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14 Articles in Volume 18, Issue #2
Ask the Expert: Is there evidence to prescribe cyclobenzaprine long-term?
Challenging the Chronic Pain Personality Profile
Designer Peptide May Prevent Chemo-Induced Neuropathy
Inside the Cancer Pain Research Consortium
Intrathecal Drug Therapy for Cancer-Related Pain
Managing Cancer Pain in an Era of Modern Oncology
Mapping Complex Pain: A Case Study
Medication Overuse Headache: Inaccurate and Overdiagnosed
Pain and Fall Risk in the Elderly
Reporting Quality of Care in Cancer Pain Management
Sharing the Risk: An Update to DEA & Doctors Working Together
The Intensifying Conflict Between Opioid Control and Pain Control
Two Mobile Apps Aim to Target Patient Compliance & Safety
Why Prescribers Need to Adopt Abuse-Deterrent Opioids

Inside the Cancer Pain Research Consortium

In advance of its 2018 annual meeting, the CPRC discusses its ongoing efforts, goals, and inspirations in cancer pain management.

Cancer is the third leading cause of death in America, and most people that battle cancer experience significant pain at some point. Unfortunately, evidence continues to demonstrate persistent under-treatment of moderate or severe pain in the setting of cancer. As oncologic care has progressed, life expectancy after cancer diagnosis has dramatically improved, and this has led to a growing number of patient years affected by complex pain syndromes. Suffering and quality of life are major concerns of palliative care oncology, but much work remains, with the issues of survivorship and pain to be addressed. There is a paucity of actual data in the specific area of pain control in the context of cancer, and progress in oncology strongly outpaces research for cancer pain, making these questions more complex. The worsening opioid epidemic makes these issues even more urgent.

Identifying Research & Knowledge Gaps

In this context, the Cancer Pain Research Consortium (CPRC) is continually working to promote and guide high-impact research leading to improved care for the suffering that arises from cancer pain. While various medical societies exist to promote or educate clinicians in many skill sets that are beneficial to the care of patients with pain related to cancer, there is no other organization focused specifically on championing research in this area and helping to inform current best practices with cutting-edge findings. As a consortium, the CPRC does not exist primarily for the benefit of its members, as a medical society might, but is instead a gathering place for like-minded individuals to direct their diverse expertise toward a shared societal goal: the elimination of suffering from cancer pain.

In recent years, the consortium has held both collaborative regional meetings focused on the state of cancer pain treatment and national summits to explore knowledge gaps in the field. The CPRC’s free online Cancer Pain Patient Resource Guide (www.cancerpainresourceguide.com) and textbooks on current treatment approaches to cancer pain (Surgical Pain Management: A Complete Guide to Implantable and Interventional Therapies/The Essentials of Interventional Cancer Pain Medicine) have been well received. For the past several years, the consortium has focused on assessing dissemination and practice knowledge gaps. For example, clinicians know that percutaneous cervical cordotomy provides rapid and profound relief of contralateral nociceptive pain below the C5 dermatome, but if the pain recurs, when should such a procedure be repeated?

Additional questions to be answered include: Why is the geographic variation in the use of percutaneous cervical cordotomy so remarkable in the treatment of cancer pain syndromes? In what histology-specific ways does the modulation of the hypothalamic-pituitary axis by high dose oral opioids affect oncologic outcomes? What is the most appropriate wash-out period for the surgical procedures associated with intrathecal drug delivery? These specific knowledge and practice gaps must be prioritized and addressed in systematic fashion to move cancer pain care forward. More recently, the consortium has begun to focus on the invitation of specific researchers to broaden the diversity of the group and bring more multidisciplinary skill sets to bear on these pressing problems.

The strength of a consortium is not in size. As a network of complimentary strengths, each node is critical. The CPRC, therefore, does not seek growth for the sake of expanding. As a purpose-driven charity, its goal is partnership with like-minded individuals and organizations in order to gather and interpret a repository of published research and unpublished data to enable ongoing knowledge gap analysis that informs best practices. For example, in 2017, the consortium selected the management of post-mastectomy pain as a best practices project; a guidance document is anticipated in late 2018.

Looking ahead, the goals of the consortium are both specific and ambitious. We aim to identify remaining individual barriers in cancer-related pain management so that we can champion research that may close those gaps and alleviate suffering. A 2018 strategic planning meeting will guide the creation of a research consensus document to commence in 2019, with a goal of preparation and publication by 2020. Additional best practice guidance documents will follow.

Connecting Chronic Pain & Cancer Pain

As regards the current opioid focus, the CPRC also intends to explore the overlap of chronic and cancer pain syndromes. Cancer disproportionately affects the elderly, and this patient population has a high prevalence of pre-existing chronic pain syndromes that do not spontaneously remit with the diagnosis of cancer. Many pain syndromes that develop during treatment of cancer, such as radiation induced changes, post-chemotherapy neuropathy (see pipeline research on this topic on page 32), or post-laminectomy syndrome after metastasis resection, persist in long-term survivors.

The distinction between chronic pain and cancer pain, however, is often ambiguous. Regardless of the cause of the pain, it has been demonstrated that significant numbers of opioid prescriptions intended for the treatment of cancer pain are diverted. Accordingly, these issues and, particularly, the role of neuromodulation, including neurostimulation in the treatment of pain syndromes in the cancer population, will be a topic of considerable focus and interest in the year ahead.

To accomplish these goals, the CPRC hopes to increasingly involve community activists, and legal and business experts in conversations, and to incorporate more diverse clinical perspectives, such as those of nurses and advanced practice nurses, physician assistants, physical therapists, and occupational and speech therapists, in its research and best practice documents. To solve a problem as complex as cancer pain, every perspective is important. Progress has been made, and working together, we can further prevent and alleviate pain in cancer patients.

As cancer pain research continues to evolve over the next decade, the CPRC has hopes for improvements in pain assessment as well. While the visual analog scale/numeric rating scale has allowed for important progress, the limitations of these measures are plain. Quality of life measures have been important in broadening our understanding of the suffering associated with pain, but these are time-consuming and are not equally applicable to each clinical situation. It appears that there may be clinically distinct pain syndromes that have important distinctive clinical characteristics, which drive best practice decision trees. It is therefore a major focus of the consortium to identify these measures and use them to provide guidelines for timely specialist referral. In the absence of clear guidelines, patient awareness is crucial to allow them to advocate for the care they need.


Technologies and Treatments in Cancer Pain that Have Inspired the CPRC

Targeted oncologic therapies have revolutionized treatment options and outcomes in cancer. Similarly, targeted treatments for patients with cancer pain may one day be available for specialized pain therapies. For example, denosumba, a bone cell inhibitor (RANKL inhibition of osteoclasts), may be used specifically to treat patients whose cancer has spread to the bones.1 Denosumab may have the ability to improve pain control compared to standard treatment such as zoledronic acid and reduce opioid usage in this population. While still in the clinical research phase, medications such as this – which both treat cancer and cancer pain symptoms – is preferred among medical oncologists.

The use of bone-marrow stem cells in the treatment of neuroimflammation in chronic neuropathic and cancer pain is an interesting concept being explored in animal models. In small animal studies, immune cells may be involved in the activation of pain signals in the peripheral nervous system; similarly, glial cells in the central nervous system.2,3 Researchers have suggested that injecting bone marrow stem cells into the spinal (intrathecal) space may mitigate inflammation, thereby reducing pain symptoms. While this research is still in its infancy, especially for cancer pain, preliminary animal study results suggest that treatments may be available for cancer pain in the near future.


About the CPRC

The Cancer Pain Research Consortium (CRPC) was established in 2013 to generate and promote interdisciplinary, patient-centered, evidence-based care for cancer-related pain and suffering. Made up of medical and radiation oncologists, physiatrists, anesthesiologists, palliative care doctors, psychiatrists, psychologists, and neurosurgeons, the nonprofit works to improve the management of cancer-related pain through collaboration in research, best practice guidelines, and patient/physician education. The CPRC 2018 annual meeting will take place April 12-15 in New Orleans. 


Last updated on: April 12, 2019
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Managing Cancer Pain in an Era of Modern Oncology
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