1. BONE PAIN PALLIATION: SUPPORTING ROLE OF STAFF DURING THE RADIONUCLIDE TREATMENT GALINA SHAMARINA EVE PALOTU East Tallinn Central Hospital, Department of Nuclear Medicine, Tallinn, Estonia

2. The World – small or big?

3. PAIN Pain is one of the main factors which is affecting the quality of life Pain has a complex nature and different factors contribute to the patient’s perception of pain

4. Symptoms of debility Noncancer pathology Side-effects of therapy Cancer SOMATIC SOURCE Loss of social position Bureaucratic bungling Loss of income Friends who are don’t visit Loss of role of family DEPRESSION ANGER Delays in diagnosis Insomnia Unavailable doctors Sense of helplessness Irritability Disfigurement TOTAL PAIN Therapeutic failure ANXIETY Fear of hospital or nursing homeFear of pain Worry about familyFamily finances Fare of deathLoss of dignity and bodily control Spiritual unrestUncertainty about future Reproduced from A.J.McEwan “ Palliation of bone pain”

5. BONE METASTASES AFFECT QUALITY OF LIFE Pain Pathologic fractures - immobility Hypercalciemia Neurological problems Anxiety Depression

6. BONE SCINTIGRAPHY Normal scan Multiple bone metastases

7. RELIEF OF PAIN RELIEF OF PAIN - GOAL IN TREATMENT OF BONE METASTASES relieving pain improve patient mobility improve patient function improve quality of life

8. QUALITY OF LIFE - HEALTH-RELATED QUALITY CRITICAL PARAMETERS: 1. Physical functioning 2. Disease- and treatment-related symptoms 3. Psychological/emotional symptoms 4. Social interactions The "Palliative Care Quality of Life Instrument (PQLI)" in terminal cancer patients. Kyriaki Mystakidou, Eleni Tsilika, Vassilios Kouloulias. Health and Quality of Life Outcomes. http://www.hqlo.com/content/2/1/8

9. THE AIM OF THE STUDY Describe and analyse the aspects of the activities nuclear medicine staff taking care of patients during the pain palliation with radioisotopes patients participate in their treatment to get a sense of control over their disease

10. METHODS FOR EVALUATION OF QUALITY OF LIFE Specifically for cancer patients are suitable:  Karnofski ja WHO daily diaries questionary  Pain descriptor scale PDC  Patient’s analgetic use (opioid)  Personal’s global assessment PGA  Othes aspects of quality of life (patient’s daytime discomfort, quality of sleep etc)

11. DIARY OF PAIN ASSESSMENT Patient assesses daily his/her intensity of pain and completes the diary in 10 point scale - APS According to the APS the efficiency of treatment is evaluated and also to compare the different methods of therapy

12. ASSESSMENT OF PAIN RELIEF USING ANALOGUE PAIN SCALE Pain relief Changes in APS Complete 80% and more Substantial 30-79% Minimal 10-29% No response 9% and less No Max pain 0 1 2 3 4 5 6 7 8 9 10 pain

13. PERSONAL’S GLOBAL ASSESSMENT 1. Condition is worse, patient feels more pain 2. Condition has not changed 3. Condition slightly better, slight relief of pain 4. Condition is moderatly better, moderate relief of pain and discomfort 5. Condition is much better, marked relief of pain and less discomfort 6. Condition is good, complete relief of pain and no discomfort during the daily performances

14. ANALGETIC USE Prior the start of treatment all the doses of medications are recorded (24h) All the doses are converted to morphine equivalents During the treatment patient records all the doses of medications Change in opiod analgetic use gives information of the treatment efficacy

15. TREATMENT ROOM

16. CHARACTERISATION OF PATIENT POPULATION 1995-2004 with bone pain due to metastatic breast (MBC) or prostate cancer (MPC) Median Age (y) NSAID Narcotics Total MPC 66 (40-79) 39 (73%) 13 (27%) 52 MBC 53 (36-68) 22 (75%) 8 ( 25%) 30 Total 61 (74%) 21 (26%) 82 23 59 Single BM Multiple BM

17. BONE PAIN RESPONSE TO THERAPY Complete 15 (18%) Substantial 43 (53%) Minimal 10 (12%) No 14 (17%) 82 patients Time of response 1 - 2 weeks after treatment Duration of response - 4 - 24 weeks

18. BONE PAIN RESPONSE TO THERAPY Multiple Mts Single Mts Complete 15 3 12 Substantial 43 32 11 Minimal 10 10 0 No 14 14 0 82 59 23

19. CONCLUSIONS Treatment with radioisotopes is an effective method for the palliation of metastatic pain providing relief in majority of our patients As the therapy affects the site of pain without affecting central nervous system the patients really feel the improvement of their QoL

20. CONCLUSIONS Patients want a voice in their life care, and participation in treatment, this would give them a sense of control over their disease It is hightly depended of staff management quality

21. YOU CAN’T STOP THE CLOCK, BUT YOU CAN CONTROL THE PAIN