Expert consensus on the management of breakthrough cancer pain in older patients. A Delphi study

Alarcón, María Dolores López; Estévez, Francisco; Cabezón-Gutiérrez, Luis; Padrós, Manuel Castillo; Martín-Arroyo, José Manuel Trinidad; Rebollo, Maite Antonio; Jiménez-López, Antonio Javier; Sanz-Yagüe, Almudena

doi:10.1016/j.jgo.2019.03.012

Cited by 13 publications

(12 citation statements)

References 42 publications

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“…Considering that in this study, most patients had a rapid-onset and short duration pain episode, and at least half of the patients had spontaneous BTCP, and as recommended in guidelines [10-12, 25, 26], the transmucosal fentanyl was the most common ROO administered. Moreover, expert consensuses recommend initiating BTcP therapy at low dose in frail patients, and then carefully titrate dose based on efficacy and tolerability [27][28][29]. In many patients of this study, because of their advanced age and frailty, and according to the physician evaluation, fentanyl was titrated starting from the lowest available dose (67 μg).…”

Section: Discussionmentioning

confidence: 99%

Impact of individualized management of breakthrough cancer pain on quality of life in advanced cancer patients: CAVIDIOPAL study

Tuca

Viejo

Maradey

et al. 2021

Support Care Cancer

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Purpose The main aim of the study was to assess the impact of individualized management of breakthrough cancer pain (BTcP) on quality of life (QoL) of patients with advanced cancer in clinical practice. Methods A prospective, observational, multicenter study was conducted in patients with advanced cancer that were assisted by palliative care units. QoL was assessed with the EORTC QLQ-C30 questionnaire at baseline (V0) and after 28 days (V28) of individualized BTcP therapy. Data on background pain, BTcP, comorbidities, and frailty were also recorded. Results Ninety-three patients completed the study. Intensity, duration, and number of BTcP episodes were reduced (p < 0.001) at V28 with individualized therapy. Transmucosal fentanyl was used in 93.8% of patients, mainly by sublingual route. Fentanyl titration was initiated at low doses (78.3% of patients received doses of 67 μg, 100 μg, or 133 μg) according to physician evaluation. At V28, mean perception of global health status had increased from 31.1 to 53.1 (p < 0.001). All scales of EORTC QLQ-C30 significantly improved (p < 0.001) except physical functioning, diarrhea, and financial difficulties. Pain scale improved from 73.6 ± 22.6 to 35.7 ± 22.3 (p < 0.001). Moreover, 85.9% of patients reported pain improvement. Probability of no ≥ 25% improvement in QoL was significantly higher in patients ≥ 65 years old (OR 1.39; 95% CI 1.001–1.079) and patients hospitalized at baseline (OR 4.126; 95% CI 1.227–13.873). Conclusion Individualized BTcP therapy improved QoL of patients with advanced cancer. Transmucosal fentanyl at low doses was the most used drug. Trial registration This study was registered at ClinicalTrials.gov database (NCT02840500) on July 19, 2016.

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Section: Discussionmentioning

confidence: 99%

Impact of individualized management of breakthrough cancer pain on quality of life in advanced cancer patients: CAVIDIOPAL study

Tuca

Viejo

Maradey

et al. 2021

Support Care Cancer

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“…Following the same format as the WHO GETC, panelists classified items as essential, desirable, possibly required, or irrelevant at the district and central hospital level. All items marked essential by at least 7 of the 10 panelists–representing a two-thirds majority consensus [36, 37]–were considered essential (i.e. a minimum requirement) for safe management of adult femoral shaft fractures.…”

Section: Methodsmentioning

confidence: 99%

Assessing the capacity of Malawi’s district and central hospitals to manage traumatic diaphyseal femoral fractures in adults

et al. 2019

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BackgroundThe burden of musculoskeletal trauma is growing worldwide, disproportionately affecting low-income countries like Malawi. However, resources required to manage musculoskeletal trauma remain inadequate. A detailed understanding of the current capacity of Malawian public hospitals to manage musculoskeletal trauma is unknown and necessary for effective trauma system development planning.MethodsWe developed a list of infrastructure, manpower, and material resources used during treatment of adult femoral shaft fractures–a representative injury managed non-operatively and operatively in Malawi. We identified, by consensus of at least 7 out of 10 experts, which items were essential at district and central hospitals. We surveyed orthopaedic providers in person at all 25 district and 4 central hospitals in Malawi on the presence, availability, and reasons for unavailability of essential resources. We validated survey responses by performing simultaneous independent on-site assessments of 25% of the hospitals.ResultsNo district or central hospital in Malawi had available all the essential resources to adequately manage femoral fractures. On average, district hospitals had 71% (range 41–90%) of essential resources, with at least 15 of 25 reporting unavailability of inpatient ward nurses, x-ray, external fixators, gauze and bandages, and walking assistive devices. District hospitals offered only non-operative treatment, though 24/25 reported barriers to performing skeletal traction. Central hospitals reported an average of 76% (71–85%) of essential resources, with at least 2 of 4 hospitals reporting unavailability of full blood count, inpatient hospital beds, a procedure room, an operating room, casualty/A&E department clinicians, orthopaedic clinicians, a circulating nurse, inpatient ward nurses, electrocardiograms, x-ray, suture, and walking assistive devices. All four central hospitals reported barriers to performing skeletal traction. Operative treatment of femur fracture with a reliable supply of implants was available at 3/4 hospitals, though 2/3 were dependent entirely on foreign donations.ConclusionWe identified critical deficiencies in infrastructure, manpower, and essential resources at district and central hospitals in Malawi. Our findings provide evidence-based guidance on how to improve the musculoskeletal trauma system in Malawi, by identifying where and why essential resources were unavailable when needed.

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“…However, in apilot study nasal fentanyl was successfully administered to opioid naïve cancer patients (36). In older patients, the inherent frailty of the population must be acknowledged (37). Hence, a more cautious dose adjustment, following the principle "start low and go slow", is recommended (36).…”

Section: Treatment Challengesmentioning

confidence: 99%

Breakthrough cancer pain in 2020

Løhre

Thronæs

Klepstad

2020

Current Opinion in Supportive &Amp; Palliative Care

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Purpose of the review: An overview on breakthrough cancer pain (BTCP), including inherent limitations of the terminology, assessment, clinical presentation, and treatment options.Recent findings: The estimated prevalence of BTCP is dependent on the defined cutoffs for controlled background pain and the magnitude of the pain flare. In addition, pain flares outside the definition of BTCP are prevalent. In the 11th Revision of the International Classification of Diseases (ICD-11), the temporal characteristics of cancer pain are described as continuous background pain and intermittent episodic pain. BTCP should be assessed by validated methods, and the patient perspective should be included. The pain may be related to neoplastic destruction of bone, viscera, or nerve tissue and is characterized by rapid onset, high intensity, and short duration. Treatment directed towards painful metastases must be considered. Due to pharmacological properties mirroring the pain characteristics, transmucosal fentanyl formulations are important for the treatment of BTCP. Oral immediate release opioids can be used for slow-onset or predictable BTCP. For more difficult pain conditions, parenteral, or even intrathecal pain medication, may be indicated.Summary: All clinically relevant episodic pains must be adequately treated in accordance with the patient's preferences. Transmucosal fentanyl formulations are effective for BTCP.

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Expert consensus on the management of breakthrough cancer pain in older patients. A Delphi study

Cited by 13 publications

References 42 publications

Impact of individualized management of breakthrough cancer pain on quality of life in advanced cancer patients: CAVIDIOPAL study

Impact of individualized management of breakthrough cancer pain on quality of life in advanced cancer patients: CAVIDIOPAL study

Assessing the capacity of Malawi’s district and central hospitals to manage traumatic diaphyseal femoral fractures in adults

Breakthrough cancer pain in 2020

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