Understanding Cancer-Related Pain: Pathophysiology, Classification, and Treatment Modalities

Background: The goal of the Edmonton Classification System for Cancer Pain (ECS-CP) is to create an international classification system for cancer pain. Previous studies reinforce the need for standardized training to ensure consistency across assessors. There is no universally accepted classification for neuropathic pain. Objectives: Our primary objective was to describe the prevalence of ECS-CP features in a diverse sample of advanced cancer patients, using assessors with standardized training. The secondary objectives were to: (1) determine the prevalence of neuropathic pain using the Neuropathic Pain Special Interest Group (NeuPSIG) criteria and (2) examine the relationship between specific predictors: ECS-CP features, age, Palliative Performance Scale, Morphine Equivalent Daily Dose (MEDD), setting, and pain intensity; and neuropathic pain. Methods: A total of 1050 adult patients with advanced cancer were recruited from 11 Canadian sites. A clinician completed the ECS-CP and NeuPSIG criteria, and collected additional information including demographics and pain intensity (now). All assessors received standardized training. Results: Of 1050 evaluable patients, 910 (87%) had cancer pain: nociceptive (n = 626; 68.8%); neuropathic (n = 227; 24.9%); incident (n = 329; 36.2%); psychological distress (n = 209; 23%); addictive behavior (n = 51; 5.6%); and normal cognition (n = 639; 70.2%). The frequencies of ECS-CP features and pain intensity scores varied across sites and settings, with more acute settings having higher frequencies of complex pain features. The overall frequency of neuropathic pain was 24.9%, ranging from 11% (hospices) to 34.2% (palliative outpatient clinic) across settings. Multivariate logistic regression analysis revealed that age <60 years, MEDD ≥19 mg, pain intensity ≥7/10, and incident pain were significant independent predictors of neuropathic pain (p < 0.05). Conclusion: The ECS-CP was able to detect salient pain features across settings. Furthermore, the frequencies of neuropathic pain utilizing the NeuPSIG criteria fits within the lower-end of literature estimates (13%-40%). Further research is warranted to validate the NeuPSIG criteria in cancer pain.

There is no standardized and universally accepted pain classification system for the assessment and management of cancer pain in both clinical practice and research studies. The Edmonton Classification System for Cancer Pain (ECS-CP) is an assessment tool that has demonstrated value in assessing pain characteristics and response. The purpose of our study was to determine the relationship between negative ECS-CP features and some pain-related variables like pain intensity and opioid use. We also explored whether the number of negative ECS-CP features was associated with higher pain intensity. The electronic charts of 100 patients at an outpatient supportive care clinic in a comprehensive cancer center were reviewed for variables like patient characteristics, initial ECS-CP assessment, morphine equivalent daily dose (MEDD), opioid rotation, Edmonton Symptom Assessment Score (ESAS), and use of adjuvant analgesics. Some 91 of the 100 charts were eligible for analysis. The most common primary cancer type was gastrointestinal (22.1%). The median pain intensity was 6, and the median MEDD was 45 mg. Neuropathic pain was associated with higher median pain intensity (7 vs. 5, p = 0.007) and median MEDD requirement (83 vs. 30, p = 0.013). Psychological distress was associated with higher median pain intensity (7 vs. 5, p = 0.042). Incident pain was also associated with a trend toward higher pain intensity (6 vs. 5, p = 0.06). A higher number of negative ECS-CP features was associated with higher pain intensity (p = 0.01). The ECS-CP was successfully completed in the majority of patients, demonstrating its utility in routine clinical practice. Neuropathic pain and psychological distress were associated with higher pain intensity. Also, neuropathic pain was associated with a higher MEDD. A higher sum of negative ECS-CP features was associated with higher pain intensity. Further studies will be needed to verify and explore these observations.

180 Background: There is no standardized and universally accepted pain classification system for the assessment and management of cancer pain in both clinical practice and in research studies. The Edmonton Classification System for Cancer Pain (ECS-CP) is an assessment tool that has demonstrated value in assessing pain characteristics and response. The purpose of the study was to determine the relationship between the negative ECS-CP features and some pain related variables like pain intensity and opioid use. Also, we explored whether the number of negative ECS-CP features was associated with higher pain intensity. Methods: Electronic charts of 100 patients at the outpatient supportive care clinic in a comprehensive cancer center were reviewed for patient characteristics, initial ECS-CP assessment, the morphine equivalent daily dose (MEDD), opioid rotation, the Edmonton Symptom Assessment Score (ESAS), Memorial Delirium Assessment Scale (MDAS), performance status, and the use of adjuvant analgesics. Results: Ninety one out of the 100 charts were therefore eligible for analysis. The median age was 58.4 years. The most common primary cancer site was gastrointestinal cancer (22.1%). The median pain intensity was 6 and the median MEDD was 45mg. Incident pain was the most common ECS-CP feature (60%) and cognitive dysfunction was the least frequent feature (2%). Neuropathic pain was associated with higher median pain intensity (7 vs. 5, p=0.007) and median MEDD requirement (83 vs. 30, p=0.013). Psychological distress was associated with higher median pain intensity (7 vs. 5, p=0.042). Incident pain was also associated with a trend for higher pain intensity (6 vs 5, p= 0.06). A higher number of negative ECS-CP features was associated with higher pain intensity (p=0.01). Conclusions: The ECS-CP was successfully completed in the majority of patients, demonstrating its utility in routine clinical practice. Neuropathic pain and psychological distress were associated with higher pain intensity. Also, neuropathic pain was associated with higher MEDD. A higher sum of negative ECS-CP features was associated with higher pain intensity. Further studies will be needed to explore this observation.

(122) Neuropathic pain in a sample of nicotine addicted advanced cancer patients: practical outcomes using the DN4 tool

Background: A universal consensus regarding standardized pain outcomes does not exist. The personalized pain goal has been suggested as a clinically relevant outcome measure. Aim: To assess the feasibility of obtaining a personalized pain goal and to compare a clinically based personalized pain goal definition versus a research-based study definition for stable pain. Design: Prospective longitudinal descriptive study. Measures: The attending physician completed routine assessments, including a personalized pain goal and the Edmonton Classification System for Cancer Pain, and followed patients daily until stable pain control, death, or discharge. Stable pain for cognitively intact patients was defined as pain intensity less than or equal to desired pain intensity goal (personalized pain goal definition) or pain intensity ⩽3 (Edmonton Classification System for Cancer Pain study definition) for three consecutive days with <3 breakthroughs per day. Setting/participants: A total of 300 consecutive advanced cancer patients were recruited from two acute care hospitals and a tertiary palliative care unit. Results: In all, 231/300 patients (77%) had a pain syndrome; 169/231 (73%) provided a personalized pain goal, with 113/169 (67%) reporting a personalized pain goal ⩽3 (median = 3, range = 0–10). Using the personalized pain goal definition as the gold standard, sensitivity and specificity of the Edmonton Classification System for Cancer Pain definition were 71.3% and 98.5%, respectively. For mild (0–3), moderate (4–6), and severe (7–10) pain, the highest sensitivity was for moderate pain (90.5%), with high specificity across all three categories (95%–100%). Conclusion: The personalized pain goal is a feasible outcome measure for cognitively intact patients. The Edmonton Classification System for Cancer Pain definition closely resembles patient-reported personalized pain goals for stable pain and would be appropriate for research purposes. For clinical pain management, it would be important to include the personalized pain goal as standard practice.

8551 Background: Comparison of cancer PS across settings is challenging due to differences in prognostic features. Data from 1 CCC participating in a multi-site international study of a pain classification system is presented to characterize cancer PS &amp; response to PCC. Methods: The Edmonton Classification System for Cancer Pain was completed by prospective chart review to characterize PS of 100 consecutive hospitalized patients (pts) seen in PCC. Pts were followed until major PR, hospital discharge or death. Major PR was defined as &lt;2 p.r.n. opioid doses/d &amp; pain intensity (PI) &lt;3/10 for 3 consecutive days (d). Results: 85% of pts had pain (n=85), with age 62.9+13.3, 47.1% male &amp; KPS 44.5+23.1. The most common tumor diagnoses were lung (24.7%) &amp; GU (21.2%). Pts were followed for a median of 4 d (0–27). 39% achieved a major PR. Except for steroids (49.4%) &amp; anticonvulsants (29.4%), other adjuvant analgesic use was all &lt;10%. Pain-associated features: *Numeric Rating Scale 0–10, 10=worst suggestivie of alcoholism + Mean morphine equivalent dailydose On univariate analysis, older age (p=.006), lower initial PI (p=.003), lower final PI (p=.001) &amp; lower final MEDD (p=.002) were significantly associated with achieving major PR. On multivariate analysis, lower initial PI (p=.03) &amp; lower final MEDD (p=.02) retained significance for achieving major PR. Conclusions: Only 39%of pts with cancer pain seen in PCC achieve a major PR by discharge or death. Despite aggressive opioid titration, 61% do not achieve a major PR &amp; require better pain management. Potential strategies for achieving improved PR include earlier PCC, identification of more sensitive prognostic variables &amp;critical evaluation of targeted therapies. [Table: see text] No significant financial relationships to disclose.

Comparisons of Patient and Physician Assessment of Pain-Related Domains in Cancer Pain Classification: Results From a Large International Multicenter Study

Fear of negative and positive evaluation as mediators and moderators of treatment outcome in social anxiety disorder

Cognitive behavioral therapy, mindfulness, and cortisol habituation: A randomized controlled trial

Secular Mindfulness-Based Interventions: Efficacy and Neurobiology.

Cognitive behavioral therapy (CBT) is believed to improve chronic pain problems by decreasing patient catastrophizing and increasing patient self-efficacy for managing pain. Mindfulness-based stress reduction (MBSR) is believed to benefit patients with chronic pain by increasing mindfulness and pain acceptance. However, little is known about how these therapeutic mechanism variables relate to each other or whether they are differentially impacted by MBSR vs CBT. In a randomized controlled trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with chronic low back pain (N = 342), we examined (1) baseline relationships among measures of catastrophizing, self-efficacy, acceptance, and mindfulness and (2) changes on these measures in the 3 treatment groups. At baseline, catastrophizing was associated negatively with self-efficacy, acceptance, and 3 aspects of mindfulness (nonreactivity, nonjudging, and acting with awareness; all P values <0.01). Acceptance was associated positively with self-efficacy (P < 0.01) and mindfulness (P values <0.05) measures. Catastrophizing decreased slightly more posttreatment with MBSR than with CBT or UC (omnibus P = 0.002). Both treatments were effective compared with UC in decreasing catastrophizing at 52 weeks (omnibus P = 0.001). In both the entire randomized sample and the subsample of participants who attended ≥6 of the 8 MBSR or CBT sessions, differences between MBSR and CBT at up to 52 weeks were few, small in size, and of questionable clinical meaningfulness. The results indicate overlap across measures of catastrophizing, self-efficacy, acceptance, and mindfulness and similar effects of MBSR and CBT on these measures among individuals with chronic low back pain.

Paediatric cancer pain management using the WHO analgesic ladder – results of a prospective analysis from 2265 treatment days during a quality improvement study

The paper in this issue makes an innovative suggestion to treat diabetes-related distress using mindfulness based stress reduction (MBSR) training.1 Their retrospective study showed positive effects of MBSR on patients' psychological distress including tension/anxiety, depression/dejection, anger/hostility, fatigue/inertia, confusion/bewilderment and vigour/activity among people with diabetes. The authors called MBSR ‘a non-traditional cognitive behavioural intervention’. The procedures used in cognitive behaviour therapy and mindfulness based training seem to be similar. Both approaches work with paying attention to the thoughts, sensations and emotions which may lead to a reduction of emotional or physical pain and better self-management. However, it has to be stressed that MBSR ‘is not […] the next promising cognitive behavioural technique’.2 Mindfulness training has a different historical and cultural background from those of cognitive behaviour techniques and, hence, these two approaches differ substantially in their nature.3 Baer, in her comprehensive review of mindfulness based training,4 summarises these differences. Firstly, cognitive behaviour therapy aims at evaluating and challenging thoughts. MBSR in turn teaches how to pay attention to the thoughts in a non-judgemental way. Secondly, cognitive behaviour treatment usually aims at changing irrational thoughts and disruptive behaviours. In contrast, in an MBSR training the participants are asked to let go of any expectations and goals. The aim of mindfulness training is a non-striving observation of thoughts and bodily sensations, non-judgementally, moment by moment. Finally, MBSR requires that facilitators themselves practise the techniques they teach to the group. This is not the usual practice of a cognitive behaviour therapy.4 Mindfulness based cognitive behaviour therapy5 showed that these two approaches can be effectively integrated. However, an adequate recognition of the qualities of both cognitive behaviour techniques and mindfulness training is crucial for exploring their unique contribution.

BackgroundPain is highly prevalent in cancer and requires proper assessment and management. The evaluation is important particularly in cancer pain management, to make some improvement in prescribing analgesics and alternative approaches in the hospitals to enhance the quality of life of cancer patients.ObjectiveThe objective of this study was to assess analgesics and alternative approaches in cancer pain management and compare current prescribing practices with WHO guidelines for pain management.MethodsA cross-sectional study was conducted at PIMS, Islamabad. Data of 203 patients was analyzed. Patients' age, gender, diagnoses, pain intensity, analgesics, and alternative approaches prescribed, were recorded. All these variables were summarized using descriptive statistics and comparison between variables done by using Chi-square test.ResultMost patients were aged 26-35 years (29%), and 76% had blood cancer. Pain intensity was moderate in 51% of patients. Weak opioids (tramadol 69%, codeine + paracetamol 68%) were the most prescribed drugs. No strong opioids were used. Only 3% of patients received alternative therapies (physiotherapy, radiotherapy). About 54% of prescriptions were consistent with WHO pain management guidelines. The majority of pain management strategies did not align with WHO's analgesic ladder, particularly for severe pain cases, where strong opioids were noticeably absent. Significant associations were found between cancer stage, pain intensity, and type of analgesics used (p < 0.05).ConclusionThis study found that the pain in cancer patients at PIMS is often undertreated, with a heavy reliance on weak opioids and low use of strong opioids and alternative therapies. Limited use of strong opioids reflects systemic barriers including restrictive regulations, high costs, and limited availability. Improved access to opioids, guideline-based prescribing, and integration of palliative care are essential to ensure effective pain relief for cancer patients in Pakistan.

Complementary integrative therapies (CITs) correspond to growing demand in patients with cancer-related pain. This demand needs to be considered alongside pharmaceutical and/or interventional therapies. CITs can be used to cover certain specific pain-related characteristics. The objective of this review is to present the options for CITs that could be used within dynamic, multidisciplinary, and personalized management, leading to an integrative oncology approach. Critical reflection based on literature analysis and clinical practice. Most CITs only showed trends in efficacy as cancer pain was mainly a secondary endpoint, or populations were restricted. Physical therapy has demonstrated efficacy in motion and pain, in some specific cancers (head and neck or breast cancers) or in treatments sequelae (lymphedema). In cancer survivors, higher levels of physical activity decrease pain intensity. Due to the multimorphism of cancer pain, certain mind-body therapies acting on anxiety, stress, depression, or mood disturbances (such as massage, acupuncture, healing touch, hypnosis, and music therapy) are efficient on cancer pain. Other mind-body therapies have shown trends in reducing the severity of cancer pain and improving other parameters, and they include education (with coping skills training), yoga, tai chi/qigong, guided imagery, virtual reality, and cognitive-behavioral therapy alone or combined. The outcome sustainability of most CITs is still questioned. High-quality clinical trials should be conducted with CITs, as their efficacy on pain is mainly based on efficacy trends in pain severity, professional judgment, and patient preferences. Finally, the implementation of CITs requires an interdisciplinary team approach to offer optimal, personalized, cancer pain management.