br Pain may arise for a variety of mechanisms including
Pain may arise for a variety of mechanisms, including direct inva-sion of bone, cancer infiltration of nerve roots, regional metastases, infection, ulceration, and Olaparib . Moreover, pain related to surgery or chemotherapy, and radiation-induced mucositis or radiation-induced brachial plexopathies often account for treatment-related pain
[8,9]. The aggressive erosive nature and the rich sensory innervation of the large area of H&N, render it one of most painful tumors [7,10–12], with consequent implications for patients in terms of quality of life, nutrition, as well as treatment outcomes. Studies have reported that pain is associated with pre-treatment pain score, less education, neck dissection, feeding tube, dry mouth, depression, analgesic consumption, less physical activity, and poor quality of sleep [7,10–15]. Thus, pa-tients with H&N cancer having these risk factors may require more aggressive pain management . Of interest, although higher doses of opioids are needed than those reported in other cancers, pain was considered acceptable and most patients were classified as partially responsive, underlining that an appropriate management may provide an adequate pain relief [13–15]. Cancer pain management in this po-pulation is challenging and often sub-optimal. Undertreatment may occur for diﬀerent reasons, mainly related to poor screening or as-sessment of pain, inadequate knowledge and prescription of analgesia, and poor opioid adverse-eﬀect management . In the long-term, H& N cancer pain impacts adversely on quality of life, and pain is persisting
E-mail addresses: [email protected] (S. Mercadante), [email protected] (F. Masedu), [email protected] (M. Valenti).
S. Mercadante, et al.
in survivors the substantial pain persisting beyond 5 years in one in six survivors .
Breakthrough pain (BTcP) may further complicate the clinical pic-ture. This phenomenon has been defined as a transitory peak in pain intensity, that occurs spontaneously or in relation to a specific trigger, in patients with stable and well controlled background cancer pain . The temporal pattern of this kind of pain interferes with quality of life . Cancer patients experience peaks of pain intensity with dif-ferent characteristics in terms of predictability, onset, and duration [19,20]. Indeed, data regarding BTcP in H&N cancer patients are lacking.
The aim of integumentary system study was to characterize BTcP and its interference in patients with H&N cancer. The secondary outcome was to analyze patients’ satisfaction and drugs used for BTcP, as well adverse eﬀects associated with BTcP medication.
This was a secondary analysis of a large, national, multicenter study of BTcP that involved 32 centers . The local ethical committees approved the protocol at each center, and written informed consent was obtained from each patient. Patients were seen as outpatient, inpatient, or day-hospital, and were recruited in palliative care, oncology, radiotherapy, and pain therapy settings. Thirty-two centers participated in the study and represented all the regions of Italy.
Inclusion criteria were: age ≥18 years, a diagnosis of cancer, stable and well-controlled background pain (pain intensity ≤4 on a 0–10 numerical scale), the presence of BTcP episodes clearly distinguished from background pain, with moderate-severe intensity, according to a pre-defined algorithm . Exclusion criteria were: a condition of an unstable or uncontrolled background pain (> 4/10); peaks of low pain intensity (< 5/10), and poor collaboration. From the original study, patients with H&N were selected.
Age, gender, visit setting, cancer characteristics, extent of the dis-ease (loco regional or metastatic), type of ongoing anticancer treat-ments, and Karnofsky status were recorded.
Average pain intensity in the last 24 h (on a numerical scale 0–10), and opioids used for background pain and their doses, expressed as oral morphine equivalents (OME) , as well as other analgesic drugs, were recorded.
The number of episodes, their intensity (on a numerical scale 0–10), predictability and precipitating factors, onset (≤10 min or > 10 min), duration of an untreated episode, interference with daily activities (on a scale from 0 to 3, none and very much, respectively), were collected. Opioid drugs and doses used for BTcP, and the mean time to meaningful pain relief after taking medication, were assessed. Adverse eﬀects to be attributed to these medications were also recorded. The presence of mucositis was assessed, grading oral lesions according to World Health Organization (WHO) criteria .