Pain, fatigue, and emotional distress are the most common adverse effects reported by cancer patients. In many studies, cancer-related pain has been identified as a preventable reason for hospital admission. And despite significant advances in pain management, providing cancer patients with better and more effective cancer pain control, some barriers remain.
A study conducted by researchers of the Department of Anesthesiology and Pain Management of the Maastricht University Medical Center (MUMC+) in Maastricht, The Netherlands, shows that cancer-related pain was reported in 55.0% of patients undergoing active treatment. This included 39.3% of patients with cancer in remission, and 66.4% of patients with advanced, metastatic, or terminal disease. [8] Another study identified pain diagnoses as associated with 41.4% of emergency department (ED) visits by patients with cancer. And in most cases liberal systemic opioid use for cancer pain remains the standard of care despite increased health care utilization secondary to frequent adverse effects.
Barriers to proper pain management
Based on their ongoing research, researchers at the Maastricht University Medical Center report a number of specific barriers limiting the benefit or causing a lack of improvement of cancer-related pain. [1] Among the most frequently mentioned reasons are:
- A patients’ inability to discuss or address the issue of pain management with their doctor,
- Infrequent or limited use of available pain measurement tools;
- Limited knowledge concerning the assessment of under-treatment of a patient’s cancer-related pain;
- Changes in patients’ characteristics, including, but not limited to the ageing of the population;
- Lack of significant improvement in the treatment of neuropathic pain;
- Limitations of pharmacological treatment combined with a lack of evidence-based nonpharmacological treatment strategies.
Skill
Safe and effective opioid use in a patient with cancer requires skill. Understanding the mechanism of action, along with the pharmacokinetics and pharmacodynamics of opioids will lead to appropriate selection, dosing, and titration of these agents.
With an increasing concern of the abuse of opioids in pain management, doctors are looking for an alternative to better control and manage their patient’s cancer-related pain. And while this needs to include physicians’ changed approach to the management of a patient’s pain management by proactively asking about pain and ‘measuring’ pain using specific pain assessment instruments, recognizing and measuring undertreatment, educational interventions to improve skills in pain management and the development of a better, more effective, and personalized strategies of pharmacological and nonpharmacological pain management is required. One of these strategies include changing the administration of cancer-related pain medication. [2]
Changing strategies
A study published in JAMA Network Open shows demonstrates a reduction in health care utilization and cost for cancer pain patients using targeted drug delivery (TDD) and conventional medical management (CMM) vs. CMM alone. [2]
The study found significant cost savings to payors, with fewer inpatient visits, shorter inpatient length of stay, and fewer emergency department (ED) visits for the TDD and CMM group.
Over 12 months, TDD therapy was associated with a significant mean overall cost savings of US $63,498 and fewer oral opioid prescriptions per patient.
Targeted drug delivery can be delivered via the Medtronic SynchroMed? II Infusion System, an implantable pump that delivers medication directly to the fluid around the spinal cord, enabling clinicians to prescribe reduced doses compared to systemically delivered medications. The system, referred to as the ?Medtronic Pain Pump,? is an alternative to oral opioids for patients and provides effective pain relief at a fraction of the oral dose with fewer side effects and may help reduce the use of oral opioids.[2][3][4][5][6]
Burden of Pain
The burden of cancer continues to increase on a personal and societal level and the National Cancer Institute projects that the yearly cost of cancer treatment in the United States will increase to US $157 billion in 2020.[7]
Pain is prevalent in cancer patients and 55% of those undergoing active treatment report pain. [8]
It has been identified as a preventable reason for hospital admission and is associated with more than 40 percent of cancer ED visits.[9]
Liberal oral opioid use for cancer pain remains the standard of care despite increased health care utilization secondary to frequent adverse effects.[10][11][12]
Opioid prescription rates for cancer survivors have been reported to be 1.22 times higher than for those without cancer.[13]
?TDD should be considered as an option for patients with cancer-related pain,? said Lisa J. Stearns, MD, Center for Pain and Supportive Care, Phoenix, AZ. and lead researcher and co-author of the study.
“It is proven safe and effective for cancer pain patients, offering pain relief and improvements in quality of life. Now, TDD also demonstrates a robust financial benefit, which is especially significant as the incidence and societal burden of cancer continues to increase,” Stearns added.
Stearns opinion is confirmed by the randomized trial data which showed that TDD provides better pain relief with fewer side effects when compared to CMM. The National Comprehensive Cancer Network recommends TDD as an option for patients who experience intolerable side effects or in whom systemic opioids are not effective.[13]
The paper reports the results of a retrospective propensity-score matched analysis conducted using a large U.S. claims database comparing mean total commercial payer costs and health care utilization at two, six, and 12 months. Researchers matched commercial insurance beneficiaries with patients with severe uncontrolled cancer pain receiving TDD and CMM or CMM alone. Participants were matched on age, sex, cancer type, comorbidity score, and pre-enrollment characteristics. After matching, each group included 268 patients.
The study found that compared with CMM alone, TDD and CMM demonstrated the following per patient:
- Cost savings: a mean total cost savings of US $ 15,142.00 at 2 months and US $ 63,498.00 at 12 months; cost savings at 6 months was not statistically significant;
- Fewer inpatient visits at 2 months, 6 months, and 12 months;
- Shorter hospital stays at 2 months (mean difference, 6.8 days), 6 months (mean difference, 6.8 days), 12 months (mean difference, 10.6 days);
- An association with fewer prescriptions for oral opioids at 12 months.
Cost-saving therapy
The study showed that TDD and CMM is a cost-saving therapy to treat cancer pain, and based on these findings, increased use of TDD may have the potential to reduce future health care cost and utilization. As cancer rates continue increasing with the aging population, the authors concluded that considering more patients with significant cancer-related pain for TDD may result in substantial cost savings alongside improved quality of life.
TDD is proven safe and effective for managing cancer pain in patients whose life expectancy is three months or more. [3] A study showed that at four weeks, 60 percent of patients using TDD and CMM reported a pain score of less than four (on a scale of 1-10) compared to 42% using CMM alone. Patients who received TDD and CMM also experienced fewer side effects, including less vomiting and confusion, fewer behavioral changes, and significantly less fatigue and sedation [4].
Patients who received TDD in another study experienced improvements in function. [14]
?Despite evidence that TDD provides better pain relief with fewer side effects than CMM, and has the potential to reduce oral opioid use, it is underutilized with appropriate patients,? noted Charlie Covert, vice president and general manager of the Targeted Drug Delivery business, which is part of the Restorative Therapies Group at Medtronic.
?The results of this study complement the growing body of TDD data demonstrating the value of TDD to patients and the healthcare system,? Covert concluded.
References
[1] Van den Beuken-van Everdingen MHJ, van Kuijk SMJ, Janssen DJA, Joosten EAJ. Treatment of Pain in Cancer: Towards Personalised Medicine. Cancers (Basel). 2018 Dec 10;10(12). pii: E502. doi: 10.3390/cancers10120502.
[2] Stearns LJ, Narang S, Albright RE Jr, Hammond K, Xia Y, Richter HB, Paramanandam GK, Haagenson KK, Doth AH. Assessment of Health Care Utilization and Cost of Targeted Drug Delivery and Conventional Medical Management vs Conventional Medical Management Alone for Patients With Cancer-Related Pain. JAMA Netw Open. 2019 Apr 5;2(4):e191549. doi: 10.1001/jamanetworkopen.2019.1549.
[3] Brogan SE, Winter NB, Abiodun A, Safarpour R. A cost utilization analysis of intrathecal therapy for refractory cancer pain: identifying factors associated with cost benefit. Pain Med. 2013;14(4):478-486.
[4] Smith TJ, Staats PS, Deer T, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002;20(19):4040-4049.
[5] Stearns LJ, Hinnenthal JA, Hammond K, Berryman E, Janjan NA. Health services utilization and payments in patients with cancer pain: a comparison of intrathecal drug delivery vs. conventional medical management. Neuromodulation. 2016;19(2):196-205.
[6] Hatheway JA, Caraway D, David G, et al. Oral opioid elimination after implantation of an intrathecal drug delivery system significantly reduced health-care expenditures. Neuromodulation : journal of the International Neuromodulation Society. 2015;18(3):207-213.
[7] Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011;103(2):117-128.
[8] Van den Beuken-van Everdingen MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. J Pain Symptom Manage. 2016;51(6):1070-1090 e1079.
[9] Panattoni LE, Fedorenko CR, Kreizenbeck KL, et al. The role of chronic disease in the costs of potentially preventable emergency department use during treatment: A regional study. J Clin Oncol. 2017;35(15 Supplement 1).
[10] Paice JA, Ferrell B. The management of cancer pain. CA Cancer J Clin. 2011;61(3):157-182.
[11] Cancer Pain Relief with A Guide to Opioid Availability. 2nd ed. Geneva: World Health Organization; 1996: http://apps.who.int/iris/bitstream/10665/37896/1/9241544821.pdf. Accessed January 31, 2018.
[12] Swarm R, Abernethy AP, Anghelescu DL, et al. Adult cancer pain. J Natl Compr Canc Netw. 2010;8(9):1046-1086.
[13] Sutradhar R, Lokku A, Barbera L. Cancer survivorship and opioid prescribing rates: A population-based matched cohort study among individuals with and without a history of cancer. Cancer. 2017;123(21):4286-4293.
[14] Deer T, Chapple I, Classen A, et al. Intrathecal drug delivery for treatment of chronic low back pain: report from the National Outcomes Registry for Low Back Pain. Pain Med. 2004;5(1): 6-13.
Last Editorial Review: April 9, 2019
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