Pain Prevention Using Head and Neck Cancer as a Model.

Pain is a common and often debilitating consequence of cancer and its treatment. Efforts to improve pain management for patients diagnosed with cancer have not resulted in widespread patient reports of acceptable management of pain. Patients and providers alike remain opiophobic due to a number of issues, resulting in suboptimal management of pain. Recent literature has revealed that it may be possible to prevent pain related to cancer and its treatment and therefore avoid or decrease the amount of opioids used to treat pain. This may result in better quality of life for patients. Several newer antiepileptic drugs (AEDs) have been found to decrease the perception of pain in a number of patient populations, including those with head and neck cancer. The side-effect profile for the newer AEDs is mild and well tolerated. Future efforts should focus on the use of newer AEDs to prevent pain in other cancer populations, with a focus on ideal dose and scheduling. Once established, recommendations regarding the prevention of pain in patients with cancer can be incorporated into national guidelines.

Late consequential surgical bed soft tissue necrosis in advanced oropharyngeal squamous cell carcinomas treated with transoral robotic surgery and postoperative radiation therapy.

PURPOSE: A subset of patients with oropharyngeal squamous cell carcinoma (OP-SCC) managed with transoral robotic surgery (TORS) and postoperative radiation therapy (PORT) developed soft tissue necrosis (STN) in the surgical bed months after completion of PORT. We investigated the frequency and risk factors. MATERIALS AND METHODS: This retrospective analysis included 170 consecutive OP-SCC patients treated with TORS and PORT between 2006 and 2012, with >6 months' of follow-up. STN was defined as ulceration of the surgical bed >6 weeks after completion of PORT, requiring opioids, biopsy, or hyperbaric oxygen therapy. RESULTS: A total of 47 of 170 patients (28%) had a diagnosis of STN. Tonsillar patients were more susceptible than base-of-tongue (BOT) patients, 39% (41 of 104) versus 9% (6 of 66), respectively. For patients with STN, median tumor size was 3.0 cm (range 1.0-5.6 cm), and depth of resection was 2.2 cm (range 1.0-5.1 cm). Median radiation dose and dose of fraction to the surgical bed were 6600 cGy and 220 cGy, respectively. Thirty-one patients (66%) received concurrent chemotherapy. Median time to STN was 2.5 months after PORT. All patients had resolution of STN after a median of 3.7 months. Multivariate analysis identified tonsillar primary (odds ratio [OR] 4.73, P=.01), depth of resection (OR 3.12, P=.001), total radiation dose to the resection bed (OR 1.51 per Gy, P<.01), and grade 3 acute mucositis (OR 3.47, P=.02) as risk factors for STN. Beginning May 2011, after implementing aggressive avoidance of delivering >2 Gy/day to the resection bed mucosa, only 8% (2 of 26 patients) experienced STN (all grade 2). CONCLUSIONS: A subset of OP-SCC patients treated with TORS and PORT are at risk for developing late consequential surgical bed STN. Risk factors include tonsillar location, depth of resection, radiation dose to the surgical bed, and severe mucositis. STN risk is significantly decreased with carefully avoiding a radiation dosage of >2 Gy/day to the surgical bed.

Pain management in palliative care oncology patients.

Palliative care is an interdisciplinary approach to relieving aversive symptoms in people with life-threatening illnesses; it aims to improve the lives of patients and their loved ones, the "patient-family unit." Palliative care should occur in parallel with all other medical interventions. Indeed, good symptom management is important in helping patients cope with the unpleasantness associated with potentially curative or life-prolonging interventions; it is absolutely essential near the end of life. Unrelieved pain is the symptom that people fear the most. In most cases, adequate pain relief can be achieved with systemic medications alone. When systemic medications fail, due to inadequate analgesia or burdensome side effects, invasive techniques may complement, or replace, systemic therapy. Using a case-based format, we illustrate some complex issues that clinicians face and offer strategies to improve the lives of oncology patients with pain.