Managing the pain of mesothelioma

Managing the pain of mesothelioma


Pain is a common symptom of mesothelioma. It is often complex and is not only caused by the cancer itself but also by investigations leading to diagnosis and treatments. It is important that doctors and nurses caring for you thoroughly assess the site, nature and severity of the pain. They will often ask you to describe and rate the pain and sometimes use a scoring tool such as zero to ten, where zero equals no pain at all and ten equals worst pain imaginable. 

Typically, mesothelioma pain occurs on one side of the chest, sometimes in the shoulder or back and movement or deep breathing often makes the pain feel worse.

There are a number of ways in which pain can be alleviated, these include using pain medicines , radiotherapy and nerve blocks. If pain is caused by the burden of disease, anti-cancer drugs such as chemotherapy or immunotherapy can shrink the cancer, relieving pressure and leading to a reduction in pain. 

Medication

 The World Health Organisation’s (WHO) Analgesic Ladder for Cancer Pain Relief, was published in 1986 and continues to be the cornerstone of pharmacological management of cancer pain. It uses a stepwise approach that has been demonstrated to relieve 80% of cancer pain [1].

The first step of the ladder involves the initiation of paracetamol and non-steroidal anti-inflammatory drugs. The addition of a weak opioid, such as codeine, occurs at step 2 for moderate pain, with a strong opioid recommended for severe pain at step 3. Additional pain killing drugs can be added at any step and can be beneficial for the management of “nerve” (neuropathic) pain [2]. some of these drugs have in the past been developed to treat epilepsy or depression but have also been shown to contain unique pain-relieving properties that can alleviate “nerve pain”.

Drugs such as morphine can be used alone or in combination with other pain relieving drugs as a slow release (longer acting) medication which provides a background level of pain control. When pain occurs in between doses, this is called 'breakthrough pain' and often responds to an additional dose of the same drug but in a faster acting formula.

Many pain killing drugs are taken by mouth (orally), however, some drugs can be delivered by a daily infusion via a needle inserted under the skin using a small battery operated devise. This is known as a syringe driver. Other drugs can also be used without the need to take orally. They are used as a patch which is applied to the skin and needs to be changed as instructed (for example, fentanyl patches are changed every 3 days.

Radiotherapy

 The use of radiotherapy in mesothelioma is largely aimed at symptom control. Recent studies have shown that radiotherapy can significantly improve pain control with very little in the way of adverse side effects [3]. Further work is ongoing to see if giving a higher dose of radiation over a longer period of time provides even better pain control [4].

Pain can be caused by seeding of malignant cells along instrument tracts at sites of diagnostic or therapeutic interventions such as biopsies or chest drains. The use of post-procedure radiotherapy to decrease this risk is controversial and clinical practice varies widely. There have been several negative studies which don’t show any benefits from prophylactic radiotherapy which aims to prevent this seeding [5, 6]. Where prophylactic radiotherapy has fallen out of favour, radiation is held in reserve and can be used if painful seeding occurs.

Other interventions

As  mesothelioma pain can be complex and difficult to manage despite the pain-relieving methods above, it’s important to consider other techniques used to manage cancer pain.

These techniques can range from simple 'self help' efforts such as applying heat packs or wheat bags to the site of pain to more specialised procedures performed in hospital.

TENS (Transcutaneous Electrical Nerve Stimulator) machines can be useful and used at home.

Other interventional techniques include peripheral nerve injections. A “nerve block” describes a procedure utilizing a needle to deliver a local anaesthetic or other agent, for analgesic purposes [7].

An operations that is designed to remove specific parts of the spinal cord that carries pain fibres is known as a percutaneous cervical cordotomy is sometimes used to treat severe pain in the chest (such as costopleural syndrome). This technique should always be considered within a multi-disciplinary team with access to specialist palliative care and pain medicine teams when pain has failed to respond to more conventional pain-relieving therapies. It involves placing an electrode (about the size of a blood test needle) into pain carrying pathways using guidance from an x-ray to remove the pathway of the pain fibres (within the spinal cord) that supply the chest. It is performed under local anaesthetic and you remain awake and able to report any sensations experienced during the procedure. Reports show excellent results in terms of controlling pain however access to services can vary meaning many will have to consider travelling out of area to be treated [8].

Conclusion

It is important to remember that there are ways of improving your pain. It is vital you tell your health care team about your pain as soon as you experience it as it is easier to control pain at an earlier stage. Some of the treatments mentioned above do not work immediately or often take days or weeks to organise.

The author Mr Simon Bolton has no relevant disclosures to report for this article.

References

[1] Ventafridda V, Tamburini M, Caraceni A, de Conno F, Naldi F. A validation study of the WHO method for cancer pain relief. Cancer. 1987;59(4):850–856. 

[2] Laird B, Colvin L, Fallon M. Management of cancer pain: basic principles and neuropathic cancer pain. European Journal Cancer. 2008;44(8):1078–1082. 

 [3] MacLeod N, Chalmers A, O'Rourke N, Moore K, Sheridan J, McMahon L, Bray C, Stobo J, Price A, Fallon M, Laird BJ. Is radiotherapy useful for treating pain in mesothelioma? A phase II trial. Journal of Thoracic Oncology. 2015;10(6):944–950. 

 [4]Ashton M, O'Rourke N, Macleod N, Laird B, Stobo J, Kelly C, Alexander L, Franks K, Moore K, Currie S, Valentine R, Chalmers AJ. SYSTEMS-2: a randomised phase II study of radiotherapy dose escalation for pain control in malignant pleural mesothelioma. Clinical and Translational Radiation Oncology. 2018;8:45–49.

 [5]Bayman N, Ardron D, Ashcroft L, Baldwin DR, Booton R, Darlison L, Edwards JG, Lang-Lazdunski L, Lester JF, Peake M, Rintoul RC, Snee M, Taylor P, Lunt C, Faivre-Finn C. Protocol for pit: a phase III trial of prophylactic irradiation of tracts in patients with malignant pleural mesothelioma following invasive chest wall intervention. BMJ Open. 2016;6(1):e010589. 

 [6] Clive AO, Taylor H, Dobson L, Wilson P, de Winton E, Panakis N, Pepperell J, Howell T, Stewart SA, Penz E, Jordan N, Morley AJ, Zahan-Evans N, Smith S, Batchelor TJP, Marchbank A, Bishop L, Ionescu AA, Bayne M, Cooper S, Kerry A, Jenkins P, Toy E, Vigneswaran V, Gildersleve J, Ahmed M, McDonald F, Button M, Lewanski C, Comins C, Dakshinamoorthy M, Lee YCG, Rahman NM, Maskell NA. Prophylactic radiotherapy for the prevention of procedure-tract metastases after surgical and large-bore pleural procedures in malignant pleural mesothelioma (smart): a multicentre, open-label, phase 3, randomised controlled trial. Lancet Oncology. 2016;17(8):1094–1104.

[7] Hochberg U, Elgueta MF, Perez J. Interventional analgesic management of lung cancer pain. Frontier in Oncology. 2017;7(12):17.

[8] Fallon M, Giusti R, Aielli F, Hoskin P, Rolke R, Sharma M, Ripamonti CI; ESMO Guidelines Committee. Management of cancer pain in adult patients: ESMO clinical practice guidelines. Annals of Oncology. 2018;29(Suppl 4):iv166–iv191.

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