Persistent and Breakthrough Cancer Pain: An Expert Video Roundtable
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Jointly sponsored by Albert Einstein College of Medicine of Yeshiva University and Montefiore Medical Center, and Asante Communications, LLC.
This activity is supported by an independent educational grant from Cephalon, Inc.
This CME activity is designed for oncologists, pain specialists, neurologists, physiatrists, physician assistants, nurses, and other clinicians dedicated to the collaborative management of cancer pain.
There are no prerequisites for this educational activity.
At the conclusion of this educational activity, participants should be better prepared to:
- Comprehensively assess pain and associated functional impairment in patients with cancer
- Define and diagnose breakthrough cancer pain and its subtypes across patient populations
- Explain the respective roles of long-acting, short-acting, and rapid-onset opioids in the management of cancer pain
- Structure opioid therapy for cancer pain based on comprehensive and continual assessment of patient-specific risks associated with opioid pharmacology and the potential for inappropriate medication use
- Tailor opioid-based therapy for breakthrough cancer pain based on temporal profile of the episodes, predictability, relationship with the baseline opioid regimen, and evaluation of potential benefits and risks of treatment
Needs Assessment and Learner’s Gap:
Pain is consistently cited as one of the most troubling cancer symptoms for patients and their families.1 Frequently impairing multiple dimensions, cancer pain affects approximately one-quarter of patients with newly diagnosed malignancy, one-half receiving active cancer treatment, and more than three-quarters with advanced cancer.2-4 For each patient, clinicians should consider the goals of therapy—for example, functional gains and relief from suffering—and the potential benefits and risks of all available behavioral, pharmacologic, and interventional treatment modalities.5-7 Orchestrated care may therefore be needed to incorporate the expertise of oncologists, pain specialists, nurses, surgeons, physical therapists, and others. Best practices for assessment and interdisciplinary, collaborative management of cancer pain are only now emerging, however. Importantly, underlying disease processes, mood, and social environments continuously interact to affect the characteristics and consequences of cancer pain.8 As a result, pain often fluctuates in patients with cancer, even when the persistent baseline component is relatively well-controlled. Indeed, pain may break through an otherwise effective analgesic regimen, resulting in transient, severe exacerbations that negatively affect patient mood, function, and quality of life.9 These episodes of breakthrough cancer pain—first described more than two decades ago10—constitute a discrete clinical construct, requiring targeted assessment and tailored management.11-13 A number of clinical practice guidelines, such as those from the National Comprehensive Cancer Network (NCCN), recommend separate evaluations of persistent and breakthrough pain with as-needed prescription medication based on ongoing assessment of benefit versus risk.7 Yet little guidance on individualized care for patients with fluctuating cancer pain is offered in these guidelines or elsewhere. And although opioids have long been considered the cornerstone of cancer pain treatment, implementing opioid-based multimodal analgesic strategies necessitates careful consideration of potential pain etiologies, patient-specific treatment goals, risks related to opioid pharmacology, and the ability of the prescriber to structure therapy accordingly and monitor adherence to the pain management plan.7,14
1. Bruera E, Kim HN. JAMA. 2003;290(18):2476-2479.
2. Cohen MZ, et al. J Pain Symptom Manage. 2003;25(6):519-527.
3. Goudas LC, et al. Cancer Invest. 2005;23(2):182-190.
4. Svendsen KB, et al. Eur J Pain. 2005;9(2):195-206.
5. de Leon-Casasola OA. Clin J Pain. 2008;24(suppl 10):S3-S7.
6. Soares LG, Chan VW. Am J Hosp Palliat Care. 2007;24(5):430-439.
7. Swarm R, et al. J Natl Compr Canc Netw. 2010;8(9):1046-1086.
8. Gatchel RJ, et al. Psychol Bull. 2007;133(4):581-624.
9. Portenoy RK, et al. Pain. 1999;81(1-2):129-134.
10. Portenoy RK, Hagen NA. Pain. 1990;41(3):273-281.
11. Swanwick M, et al. Palliat Med. 2001;15(1):9-18.
12. Zeppetella G. Curr Opin Support Palliat Care. 2009;3(1):1-6.
13. William L, Macleod R. Drugs. 2008;68(7):913-924.
14. Starr TD, et al. Curr Pain Headache Rep. 2010;14(4):268-275.
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Albert Einstein College of Medicine of Yeshiva University and Montefiore Medical Center, and Asante Communications, LLC. Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Albert Einstein College of Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Attendees other than physicians will receive certificates of attendance, which may or may not qualify for credit for other types of healthcare professionals.
Method of Participation:
There are no fees for participating in and receiving credit for this activity. Participants must read the objectives and enduring material, and answer the multiple-choice posttest. Please complete the evaluation form, which enables you to comment on the quality of the instructional process, the perception of enhanced professional effectiveness and commercial bias, and express your views on future educational needs. A score of at least 70% is required to successfully obtain credit for this activity. Credit is available through January 25, 2013.
Conflict of Interest Statement:
The opinions, ideas, recommendations, and perspectives expressed in this program and accompanying materials are those of the program authors and presenting faculty only and do not necessarily reflect the opinions, ideas, recommendations, or perspectives of their affiliated institutions, Albert Einstein College of Medicine, Montefiore Medical Center, Asante Communications, or the activity’s commercial supporters.
The Conflict of Interest Disclosure Policy of Albert Einstein College of Medicine requires that faculty participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical, product, or device company. Presenters whose disclosed relationships prove to create a conflict of interest with regard to their contribution to the activity will not be permitted to present.
Albert Einstein College of Medicine also requires that faculty participating in any CME activity and anyone in a position to influence content disclose to the audience when discussing any unlabeled or investigational use of any commercial product, or device, not yet approved for use in the United States.
The CME Reviewer has determined that this activity does discuss the off-label uses of various analgesic agents for the treatment of cancer-related pain and cancer-related breakthrough pain.
Faculty and Planning Committee disclosures:
Barbara A. Murphy, MD
Archimedes Pharma LTD. (Consultant); Bristol-Myers Squibb (Consultant); ActoGeniX (Grant/Research)
Neal E. Slatkin, MD, DABPM
Archimedes Pharma LTD. (Consultant, Speakers Bureau); Covidien (Consultant, Speakers Bureau); Johnson & Johnson (Consultant); Meda Pharmaceuticals Inc. (Consultant, Speakers Bureau); Pfizer Inc. (Consultant, Speakers Bureau); Salix Pharmaceuticals, Inc. (Consultant, Speakers Bureau)
Sharon M. Weinstein, MD, FAAHPM
Archimedes Pharma LTD. (Consultant, Grant/Research); GW Pharmaceuticals (Grant/Research); OptumHealth (Consultant); Pfizer Inc. (Grant/Research)
David M. Kaufman, MD – CME Reviewer
Has no relevant financial relationships to disclose.
Jim Kappler, PhD
Vice President, Scientific Services
Asante Communications, LLC
Has no relevant financial relationships to disclose.
The staff of the Center for Continuing Medical Education (CCME) of Albert Einstein College of Medicine and Montefiore Medical Center and the staff of Asante Communications, LLC, have no disclosures to report with any commercial interests other than the following:
Steven Jay Feld of Albert Einstein College of Medicine, or a member of his household, owns securities in Bioheart, Inc., Chelsea Therapeutics, Inc., and Pharmacopeia, Inc.
The opinions, ideas, recommendations, and perspectives expressed in this program and accompanying materials are those of the presenting faculty only and do not necessarily reflect the opinions, ideas, recommendations, or perspectives of their affiliated institutions, Albert Einstein College of Medicine, Montefiore Medical Center, Asante Communications, or the activity’s commercial supporters.
© 2012 Albert Einstein College of Medicine and Montefiore Medical Center, and Asante Communications, LLC.