source of persisting pain. These include 

• The medial cutaneous nerve of the arm (provides sensation to the lower medial skin of the upper arm (damaged during a section of the tributaries of the axillary vein)
• Medial and lateral pectoral nerves (control the chest wall or pectoral muscles)
• Long thoracic nerve (controls the serratus anterior muscle present along the side of chest wall close to armpit)
• Thoracodorsal nerve (controls the latissimus dorsi muscle)

Other treatments like radiation therapy administered in conjunction with surgery increase risk of persisting pain. This may be due to increased tissue fibrosis, neural entrapment, and impaired shoulder movement. Moreover, radiotherapy also increases the risk for lymphedema which is another reason for persisting pain. The later-stage disease also is likely to require more aggressive treatment (i.e., chemotherapy) and may be associated with higher rates of pain. Regardless these are necessary treatments and when indicated should be pursued. 

Pre-existing pain prior to surgery is one of the most consistent factors related to the increased risk of persisting pain after surgery. Even those patients with unrelated pain conditions such as headaches or low back pain are more likely to develop chronic pain after surgery. 

Severe pain after the operation requiring high doses of painkillers increases the likelihood of persisting pain.

Age: In several studies, younger age was seen to be associated with a greater likelihood of persistent pain. Although the exact reason is not known, some postulated factors include the presence of more aggressive cancers requiring more aggressive treatment, higher preoperative anxiety, and the need for adjuvant chemotherapy in this group.

Psychosocial distress can be both a risk factor for and a consequence of chronic pain. Preoperative anxiety has been found to be related with immediate postoperative pain levels. Numerous studies have found correlations between persisting pain after surgery and depression, stress, and psychological vulnerability. 

Tag = Cancer Pain Treatment in Gurgaon, Cancer Pain Treatment in Delhi, Pain specialist in Gurgaon, Pain specialist in Delhi, Pain Management in Delhi

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Are You suffering from numbness, tingling or burning sensation after Chemotherapy?

 

What is peripheral neuropathy?

Peripheral nerves carry sensations from the different parts of your body to the brain and control the movement of our arms and legs. The set of symptoms resulting from damage to these nerves is addressed as Peripheral neuropathy. Symptoms are usually symmetrical starting from toes and fingers, and progress towards the body. Common symptoms include

• Tingling or pins and needles sensation in hands of feet
• Numbness and reduced ability to feel hot and cold
• Sharp, electric, burning pain
• Sensitivity to touch, pressure or temperature 
• Balance issues and difficulty walking
• Leg cramps 
• Weakness
• Difficulty with fine activities such as writing, buttoning and unbuttoning 

What is Chemotherapy Induced Peripheral Neuropathy (CIPN)?

Some of the chemotherapy drugs used to treat cancer can cause peripheral nerve damage. This is addressed as chemotherapy-induced peripheral neuropathy (CIPN).

The symptoms of CIPN include all peripheral neuropathy symptoms mentioned above, with the most common one being numbness and tingling starting in fingers and toes and progressing proximally as the condition progresses. This appears earlier and is generally more prominent than pain. CIPN can have an impact on ones sleep, mood, functionality and quality of life (QOL).

Symptoms can appear hours to days after chemotherapy and the condition can worsen with additional chemotherapy cycles. The progression usually levels off after stopping the chemotherapy except in the case of platinum-based drugs where the sensation may continue to deteriorate for several months.

Different patterns can be seen with different drugs like in Oxaliplatin (a chemotherapy drug) induced acute neuropathy, there is cold sensitivity, throat discomfort, discomfort swallowing cold liquids, and muscle cramps with more severe symptoms in upper limbs. The usually peaks 2 to 3 days after each dose and can increase in subsequent treatment cycles.

In Paclitaxel (another chemotherapy drug) induced acute neuropathy the pain occurs in truncal/hip distribution or lower extremities and tends to resolve more between doses. The symptoms peak approximately in 2 to 3 days after each dose and are not worsened in subsequent cycles.

What are my chances of getting CIPN?

CIPN affects approximately 30% and 40% of patients undergoing chemotherapy and the risk varies with factors such as

• Drugs used – Some drugs are more likely to cause CIPN than others. A list of some of these is included at the end of this blog.
• Duration of use
• Dose used
• Pre-existing neuropathy
• Comorbidities such as diabetes, vitamin deficiencies
• Age

Can CIPN be cured or is it permanent?

In most cases the CIPN symptoms go away with time. They can last for weeks, months, or even years after treatment. It does vary depending on the drugs, doses used and in some cases it can be permanent. Unfortunately, there is no clear cure or treatment that will repair nerve damage.

What should I do to deal with CIPN?

It is a good idea to report your symptoms to the team looking after you and they may consider altering the treatment plan to prevent your symptoms from worsening. This may involve dose delaying, reduction, stopping chemotherapy or substituting with other agents that do not cause CIPN. A pain specialist opinion should be taken if your symptoms are severe and require specialist input. A pain specialist may prescribe nerve types of painkillers which need to be taken regularly to help manage your symptoms.

Other measures which can help include

• Avoiding things that make your symptoms worse, such as hot or cold temperature, or tight clothes or shoes
• Regular exercises
• Avoiding smoking and alcohol
• Ensuring normal vitamin levels and blood sugars.

No medication or supplement has been shown to definitively prevent CIPN including N-acetylcysteine, calcium, magnesium vitamin B, vitamin E, omega-3 fatty acids, alpha lipoic acid and cannabinoids. It, however, makes sense to regulate other factors which are known to cause nerve injury such as alcohol intake and blood sugar levels.

When the sensation in hands and feet is affected one might be more prone to injury and sensible precautions are required like

• If the neuropathy involves your hands, protect them while using sharp objects, if it affects the feet protect them by wearing shoes even when you are indoors.
• Avoid extreme temperatures and keep your hands and feet covered, warm in cold weather
• Protect yourself from heat injuries especially when using warm water for washing bathing

What are the other causes of peripheral neuropathy?

There can be many other causes of peripheral nerve damage- some related to cancer and some independent. Determining the underlying cause is important as it may have a bearing on the treatment.

Related to cancer and its treatments.

• Surgery or radiotherapy
• Tumors pressing on nerves

Other independent causes

• Diabetes
• Alcohol abuse
• Shingles, infections involving the nerves
• Low vitamin B levels
• Spinal cord injuries
• Poor circulation (peripheral vascular disease)

How do we manage CIPN?

The importance of discussing with the admitting team, if symptoms of CIPN develop during treatment, has already been discussed. This provides an opportunity to modify treatment and prevent further damage rather than dealing with an irreversible situation later.

IF CIPN develops, pain can often be helped with treatments but the numbness is usually resistant to treatment. Some of the modalities which can be used for treatment include

• Medications used to treat nerve pain such as antiepileptics, antidepressants, topical gels, patches or creams of numbing medicine, strong painkillers such as opioids, steroids
• Drug infusions or pain relieving medications which act on nerves
• Physical therapy can help with balance, strength and safety.
• Occupational therapy can help improve fine motor skills like buttoning shirts
• Relaxation therapy, distraction, biofeedback

Some chemotherapy drugs which are likely to cause CIPN

Certain chemo drugs are more likely to cause CIPN. Some of the more common ones include:

• Platinum drugs like cisplatin, carboplatin, and oxaliplatin
• Taxanes including paclitaxel, docetaxel, and cabazitaxel
• Plant alkaloids such as vinblastine, vincristine, and etoposide
• Immunomodulating drugs like thalidomide, lenalidomide
• Proteasome inhibitors such as bortezomib, carfilzomib, and ixazomib

Tags >> Cancer Pain Treatment in Delhi, Cancer Pain Treatment in Gurgaon, Chemotherapy Induced Peripheral Neuropathy, Peripheral nerves, peripheral neuropathy

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Cancer Pain Treatment In Delhi and Gurgaon - Dr. Amod Manocha

Pain in cancer may arise due to many reasons and is often the presenting complaint leading to the diagnosis of cancer. It may be

• Related to cancer itself or its spread to other body parts
• A late presentation due to side effect of treatments such as chemotherapy, radiotherapy and surgery
• A result of extra stress placed on other body parts for example shoulder pain due to using of a stick for walking
• A totally unrelated coincidental problem such as arthritis

Pain can be of differentiated into background pain (which is always present in the background and is managed with regular medications) and breakthrough pain (pain that breaks through your regular pain relief). Breakthrough pain may occur unprovoked or may be triggered by external or internal factors. In cancer patients, different types of pain may coexist. It is not just limited to pain arising from inflammation and tissue damage for example cancer of the pancreas spreading to neighboring organs and nerves leading to visceral and neuropathic pain respectively and a distant spread to bones producing bone pain. Different types of pain present differently for example

• Neuropathic/ Nerve pain is generally described as burning, shooting, electric shock-like, or stabbing pain with associated tingling or numbness. It may be a consequence of cancer itself or a result of treatments such as chemotherapy (chemotherapy-induced peripheral neuropathy- CIPN).
• Visceral Pain originates from the viscera (organs in the body cavity) and is generally described as deep aching, squeezing, and cramping sensation
• Bone pain presents as an aching, throbbing sensation. Some cancers have a preference to spread to bones

Pain Management

Pain relief needs to be tailored to the cause, severity, and duration of pain. In most cases, a reasonable control can be achieved by using a combination of methods. Multimodal, Multidisciplinary approach provides the opportunity to maximize pain relief and provide support not only for the physical needs but also for the emotional, spiritual, and social needs.  

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