Cancer
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Patients with pain syndromes resulting from recurrent or metastatic cancer should be evaluated carefully to determine the cause of their pain and the need for appropriate antitumor treatment. Currently, opioid analgesics are the mainstay of pain control, but side effects limit their use in some patients. When pharmacologic pain control is inadequate or associated with intolerable side effects, neurosurgery should be considered. ⋯ Although the place of neurostimulatory procedures in controlling cancer pain is not well established, they are attractive because of their nondestructive nature and potential usefulness in the treatment of bilateral pain syndromes. Specific antitumor surgical procedures should be considered in patients with certain spinal and plexopathy syndromes, because such intervention offers the prospect of both pain relief and tumor control. In this article, the neurosurgical procedures used in the management of cancer pain are reviewed.
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Clinical Trial Controlled Clinical Trial
Evaluation of a cancer pain model for the testing of long-acting analgesics. The effect of MS Contin in a double-blind, randomized crossover design.
A double-blind, double-dummy, crossover study compared oral controlled-release morphine sulfate (MS Contin tablets [MSC], Purdue Frederick, Norwalk, CT) every 12 hours, and immediate-release morphine sulfate (IRMS) tablets, every 4 hours, in 14 evaluable patients with chronic cancer pain. The test model described showed assay sensitivity for steady-state analgesia, requiring relatively few subjects to yield statistical significance in pharmacologic potency estimates. Initial doses were the calculated equivalents of about one third the previous opioid requirements or at least 30 mg MSC every 12 hours or 15 mg IRMS every 4 hours. ⋯ MS Contin exhibits a 12-hour duration of action as previously shown in other well-controlled trials. A problem of pain exacerbation at the start of each study phase was found to be associated with the design of this study. It may be resolved with a higher initial study dose and/or use of a patient-controlled analgesia device for parenteral rescue doses.
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Cancer pain can be divided into three classes: somatic, visceral, and deafferentation. Somatic and visceral pain result from activation of nociceptors by tumor infiltration of tissues and from secondary inflammatory changes with release of algesic chemicals that act to sensitize nociceptors. Pain may be experienced locally (somatic and visceral) or referred to remote cutaneous sites (visceral). ⋯ Somatic, visceral, and deafferentation pain may be complicated by sympathetically maintained pain, in which efferent sympathetic activity promotes persistent pain, hyperpathia, and vasomotor and sudomotor changes after tissue injury from cancer or its therapy. The neurobiology of cancer pain is complex and incompletely understood. This article summarizes current knowledge in this area and briefly discusses approaches to cancer pain management that are based on this knowledge.
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Randomized Controlled Trial Clinical Trial
Oral controlled-release morphine sulfate. Analgesic efficacy and side effects of a 100-mg tablet in cancer pain patients.
Fifty-one cancer pain patients with limited opioid exposure participated in a randomized, double-blind, repeated-dose, parallel-group comparison of two dosage strengths of the controlled-release morphine preparation, MS Contin tablets (The Purdue Frederick Company, Norwalk, CT). The patients were first stabilized on immediate-release oral morphine 30 mg every 4 hours, with 15 mg available every 2 hours as needed for breakthrough pain ("rescue" dose). Each patient then received either one 100 mg MS Contin tablet or three 30-mg MS Contin tablets every 12 hours, with rescue medication as needed, for 3 days. ⋯ In the study population as a whole, pain intensity was lower and total morphine intake higher during the period on controlled-release morphine. These data establish comparable analgesic efficacy and side effect potential of these two dosage strengths and confirm a 12-hour duration of effect for both. The improved analgesia on the controlled-release morphine may be attributable to increased consumption of drug resulting from improved compliance.
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Randomized Controlled Trial Clinical Trial
Supportive care versus supportive care and combination chemotherapy in metastatic non-small cell lung cancer. Does chemotherapy make a difference?
Current chemotherapy treatment of metastatic non-small cell lung cancer has demonstrated some objective responses, but is still largely palliative. This report reviews the results of a randomized trial in patients with advanced metastatic non-small cell lung cancer which compared treatment with supportive care (treatment with palliative radiation, psychosocial support, analgesics, nutritional support) to supportive care plus combination chemotherapy with cisplatin and vinblastine. ⋯ The authors conclude that contemporary combination chemotherapy provides only modest survival benefit to patients with advanced metastatic non-small cell lung cancer and should not be considered standard therapy. Future investigations of chemotherapy in patients with unresectable non-small cell lung cancer should continue to utilize control arms which provide high-quality supportive care.