Improving quality of care for cancer pain: an Italian five-year project

Background: cancer pain is still undertreated as for inappropriate use of opioids, as for reason related to other factors. To increase knowledge of cancer pain, the “Mario Negri” Institute promote a series of initiatives to improve the quality of care and patients’ outcomes. Methods: a series of activities were launched including literature review, clinical studies and training schemes. Results: literature reviews shown a prevalence of undertreatment ranged from 8% to 82% and a raw prevalence of BTcP (Breakthrough Cancer Pain) of 51%. In the outcome research study mean worst pain at baseline was 6.8, and 38.3% received a strong opioids. Prevalence of BTcP was 40.3%, and 33.9% of the patients were not receiving rescue therapy at the study inclusion. About analgesic effectiveness of oral and transdermal opioids (TD), treatments with TD were associated with a lower probability to switch (OR=0.83) and to drop out from the study (OR=0.68). Conclusions: the initiative, still ongoing, has allowed a) the creation of a unit for the study and evaluation of cancer pain, b) the production of clinical evidence about the epidemiology, quality and effects of cancer pain management in Italy, c) the design and promotion of a Randomized Controlled Trial to evaluate the effectiveness of four major opioids

Pain management and outcomes in cancer patients: comparison between oncological and palliative sets of care

Background: medical oncologists and palliative care physicians have different tasks even if they play a similar role when coping with pain of their patients. In spite of this converging goal, oncologists and palliative care therapists can not have the same approach and impact in managing pain. This study analyzes how pain is treated and which outcomes derive from in 1 461 cancer patients separately cared by oncologists or palliative care physicians. Methods: data derive from an observational, multicentre, prospective, longitudinal study carried out in 110 Italian hospitals. After inclusion, the data were recorded weekly for a 28 days period of follow-up. Results: 876 patients (60%) were cared by oncologists and 585 (40%) by palliative care physicians. The two professional categories tended to similarly manage the drugs of WHO analgesic ladder, while rescue and adjuvant therapies were more frequently used by palliative care physicians. Opioids daily dose increased from 68.3 to 92.5 mg/day (Effect size=0.282) among oncologists and from 70.8 to 107.8 mg/day (Effect size=0.402) among palliative care physicians. The switch of opioids was applied in 12.3% and in 19.1% (p=0.1634), respectively. Pain intensity decreased in both groups but more strongly in the palliative context. The full responders patients were 50% in oncology wards and 58.9% in palliative care (p=0.0588). Conclusions: this study indicates how much oncologists and palliative care physicians differ in managing cancer pain. The observational nature of this study reflects the natural and unaffected choice of the professionals. As intrinsic limit the study only describes their behaviors without a stringent comparative evaluation

Clinical Care Conditions and Needs of Palliative Care Patients from Five Italian Regions: Preliminary Data of the DEMETRA Project

In order to plan the right palliative care for patients and their families, it is essential to have detailed information about patients' needs. To gain insight into these needs, we analyzed five Italian local palliative care networks and assessed the clinical care conditions of patients facing the complexities of advanced and chronic disease. A longitudinal, observational, noninterventional study was carried out in five Italian regions from May 2017 to November 2018. Patients who accessed the palliative care networks were monitored for 12 months. Sociodemographic, clinical, and symptom information was collected with several tools, including the Necesidades Paliativas CCOMS-ICO (NECPAL) tool, the Edmonton Symptom Assessment System (ESAS), and interRAI Palliative Care (interRAI-PC). There were 1013 patients in the study. The majority (51.7%) were recruited at home palliative care units. Cancer was the most frequent diagnosis (85.4%), and most patients had at least one comorbidity (58.8%). Cancer patients reported emotional stress with severe symptoms (38.7% vs. 24.3% in noncancer patients; p = 0.001) and were less likely to have clinical frailty (13.3% vs. 43.9%; p < 0.001). Our study confirms that many patients face the last few months of life with comorbidities or extreme frailty. This study contributes to increasing the general knowledge on palliative care needs in a high-income country

Nutraceuticals and Exercise against Muscle Wasting during Cancer Cachexia

Cancer cachexia (CC) is a debilitating multifactorial syndrome, involving progressive deterioration and functional impairment of skeletal muscles. It affects about 80% of patients with advanced cancer and causes premature death. No causal therapy is available against CC. In the last few decades, our understanding of the mechanisms contributing to muscle wasting during cancer has markedly increased. Both inflammation and oxidative stress (OS) alter anabolic and catabolic signaling pathways mostly culminating with muscle depletion. Several preclinical studies have emphasized the beneficial roles of several classes of nutraceuticals and modes of physical exercise, but their efficacy in CC patients remains scant. The route of nutraceutical administration is critical to increase its bioavailability and achieve the desired anti-cachexia effects. Accumulating evidence suggests that a single therapy may not be enough, and a bimodal intervention (nutraceuticals plus exercise) may be a more effective treatment for CC. This review focuses on the current state of the field on the role of inflammation and OS in the pathogenesis of muscle atrophy during CC, and how nutraceuticals and physical activity may act synergistically to limit muscle wasting and dysfunction

A new focus on breakthrough cancer pain: Commentary on Davies et al.

A recent review article reports that more than one out of two patients with cancer-related pain also suffers from breakthrough pain (BTcP), however, this finding is based on several investigations with inconsistencies in the definition and assessment of the phenomenon. In the study by Davies et al., led in a sample of 1000 European BTcP patients, BTcP was defined by a unique and standardized diagnostic algorithm. A first interesting result of this study is that epidemiological and clinical aspects of BTcP (prevalence, daily numbers of episodes, time to peak, duration, interferences with daily activities) are referred to separately for the main sub-types of BTcP i.e. incident (44% of the sample) and spontaneous (42%). This is an original approach that highlights some dissimilar features—most notably peak and duration - which could imply the use of different therapeutic strategies. For instance, these observed differences could be used to determine which available rescue drugs are likely to be most effective on the basis of their different pharmacokinetic properties. Moreover, as to the treatments referred by the patients, pharmacological intervention was the preferred option in 29% of cases while a non-pharmacological option was selected by 23% of patients. That is quite surprising because a higher rate of pharmacological strategies would be expected. In parallel, other treatment options selected by patients (e.g., rest, position change, movement, heat/cold, complimentary therapies) reveals a range of solutions rarely described in clinical studies. In conclusion, the results from this study increase our knowledge of BTcP and can steer the direction of its management toward a broader spectrum of effective treatments, including non-pharmacological solutions.JRC.I.2-Public Health Policy Suppor

Nutraceuticals and Exercise against Muscle Wasting during Cancer Cachexia

Cancer cachexia (CC) is a debilitating multifactorial syndrome, involving progressive deterioration and functional impairment of skeletal muscles. It affects about 80% of patients with advanced cancer and causes premature death. No causal therapy is available against CC. In the last few decades, our understanding of the mechanisms contributing to muscle wasting during cancer has markedly increased. Both inflammation and oxidative stress (OS) alter anabolic and catabolic signaling pathways mostly culminating with muscle depletion. Several preclinical studies have emphasized the beneficial roles of several classes of nutraceuticals and modes of physical exercise, but their efficacy in CC patients remains scant. The route of nutraceutical administration is critical to increase its bioavailability and achieve the desired anti-cachexia effects. Accumulating evidence suggests that a single therapy may not be enough, and a bimodal intervention (nutraceuticals plus exercise) may be a more effective treatment for CC. This review focuses on the current state of the field on the role of inflammation and OS in the pathogenesis of muscle atrophy during CC, and how nutraceuticals and physical activity may act synergistically to limit muscle wasting and dysfunction

Quality of cancer pain management: an update of a systematic review of undertreatment of patients with cancer

Purpose: Pain is a frequent symptom in cancer patients with substantial impact. Despite the availability of opioids and updated guidelines from reliable leading societies, under-treatment is still very frequent. Materials and methods: We updated a systematic review published in 2008 which showed that, according to the Pain Management Index (PMI), 43.4% of cancer patients were under-treated. This review included observational and experimental studies reporting negative PMI for adults with cancer and pain published from 2007 to 2013 and retrieved through Medline, Embase and Google Scholar. In order to detect any temporal trend and identify potential determinants of under-treatment we compared papers published before and after 2007 with univariate, multivariate and sensitivity analyses. Results: In the new set of 20 papers published from 2007 to 2013 there was a decrease in undertreatment of about 25% (from 43.4 to 31.8%). In the whole sample the proportion of under-treated patients felt from 2007 to 2013, and an association was confirmed between negative PMI, economic level and non-specific setting for cancer pain. Sensitivity analysis confirmed the robustness of results. Conclusion: Analysis of 46 papers published from 1994 to 2013 using the PMI to assess the adequacy of analgesic therapy suggests the quality of pharmacological pain management has improved. However, about one third of patients still do not receive pain medication proportional to their pain intensity.JRC.I.2-Public Health Policy Suppor

Pain and Frailty in Hospitalized Older Adults

Introduction: Pain and frailty are prevalent conditions in the older population. Many chronic diseases are likely involved in their origin, and both have a negative impact on quality of life. However, few studies have analysed their association. Methods: In light of this knowledge gap, 3577 acutely hospitalized patients 65 years or older enrolled in the REPOSI register, an Italian network of internal medicine and geriatric hospital wards, were assessed to calculate the frailty index (FI). The impact of pain and some of its characteristics on the degree of frailty was evaluated using an ordinal logistic regression model after adjusting for age and gender. Results: The prevalence of pain was 24.7%, and among patients with pain, 42.9% was regarded as chronic pain. Chronic pain was associated with severe frailty (OR = 1.69, 95% CI 1.38-2.07). Somatic pain (OR = 1.59, 95% CI 1.23-2.07) and widespread pain (OR = 1.60, 95% CI 0.93-2.78) were associated with frailty. Osteoarthritis was the most common cause of chronic pain, diagnosed in 157 patients (33.5%). Polymyalgia, rheumatoid arthritis and other musculoskeletal diseases causing chronic pain were associated with a lower degree of frailty than osteoarthritis (OR = 0.49, 95%CI 0.28-0.85). Conclusions: Chronic and somatic pain negatively affect the degree of frailty. The duration and type of pain, as well as the underlying diseases associated with chronic pain, should be evaluated to improve the hospital management of frail older people