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PATIENT AND SURVIVOR CARE The Challenges of Pain Management CHAIR Judith A. Paice, PhD, RN Northwestern University Chicago, IL SPEAKERS Toby Christopher Campbell, MD University of Wisconsin Carbone Cancer Center Madison, WI Eduardo Bruera, MD The University of Texas MD Anderson Cancer Center Houston, TX
CANCER PAIN MANAGEMENT Cancer Pain Management: Safe and Effective Use of Opioids Eduardo Bruera, MD, and Judith A. Paice, PhD, RN OVERVIEW Pain remains a serious consequence of cancer and its treatment. Although significant advances have been made in providing effective cancer pain control, barriers persist. Lack of knowledge, limited time, financial restrictions, and diminished availability of necessary medications serve as significant obstacles. Safe and effective opioid use in a patient with cancer requires skill to overcome these challenges. Understanding the mechanism of action, along with the pharmacokinetics and pharmacodynamics, of opioids will lead to appropriate selection, dosing, and titration of these agents. Rotation from one opioid or route to another is an essential proficiency for oncologists. As opioid-related adverse effects often occur, the oncology team must be expert in preventing and managing constipation, nausea, sedation, and neurotoxicities. An emerging concern is overtreatment—the excessive and prolonged use of opioids in patients when these agents may produce more harm than benefit. This can occur when opioids are used inappropriately to treat comorbid psychologic issues such as anxiety and depression. Recognizing risk factors for overuse along with key components of universal precautions will promote safe use of these medications, supporting adherence and preventing diversion, thereby protecting the patient, the prescriber, and the community. Because substance use disorders are not rare in the oncology setting, attention must be given to the balance of providing analgesia while limiting harm. Caring for patients with substance misuse requires compassionate, multidisciplinary care, with input from supportive oncology/palliative care as well as addiction specialists. Pain is a serious consequence of cancer and its treatment. Although great strides have been made in increasing awareness of the need for effective cancer pain control, barriers persist that lead to undertreatment. 1-3 Health care professionals’ lack of knowledge (despite extensive efforts to improve education), limited access to specialists, and diminished availability of necessary medications are signifıcant obstacles. Insuffıcient time, resulting from increased demands to provide care for more patients during shorter visits, along with expanding requests for documentation, insurance authorizations, and other regulatory requirements, complicates delivery of comprehensive pain control. 4,5 Balancing these demands has proven challenging, and excellent pain control can suffer as a result. Awareness of the safe and effective use of opioids in the oncology setting is essential to the provision of adequate pain relief. Understanding the mechanism of action, along with the pharmacokinetics and pharmacodynamics of opioids will lead to appropriate selection, dosing, and titration of these agents. As adverse effects often occur, the oncology team must be skilled in preventing and managing constipation, nausea, sedation, and neurotoxicities. An emerging concern is overtreatment with opioids—the excessive and prolonged use of opioids in patients when these agents may produce more harm than benefıt. This can occur when opioids are used inappropriately to treat comorbid psychologic issues such as anxiety and depression. Recognizing risk factors for overuse along with key components of universal precautions will promote safe use of these medications, protecting the patient, the prescriber, and the community. PRINCIPLES OF OPIOID USE Opioid analgesics have been the most useful group of drugs for the management of severe pain for more than 200 years. 6 All opioid analgesics work mainly by binding the Mu opioid receptors located along the nociceptive pathway. These Mu receptors are found in multiple locations presynaptically and postsynaptically. The direct result of the opioid binding to the receptor is decreased afferent nociceptive neuronal depolarization. In recent years it has become clear that new receptors have multiple subtypes. 7 Different opioid Mu agonists will bind to slightly different subtypes of Mu receptors. This variability and the differences in pharmacokinetic and pharmacodynamic profıle explain the frequently observed difference in both analgesic response and side effect to different opioid analgesics. An important pearl for clinicians is that there is considerable interpersonal variation in analgesic response to opioid agonists. From the The University of Texas MD Anderson Cancer Center, Houston, TX; Feinberg School of Medicine, Northwestern University, Chicago, IL; Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL. Disclosures of potential conflicts of interest are found at the end of this article. Corresponding author: Judith A. Paice, PhD, RN, Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St., Suite 850, Chicago, IL 60611; email: j-paice@northwestern.edu. © 2015 by American Society of Clinical Oncology. asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK e593
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AMERICAN SOCIETY OF CLINICAL ONCOLO
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American Society of Clinical Oncolo
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Controversies in Neoadjuvant Therap
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Clinical Trials of Precision Medici
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Managing Ovarian Cancer in the Olde
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Updates in the Multimodality Manage
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PEDIATRIC ONCOLOGY Real-Time Molecu
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2015 ASCO Annual Meeting Disclosure
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2015 Educational Book Expert Panel
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James Marshall, PhD Roswell Park Ca
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2015 Annual Meeting Supporters* MIS
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David Yurman Corporate Allies Conqu
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INVITED ARTICLES This year’s invi
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WONG, CAPASSO, AND ECKHARDT 3 3 sc
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WONG, CAPASSO, AND ECKHARDT terize
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STEPHEN T. SONIS portantly, patient
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HUSSAIN AND DIPAOLA TABLE 1. U.S. F
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EDWARD S. KIM TABLE 1. Selected Umb
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INVITED ARTICLES HEAD AND NECK CANC
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GILBERT ET AL tional scholars, lead
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INVITED ARTICLES BREAST CANCER I Wi
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WILLIAM M. SIKOV gational treatment
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DELUCHE, ONESTI, AND ANDRE Precisio
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WHITE AND DEMICHELE KEY POINTS
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BREAST CANCER Individualizing the A
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IMMUNITY IN TRIPLE-NEGATIVE BREAST
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MOLECULAR SUBTYPES AND NEW TARGETS
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CANCER PREVENTION, GENETICS, AND EP
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ADDRESSING BARRIERS TO BREAST CANCE
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DECISION MAKING IN THE CONTEXT OF B
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CAN DIET AND LIFESTYLE PREVENT BREA
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REFORMING THE BUY-AND-BILL CHEMOTHE
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CARE DELIVERY AND PRACTICE MANAGEME
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THE PATIENT-CENTERED MEDICAL HOME c
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MAWRIN, CHUNG, AND PREUSSER Biology
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MICHAEL A. POSTOW Managing Immune C
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MICHAEL A. POSTOW diarrhea symptoms
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CERCEK, CUSACK, AND RYAN Treatment
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GASTROINTESTINAL (NONCOLORECTAL) CA
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ABOU-ALFA ET AL sess liver function
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ABOU-ALFA ET AL HCC (Anti-Programme
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AHN ET AL Making Sense of Current a
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AHN ET AL Pancreatic cancer has bee
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AHN ET AL Disclosures of Potential
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EGIDIO DEL FABBRO tion of precachex
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EGIDIO DEL FABBRO FIGURE 3. Mechani
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EGIDIO DEL FABBRO II RCT of ghrelin
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STAGE I TESTICULAR GERM CELL CANCER
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STAGE I TESTICULAR GERM CELL CANCER
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GERM CELL TUMORS: LOOKING TO THE FU
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SALVAGE CHEMOTHERAPY Salvage Therap
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GYNECOLOGIC CANCER Cervical Cancer
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GYNECOLOGIC CANCER Managing Ovarian
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DUSKA, TEW, AND MOORE KEY POINTS A
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GYNECOLOGIC CANCER Treatment of the
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CHEMOTHERAPY FOR PATIENTS WITH BMOC
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PROGRESS IN HEAD AND NECK SQUAMOUS
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ISAACSSON VELHO, CASTRO JR, AND CHU
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SHARON H. GIORDANO Comparative Effe
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HEALTH SERVICES RESEARCH AND QUALIT
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INDUSTRY AND ONCOLOGY KEY POINTS F
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INDUSTRY AND ONCOLOGY has been “l
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INDUSTRY AND ONCOLOGY by (covered)
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INDUSTRY AND ONCOLOGY 42. World Hea
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CANCER CARE QUALITY: CURRENT STATE
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MANAGING OLDER PATIENTS WITH ALL Th
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MANAGING OLDER PATIENTS WITH ALL TA
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MANAGING OLDER PATIENTS WITH ALL FI
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MANAGING OLDER PATIENTS WITH ALL ra
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TREATMENT OF PHILADELPHIA CHROMOSOM
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CD19 CAR THERAPY FOR ALL FIGURE 1.
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CD19 CAR THERAPY FOR ALL 5. Zhou G,
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NEW TARGETED THERAPIES FOR iNHL New
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HEMATOPOIETIC CELL TRANSPLANTATION
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LEUKEMIA, MYELODYSPLASIA, AND TRANS
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MICHAEL W. DEININGER TABLE 1. Defin
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MICHAEL W. DEININGER broad range ef
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PEMMARAJU AND MOLITERNO TABLE 1. Ac
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PEMMARAJU AND MOLITERNO drome (BCS)
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PEMMARAJU AND MOLITERNO 13. Xing S,
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THERAPIES AND INDICATIONS FOR PH-NE
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LEUKEMIA, MYELODYSPLASIA, AND TRANS
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BEYOND SECOND-LINE TREATMENT FOR LU
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GERBER, PAIK, AND DOWLATI a tumor t
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GERBER, PAIK, AND DOWLATI gression
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GERBER, PAIK, AND DOWLATI receptor
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BERNARDO H.L. GOULART lung-cancer/l
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LUNG CANCER Updates in the Multimod
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WOODARD AND JABLONS section, becaus
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NASSER HANNA Current Standards and
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NASSER HANNA At the 2014 ASCO Annua
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NASSER HANNA culty of this task. Va
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LYMPHOMA AND PLASMA CELL DISORDERS
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NOWAKOWSKI AND CZUCZMAN sociated wi
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DAVID W. SCOTT Cell-of-Origin in Di
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DAVID W. SCOTT 10. Shaffer AL 3rd,
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CHEAH, OKI, AND FANALE Novel Treatm
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CHEAH, OKI, AND FANALE TABLE 3. Sel
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MOREAU AND TOUZEAU Multiple Myeloma
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LYMPHOMA AND PLASMA CELL DISORDERS
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MANAGEMENT OF CLL Up-Front Manageme
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MANAGEMENT OF CLL than 17p-/TP53mut
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MANAGEMENT OF CLL could be associat
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MANAGEMENT OF CLL tion by nonmalign
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MANAGEMENT OF CLL fludarabine and c
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MANAGEMENT OF CLL lymphocytic leuke
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PROGNOSTIC FACTORS AND ADJUVANT RAD
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MERKEL CELL CARCINOMA Merkel Cell C
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MERKEL CELL CARCINOMA tions in PIK3
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MERKEL CELL CARCINOMA treating MCC
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MERKEL CELL CARCINOMA 32. Leonard J
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MELANOMA/SKIN CANCERS Locoregional
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PERFUSION AND INFUSION IN THE ERA O
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NEOADJUVANT THERAPY OF MELANOMA Neo
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SULLIVAN ET AL FIGURE 1. Relevant S
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SULLIVAN ET AL Resistance to BRAF i
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SULLIVAN ET AL TABLE 1. Clinical Tr
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SULLIVAN ET AL 17. Halait H, Demart
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SULLIVAN ET AL NRAS-mutant melanoma
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KLEPIN, RODIN, AND HURRIA Treating
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KLEPIN, RODIN, AND HURRIA plication
Page 758 and 759:
KLEPIN, RODIN, AND HURRIA plan was
Page 760 and 761: KLEPIN, RODIN, AND HURRIA patient-s
Page 762 and 763: KLEPIN, RODIN, AND HURRIA 62. Blanc
Page 764 and 765: PERIPHERAL NEUROTOXICITY IN CANCER
Page 772 and 773: PARTRIDGE, JACOBSEN, AND ANDERSEN C
Page 774 and 775: PARTRIDGE, JACOBSEN, AND ANDERSEN c
Page 776 and 777: PARTRIDGE, JACOBSEN, AND ANDERSEN w
Page 778 and 779: PARTRIDGE, JACOBSEN, AND ANDERSEN v
Page 780 and 781: LESLIE R. SCHOVER Sexual Healing in
Page 782 and 783: LESLIE R. SCHOVER tinuous ADT in pr
Page 784 and 785: LESLIE R. SCHOVER 12. Potosky AL, H
Page 786 and 787: CATHERINE H. VAN POZNAK TABLE 1. Wo
Page 788 and 789: CATHERINE H. VAN POZNAK (tamoxifen,
Page 790 and 791: CATHERINE H. VAN POZNAK TABLE 3. FD
Page 792 and 793: CATHERINE H. VAN POZNAK premenopaus
Page 794 and 795: SHARI GOLDFARB KEY POINTS Brea
Page 796 and 797: SHARI GOLDFARB and friction with va
Page 798 and 799: SHARI GOLDFARB importance both duri
Page 800 and 801: PATIENT AND SURVIVOR CARE Moving Su
Page 802 and 803: MAYER ET AL TABLE 1. Quality Metric
Page 804 and 805: MAYER ET AL to enhance the quality
Page 806 and 807: MAYER ET AL FIGURE 2. (A) Infertili
Page 808 and 809: MAYER ET AL efıcial suggests that
Page 812 and 813: BRUERA AND PAICE Choice of Opioid a
Page 814 and 815: BRUERA AND PAICE toxicity and proce
Page 816 and 817: BRUERA AND PAICE effective. Basic s
Page 818 and 819: PEDIATRIC ONCOLOGY Real-Time Molecu
Page 820 and 821: CARROLL, RAETZ, AND MEYER KEY POINT
Page 822 and 823: CARROLL, RAETZ, AND MEYER most are
Page 824 and 825: CARROLL, RAETZ, AND MEYER markers a
Page 826 and 827: PEDIATRIC ONCOLOGY Translating Surv
Page 828 and 829: REDUCING THE BURDEN OF LATE EFFECTS
Page 836 and 837: PROFESSIONAL DEVELOPMENT The Challe
Page 838 and 839: ADVANCES IN WEBSITE INFORMATION RES
Page 846 and 847: COMMUNICATION AND TECHNOLOGY: IT’
Page 852 and 853: PATIENT-REPORTED OUTCOMES IN ONCOLO
Page 854 and 855: PATIENT-REPORTED OUTCOMES IN ONCOLO
Page 856 and 857: PROFESSIONAL DEVELOPMENT Trends, An
Page 858 and 859: CLINICAL ONCOLOGY PRACTICE 2015 FIG
Page 860 and 861:
CLINICAL ONCOLOGY PRACTICE 2015 (6.
Page 862 and 863:
CLINICAL ONCOLOGY PRACTICE 2015 Pro
Page 864 and 865:
ADJUVANT/NEOADJUVANT MEDICAL THERAP
Page 866 and 867:
Page 868 and 869:
Page 870 and 871:
INDICATIONS FOR ADJUVANT RADIATION
Page 872 and 873:
Page 874 and 875:
Page 876 and 877:
Page 878 and 879:
SARCOMA Latest Advances in Systemic
Page 880 and 881:
SYSTEMIC THERAPY FOR OSTEOSARCOMA A
Page 882 and 883:
SYSTEMIC THERAPY FOR OSTEOSARCOMA A
Page 884 and 885:
RETHINKING TREATMENT FOR CHONDROSAR
Page 886 and 887:
Page 888 and 889:
Page 890 and 891:
Page 892 and 893:
BONE SARCOMAS IN ADULTS local disea
Page 894 and 895:
BONE SARCOMAS IN ADULTS structure a
Page 896 and 897:
SARCOMA Well-Differentiated and Ded
Page 898 and 899:
ABBAS MANJI ET AL ticular region. 7
Page 900 and 901:
ABBAS MANJI ET AL MYXOID (ROUND CEL
Page 902 and 903:
ABBAS MANJI ET AL versus doxorubici
Page 904 and 905:
SHLUSH AND HERSHKOVITZ Clonal Evolu
Page 906 and 907:
SHLUSH AND HERSHKOVITZ FIGURE 1. Ti
Page 908 and 909:
TUMOR BIOLOGY New Strategies to Und
Page 910 and 911:
KNAPP, DHAWAN, AND OSTRANDER in dog
Page 912 and 913:
KNAPP, DHAWAN, AND OSTRANDER TABLE
Page 914 and 915:
KNAPP, DHAWAN, AND OSTRANDER 14. Fe
Page 916 and 917:
SOURBIER, SRINIVASAN, AND LINEHAN M
Page 918 and 919:
SOURBIER, SRINIVASAN, AND LINEHAN F
Page 920 and 921:
SOURBIER, SRINIVASAN, AND LINEHAN T
Page 922:
Author Index Abbas Manji, Gulam ...
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