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

2. Epidemiology of Cancer
In Peninsular Malaysia, Age Standardised Incidence Rate = 131.3/100,000 population (annual incidence of cancer in Malaysia estimated 35, ,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

3. 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

4. 15,000 patients with moderate to severe cancer pain
“Have you seen this man?”

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

6. 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

8. 2005 Global Consumption of Morphine
Malaysia ( mg)
International Narcotics Control Board 2007

9. 2005 Global Consumption of Fentanyl
Malaysia ( mg)
International Narcotics Control Board 2007

10. Usage of Opioids in Malaysia 2005
DDD/1000 population/day
Morphine
Total
Public
Private
Fentanyl
Total
Public
Private
Oxycodone
Total
Public <0.0001
Private
Malaysian statistics on medicine 2005

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

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

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. THANK YOU