introduction & principles of cancer pain management clinical practice guidelines management of...
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INTRODUCTION &
PRINCIPLES OF CANCER
PAIN MANAGEMENT
Clinical Practice Guidelines
Management of Cancer Pain
Development Group
1
Epidemiology of Cancer
In Peninsular Malaysia, Age Standardised Incidence Rate = 131.3/100,000 population (annual incidence of cancer in Malaysia estimated 35,000 - 40,000)1
Prevalence estimated at 90,0002
Pain is among the commonest symptoms experienced by cancer patients
1NCR Cancer Incidence Report 20062GCC Lim 2001 2
Cancer Pain Statistics
Paucity of data available in Malaysia
Based on global figures: Cancer pain prevalence = 45,0001 (50% of cancer patients experience pain and 70% of
advanced cancer patients experience pain – Bonica JJ 1985)
Moderate to severe cancer pain prevalence = 15,000 (1/3 of cancer pain patients have moderate to severe pain)2
1Lim R, Oncology, 20082van den Beuken-van Everdingen MH et al., Ann Oncol, 2007 3
““Relief of pain allows the Relief of pain allows the person to live the rest of person to live the rest of his/her life constructively his/her life constructively & productively.& productively.
PALLIATIVE CARE PALLIATIVE CARE USING MORPHINE USING MORPHINE RELIEVES CANCER RELIEVES CANCER PAIN IN 90% OF PAIN IN 90% OF PATIENTS.”PATIENTS.” WHO Cancer & Palliative Care Unit, WHO Cancer & Palliative Care Unit, GenevaGeneva
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2005 Global Consumption of Morphine
0
20
40
60
80
100
120
140
156 Countries
Global mean (5.5708 mg)
Malaysia (0.9230 mg)
International Narcotics Control Board 20078
2005 Global Consumption of Fentanyl
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
147 Countries
Global mean (0.1643 mg)
Malaysia (0.0122 mg)
International Narcotics Control Board 20079
Usage of Opioids in Malaysia 2005
Opioid DDD/1000 population/day
Morphine Total 0.1094
Public 0.0867
Private 0.0227
Fentanyl Total 0.0065
Public 0.0032
Private 0.0033
Oxycodone Total 0.0002
Public <0.0001
Private 0.0002
Malaysian statistics on medicine 200510
Interpretation
If the DDD for morphine of a country is 1 DDD/1000 population/day:
1 person in every 1000 population has 1 person in every 1000 population has received 100 mg of oral morphine dailyreceived 100 mg of oral morphine daily
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Morphine Usage in Malaysia Total population in Malaysia in 2005 =
26.13 million
1 DDD/1000 population/day = 26,130 people receiving 100 mg of oral morphine daily
26,130 x 0.1094 = 2,858 Malaysians receive an average of 100 mg oral morphine daily
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Why is a CPG on Cancer Pain Management needed?
It is estimated that <20% of cancer patients in Malaysia who experienced moderate to severe cancer pain received opioid analgesia1
Many healthcare providers are “uncomfortable” & unfamiliar with using opioid analgesia for treating cancer pain adequately
The World Health Organization & the International Association for the Study of Pain have stated that “Pain Relief is a Basic Human Right”
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1Lim R, Oncology, 2008
Principles of Cancer Pain Management Comprehensive pain assessment prior to
treatment Understanding the concept of ‘total pain’ Reassessment & adjustment of treatment when
indicated Inter-professional collaboration in
multidisciplinary teams Participation of patients & their family
members/carers
14
1.Mehta A et al.., J Hospice & Palliative Nursing, 2008 2Clark, D. “Total pain,” disciplinary power and the body in the work of Cicely Saunders, 1958–1967. Social Science and Medicine, 1999; 49: 727–736
Total Total PainPain
PhysicalPhysical PsychologicalPsychological
SocialSocial SpiritualSpiritual
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Four-pronged approach1
1. Assess & reduce noxious stimuli. Treat the cancer – RT, Chemo, Surgery
2. Raise threshold to pain – listen to the patient’s story. Reduce anxiety/depression
3. Consider opioid therapy – WHO ladder
4. Consider management of opioid poorly responsive opioid pain – adjuvants, nerve blocks
1Lickiss JN, Eur J Pain, 200116
Multidisciplinary Care & Involvement of Family
Inter-professional collaboration in managing cancer pain has shown:1, level III
o Improvement in mean patient satisfaction (p<0.001)o Less uncertainty & concerns among patients (p=0.047)o Adequacy in pain management (p=0.016)
Involvement of patients & their family carers in the management of cancer pain reduces barriers to analgesic use (p<0.0001) & decreases the worst pain score (p<0.05)2, level I
1San Martin-Rodriguez L et al., Cancer Nurs, 20082Lin CC, et al., Pain, 2006 17
CPG Development CommitteeChairman: Dr. Richard Lim Boon Leong Consultant Palliative Medicine Physician
Dr. Azizul Awaluddin,
Consultant Psychiatrist, Hospital Putrajaya Dr. Azura Deniel, Clinical Oncologist , HKL A/P Dr. Choy Yin Choy, Senior Consultant
Anaesthesiologist , PPUKM Matron Morna Chua Wui Lang, Hospital QE Dr. Eni Juraida Abdul Rahman, Senior
Consultant. Paediatric Haemato-oncologist, HKL Dr. Ismail Aliyas, Consultant Gynae-oncologist,
Hospital Sultanah Bahiyah Datuk Dr. Kuan Geok Lan ,
Senior Consultant Paediatrician, H. Melaka Dr. Lim Zee Nee,
Palliative Medicine Physician, Hospis Malaysia Cik Lee Ai Wei, Pharmacist ,Hosp. Selayang Pn. Lim Khee Li, Physiotherapist ,HKL
Dr. Mary Suma Cardosa, Sen. Consultant Anaesthesiologist & Pain Specialist,H. Slyg
Professor Dr. Marzida Mansor, Senior Consultant Anaesthesiologist, PPUM
Dr. Mohd. Aminuddin Mohd. Yusof, Public Health Physician. MaHTAS
Dr. Ramesh R. Thangaratnam, Consultant Surgeon ,Hospital Serdang
Pn. Rosaniza Zakaria ,
Medical Social Worker , Hospital Selayang Dr. Sinari Salleh, Consultant Clinical
Haematologist, Hospital RPZ II Dr. Sri Wahyu Taher, Consultant Family
Medicine Specialist, KK Bdr Sg. Petani Dr. Yeat Choi Ling , Palliative Medicine
Physician, Hosp. Raja Perempuan Bainun Dr. Zubaidah Jamil ,
Clinical Psychologist, UPM
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Level of Evidence
Level Study design
I Evidence from at least one properly randomised controlled trial
II -1 Evidence obtained from well-designed controlled trials without randomisation
II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or group
II-3 Evidence from multiple time series with or without intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence
III Opinions of respected authorities based on clinical experience; descriptive studies and case reports; or reports of expert committees
SOURCE: US / CANADIAN PREVENTIVE SERVICES TASK FORCE
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Grades of Recommendations
AAt least one meta analysis, systematic review, or RCT, or evidence rated as good and directly applicable to the target population
B
Evidence from well conducted clinical trials, directly applicable to the target population, and demonstrating overall consistency of results; or evidence extrapolated from meta analysis, systematic review, or RCT
CEvidence from expert committee reports, or opinions and /or clinical experiences of respected authorities; indicates absence of directly applicable clinical studies of good quality
SOURCE: MODIFIED FROM THE SIGNNote: The grades of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation
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