The relationship between pain, analgesics and survival in patients with advanced cancer; a secondary data analysis of the international European palliative care Cancer symptom study.

PURPOSE: Opioids reduce cancer-related pain but an association with shorter survival is variably reported. AIM: To investigate the relationship between pain, analgesics, cancer and survival within the European Palliative Care Cancer Symptom (EPCCS) study to help inform clinical decision making. METHODS: Secondary analysis of the international prospective, longitudinal EPCCS study which included 1739 adults with advanced, incurable cancer receiving palliative care. In this secondary analysis, for all participants with date of death or last follow up, a multilevel Weibull survival analysis examined whether pain, analgesics, and other relevant variables are associated with time to death. RESULTS: Date of death or last follow-up was available for 1404 patients (mean age 65.7 [SD:12.3];men 50%). Secondary analysis of this group showed the mean survival from baseline was 46.5 (SD:1.5) weeks (95% CI:43.6-49.3). Pain was reported by 76%; 60% were taking opioids, 51% non-opioid analgesics and 24% co-analgesics. Opioid-use was associated with decreased survival in the multivariable model (HR = 1.59 (95% CI:1.38-1.84), p < 0.001). An exploratory subgroup analysis of those with C-reactive protein (CRP) measures (n = 219) indicated higher CRP was associated with poorer survival (p = 0.001). In this model, the strength of relationship between survival and opioid-use weakened (p = 0.029). CONCLUSION: Opioid-use and survival were associated; this relationship weakened in a small sensitivity-testing subgroup analysis adjusting for CRP. Thus, the observed relationship between survival and opioid-use may partly be due to tumour-related inflammation. Larger studies, measuring disease activity, are needed to confirm this finding to more accurately judge the benefits and risks of opioids in advanced progressive disease.

Clinical expert guidelines for the management of cough in lung cancer: report of a UK task group on cough.

BACKGROUND: Cough is a common and distressing symptom in lung cancer patients. The clinical management of cough in lung cancer patients is suboptimal with limited high quality research evidence available. The aim of the present paper is to present a clinical guideline developed in the UK through scrutiny of the literature and expert opinion, in order to aid decision making in clinicians and highlight good practice. METHODS: Two systematic reviews, one focusing on the management of cough in respiratory illness and one Cochrane review specifically on cancer, were conducted. Also, data from reviews, phase II trials and case studies were synthesized. A panel of experts in the field was also convened in an expert consensus meeting to make sense of the data and make clinical propositions. RESULTS: A pyramid of cough management was developed, starting with the treatment of reversible causes of cough/specific pathology. Initial cough management should focus on peripherally acting and intermittent treatment; more resistant symptoms require the addition of (or replacement by) centrally acting and continuous treatment. The pyramid for the symptomatic management starts from the simpler and most practical regimens (demulcents, simple linctus) to weak opioids to morphine and methadone before considering less well-researched and experimental approaches. CONCLUSION: The clinical guidelines presented aim to provide a sensible clinical approach to the management of cough in lung cancer. High quality research in this field is urgently required to provide more evidence-based recommendations.

Managing the symptoms of neuropathic pain: an exploration of patients' experiences.

The debilitating effects of chronic neuropathic pain on everyday life are considerable, but little is known about how individual sufferers manage these effects. Virtually nothing is known about what patients prefer, what measures they take themselves and when, or in what combinations. The aim of this study was to explore patients' reports of how they managed their neuropathic pain symptoms. Three focus groups (10 participants in total) were used to generate qualitative data on both individual and shared experiences of managing symptoms of neuropathic pain. Discussions were recorded and transcribed verbatim. Data were analyzed using thematic analysis, identifying categories and broader themes of importance to patients. The most common management strategy was the use of conventional medications, often associated with poor effectiveness and unpleasant side effects. Complementary and alternative medicine was ineffective, but many found resting or retreating helpful. They exhibited a repeated cycle of seeking help to manage the pain, with each unsuccessful attempt followed by new attempts. Some had tried to accept their pain, but there was insufficient psychological, social, emotional, and practical support to allow them to do this successfully. This exploratory study provides a basis from which to develop a larger study to validate and extend the findings. Other issues meriting research are the effectiveness of cognitive-behavioral therapies for those with neuropathic pain, and an exploration and subsequent evaluation of different types of social, practical, and emotional support needed to help live with neuropathic pain.