Odynophagia and dysphagia,: clinical experiences and cancer pain integrated management

Abstract

Background: PMPS affects about 25% of breast cancer survivors. Drugs, sometimes ineffective, carry risks of adverse events. Purpose: This study assesses the effect of Manipulative Scar Treatment (MST), with/ without Osteopathic Manipulative Treatment (OMT), on pain, shoulder range of motion in external rotation (ROM-RE), distress and Quality of Life (QoL). Methods: Upon informed consent, 18 (mean age 52.88, SD 10.92) PMPS patients, attending oncologic follow-up, were randomized during 5 weekly sessions of treatment MSTþOMT (9 patients) vs MST-alone (9 patients). Pain quality/intensity was assessed with Short-form McGill Pain Questionnaire (SF-MPQ) and Douleur Neuropatique-4 (DN-4); Distress with Distress Thermometer (DT); QoL with 36-Item-Short-Form Health Survey (SF-36); ROM-RE of the shoulder with an universal goniometer. Data were collected before the 1 st (T0),3 rd (T2),5 th (T4) sessions, and monthly thereafter (F1,F2). Wilcoxon, Paired t test, Mann-Whitney test and Two-sample t-test were used for statistical analysis. Results: 18 patients attended the entire schedule until F1 and 17 patients until F2. Both group MSTþOMT and MST improved their condition concerning pain intensity at T4, F1 and F2 vs T0: SF-MPQ overall score at F2 vs T0 decreased in group MSTþOMT (mean change-5.88, SD 3.72; P ¼ 0.009) and MST (-5.62, SD 5.31; P ¼ 0.020); SF-MPQ Visual-analogue scale at T2 vs T0 decreased in group MSTþOMT (-25.33, SD 14.43; P ¼ 0.007) and MST (-28.25, SD 21.49; P ¼ 0.017). DN-4 score decreased at F2 vs T0 in group MSTþOMT (-2.33, SD 1.58; P ¼ 0.008) and MST (-2.12, SD 3.35; P ¼ 0.11). DT score improved in F2 vs T0 in group MSTþOMT: (-3.77, SD 2.65; P ¼ 0.007) and MST (-2, SD 2.13; P ¼ 0.040). ROM-RE significantly improved in MSTþOMT at all intervals (F2 vs T0: þ10.55, SD 5.72; P < 0.001), but not in MST. QoL by SF-36 improved at F2 vs T0 in group MSTþOMT, with significant differences in physical functioning (þ11.11, SD 9.27; P ¼ 0.016), pain (þ23.66, SD 16.79; P ¼ 0.011), social functioning (þ24.88, SD 19.77; P ¼ 0.017), emotional role (þ37.11, SD 38.88; P ¼ 0.026) and emotional well-being (þ12.44, SD 15.15; P ¼ 0.008), while group MST showed no significant change in all scales, at all intervals. Between-group differences at F1 vs T0 were observed in general health (P ¼ 0.037), energy/fatigue (P ¼ 0.002), emotional role (P ¼ 0.007). Conclusions: Our results suggest a reduction in pain and distress in all patients, with/ without OMT, maintained at 2 months, and an additional improvement in range-of-motion and QoL in MSTþOMT group. A larger study is required to confirm these results. An optimal pain control is a constant challenge for palliative care professionals. As with all treatment and medical assistance processes, palliative care patients can undergo potentially painful procedures. Procedural pain is therefore a form of breakthrough pain that should be averted and treated adequately in order to improve the quality of life of terminally ill patients. Detection and control of procedural pain can be effectively achieved only if medical operatives have the necessary training. In order to assess the knowledge and awareness of this issue, palliative care workers of the home care and residential care staff of our Hospice were given a specific questionnaire to complete. 27 doctors and 36 nurses were interviewed. 96% of doctors and 90% of nurses indicated knowledge of the definition of procedural pain. Among doctors, 85% state that they prescribe a medication for intense breakthrough pain, although only 65% of nurses claim to be able to find them amongst available prescriptions. For both operative categories , procedural pain affect the quality of life of patients, but only 68% of nurses and 77% of doctors interviewed ordinarily detect it. The procedure most commonly believed to be a source of procedural pain is mobilisation, followed by medication. Overall, operatives think that in 84% of the situations, procedural pain is appropriately managed in their own setting. Our results show evidence of high levels of awareness about procedural pain by pallia-tive care professionals. However, this does not seem to be reflected in its systematic detection al the bedside nor in a regular prescription of appropriate medication to control it, which results in a sub-optimal management of this type of breakthrough pain. Although the majority of the operatives apply their theoretical training to their medical practice, an increasing appreciation of the importance of procedural pain remains an important goal to improve these results, which will be compared to the findings of a targeted survey shortly to be conducted among patients. U9 Odynophagia and dysphagia,: clinical experiences and cancer pain integrated management Background: Most patients experience pain in swallowing during cytotoxic treatments and radiotherapy, worsing Cancer Related Cachexia. Transdermal fentanyl can provide effective pain relief. An effective pain treatment should include a fixed medication and breakthrough medication with an appropriate dose and schedule for each. Odynophagia should be considered breakthrough pain to be treated with appropriate breakthrough medication dosing. Increasing evidence, supports to adequate pain control in patients with cancer related dysphagia/odynophagia, to avoid malnutrition and cachexia. Most pain/palliative care specialists and oncologists worldwide are well aware to adequately treat the pain, but it was yet established that half of cancer patients have insufficient pain control. The goal of pain control in any patient with cancer should be to optimize the patient's comfort and function. Methods: Clinically, 103 Patients with cancer pain and cancer-related dysphagia/ody-nophagia we followed. Everyone was treated with analgesic opioids at a stable dose equivalent to 60 mg oral morphine to control background pain using transdermal administration to control background pain. It is considered a convenient method of continuous administration of opioid drugs in situations requiring alternative routes to the oral route. This is possible with fentanyl, as it has physical-chemical characteristics suitable for transdermal administration. We measured the BTCP using algorithm.We used Fentanyl pectin nasal spray (FPNS) 100 mcg per 2 at Btcp .11 patients had opioid induced constipation, 13 developed cachexia. Furthermore, we corrected the cachexia and improved the BMI, using dietetic foods for special purposes. We used naloxegol in the treatment of opioid-induced constipation. Results: Fentanyl is a rational approach to odynophagia. A wide range of assessment tools for dysphagia were identified. Increasing BMI is very important, as fentanyl is a lipophilic drug. Preventive administrations of breakthrough pain medication a half hour before eating may improve swallow function. We have performed frequent monitoring , using NRS scale. Patient assumed no more than 3 doses per day at main meals. Conclusions: To promote effective and total pain control, it is strictly necessary to identify patients with odynophagia and dysphagia for avoiding malnutrition, dehydration and cachexia. Correct integrated management of cancer pain improves Quality of Life in this pool of cancer's patient.