7.17 (13.5) management issues in chronic pain following cancer therapy

Question 1

List three contributors to greater life expectency surrounding cancer

Answer 1

improved cancer surveillance
more accurate diagnoses
more effacacious tx
longer follow up

Question 2

List two major potential pain complications due to exposure to chemo

Answer 2

chronic peripheral neuropathy

myopathy

Question 3

List three surgeries used for cancer treatment that carry significant risk of post operative chronic pain

Answer 3

thoracotomy*
breast surgery*
modified radical neck dissection
limb amputation*
nephrectomy*
Inguinal LN dissection*

Question 4

List SIX chronic pain syndromes associated w/ radiation treatment for cancer

Answer 4

◆ plexopathies
◆ Peripheral nerve entrapment
◆ myelopathy
◆ enteritis/proctitis**
◆ cystitis/prostatitis**
◆ visceral stricture
◆ osteoradionecrosis**
◆ pelvic insuffiency fractures**
◆ fibrosis of skin/myofascia**
◆ fistula formation
◆ chest pain/tightness

6th Ed. Table 7.17.1

Question 5

What 1 chronic pain issue that may develop in a patient exposed to bisphosphonates during cancer therapy?

List four risk factors for this

Answer 5

osteonecrosis of the jaw

Risk factors:
steroids
chemotherapy
infection
Periodontal disease 
poor dental hygiene

FS: anything that impairs healing
Dental procedure

Question 6

List FOUR classes of cancer tx that can cause chemotherapy induced peripheral neuropathy. Name ONE from each class.

Answer 6

◆ Epothilones
- ixabepilone

◆ Platinum agents*
- carboplatin
- cisplatin
- oxaliplatin

◆ Taxanes*
- cabazitaxel
- docetaxel
- paclitaxel

◆ Immunomodulatory agents* (MM treatments)
- lenalidomide
- pomalidomide
- thalidomide

◆ Proteasome inhibitors
- bortezomib
- carfilzomib

◆ Vinca alkaloids*
- etoposide
- vinblastine
- vincrstine
- vinorelbine

6th Ed. Table 7.17.2

FS: COP - MV

Question 7

After surgery a patient has a shoulder tilt, winged scapula, and is unable to retract the shoulder.

• What is the syndrome called?
• What surgery likely caused it?
• What nerve is involved?

Answer 7

Shoulder syndrome

radical neck dissection

removal of spinal accesory nerve (SAN)

Question 8

List 3 types of pain syndrome that can develop after breast surgery for cancer treatment

Answer 8

phantom breast syndrome*

neuroma pain

intercostobrachial neuralgia

other nerve injury pain*

pain related to breast implants and surgical reconstruction*

Question 9

List three benefits of the involvement of an interdisciplinary team in the management of a patient with chronic pain from cancer therapy

Answer 9

Decreased pain
Improved mood
Improved function (return to work)

Question 10

List four non pharm techniques that can be used with patients with chronic pain following cancer tx

Answer 10

exercise training
self-regulation techniques
relaxation
hypnosis
TENS
CBT
Desensitization strategies
Mindfulness based stress reduction
guided imagery

FS:
Exercise
Massage
Acupuncture
Mind body treatments: meditation, yoga, CBT, hypnosis, relaxation Tai chi

Question 11

List four factors that influence a person’s experience of pain

Answer 11

psychological
cognitive
cultural
environmental

FS: cicely saunders total pain
Physical
Psychological
Social
Spiritual

Question 12

List four types of pharmacologic agents used for the management of chronic pain in cancer survivors

Answer 12

opioids
Antidepressants 
Anticonvulsants 
NSAIDS
topical lidocaine
ketamine

Question 13

Name THREE chronic pain syndromes associated with immunotherapy

Answer 13

◆ inflammatory arthritis**
◆ myositis
◆ peripheral neuropathy*
◆ polymyalgia-like syndrome

FS: like chemo + arthritis

Question 14

Name SIX chronic pain syndromes associated w/ haematopoietic stem cell transplant (graft vs host disease).

Answer 14

◆ abdominal/GI adhesions
◆ arthralgia/myalgia
◆ corneal ulcerations
◆ cystitis*
◆ esophageal structures/ulcers (retrosternal pain)
◆ fibrosis/scleroderma*
◆ infection
◆ inflammation/edema
◆ mucous mem inflam, thinning, strictures, ulcers*
◆ muscle cramps
◆ osteonecrosis of joints
◆ osteoporosis & osteonecrosis *
- avascular necrosis of fem head, knee, hum head
◆ peripheral neuropathy

6th Ed Table 7.17.1

FS: very similar to radiation and chemo effects

• cystitis
• enteritis
• osteonecrosis
• fibrosis
• neuropathy
• myopathy

Question 15

Name TWO risk factors for chemo induced peripheral neuropathy (CIPN).

Answer 15

◆ cancer treatment used*
- paclitaxel>docetaxel
◆ age
◆ comorbid diabetes*

In breast cancer:
◆ obesity
◆ low activity level

Question 16

America Society of Clinical Onc practice guidelines state which agent is approved for existing chemo induced peripheral neuropathy?

Answer 16

duloxetine (Cymbalta)

Question 17

Name TWO risk factors for arthralgias associated w/ aromatase inhibitors

Answer 17

◆ elevated BMI*
◆ previous taxane tx
◆ stage III cancer
◆ menopause of 5-10 years*

Question 18

Name 2 risk factors for developing graft vs host disease (GVHD)

Answer 18

◆ amount of human leucocyte antigen disparity between host & donor
◆ sex mismatch*
◆ older age*
◆ intensity of conditioning regime
- ablative vs non-myeloablative

Question 19

Name THREE consequences of long term opioid use

Answer 19

◆ hypogonadism*
◆ mental clouding*
◆ neurotoxicity*
◆ sleep disordered breathing
◆ impaired immune function (maybe)
◆ misuse*

Question 20

Name THREE risk factors for potential misuse of opioids and other substances

Answer 20

◆ current/past hx of substance misuse
◆ family history
◆ exposure to trauma
- ex. sexual assault

Question 21

Name TWO tools that can be used in history taking to assess opioid misuse risk

Answer 21

◆ CAGE
◆ Opioid Risk Tool (ORT)
◆ SOAPP

FS:
Screener and Opioid Assessment for Pain Patients (SOAPP)

Current Opioid Misuse Measure (COMM)