INTRODUCTION & PRINCIPLES OF CANCER PAIN MANAGEMENT Clinical Practice Guidelines Management of Cancer Pain Development Group

Epidemiology of Cancer In Peninsular Malaysia, Age Standardised Incidence Rate = 131.3/100,000 population (annual incidence of cancer in Malaysia estimated 35,000 - 40,000)1 Prevalence estimated at 90,0002 Pain is among the commonest symptoms experienced by cancer patients 1NCR Cancer Incidence Report 2006 2GCC Lim 2001

Cancer Pain Statistics Paucity of data available in Malaysia Based on global figures: Cancer pain prevalence = 45,0001 (50% of cancer patients experience pain and 70% of advanced cancer patients experience pain – Bonica JJ 1985) Moderate to severe cancer pain prevalence = 15,000 (1/3 of cancer pain patients have moderate to severe pain)2 1Lim R, Oncology, 2008 2van den Beuken-van Everdingen MH et al., Ann Oncol, 2007

15,000 patients with moderate to severe cancer pain “Have you seen this man?”

Unrelieved pain DESTROYS quality of life for both the cancer patient & the family

WHO Cancer & Palliative Care Unit, Geneva “Relief of pain allows the person to live the rest of his/her life constructively & productively. PALLIATIVE CARE USING MORPHINE RELIEVES CANCER PAIN IN 90% OF PATIENTS.” WHO Cancer & Palliative Care Unit, Geneva

2005 Global Consumption of Morphine Malaysia (0.9230 mg) International Narcotics Control Board 2007

2005 Global Consumption of Fentanyl Malaysia (0.0122 mg) International Narcotics Control Board 2007

Usage of Opioids in Malaysia 2005 DDD/1000 population/day Morphine Total 0.1094 Public 0.0867 Private 0.0227 Fentanyl Total 0.0065 Public 0.0032 Private 0.0033 Oxycodone Total 0.0002 Public <0.0001 Private 0.0002 Malaysian statistics on medicine 2005

Interpretation If the DDD for morphine of a country is 1 DDD/1000 population/day: 1 person in every 1000 population has received 100 mg of oral morphine daily

Morphine Usage in Malaysia Total population in Malaysia in 2005 = 26.13 million 1 DDD/1000 population/day = 26,130 people receiving 100 mg of oral morphine daily 26,130 x 0.1094 = 2,858 Malaysians receive an average of 100 mg oral morphine daily

Why is a CPG on Cancer Pain Management needed? It is estimated that <20% of cancer patients in Malaysia who experienced moderate to severe cancer pain received opioid analgesia1 Many healthcare providers are “uncomfortable” & unfamiliar with using opioid analgesia for treating cancer pain adequately The World Health Organization & the International Association for the Study of Pain have stated that “Pain Relief is a Basic Human Right” 1Lim R, Oncology, 2008

Principles of Cancer Pain Management Comprehensive pain assessment prior to treatment Understanding the concept of ‘total pain’ Reassessment & adjustment of treatment when indicated Inter-professional collaboration in multidisciplinary teams Participation of patients & their family members/carers

Total Pain Physical Psychological Social Spiritual 1.Mehta A et al.., J Hospice & Palliative Nursing, 2008 2Clark, D. “Total pain,” disciplinary power and the body in the work of Cicely Saunders, 1958–1967. Social Science and Medicine, 1999; 49: 727–736

Four-pronged approach1 Assess & reduce noxious stimuli. Treat the cancer – RT, Chemo, Surgery Raise threshold to pain – listen to the patient’s story. Reduce anxiety/depression Consider opioid therapy – WHO ladder Consider management of opioid poorly responsive opioid pain – adjuvants, nerve blocks 1Lickiss JN, Eur J Pain, 2001

Multidisciplinary Care & Involvement of Family Inter-professional collaboration in managing cancer pain has shown:1, level III Improvement in mean patient satisfaction (p<0.001) Less uncertainty & concerns among patients (p=0.047) Adequacy in pain management (p=0.016) Involvement of patients & their family carers in the management of cancer pain reduces barriers to analgesic use (p<0.0001) & decreases the worst pain score (p<0.05)2, level I 1San Martin-Rodriguez L et al., Cancer Nurs, 2008 2Lin CC, et al., Pain, 2006

CPG Development Committee Chairman: Dr CPG Development Committee Chairman: Dr. Richard Lim Boon Leong Consultant Palliative Medicine Physician Dr. Azizul Awaluddin, Consultant Psychiatrist, Hospital Putrajaya Dr. Azura Deniel, Clinical Oncologist , HKL A/P Dr. Choy Yin Choy, Senior Consultant Anaesthesiologist , PPUKM Matron Morna Chua Wui Lang, Hospital QE Dr. Eni Juraida Abdul Rahman, Senior Consultant. Paediatric Haemato-oncologist, HKL Dr. Ismail Aliyas, Consultant Gynae-oncologist, Hospital Sultanah Bahiyah Datuk Dr. Kuan Geok Lan , Senior Consultant Paediatrician, H. Melaka Dr. Lim Zee Nee, Palliative Medicine Physician, Hospis Malaysia Cik Lee Ai Wei, Pharmacist ,Hosp. Selayang Pn. Lim Khee Li, Physiotherapist ,HKL Dr. Mary Suma Cardosa, Sen. Consultant Anaesthesiologist & Pain Specialist,H. Slyg Professor Dr. Marzida Mansor, Senior Consultant Anaesthesiologist, PPUM Dr. Mohd. Aminuddin Mohd. Yusof, Public Health Physician. MaHTAS Dr. Ramesh R. Thangaratnam, Consultant Surgeon ,Hospital Serdang Pn. Rosaniza Zakaria , Medical Social Worker , Hospital Selayang Dr. Sinari Salleh, Consultant Clinical Haematologist, Hospital RPZ II Dr. Sri Wahyu Taher, Consultant Family Medicine Specialist, KK Bdr Sg. Petani Dr. Yeat Choi Ling , Palliative Medicine Physician, Hosp. Raja Perempuan Bainun Dr. Zubaidah Jamil , Clinical Psychologist, UPM

SOURCE: US / CANADIAN PREVENTIVE SERVICES TASK FORCE Level of Evidence Level Study design I Evidence from at least one properly randomised controlled trial II -1 Evidence obtained from well-designed controlled trials without randomisation II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or group II-3 Evidence from multiple time series with or without intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence III Opinions of respected authorities based on clinical experience; descriptive studies and case reports; or reports of expert committees SOURCE: US / CANADIAN PREVENTIVE SERVICES TASK FORCE

Grades of Recommendations At least one meta analysis, systematic review, or RCT, or evidence rated as good and directly applicable to the target population B Evidence from well conducted clinical trials, directly applicable to the target population, and demonstrating overall consistency of results; or evidence extrapolated from meta analysis, systematic review, or RCT C Evidence from expert committee reports, or opinions and /or clinical experiences of respected authorities; indicates absence of directly applicable clinical studies of good quality SOURCE: MODIFIED FROM THE SIGN Note: The grades of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation

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