Cancer Pain – Indication and Efficacy

Despite our best efforts, advances in treatment and new technology, pain and suffering continues to afflict those with cancer. Even in those who are cured of their cancer, many will experience devastating physical, psychological and financial devastation.

Although the use of opioids to treat cancer pain is more accepted today, there still are many physicians, patients and family members that are fearful of using opioids because of concerns for addiction, side effects, and religious implications

Pharmacological therapy continues to be the primary method for controlling cancer pain. In fact, the use of non-opioid and opioid analgesics along with adjuvant medications can adequately control the pain in 85% of cancer patients. The World Health Organization (WHO) developed a three-step approach in treating malignant and chronic benign pain. This approach, along with medications to treat the side effects from opioids (namely nausea, constipation, pruritis and sedation), has been effective in controlling cancer pain.

In cancer pain refractory to pharmacological management (15% of cancer patients have unrelieved pain or drug side effects), invasive methods of pain control, such as intrathecal pump drug delivery (IPDD), have been successful in reducing pain and drug toxicity.

Smith et al (Curr Oncol Rep 6:291-296,2004) evaluated 202 patients with a VAS =7.5 and taking = 200 mg morphine or opiod equivalent in a prospective, randomized study. The patients were divided into IPDD and medical management groups. The IPDD patients had better clinical success with lower pain (52% vs. 39%), lower drug toxicity (50% vs. 17%) and lived longer when compared to the medical group. IPDD also lower pain by 27% and lower drug toxicity by 50% in the most refractory of cancer patients who first failed to experience any improvement in the medical group.

Low Back Pain – Do's, Don'ts and Red Flags

Low back pain (LBP) is the second most common reason, other than having a cold, that we seek medical care. Approximately 90% of us will suffer a significant episode of LBP in our lifetime. LBP is the leading cause for disability under the age of 45 and second for those over 45.

The good news is that nine out of ten patients will recover from their back pain within four weeks with or without treatment. Tips (DO'S) to prevent back pain include:

* Lift with the legs not the back
* Do not lift heavy objects
* Wear low heeled shoes
* Get consistent sleep
* Shift heavy purses/briefcases
* Stop activity that hurts
* Do not stoop, and
* Exercise regularly.

Low back pain typically is due to injuries of the soft tissue structures, spinal joints, or discs. Risk factors (DON'TS) for developing low back pain include: poor posture, repetitive motion, prolonged sitting/standing, smoking, poor nutrition, and incorrect bending, lifting, and twisting.

Seek medical attention if your pain does not improve or if it increases over a period of two to three weeks. In addition, you should seek immediate medical care for any of the following RED FLAGS:

* Sudden pain onset if > age 50 O LBP related to a fall or trauma
* Sciatica (leg pain)
* Loss of bowel or bladder control
* Loss of groin or rectal sensation
* Leg weakness
* Falling when walking
* Fever or weight loss, and
* LBP worse at night.

Osteoporosis – Diagnosing and Treating

The most common method of diagnosing osteoporosis is via a DEXA (Dual Energy X-ray Absorptiometry) scan. Osteopenia, osteoporosis and severe osteoporosis are respectively defined as DEXA scan T scores of -1 to -2.5, less than -2.5 and less than -2.5 with a fragility fracture.

Vertebral compression fractures are the most common complication of osteoporosis at a cost of 10 to 15 billion dollars every year. There are approximately 700,000 vertebral compression fractures per year in the United States that result in spinal deformity (kyphosis/lordosis), acute/chronic pain, disability and reduced vital respiratory capacity. An osteoporotic vertebral compression fracture should be considered in anyone over the age of fifty with a complaint of acute or chronic back pain. The most common location for vertebral compression fractures are at the T7-8 and T12-L1 levels which correspond to the most mechanically compromised spine regions. The diagnostic work up for someone suspected of having a spinal compression fracture includes spine x-rays looking for wedged shaped vertebral fractures as well as MRI imaging with T2 and STIR sequences to evaluate the acuity of the fracture. Nuclear bone scans and CT can also be helpful in evaluating vertebral compression fractures.

Vertebral compression fractures lead to decreased physical function, restricted activities of daily living, sleep disturbances, early satiety, psychological disturbances and reduced pulmonary function. The subsequent risk of additional vertebral fractures increased after the first fracture. Women with a vertebral fracture had a >20% higher mortality rate adjusted for age. Patients with vertebral fractures are 2-3 times more likely to die of pulmonary causes typically due to COPD and pneumonia complications.

Kyphoplasty is a minimally invasive percutaneous procedure that restores vertebral body height, provides fracture stability and reduces pain associated with vertebral compression fractures. The procedure involves the placement of a balloon catheter through a needle introducer into the vertebral fracture, inflation of the balloon (which creates a cavity and restores vertebral body height) and injection of cement into the cavity. The indications for kyphoplasty include an osteoporotic or malignant spinal compression fracture, persistent back pain, progressive vertebral collapse, spinal deformity and a correct diagnosis from imaging studies. Contraindications consist of bone retropulsion with neurological complications, infection and greater than 80% loss of vertebral body height. Clinical studies have demonstrated that kyphoplasty is a highly effective treatment for compression fractures and provides correction of spinal deformities with significant pain relief, improved quality of life and increased physical function.

Osteoporosis and Vertebral Compression Fractures

Osteoporosis is the most common metabolic bone disease in the United States and is a chronic progressive disease that can affect almost the entire skeleton. It is characterized by low bone mass and bone weakening that increases the risk for bone fractures. Osteoporosis often does not become clinically evident until a complication occurs such as a bone fracture that can lead to severe pain, disability and a poor quality of life.

There are about 10 million people in the United States that have osteoporosis and 14 to 18 million that have osteopenia – low bone mass. Osteoporosis affects one in every three women and one in every eight men worldwide.

Osteoblasts are specialized cells that make bone and osteoclasts are unique cells that resorb bone. These cells are constantly remodeling the skeletal system with bone resorption followed by bone formation known as coupling. Osteoporosis occurs when there is a disruption in the coupling process that leads to a reduction in skeletal mass.

During the post menopausal state bone loss is due to excessive osteoclast activity whereas the loss of osteoblasts leads to skeletal mass loss in the elderly.

Osteoporosis can be divided into primary and secondary disorders. Primary osteoporosis can be categorized as juvenile, postmenopausal, and age related or senile. Juvenile osteoporosis occurs in children or young adults with an onset of 8 to 14 years of age. The characteristic finding in juvenile osteoporosis is the abrupt commencement of bone pain or a trauma related fracture. Post menopausal (type I) osteoporosis occurs in women from the age of 50 to 65 years old. This form of osteoporosis is exemplified by accelerated bone loss. The skeletal loss occurs primarily from trabecular bone leading to distal forearm and vertebral body fractures. Senile osteoporosis (type II) occurs in both men and women over the age of 70 years and is due to the loss of cortical as well as trabecular bone. Fractures of the wrist, spine and hip are often seen with type II osteoporosis.

Secondary causes of osteoporosis are due to disorders classified as genetic (congenital), endocrine, hypogonadal states, deficiency states, drug-induced, inflammatory states, hematologic, neoplastic and miscellaneous.

Risk factors for the development of osteoporosis include advanced age, alcohol use, androgen or estrogen deficiency, amenorrhea, body weight less than 127 pounds, Caucasian or Asian ethnicity, calcium deficiency, early menopause, family history of osteoporosis, female gender, fragility fracture, late menarche, physical inactivity and tobacco use.