Pharmacogenetic (PGx) guided cancer pain management in an oncology palliative medicine (PM) clinic.

117 Background: About 30% of cancer patients presenting with pain have symptomatic improvement using conventional strategies within one month. PGx may help personalize opioid selection and improve cancer pain management. Methods: This is a pragmatic pilot trial investigating the feasibility and application of PGx testing to improve pain management in adults with uncontrolled cancer pain referred to an oncology PM clinic. PM providers assessed patients using Edmonton Symptom Assessment Scale at baseline and opioid therapy was initiated or modified. A buccal swab was obtained for genotyping single nucleotide polymorphisms in: COMT, CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A4, CYP3A5, and OPRM1. The first assessment occurred within one week of baseline and a second within another week if intervention was required. PGx results were available before the first assessment and utilized, if applicable, throughout the one-month study period. Pain improvement rate (≥ 2-point reduction on a 0-10 scale) from baseline to final visit, was compared to historical control data by a one-sided exact binomial test of proportions. Results: Of 75 undergoing PGx testing, 52 were evaluable for the primary endpoint (54% female, 81% white, 17% black, median age 63, 75% stage 3 or 4 disease, median personalized pain goal 3 [0-6]). 56% had pain improvement compared to 30% in historical controls (p < 0.001). At final assessment, 35% met their personalized pain goal. Of 26 (50%) requiring opioid adjustments, 18 (69%) had an actionable genotype with a 61% pain improvement rate. The two most common genes for opioid adjustment were CYP2D6 (16/18; 89%) and COMT (8/18; 44%). The most common PGx-guided modification involved switching from a CYP2D6-metabolized drug (hydrocodone, oxycodone, tramadol) to a non-CYP2D6-metabolized drug (fentanyl, hydromorphone, methadone, morphine). Conclusions: PGx implementation in an oncology PM clinic was feasible and improved pain management. Half of those requiring opioid adjustments had an actionable genotype, with the largest impact from CYP2D6 polymorphisms. Future studies should focus on preemptive PGx testing to guide initial drug selection and confirm clinical utility in a randomized trial. Clinical trial information: NCT02542397.

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Pain Management Using Clinical Pharmacy Assessments With and Without Pharmacogenomics in an Oncology Palliative Medicine Clinic

JCO Oncology Practice ◽

10.1200/jop.19.00206 ◽

2020 ◽

Vol 16 (2) ◽

pp. e166-e174 ◽

Cited By ~ 1

Author(s):

Jai N. Patel ◽

Danielle Boselli ◽

Issam S. Hamadeh ◽

James Symanowski ◽

Rebecca Edwards ◽

...

Keyword(s):

Pain Management ◽

Palliative Medicine ◽

Performance Status ◽

Historical Control ◽

Final Visit ◽

Fisher Exact Test ◽

Improvement Rate ◽

Patients With Cancer ◽

Edmonton Symptom Assessment Scale ◽

Pain Improvement

PURPOSE: Approximately 30% of patients with cancer who have pain have symptomatic improvement within 1 month using conventional pain management strategies. Engaging clinical pharmacists in palliative medicine (PM) and use of pharmacogenomic testing may improve cancer pain management. METHODS: Adult patients with cancer with uncontrolled pain had baseline assessments performed by PM providers using the Edmonton Symptom Assessment Scale. Pharmacotherapy was initiated or modified accordingly. A subset of patients consented to pharmacogenomic testing. The first pharmacy assessment occurred within 1 week of baseline and a second assessment was done within another week if intervention was required. Each patient’s final visit was at 1 month. Pain improvement rate (a reduction of two or more points on a 0-to-10 pain scale) from baseline to final visit was compared applying the Fisher exact test to published historical control data, and between patients with and without pharmacogenomic testing. Multivariate logistic regression identified pain improvement covariates. RESULTS: Of 142 patients undergoing pharmacy assessments, 53% had pain improvement compared with 30% in historical control subjects ( P < .001). Pain improvement was not different between those who received (n = 43) and did not receive (n = 99) pharmacogenomics testing (56% v 52%; P = .716). However, of 15 patients with an actionable genotype, 73% had pain improvement. Higher baseline pain (odds ratio [OR], 1.79; 95% CI, 1.43 to 2.24; P < .001), black or other race (OR, 0.42; 95% CI, 0.18 to 0.95; P = .04), and performance status 3 or 4 (OR, 0.18; 95% CI, 0.04 to 0.83; P = .03) were associated with odds of pain improvement, but pharmacogenomic testing was not ( P = .64). CONCLUSION: Including pharmacists in PM improves pain management effectiveness. Although pharmacogenomics did not statistically improve pain, a subset of patients with actionable genotypes may have benefited, warranting larger and randomized studies.

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Impact of pharmacy interventions on pain management in an oncology palliative medicine (PM) outpatient clinic.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.31_suppl.119 ◽

2017 ◽

Vol 35 (31_suppl) ◽

pp. 119-119

Author(s):

Jai Narendra Patel ◽

Issam Hamadeh ◽

James Thomas Symanowski ◽

Rebecca Edwards ◽

Beth Susi ◽

...

Keyword(s):

Pain Management ◽

Primary Endpoint ◽

Stage Iv ◽

Pain Severity ◽

Final Visit ◽

Significant Pain ◽

Edmonton Symptom Assessment Scale ◽

Pain Improvement ◽

Historical Controls

119 Background: PM can improve the quality of life and survival for cancer patients (pts); however, the demand for PM challenges providers with delayed follow ups resulting in less than one-third of pts achieving significant pain improvement between clinic visits. Engaging pharmacists in the provision of PM may help improve pain management in cancer pts. Methods: Adult cancer pts starting a new pain regimen or requiring changes to an existing regimen at baseline were referred for pharmacy follow up in 3-7 days (assessment #1). The pharmacist evaluated each pt using the Edmonton Symptom Assessment Scale and recommended changes to the referring PM provider, prompting a 2nd follow up in 3-7 days (assessment #2). If no changes were required, pts continued therapy and returned for the final clinic visit (day 28 +/- 7). The primary endpoint was the proportion of pts achieving significant pain improvement (≥ 2-point decrease in pain score on a scale of 0-10) from baseline to final visit, which was compared to historical controls using Fisher’s Exact test. Changes in pain severity from baseline to final visit were compared using Generalized McNemar’s test, and descriptive statistics were used to describe characteristics at assessment #1. Results: Of 102 pts evaluable for the primary endpoint, 76% had stage IV disease, 58% were female, and median age was 57 yrs. Significantly more pts achieved pain improvement from baseline to final visit compared to historical controls (49% v 30%; P < 0.001). Changes in pain severity from baseline to final visit are described in the table. At assessment #1, 70% of pts required an intervention, primarily due to uncontrolled pain (72%), side effects (26%), and/or lack of response to non-pain medications (22%). The most common types of interventions were dose adjustments (62%), education (36%), and/or adding a new medication (30%). Over 90% of recommendations were accepted by the referring PM provider. The median time of assessment was 15 mins. Conclusions: Routine inclusion of pharmacists in the outpatient PM interdisciplinary team improves the effectiveness of pain management. [Table: see text]

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The McGill University Health Centre Cancer Pain Clinic: A Retrospective Analysis of an Interdisciplinary Approach to Cancer Pain Management

Pain Research and Management ◽

10.1155/2016/2157950 ◽

2016 ◽

Vol 2016 ◽

pp. 1-7 ◽

Cited By ~ 6

Author(s):

Jordi Perez ◽

Sara Olivier ◽

Emmanouil Rampakakis ◽

Manuel Borod ◽

Yoram Shir

Keyword(s):

Pain Management ◽

Cancer Pain ◽

Retrospective Analysis ◽

Health Centre ◽

Interdisciplinary Approach ◽

Pain Clinic ◽

Initial Assessment ◽

Cancer Pain Management ◽

Edmonton Symptom Assessment Scale ◽

Mcgill University

Context. The McGill University Health Center (MUHC) Cancer Pain Clinic offers an interdisciplinary approach to cancer pain management for patients. The core team includes a nurse clinician specialist in oncology and palliative care, a palliativist, an anaesthetist, and a radiation oncologist. This tailored approach includes pharmacological and nonpharmacological therapies offered concurrently in an interdisciplinary fashion.Objectives. Description of the interdisciplinary MUHC cancer pain approach and analysis of treatments and outcomes.Methods. A retrospective analysis of new outpatients completing two subsequent visits (baseline and follow-ups: FU1, FU2) was conducted. Variables included (a) symptom severity measured by the Edmonton Symptom Assessment Scale, (b) pain and disability measured with the Brief Pain Inventory, and (c) analgesic plan implementation including pharmacological and nonpharmacological therapies.Results. 71 charts were reviewed. Significant pain relief was achieved consistently at FU1and FU2. The average pain severity decreased by 2 points between initial assessment and FU2. More than half (53%) of patients responded with a pain reduction greater than 30%. Severity of other symptoms (i.e., fatigue, nausea, depression, and anxiety) and disability also decreased significantly at FU2. The total consumption of opioids remained stable; however, the consumption of short acting preparations decreased by 52% whereas the prescription of nonopioid agents increased. Beyond drug management, 60% of patients received other analgesic therapies, being the most common interventional pain procedures and psychosocial approaches.Conclusion. The MUHC interdisciplinary approach to cancer pain management provides meaningful relief of pain and other cancer-related symptoms and decreases patients’ disability.

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Cancer pain management: Implications for psychologists

PsycEXTRA Dataset ◽

10.1037/e570662013-027 ◽

2013 ◽

Author(s):

Stacy A. Ogbeide

Keyword(s):

Pain Management ◽

Cancer Pain ◽

Cancer Pain Management ◽

Management Implications

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Cancer pain management

Orvosi Hetilap ◽

10.1556/oh.2014.29808 ◽

2014 ◽

Vol 155 (3) ◽

pp. 93-99

Author(s):

Péter Heigl

Keyword(s):

Quality Of Life ◽

Pain Management ◽

Pain Relief ◽

Life Expectancy ◽

Cancer Pain ◽

Cancer Pain Management ◽

Medical Activity ◽

Short Summary ◽

Adequate Quality

Pain is a significant and alarming symptom of cancer seriously affecting the activity and quality of life of patients. Recent research proved that inadequate analgesia shortens life expectancy. Therefore, pain relief is not only a possibility but a professional, ethical and moral commitment to relieve patients from suffering, as well as ensure their adequate quality of life and human dignity. Proper pain relief can be achieved with medical therapy in most of the cases and the pharmacological alternatives are available in Hungary. Yet medical activity regarding pain relief is far from the desired. This paper gives a short summary of the guidelines on medical pain management focusing particularly on the use of opioids. Orv. Hetil., 2014, 155(3), 93–99.

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