by Kelly Simpson, Manager, Global Initiatives
Approximately 70 percent of patients with cancer require pain therapy during the course of their disease, making pain management a significant and overarching aspect of oncology care. Dr. Robert Swarm of Washington University School of Medicine routinely handles complex pain management cases referred by oncologists at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine.
Last month, Dr. Swarm brought to China his experience with pain management and his expertise as Chair of the NCCN Guidelines Panel for Adult Pain. Dr. Swarm gave thoughtful, evidence-based presentations to a live audience of 150 oncology professionals who eagerly participated in a live symposium in Beijing on October 30, 2010. Initially, Dr. Swarm educated the group on the fundamentals of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) and the data that supports some of the key decisions behind featured recommendations from the NCCN Guidelines Panel for Adult Pain. He stressed the importance of considering symptom control to be a core component of comprehensive cancer care, along with the more commonly discussed prevention, detection, and treatment. To emphasize the need for this focus, he illustrated how, in developed countries, 1 in 8 people is at risk of dying of cancer with severe pain. Dr. Swarm referenced and evaluated the World Health Organization (WHO) Analgesic Ladder as a tool that can be used in decision-making with the patient's individual goals in mind. He also described and discussed opioids as having a large role in the management of pain symptoms in oncology patient population.
While outlining select recommendations from the NCCN Guidelines™ for Adult Pain, Dr. Swarm identified the principal features as universal screening and assessment, comprehensive pain assessment, and analgesic therapy for each patient titrated to his/her goals of comfort and function. He also noted the multidisciplinary composition of the NCCN Guidelines Panel for Adult Pain, which includes anesthesiology (pain), medical oncology, neurology, nursing, palliative and supportive care, clinical pharmacy, psychology, and radiation oncology. He closed the talk with a pertinent quote from Robert G. Twycross, “Good symptom control requires clearly defined medical leadership.”
Building upon his presentation on the NCCN Guidelines, Dr. Swarm provided an insightful lecture on interventional pain management to the same audience in Beijing. This lecture focused on some specific challenges that face practicing clinicians and their patients with cancer pain. The Chinese professionals in attendance were openly appreciative of the opportunity to hear Dr. Swarm and to discuss strategies to mediate discomfort without overburdening patients with side-effects. He revisited the WHO Analgesic Ladder and focused on the top tier: Freedom from Cancer Pain. While unfortunate, this clearly has not been achieved in full, and according to Dr. Swarm, it is often helpful to reapply the ladder while making adjustments for optimal results.
Differentiation and the need for careful titration of therapy for opioid-naïve versus opioid-tolerant populations were described. Further to this topic, considerations regarding opioid tolerance, hyperalgesia, and toxicity were presented by Dr. Swarm. He evaluated the various analgesic delivery methods and, additionally, neurolytic celiac plexus block, vertebroplasty, and pathologic vertebral compression fracture as alternatives.
During his time in Beijing, Dr. Swarm also participated in the launching activity for the development of a region-specific, Chinese language version of the NCCN Guidelines for Adult Pain. This involved a non-public meeting with a panel of China's thought leaders in oncology pain management to form consensus on modifications to make the recommendations more applicable for use in China. The NCCN Guidelines for Adult Pain: China Edition will be available on the International portion of NCCN.org in early 2011.