Cancer Newsline Audio Podcast Series
Date: September 14, 2009
Duration: 0 / 18:282009
Return to Cancer Newsline
Dr. Edward Kim:
Welcome to Cancer News Line, a weekly podcast
series from the
Joining me today is Dr. Allen Burton, Professor and Chair of M.D. Anderson's Department of Pain Medicine. Dr. Burton and his team provide a multidisciplinary approach to treating pain and related symptoms, all with the ultimate goal of giving patients and survivors an improved quality of life. Under Dr. Burton's leadership, the Department of Pain Management recently was recognized by the American Pain Society as one of the nation's five clinical centers of excellence and it was the first cancer pain clinic to receive the award. Dr. Burton also is the current president of the Texas Pain Society. Thank you for speaking with Cancer News Line today, Dr. Burton.
Dr. Allen Burton:
It's a pleasure to be here.
Dr. Edward Kim:
So let's first start by defining what really is cancer pain. What is the cause of it, how do you measure it?
Dr. Allen Burton:
Cancer pain is one of the most feared symptoms of cancer and most famously, cancer pain comes from the tumor itself. Tumors themselves can actually cause discomfort when they're rapidly growing but mainly tumors cause pain by their location in the body. Tumors that are growing into bone or into an organ or into the nervous system can be extremely painful whereas a slow growing tumor that maybe in the abdomen may cause very little symptoms until it is quite advanced. So, this is the most common source of cancer pain that often gets worse when the cancer becomes further advanced or untreatable. A related, more common issue that we're seeing today is the pain that comes along with cancer treatments or indeed the pain that is seen in cancer survivors. This becomes more of a chronic pain situation and to some extent, we are victims of our success and disregard as the oncologic treatments have gotten more sophisticated and increasing in their success, some of the fallout is chronic pain in some of the cancer survivors.
I imagine it becomes more complex as patients go through longer and longer periods of treatment. Being a lung cancer doc, we're trying to get there but of course in breast cancer we see this quite often where patients are being treated for many years and even decades and probably have this type of problem occurring.
Certainly, we have some recent data that shows about a third of cancer survivors complain of some ongoing chronic pain issues and perhaps as many as the third of those have very severe pain that is an ongoing problem for them for which they need ongoing medical care, sometimes for years or decades to come. And as you correctly stated some of the more survivable cancers, i.e. the early stage breast cancer, many of those patients, in some studies up to 50 percent of post-mastectomy patients have some ongoing discomfort.
Now what types of treatments or other aspects do you approach when you see patients in your clinic and what types of prescribed therapies are you offering patients?
Some of the most common treatments that we utilize for pain, again, it's context specific. So patients that are in active treatment for their cancer that have ongoing needs for chemotherapy, radiation, they have upcoming or recent surgeries, these patients have a goal of getting through their treatment successfully. So our goal is to just really make that pain tolerable. Keep the patients active and treat concomitant symptoms like nausea, or fatigue, or insomnia, and keep the patients' energy level up and keep them functional in order that they may successfully complete their cancer treatment. When the context shifts and the patient becomes a survivor or they become a long-term remission or with a very indolent, slowly progressive cancer, then some of our goals take on a more complicated longer-term nature where we begin to shift into some chronic pain treatment algorithms.
I can imagine it's so subjective when someone complains of different symptoms or pain and it's very easy when there is a lesion you can see or if they've had a surgical procedure done. How do you assess in clinic with some of these patients?
Well, as you very correctly point out pain is a subjective symptom. It is sometimes very difficult to see and for this reason, pain has often been under recognized and under treated because the patients, it's not obvious when a patient's having pain. We do have a variety of assessment tools. The most common one is just simply asking the patient and an awareness that there are chronic pain treatment sequel that can come after surgery, after chemotherapy, after radiation, or indeed just from having a tumor located in a sensitive spot and now when the tumor is ablated, the nerves in that spot for example don't grow back properly or they grow back into a bundle of nerves called a neuroma or another painful condition.
And many times in the past, the ongoing survivorship was limited so we didn't really have an opportunity to fully study and evaluate these and really recognize these as clinical problems. Now with the increasing, I guess with the combination of early diagnosis, better cancer therapies, we really are much more able to quantify these syndromes and we're getting, I think, a lot better at treating them quite successfully and improving the long-term quality of life. As the problems become more complex medically with the patient, the treatment algorithms become more complex involving a psychologist, often a physical or occupational therapist, sometimes a physical medicine physician to help guide that rehabilitative therapy and then a pain specialist to provide the analgesic component whether that's medications, topically other interventional procedures or sometimes even holistic measures.
Now you just segueing on what you just mentioned here. I think many of us, especially your colleagues here at M.D. Anderson, view pain management mostly through pharmaceutical means and you alluded to several other techniques and other aspects of it. Could you fully go into more full description on other techniques that are available?
Certainly, I think that, again, in keeping with one of the themes is personalized medicine and we really try to address the patient's pain in context and when the patient is facing an acute cancer situation where they have a tumor that's there, that they're going through active treatment on, then often the most appropriate course of therapy is pharmacologic and these often takes the form of episodes and/or adjuvant medications. Some of the more commonly used opioid medications are hydrocodone or morphine and some of the more commonly used adjuvant are gabapentin or Neurontin or pregabalin which are anti-neuropathic or anti-nerve pain medicines and sometimes these are blended in order to just bring the pain down to a tolerable level so the patient can continue on in their therapy. When the patient shifts into a more chronic pain mode, oftentimes the psychological issues begin to intertwine to a great degree and this is somewhat inevitable with chronic pain. The patient begins to ruminate on the pain.
The pain impact on their ability to get back into fully into their life and for instance, go back to their vocation or go back to their full roles as a family member, as a productive member of society, and there's a great deal of uncertainty even am I fully cured, is the cancer fully behind me, will it come back, you know how am I going to deal with this, is sort of a related set of issues and then when you impact that with a day-to-day high level of symptoms in the form of pain, that pain can be a constant reminder of that sort of lurking threat of recurrent cancer or gee, I'm not sure the caner is really in remission, why do I hurt so much if I'm cured of cancer. And so, these patients have a complex psychological set of issues that really needs teasing apart and guidance on how to compartmentalize those, how to set goals and how to slowly get back to their previous productive self.
Well, in that same vein, we mention a word like addiction, and addiction is used in such a negative context or at least perceived in that way although there are many addicts who are addicts to good things as well. How do you deal with someone with addiction and alluding to the fact that again, when the pain goes away, it may seem like they associate that with the cancer going away as well?
Addiction is always a very common issue when you start talking about pain medications, just because of the fact that many of the medications that are used to treat pain also can have addictive properties to them and there have been some famous cases of celebrities that have had addictions to pain medications. Over the past 10 to 15 years, there's been an increasing push on the need to treat pain. With this has a come a surge in the prescribing of opioid medications particularly to patients. And along with that, has become an increasing misuse of these medications out in either in non-patients or patients misusing their medications. Some patients have preexisting, before their cancer, before their pain, have preexisting problems with addictions either chemically coping with situations through the use of illegal drugs, prescription drugs or alcohol, and sometimes those life patterns or those psychological traits that led them into an addiction will come back with the stress of a cancer or the stress of an ongoing chronic pain issue. So the pain community is increasingly aware that the medications we use have the potential to cause addiction. But some patients do require the ongoing use of medications with an addictive potential. That doesn't mean that those patients are addicted to those medications in the same way that a diabetic, for example, is not addicted to insulin. Or that a hypertensive patient is not addicted antihypertensives. We are increasingly aware of a subset of patients that may get into trouble with pain medication such as accelerating the use, using inappropriate doses, using them not as prescribed, and we are aware that there are a subset of patients that may get into trouble with these medications. The vast majority of patients will not have those issues.
And many of my patients will ask about acupuncture and other sort of non-pharmacologic means. How common are these being used these days?
I think there's a growing awareness of the importance of alternative, more holistic therapies to the extent that there is a department here at M.D. Anderson that is devoted to studying and utilizing these techniques. We are close collaborators. We refer many patients through our center for acupuncture and related techniques. Our psychologist applies cognitive behavioral therapies and biofeedback in our center and we do believe that there is a role for these techniques. The mind is, if you will, is the central processing unit of all pain signals and there's many ways that the mind can impact or filter the signals differently. And some of those are well understood and some are only now beginning to be opened up and teased apart. So we think it's best to use a blend of standard techniques like medications and perhaps nerve blocks where appropriate as well as some of these holistic techniques. Again, some of it is patient driven. Certain patients really seek this and some of it patients that are just not doing well with conventional therapies. So, I think all of those patients are appropriate. And finally, I think it's important that we're studying these techniques in trying to bring that level of evidence for using some of those techniques up. One of our colleagues is currently doing finishing up an acupuncture study that has been quite exciting.
Well, I imagine this is an extremely underreported aspect of medicine in general and especially in cancer care. What suggestions would you have to our listeners out there right now who either are being treated right now or have a loved one who's being treated? How do they approach their doctor about being referred to a pain specialist and when in the equation should a pain specialist be brought in to help with the patients?
I think that's a very good question and I would encourage the listener, even in the often, the listener is under time pressure. Their oncologists are very busy. They have just a few minutes periodically with the oncologist. They have really important questions to ask them, is the tumor smaller, am I going to need more therapy, indeed these are sometimes life and death issues. So the patient tends to hit the oncologist with the kind of hard questions and then often they'd get through the visit or they're on their way out the door going home and they really haven't mentioned some of the symptoms that they're dealing with and living with on a day-to-day basis.
So there are a couple strategies. We encourage our patients to write down things before they come to the oncologist office. Obviously, their most important questions are going to have to do with their chemotherapy, their cancer, ect., but we encourage them to write down symptoms that they're having. Are they having a lot of nausea? Are they having appetite problems? Are they having pain? What kind of pain? Is it located with the tumor? Is it from where they had surgery 6 months ago?
What is the pain easy to treat with just a Tylenol, or is it something that is really bothering them, keeping them up at night, keeping them from functioning. If it's at the point where it's really impacting their life significantly, and that's different for a given patient. It may interrupt sleep, it may interrupt the ability to walk, it may interrupt the ability to function to any extent other than just perseverating on the pain. If the pain is that severe, they certainly should talk, if not to the oncologist, then to the nurse practitioner or to the oncologist nurse or team about that. And even perhaps bring it up with the oncologist who at that point may often make an attempt. And oncologists are very good symptom managers and will be able, in most cases, to provide some prompt addressing of that symptom. And often, I would say, at least 50 percent of the time, the oncologist with a medication or two or prescribing physical therapy will be able to address those symptoms successfully. When their first or second line treatment for that symptom is not working out then generally, the oncologist in discussion with the patient or they'll decide, or you know, some collaborative decision making will be, "I think we're beyond our level of expertise here. Let's get somebody else involved." And in our setting, that would probably be the pain medicine department.
We also have palliative care colleagues, that supportive care that are very good at this in context, you know, again, depending on the patient's situation. And in the community, there may be different avenues for this. There may be general practitioners who do pain medicine. There may be hospital practitioners who do this or there may be pain specialists and some of it may be local variations, but generally, the goal would be to get to another level of care where multidisciplinary care can be applied.
So, Dr. Burton, could you describe some new areas of pain research that you find are most promising and perhaps things that we may be able to integrate into our patient care over the next several years?
Dr. Kim, we have a variety of areas of research that are actively ongoing in the pain community and also here at M.D. Anderson. Some are to do with injection therapies that would be toward the end of life that would help ablate nerve pathways that are causing significant pain and discomfort. Some are evaluating new technologies such as new pain pumps that are more interactive with the patient and providing analgesia or pain relief when the patient needs it but not on an ongoing basis. More tailored to controlling their symptoms. And finally, in the area of pharmacologic, there are several new medications that are in phase 2 and phase 3 trials for treating severe cancer pain, and also different types of cancer pain, such as that following shingles or following the pain of surgery, and a variety of these new medications are again in the clinical trial phase but they are showing some promise. And then lastly, our integrative medicine colleagues have a variety of symptom-related research ongoing. Again, some of it in collaboration with us in chronic cancer pain situations. So there's a really a--it is a burgeoning area of research that is quite exciting.
Well, I can speak from my own experience that your department and what you're doing has really been helpful to our patients and in our overall multidisciplinary care here at M.D. Anderson. Allen, thank you! For joining Cancer News Line today and reminding us all that there is hope for those suffering from cancer pain.
Thank you, Dr. Kim.
Thank you for tuning in to Cancer News Line this week, and be sure to check out another new edition next week..
Return to Cancer Newsline
The University of