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The patient with metastatic bone pain: A practical evidenced based approach

P Sylvester (MBBS),D Narinesingh (MBBS ,MMed ,FCRadOnc). The patient with metastatic bone pain: A practical evidenced based approach. Case . 50 year old female Metastatic Left Breast cancer Solitary Liver metastases ER+ PR+ HER2+ Performance status (PS) = 2 Severe lower back pain

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The patient with metastatic bone pain: A practical evidenced based approach

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  1. P Sylvester (MBBS),D Narinesingh (MBBS ,MMed ,FCRadOnc) The patient with metastatic bone pain: A practical evidenced based approach

  2. Case • 50 year old female • Metastatic Left Breast cancer • Solitary Liver metastases • ER+ PR+ HER2+ • Performance status (PS) = 2 • Severe lower back pain • Numerical pain score = 8 • Bone scan and MRI revealed bone metastases to vertebra L5

  3. Bone pain • Affects quality of life (Mental + Physical) • Nociceptive somatic pain • Assessment of pain by : • 0-10 Numeric pain scale • Faces pain rating scale • Three intensities: • Mild pain(1-3); Moderate(4-6); Severe (7-10) • Psychosocial support and Patient education NCCN guidelines Version 1.2012 , Adult Cancer Pain

  4. WHO Analgesic Ladder http://pharmacologycorner.com/wp-content/uploads/2009/03/image.png

  5. Commonly Selected Analgesics • Non opiod • Acetaminophen • Ibuprofen • Diclofenac • Arcoxia/ Celebrex • Combined ( Weak Opioid + Non opioid) • Panadeine • Tramacet • Opioids • Morphine sulphate oral • Morphine parenteral Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v257-v260, 2010

  6. Opioid Scheduling and titration • Goal Rapid pain relief • Initial dose regime  5-7.5mg sc q 4hr • “Breakthrough dose”transient exacerbations of pain = 10-15% of total daily dose • Revision of analgesic regime • more than 4 “breakthrough” doses per day are administered dose titration Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v257-v260, 2010

  7. Co analgesics for neuropathic pain • Antiepileptic • Carbamazepine • Pregabalin • Antidepressant • Fluoxetine • Amitryptiline • Neuroleptic • Haloperidol • Chlorpromazine Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v257-v260, 2010

  8. Bone modifying agents (BMA’s)[1] • Adjunctive therapy for pain control • Zoledronic acid/Donesumab • Donesumab superior in terms of delaying SRE[2] • Calcium and Vitamin D supplementation • Monitor creatinine clearance for intravenous bisphosphonates • Monitor calcium levels • Dental exam and preventive dentistry before using a BMA [1]Van Poznak CH, Temin S, Yee GC, et al: American Society of Clinical Oncology Executive Summary of the Clinical Practice Guideline Update on the role of Bone-Modifying Agents in Metastatic Breast Cancer. J ClinOncol 29:1221-1227, 2011 [2]Stopeck A, et al. J ClinOncol. 2010;28:5132-5139.

  9. Palliative radiotherapy • Specific and Critical efficacy in pain relief[1] • Clinical mark up • Areas of maximal pain intensity • Whole pelvis radiation • Radiation to spine • Doses (tailored to Performance Status) • 8Gy in 1# / 30Gy in 10# / 20Gy in 5# • Studies show 8Gy in 1# = 30Gy in 10# [2] • Bone targeted radioisotopes • E.g.Strontium-89 [1] Jost L, Roila F et al. Annals of Oncology 21 (Supplement 5): v257-v260, 2010 [2]  Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases. J Natl Cancer Inst. 2005;97:798-804.

  10. Case Management • Initial Bone Pain Management • Zoledronic acid 4mg iv q 4weeks • Oral Morphine • Mild relief after initial management • Also developed BL Lower limb paresthesiae 2o tumor infiltration • Palliative RT to L5 (30Gy in10#) • Had good pain relief after RT • Now on Pregabalin • After one year of BMA therapy • Pain score = 1 • PS = 0

  11. IN SUMMARY

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