Current practices, gaps, and opportunities on the role of clinical pharmacists in cancer pain management:Perspectives from Nepal

N/

What is “Opioid Stewardship”?:An Overview of Current Definitions and Proposal for a Universally Acceptable Definition

Introduction: Opioid stewardship has been widely used to promote rational use, monitoring and discontinuation of opioid therapy; however, its definition and scope of practice remain unclear. Objective: To synthesize definitions of opioid stewardship proposed by clinical practice guidelines and professional societies, and to offer a proposal for a universally acceptable definition. Methods: Systematic literature searches were performed (earliest records to May 2022) in six databases (MEDLINE, EMBASE, APA PsycINFO, Scopus, and CENTRAL) and grey sources guidelines development bodies and professional societies through Google. The conventional but widely applied content analysis and word frequencies were used to analyze the definitions and scope of practice. Results: After removing duplicates, 449 articles were retrieved (439 databases and registers and 11 from other sources), 19 of which included a definition of “opioids stewardship”. A total of 12 themes was identified in the definitions, including 1) improvement or appropriateness of prescribing opioids use, 2) mitigation of risk from opioids, 3) monitoring opioid use, 4) evaluation of opioid use, 5) judicious opioid use, 6) appropriateness of opioid disposal, 7) identification and treatment of opioid use disorder, 8) reduction in mortality associated with opioid overdoses, 9) appropriate procurement practices, 10) appropriate storage, 11) promoting better communications between patients and prescribers including education provision and 12) patient-centered decision-making. Conclusion: Opioid stewardship is inconsistently defined across professional and research literature. While there is a greater focus on appropriateness and need for improvement of prescribing and monitoring of opioid use, the importance of communications between patients and prescribers, and patient involvement in both prescribing and deprescribing decision-making remains sparse. A comprehensive definition has been proposed as part of the work. There is a need to develop and validate the proposed definition and scope of practice to promote rationale for opioid prescribing, use and attainment of favourable outcomes through international consensus involving practitioners, researchers, and patients

Acrometastasis to hand in vaginal carcinoma: A rare entity

Although metastases to bones from solid tumors are very common, involvement of small bones of the hands is extremely rare. We report the first case of acrometastasis in vaginal carcinoma. We present a 65-year-old multiparous woman with FIGO Stage II vaginal carcinoma. The patient received treatment with external beam radiotherapy followed by brachytherapy. She had complete response to above treatment. Eleven months later, she presented with swelling on dorsum of hand. Investigations revealed metastasis to 4th metacarpal bone with lung metastasis. Hence, we present a patient with metastasis of carcinoma vagina to the 4 th metacarpal to draw the attention for the potential of such lesions to be developed in this region. It should be remembered that bone metastasis at unusual sites might be seen in vaginal carcinoma. We present this case because of its rarity and for documentation and discussion

Interstitial brachytherapy for internal mammary node in breast cancer: A case report

This case study reports the feasibility, safety, and efficacy of interstitial brachytherapy for internal mammary nodal recurrence in a 68-year-old woman with triple-negative breast cancer. The patient had previously undergone mastectomy followed by chemotherapy and radiotherapy. However, an internal mammary node was discovered during a routine follow-up a year later, which was confirmed as metastatic carcinoma by fine needle aspiration, with no other metastatic lesions. The patient underwent interstitial brachytherapy under ultrasound and computed tomography (CT) guidance, with a prescribed dose of 20 Gray in one fraction. Follow-up CT scan imaging over a 2-year period of treatment showed a complete resolution of internal mammary node. Therefore, brachytherapy may be considered a potential treatment option for cases of isolated internal mammary node recurrence in breast cancer

“The Use of Olanzapine compared to Aprepitant as antiemetic for prevention of chemotherapy induced nausea and vomiting in highly emetogenic chemotherapy -A Randomized Trial.”

Chemotherapy induced nausea and vomiting (CINV) is still major problem in oncology. Though new antiemetic drug have markedly reduced incidence of CINV those who experience it have poor quality of life. NK1 receptor antagonist(Aprepitant or Fosparitant), 5HT3 receptor antagonist and dexamethasone combination are recommended for highly emetogenic chemotherapy. Though alternative drugs are tried only olanzapine had showed some potential as standard antiemetic therapy and has been used in addition to standard therapy or replacing NK1 receptor antagonist. In developing country like Nepal NK1 receptor is not freely available and expensive as well so sometimes clinicians have to prescribe substandard antiemetic therapy (5HT3 receptor antagonist and dexamethasone only). This study was done to check if Olanzapine have similar efficacy as NK1 receptor antagonist so we can replace it with freely available, cheaper alternative. The results are encouraging and future studies will help to establish olanzapine as equally effective alternative to NK1 receptor antagonist

Clinical pharmacists’ intervention on pain management in cancer patients (PharmaCAP trial):study protocol for a randomized controlled trial

Introduction: Evidence-based services to support cancer patients with pain via clinical pharmacy services are currently lacking. Therefore, there is a need to undertake a randomized controlled trial (RCT) to explore the effectiveness of clinical pharmacists (CPs)’ input into the multidisciplinary team (MDT) in providing better therapeutic outcomes for cancer pain management. Objectives: The main aim of this pilot RCT is to determine the feasibility and preliminary efficacy of integrating CPs into the MDT for cancer pain management on the clinical outcomes of cancer patients experiencing pain. Methods: This study protocol outlines two-armed multicenter pilot RCT. Cancer patients suffering from pain will be randomly allocated to receive either clinical pharmacy services, i.e., PharmaCAP trial intervention from the CP, or the usual standard care (i.e., control group). Patients will be recruited consecutively from two hospitals in Kathmandu valley, Nepal. The outcomes will be assessed at baseline (pre-intervention) and 4 weeks post-intervention. The primary feasibility outcomes will include eligibility rate, recruitment rate, willingness to participate, acceptability of screening procedures and random allocation, possible contamination between the groups, intervention fidelity and compliance, treatment satisfaction, and patient understanding of the provided interventions. Subsequently, the primary clinical outcome, i.e., pain intensity of cancer patients, will be assessed. The secondary clinical outcomes will include health-related quality of life (HRQoL), anxiety, depression, adverse drug reactions, and patient medication compliance following the integration of CP into the healthcare team. Discussion: The feasibility and potential for integrating CP involvement in MDT to improve clinical outcomes of cancer patients with pain will be evaluated through the PharmaCAP trial

Clinical pharmacists’ intervention on pain management in cancer patients (PharmaCAP trial): study protocol for a randomized controlled trial

Introduction: Evidence-based services to support cancer patients with pain via clinical pharmacy services are currently lacking. Therefore, there is a need to undertake a randomized controlled trial (RCT) to explore the effectiveness of clinical pharmacists (CPs)’ input into the multidisciplinary team (MDT) in providing better therapeutic outcomes for cancer pain management. Objectives: The main aim of this pilot RCT is to determine the feasibility and preliminary efficacy of integrating CPs into the MDT for cancer pain management on the clinical outcomes of cancer patients experiencing pain. Methods: This study protocol outlines two-armed multicenter pilot RCT. Cancer patients suffering from pain will be randomly allocated to receive either clinical pharmacy services, i.e., PharmaCAP trial intervention from the CP, or the usual standard care (i.e., control group). Patients will be recruited consecutively from two hospitals in Kathmandu valley, Nepal. The outcomes will be assessed at baseline (pre-intervention) and 4 weeks post-intervention. The primary feasibility outcomes will include eligibility rate, recruitment rate, willingness to participate, acceptability of screening procedures and random allocation, possible contamination between the groups, intervention fidelity and compliance, treatment satisfaction, and patient understanding of the provided interventions. Subsequently, the primary clinical outcome, i.e., pain intensity of cancer patients, will be assessed. The secondary clinical outcomes will include health-related quality of life (HRQoL), anxiety, depression, adverse drug reactions, and patient medication compliance following the integration of CP into the healthcare team. Discussion: The feasibility and potential for integrating CP involvement in MDT to improve clinical outcomes of cancer patients with pain will be evaluated through the PharmaCAP trial. Trial registration: ClinicalTrials.gov NCT05021393. Registered on 25th August 2022.</p

Uterine Cancer Treatment: Experience in two Centres in Nepal

Background: Information and studies regarding uterine cancer are limited in Nepal. The aim of this study is to assess the clinical characteristic features and treatment outcomes of uterine cancer managed in two hospitals of Nepal. Methods: A retrospective descriptive study was conducted of all uterine cancer cases managed in gynecology department of Civil Service Hospital and National Cancer Hospital from August 2014-January 2016. The case record of all women diagnosed to have uterine cancer were retrieved and demographic characteristics, clinical presentations, histological type, treatment modalities and outcome were obtained and analyzed. Patients were followed up to five years and information regarding recurrence and mortality were obtained. Results: There were 30 uterine cancers cases during study period with age ranging from 33-72 years (mean 53.3years). One case was unmarried while rest 29 (96%) were married, with parity ranging from 0-11. Abnormal uterine and postmenopausal bleeding were the commonest presentations. Histopathologically, endometrial adenocarcinoma accounted for 25 cases (83%), uterine sarcoma four cases (13%) and malignant mixed mullerian tumour one case (4%). All the endometrial cancers were preoperatively diagnosed by endometrial biopsy whereas all cases of uterine sarcomas were reported as leiomyoma radiologically, had benign findings in endometrial biopsy and were only diagnosed post-operatively by histopathology. All cases were treated primarily with surgery. Twenty four patients (80%) received adjuvant therapy according to stage and grade of the disease. Clinical follow-up showed 18 (62%) cases were disease free; 11 (36.67%) developed recurrence, mortality occurred in 9 (31%), two are living with disease and one case is lost to follow up. Conclusions: Endometrial cancer can be usually diagnosed pre-operatively by endometrial biopsy, however, uterine sarcoma is often missed. Surgery is the main treatment modality of uterine cancers