Ulf E. Kongsgaard, MD, PhD. Professor and Chairman. Dept. of Anaesthesia and Intensive Care. The Norwegian Radium Hospital, Oslo, Norway

In spite of increased knowledge in care of the cancer patient, there are still a few patients who unfortunately experience intolerable or uncontrollable suffering, especially in the last days of their life. Even in a hospital or hospice with extensive expertise, clinical experience suggests that there is a subgroup of especially problematic patients who's management taxes the skills and compassion of clinicians as well as the resources of the patient and family (1)

These patients may experience unendurable symptoms that may be termed "intractable or "refractory". This term ("refractory") is used when a symptom cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness (2). For patients with advanced cancer, the description of a symptom as refractory has profound implications, suggesting that suffering will not be relieved with routine measures. In deciding that a symptom is refractory, the clinician should recognize that further interventions are unable of providing sufficient relief, associated with excessive and unwarranted morbidity, or unlikely to provide relief within a reasonable time frame. The prevalence of refractory symptoms in patients with advanced cancer is controversial, ranging from less than 1 % up to 52 % (3,4,5,6,). There is, however, very little controversy about the emancipation principle of palliative care : "spare no scientific or clinical effort to free dying persons from twisting and racking pain that invades, dominates, and shrivels their consciousness, that leaves them no psychic or mental space for the things they want to think and say and do before they die" (7). Unfortunately, there is still a gap between what can should be done for these patients and what is actually achieved in relieving them from terminal suffering.

Pharmacologic approaches with alternative routes of drug delivery, switch ofopioids, and the addition of adjuvant drugs are the cornerstone of analgesic therapy in cancer pain patients. A thorough diagnostic work-up exploiting the possibilities of palliative chemotherapy, radiation therapy or surgery should be performed. An assessment of the affective, cognitive and behavioral components should always be included.

In selected patients, aggressive and invasive treatments, such as neurolysis, implantable intrathecal or epidural catheters for infusion of analgesic medications, or neuroaugmentative procedures may reduce or eliminate the requirement for systemically administered analgesics. Like other interventions, however, they should never be instituted in isolation, but rather as a component of a therapeutic strategy implemented in a multidisciplinary setting.

At the end of life, induced sedation in the management of refractory symptoms may be the only therapeutic option capable of providing adequate relief. This approach is described as sedation in the management.of intolerable symptoms in the imminently dying. The medical and ethical issues surrounding this therapy are complex and have become a focus of palliative medicine (2,7,8). A strategy including induced sedation must be, of course, be discussed with both the patient and family. The published literature describing the use of sedation the management of refractory symptoms at the end of life is anecdotal. Designing clinical trials for this patient group is difficult, and the only justification for starting such a treatment is a reasonable expectation that it will work, coupled with a lack of reasonable alternatives. Clinicians want neither to subject patients with refractory symptoms to therapies that provide inadequate relief or excessive morbidity nor to hastily render the patients with remediable problems unconscious when viable alternatives remain unexplored. The challenge in this decision making requires that patients with unrelieved symptoms undergo application of routine therapies and repeated assessment. Cherny and Portenoy (2) has suggested an algorithm for the management of patients with cancer pain, which offers a model for clinical approach that aims to identify patients with tmly refractory pain. Patients must be evaluated repeatedly to determine therapeutic failure and to weigh the risk and benefits of the next approach. However, such an algorithm must always be individualized to each patient and applied by a compassionate, knowledgeable, and committed team of health care providers.

The fear of uncontrolled pain and other intolerable symptoms is a key motivator behind a growing movement to legalize euthanasia for terminal ill patients. No patient should have to ask to be killed because of persistently unrelieved pain or other unendurable symptoms The group of dying patients with uncontrollable symptoms are often associated with concurrent deterioration or physical, psychological, and social functioning When the disease progresses and there is no longer hope for cure, the patient is compelled to face his own mortality and to adjust to the reality that his life has limited measures The physician in turn, is forced to redefine the goal of care Unrealistic goals increase the level of frustrations expenenced by the patient, family and staff Health care providers have an obligation to continue to offer care for patients with unmanageable suffering that are refractory to pharmacological management and standard approaches, even when the availability of treatments that appear to be effective are limited The provision of clinical care must furthermore, advance in parallel with an increased focus on, and resources for, the development of research initiatives

References

(1) Coyle N Adelhard J Foley KM Ponenoy RK Character of terminal illness in the advanced cancer patient pain and other symptoms during the last four weeks of life J Pain Symtpom Manage 1990 5 83 93

(2) Chemy NI Portenoy RK Sedation in the management of refractory symptoms guidelines tor evaluation and treatment J Palhat Care 1994, 10 31 38 1994

(3) Ventatndda V Ripamonti C De Coonnon F Tambunn M Symptom prevalence and control during cancer patients last days of life J Palliat Care 1990 6711

(4) Greene WR Davis WH Titrated intravenous barbiturates in the control of symptoms in patients with terminal cancer South Med J 199184 332 7

(5) Enck RE Drug induced terminal sedation for symptom control Am J Hosp Palliat Care 1991 8 35

(6) Faismger R Miller MJ Bruera E Hanson J Maceachem T Symptom control during the last week of life on an palliative care unit J Palliat Care 1991 7511

(7) Roy DR Need they sleep before they die⁹ J Palliat Care 1991 6 34

(8) Chater S Viola R, Paterson J Jarvis V Sedation for intractable distress in the dying - a survey of experts Palliat Med 1998 12 255-269

MANAGEMENT OF DIFFICULT CANCER PAIN

K H Simpson Consultant in Pain Management, St James s University Hospital, Leeds, UK

Pain in cancer is not just a medical issue and pain management should not be seen in isolation, but as part of a continuum of care delivered by a group of professionals (Levy 1991) Failure to recognise and treat cancer pain is still a problem (Von Roenn et al 1993) Undergraduate education in all aspects of palliative care is often inadequate (Billings and Block 1997) Insufficient continuing education of doctors in cancer pain management is a factor in the poor delivery of pain control (Elliott and Elliott 1991,Weissman 1996)

There has been a world wide increase in the incidence of cancer (Davies et al 1990) Many of the cancers which are becoming commoner are not curable Many tumours occur in the older age group, where pain management may pose particular problems (Portenoy 1992) Pain is often not a significant problem for patients in the early stages of disease, with less than 10% patients with solid tumours reporting pain that interferes with mood or activity About one in three patients with metastatic disease report significant pain The majority of patients with end stage disease have pain problems (Cleeland 1984) More than 50% patients with cancer probably have unrelieved pain Breakthrough pain is often a particular problem (Portenoy and Hagen 1990 Yarbro etal 1997)

The basic principles of pain management are to decrease pain and improve quality of life, to do no further harm, to allow patient and carers choices and to use resources as effectively as possible Disease modification should always be considered in each patient, surgery, radiation or chemotherapy might be appropriate in some circumstances Oral analgesic drugs are the mainstays of cancer pain management, these are effective treatment for 90% patients Specialised management techniques such as simple or complex nerve blocks, spinal cord stimulation, percutaneous cordotomy or neurosurgery may be needed for selected patients with pain that is difficult to control Physical treatments such as electrical stimulation or acupuncture may be appropriate Ideally a combined approach aimed at several different levels within the nervous system might provide the best pain relief with the least adverse effects The importance of psychological, social and spiritual support must not be forgotten Good communication with patients, carers and other professionals is essential for optimum treatment

There are alternatives for patients whose pain resists oral drugs, those in whom medication produces side effects or those m whom simple drug delivery methods cannot be used These may include neural blockade or spinal drug delivery Neural blocks may target main division of nervous system, and may involve local anaesthetic, steroid or neurolyuc agents Nerve blocks may be aimed at peripheral nerves, spinal cord or autonomic ganglia These techniques have a significant role in about 10% patients with cancer pain (Cleeland et al, 1994) There is still a place for use of neurolytic techniques e g coehac plexus block, however concern about possible adverse effects limits the application of some neuro-destructive procedures Smgle blocks are not likely to provide long term benefit for complex pain problems It is possible to deliver drugs epidurally or mtrathecally using externalised systems, but there are difficulties with long term use of this systems (Mercadante 1999) Continuous mtrathecal drug delivery (ITDD) via implanted pumps is a significant advance m pain and spasticity management in selected patients Choice of route - mtrathecal or epidural ⁹ There is controversy about the relativemerits of mtrathecal and epidural drug administration for pain management ITDD does not pose a greater infection risk than epidural drug delivery (Nitescu et al 1995) and is not associated with neurotoxicity ("Wagemanser al 1997) ITDD provides better pain control than epidural drug administration (Wang et al 1991) Choice of system - fully implantable or external⁹ The choice of spinal system depends upon the pain problem and experience of the team looking after the patient Epidural or mtrathecal catheters may be externalised through the skin at the puncture site or tunnelled subcutaneously away from the spme Epidural catheters have a high rate of infection and technical complications (Smitt et al 1998) There is no evidence that externalised tunnelled mtrathecal catheters have a higher infection risk than epidural catheters (Nitescu et al 1995) Totally implantable systems are more expensive and require more expertise to implant but there is less nsk of technical failure and perhaps infection Cost effectiveness studies have shown that decreased drug requirement offsets the initial high cost of the ITDD system, medical input and mpatient time if the patient lives for three months (Mueller Schwefe et al 1999) If the patient s life expectancy is weeks an external system is more appropriate Choice of patient ^? Careful patient selection and education are important It is not clear whether differentiating between types of pain helps to predict success however neuropathic pain, visceral pain from distension, incident and cutaneous pain may be more refractory Those with segmental pain or spasticity are often good candidates Patients with slowly progressive indolent disease are more likely to get benefit than those with a rapidly progressive incident or changing pain pattern Those who get analgesia but intolerable side effects from systemic medication may be good candidates for ITDD Choice of drug ⁷ Many different drugs have now been administered spmally (Hassenbusch et al 1999) Opioids, clomdme, ketamine, octreotide, midazolam, neostigmme, baclofen and local anaesthetics all have advantage and disadvantages (Naumann etal 1999) Spinal toxicity of drugs and their preservatives must be considered Stability of drugs in CSF, over time and at body temperature are important in deciding which agents to use Patients must be carefully monitored for side effects and appropnate changes in ITDD made (Naumann et al 1999) The use of ITDD is a valid technique for a small number of patients with difficult to manage cancer pain However it must be used in the context of the care of the whole patient as part of a strategy for treating pain Appropnate pain control involves so much more than the provision of medication It must encompass the total care of the patient and often needs a multi professional team to deliver adequate analgesia

References

Billings J A and Block S (1997) Palliative care in undergraduate medical education Status report and future directions Journal of the American Medical Association 278(9) 733 38

Cleeland C S (1984) The impact ot pain on the patient with cancer Cancer 54 (11 Suppi) 2635 41

Cleeland C S Gomn R Hatfield A K Edmondson J H Bum K H Stew an J S Pandaya K J Pain ands its treatment in patients with metastatic cancer (1994) New England Journal of Medicine 330 59296

Davies D C Hoel D Fox J Lopez A (1990) International trends in cancer mortality Lancet 336 47481

Elliott T E and Elliot! B A (1991) Physician acquisition of cancer pain management knowledge Journal of Pain and Symptom Management 6 (4) 224 29

Hassenbusch SJ Garber J Buscher E Alternative mtrathecal agents for the treatment of pain Neuromodulation 1999, 2 85 92

Levy M H (1991) Effective integration of pain management into comprehensive cancer care Postgraduate Medical Journal 67 (Suppi 2)35-43

Mercadante S Problems of long term spinal opioid treatment in advanced cancer patients Pain 1999 1 1 13 Mueller Schwefe G Hassenbusch SJ Reig E Cost effectiveness of mtrathecal therapy for pain Neuromodulation 1999, 2 7784

Naumann C Erdme S Koulousakis A et al Drug adverse effects and system complications of mtrathecal opioid delivery for pain origins detection manifestations and management Neuromodulation 1999 2, 92 108

Nitescu P Sjoberg M Applegren L et al Complications of mtrathecal opioids and bupivacame in the treatment of "refractory cancer pain Clin J Pain 1995 11 45 62

Portenoy R K (1992) Pain management in the older cancer patient Oncology 6 (Suppi 2) 86 98 Portenoy R K and Hagen N A (1990) Breakthrough pain definition prevalence and characteristics Pain 41(3) 273 81

Smitt PS Tsafka A Teng van de Zande F et al Outcome and complications of epidural analgesia in patients with chronic cancer pain Cancer 1998 83 2015 22

Von Roenn J H Cleeland C S Gonm R Hatfield A Pondaya, K J (1993) Physicians:: attitudes and practice in cancer pain management A survey for the Eastern Co operative Oncology group Annals of Internal Medicine 119 121 26

Wagemans ME van der Valk P Spoelder EM Neurohistopathological findings after continuous mtrathecal administration of morphine or a morphine/bupivacame mixture in cancer pain patients Acta Anaesthesiol Scand 1997 41 1033-8

Wang JF Nauss LA Thomas JE et al Pain relief by mtrathecally applied morphine in man Anesthesiology 1979 50 149 151

Weissman D E (1996) Cancer pain education for physicians in practice establishing a new paradigm Journal ot Pain and Symptom Management 12(6) 36471

Yarbro, J W Bomstem R S Mastrangelo M J Cancer pain management update on breakthrough pain (1997) Seminars in Oncology 24(5) (Suppi 16), SI 6-42

QUALITY ASSURANCE IN CANCER PAIN TREATMENT

Louis Brasseur, CET Douleur, Hopital A. Pare, 92 Boulogne, France.

Pain is often associated with cancer. It is more frequent in advanced stages, but may be encountered in early stages. It may be considered as an acute pain which persist, but pure acute phases in relation with treatment, diagnostic techniques and surgery are not rare.

Attemps to improve management of cancer pain have been made : no cleat cut evidence that this is the case, even if wide information and encouragements had been provided.

Quality insurance is an another attempt to improve the situation. It is based on the intervention of an interdisciplinaru group. This group have to implement knowledge. Pain evaluation as pain satisfaction from treatment are key points, even studies had shown discrepancies between the two. Procedures within institutions have to be revisited and systematic evaluation of practices to be undertooken. Pain charts have to be implemented.

Regular follow-up is the base for improvement. If improvement of pain treatment have a cost, undertreatment of pain do also have a cost.

References

American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute and cancer pain. JAMA, 1995, 274 : 1874-1880.

CANCER PAIN SYNDROMES

Augusto Caraceni, Neurology Unit, Rehabilitation and Palliative Care Unit National Cancer Institute of Milan, via Venezian 1, Milan 20133, Italy, e-mail caraceni@istitutotumori. mi. it

Clinical experience and systematic assessment of cancer pain syndromes evolved since the pioneering work of Kathleen Foley (Foley 1979 ; Foley 1979) into a classification that should be clinically useful and encourage further research and study (Caraceni and Foley 1997) .

The assessment of pain is of uppermost importance in the overall strategy for cancer pain management. Assessment includes pain characteristics, intensity, interference with quality of life, pathophysiology, etiology and relationship with the underlying oncological disease. From the accurate assessment of pain characteristics, pathophysiology and causal factors, and the results of imaging and laboratory exams it is possible to establish a pain diagnosis that will identify a specific cancer pain syndrome. The identification of cancer pain syndromes has an impact on directing oncological work-up and therapies (Banning, Sjogren et al. 1991 ; Gonzales, Elliot et al. 1991)

Pain in patients with cancer is due in 70% of cases to the cancer itself in 20% to treatment related complications. A recent study on 1095 consecutive patients showed that pain due to antineoplastic treatments and pain due directly to cancer can overlap in at least another 10% of patients (Caraceni, Portenoy et al. 1999). In this study pain was due to bone lesion due to metastases or directly to tumor invasion of bone and joint structures in 41% of patients, to neoplastic visceral damage in 28% and to lesions of the nervous system in 28% of cases. On the basis of expert opinion the painpathophysiology was assigned to somatic, visceral and neuropathic processes. Somatic-nociceptive -type pain was the most common single pathophysiology ( 32%), pure visceral pain was reported in 15% of patients , pure neuropathic pain in only 7. 7 % of cases. All the remaining pain syndromes were diagnosed with mixed pathophysiologies the most common being somatic-neuropathic (23%).

By using a detailed checklist, based on previously published experiences (Chemy and Portenoy 1994) (Caraceni and Foley 1997) and expert consensus, pain syndromes were assigned to 69 possible different anatomo-clinical entities. A convenience classification of main anatomical sites was used to order cancer-related syndromes in 24 anatomical definitions. The most prevalent syndromes, were vertebral bone pain (13%), plexopathies (12%), generalized bone pain due to multiple lesions (12%) bone pain due to pelvis, long bones and joint lesions (11 %), pain due to infiltration of muscle and fasciae (11 %) but a number of other lesions of visceral, somatic and neurological structures were also identified. Different primary tumors are associated with a different distribution and frequency of pain syndromes confirming that the natural history of different neoplasms modifies the pain history. More severe pain was associated with the presence of breakthrough pain, somatic pain worse performance status and younger age.

This classification is open to revision and has to be considered only as a starting point for further developments. More refined anatomical definitions can be achieved by using the detailed list or part of it according to different clinical or research needs.

Breakthrough pain (BKP) has been described by several authors as one of the factors that worsens the prognosis of pain management (Banning, et al 1991) Portenoy at al 1999) In the same survey of 1095 patients with cacer pain, mentioned above, 67% had BKP (Caraceni et al In PRESS) There was an eneven recognition of BKP across specialists from different parts of the world This observation calls for more standardized methods for diagnosing BKP in non Anglosaxon clinical contexts Patients with BKP had more severe pain and higher interference with function BKP was sigmfcantky associated with bone pain and in particular with vertebral syndromes (87%), pelvis long bones and joint lesions (78%), and with lesions of nervous plexi (78%)

BKP due to bone invasion is therefore one of the most prevalent pain syndrome due to cancer with a particular impact on patients quality of life Also neurogenic pain often presents with BKP suggesting specific pathophysiologies for different types of BKPs which therefore requires different treatment strategies

In conclusion the assessment and diagnosis of pain syndromes is a very important clinical task and requires a special effort on the side of the oncologist and pain specialist for the prevention and treatment of cancer pain

References

Banning A P Sjogren et al (1991) Pain causes in 200 patients referred to a multidisciplinary cancer pain clinic Pain 45(1) 458

Banning A P Sjogren et al (1991) Treatment outcome in a multidisciplmary cancer pain clinicc Pain 47 129 134

Caraceni A and K M Foley (1997) La douleur du cancer et les syndromes douloureux du cancer Douleurs bases fondamentales, pharmacologie douleurs aigues douleurs chromques therapeutiques L Brasseur M Chauvm and G Guilbaud Pans Malome 567 587

Caracem ARK Portenoy et al (1999) An international survey of cancer pain characteristics and syndromesc ' Pain 82 263-274

Chemy N I and R K Portenoy (1994) Cancer Pain pnnciples of assessment and syndromes Textbook of Pain P D Wall and R Melzack Edinburgh Churchill Livmgstone 787-823

Foley K M (1979) The management of pain of malignant origin Current Neurology H D Tyier and P M Dawson New York Raven Press vol 2 279-302

Foley K M (1979) Pain syndromes in patients with cancer Advances in Pain Research and Therapy vol 2 J J Bonica and V Ventafndda New York Raven Press 59-75

Gonzales G R K J Elliot et al (1991) The impact of a comprehensive evaluation in the management of cancer pain ' Pain 47 141-144 Portenoy RK Payne D Jacobsen P Breakthrough pain characteristics and impact in patients with cancer Pain 1999 81 129134

HOME CARE IN CANCER PAIN MANAGEMENT

Dr Nigel Sykes Consultant in Palliative Medicine St Christopher's Hospice Senior Lecturer in Palliative Medicine King's College University of London London U K

Home management of cancer pain is important because 60 80% of patients express a preference to be cared for in that setting, and because palliative care cannot meet the level of unmet need unless it does so outside its institutional base For these reasons a rapidly growing form of hospice provision over the last 20 years has been the specialist home palliative care team, and in many countries this is the principal pattern of palliative care provision

Pain control is a fundamental part of the function of these teams not only because pain affects about 70% of patients with advanced cancer but because it is the main expectation of those who are referred to them (Jarrett et al, 1999) However, pain is in fact neither the most common symptom in advanced cancer nor the one which causes most distress (Ferrell et al, 1998), so a home care team must have wider competencies than simply analgesia

How successful is pain control at home ?

Pain is said to increase in prevalence as death approaches and indeed is frequently experienced at the end of life but not more frequently than in an m-patient unit (Dobratz et al, 1991) However, carers recall pain at home as having been more intense than that expenenced in an m-patient unit (Parkes and Parkes, 1984), and pain control may be more problematic in the home

There is limited evidence for the effectiveness of home palliative care teams in providing pain control Wenk (1991) showed a marked fall in pain scores following involvement of the specialist team This dramatic result has not been shown elsewhere, but pain prevalence and seventy can be contained as death approaches 9% of patients at home had moments of distressing pain in the average week, but less than 2% had distress of any sort continuing for more than 28 hours/week (Hmton, 1994a)

About 65% had some pain each week but the prevalence and seventy of pain did not nse as death approached Pain was stable in home care cancer patients between the penods less than six weeks before death and 7 12 weeks before death (Axelsson and Sjoden, 1998)

There is a marked discrepancy between the proportions of patients who say they would prefer to die at home and those who actually do so The reasons for in-patient unit admissions vary and whilst pain was a reason for intermediate or longer terminal admissions, it was less important for short terminal admissions, when detenoration/carer stress took over (Hmton 1994b) However, patients who expenence good pain control are more likely to die at home than those who do not (Karlsen and Addmgton Hall 1998)

What are the difficulties in achieving pain control at home ?

Multiple psychosocial factors combine to impede pain control at home Patients and carers have been shown to fear addiction have a sense of hopelessness, wish to maintain control lack knowledge about drugs and doses and want to avoid side effects (Ferrell et al 1998 , Dobratz 1991) These issues add to the level of anxiety, which itself will exacerbate pain, and also lead to reduced compliance with medication Indeed, as few as 45% of home hospice patients may comply with an analgesic regime (Austin et al, 1986) This failure of compliance is generally m one direction 50-83% cancer patients reduce analgesia when discharged home and in another study the median oral morphine dose actually taken was 84 mg/24h although the prescribed median dose was 120 mg/24h (Ferrell et al, 1998) Patient and carer education is a vital factor in improving compliance, but it has also been shown that a single prescnber rather than the patient receiving medication from both hospital and family doctor or hospice service is also important (Zeppetella 1999)

Additional difficulties include poor knowledge of analgesia on the part of doctors and attending nurses, and problems in contacting doctors (Byrd et al, 1987) Paradoxically monitored dosage systems may be difficult for patients to use and actually impair compliance further Patients also use a wider variety of complementary methods of analgesia than professional carers tend to acknowledge

What are the implications for practice ?

Specialist palliative care teams have been found to improve outcomes compared with other settings (Moms et al, 1986 , Parkes and Parkes, 1984) Education is a fundamental role of such teams although patients and carers are less conscious of this activity than are team members (Hmton 1996) The team can also contribute to professional education about symptom control Although such education is apparently wanted (Boyd 1995) only 8% ofGPs specifically rated pain control as difficult (Grande, 1997) Formulation of guidelines and the nomination of a key worker may also assist quality of care (Robinson and Stacy, 1994)

In order to most effective in providing symptom control and avoiding unnecessary admissions specialist teams should probably be available 24 hours a day (Thomas, 2000) To enable this service there has to be ready out of hours availability of medication, including opioids, by means of specialist pharmacies or the provision of supplies of emergency medication to be kept in the patient's home Although the highest home death rate is achieved where specialist admission is not readily available, it is likely that the best quality of life for both patients and family will result from close co-operation between a highly accessible home palliative care team and a responsive specialist in patient unit

References

Austin C Cody CP Eyres PJ, Hetfenn EA Krasnow RW (1986) Hospice home care pain management four critical variables Cancer Nursing 9 58 65

Axelsson B Sjoden P(1998) Quality of life of cancer patients and their spouses in palliative home care Palliative Medicine 12 2939 Boyd KJ (1995) The role of specialist home care teams views of general practitioners in south London Palliative Medicine 9 138 144 Byrd S Taylor S Altmiller R (1987) Pain management practices in a home hospice care program American J Hospice Care 4(6) 21 29 Dobratz MC Wade R Herbst L Ryndes T (1991) Pain efficacy in home hospice patients a longitudinal study Cancer Nursing 14 2026 Ferrell BR Bomeman T Juarez G (1998) Integration ot pain education in home care J Palliative Care 14 62 68

Grande GE, Barclay S ToddC(1997) Difficulty of symptom control and general practitioners knowledge of patients symptoms Palliative Medicine 11 399406

Hmton J (1994a) Can home care maintain an acceptable quality of life for patients with terminal cancer and their relatives' Palliative Medicine 8 183 196

Hmton J (1994b) Which patients with terminal cancer are admitted from home care⁹ Palliative Medicine 8 197-210 Hmton J (1996) Services given and help perceived during home care for terminal cancer Palliative Medicine 10 125 134

Jarrett N Payne S Turner P Hillier R (1999) Someone to talk to and pain control what people expect from a specialist palliative (.are team Palliative Medicine 13 139 144

Karlsen S Addmgton Hall J (1998) How do cancer patients who die at home differ from those who die elsewhere⁹ Palliative Medicine 12 279 286

Parkes CM Parkes J (1984) Hospice versus hospital care re evaluation after 10 years as seen by surviving spouses Postgrad Med J 60 120 124

Robinson L, Stacy R (1994) Palliative care in the community setting practice guidelines for primary care teams British J General Practice 44 461 464

Thomas K (2000) Out-of hours palliative care - bridging the gap Eur J Palliative Care 7 22-25

WenkR DiazC Echevema M et al (1991) Argentina s WHO cancer pain relief program a patient care model J Pain Symptom Management 6 4043

Zeppetella G (1999) How do terminally ill patients at home take their medication⁹ Palliative Medicine 13 469 475

EASTERN AND CENTRAL EUROPE PALLIATIVE TASK FORCE (ECEPT)

Jacek Luczak, Maciej Kluziak. Palliative Care Department. Ul. Lakowa 1/2. Poznan, Poland.

WHAT IS ECEPT ?

ECEPT is a newly created international association meant to group palliative care professionals from Eastern and Central Europe, the people who take leading part in the field of caring for the terminally ill. ECEPT is based in Poznan, Poland which is one of the most important educational centres for palliative care in the whole region. Its president, Jacek Luczak is well known for his dedication to the problems of developing care for the dying patients and their families.

THE CORNER-STONE - POZNAN DECLARATION 1998"

The Poznan Declaration was initially made during the 9th Palliative Medicine Advanced Course (May 1998) by the participants from Belarus Bulgaria the Czech Republic Hungary Latvia Lithuania Poland Romania and Slovakia It emerged as a result of workshops on present status and future development of palliative care in the countries of participants chaired by lan Stjemsward and Jacek Luczak The declaration included regional analysis of palliative care issues stated goals to achieve in the palliative care field (national policy education drug availability, multidisciplmary teams public awareness) and gave some recommendations of how to do that.

Dunng the 10th Palliative Medicine Advanced Course which took place in May 1999 meetings were held to discuss present achievements and obstacles to the improvement of cancer pain control and palliative care Apart from the representatives from the countries listed above the participants from Estonia Greece and Ukraine took part in the course Questionnaires covering the incidence of cancer and dying of cancer drug availability drug consumption and national policies were prepared and sent to professionals working in palliative care teams in Eastern Europe The Founding Committee for the registration of the Eastern and Central Europe Palliative Care Taskforce (ECEPT) was established The pnncipal purpose of this organisation is to implement the objectives stated in the Poznan Declaration

THE TASKS

Gathering data on palliative care provision in East and Central European countries from the basic statistics (e. g. the numbers of cancer deaths per year deaths at home and in the hospital) to the precise number of professionals involved in palliative care the opioid consumption the laws and rules which regulate opioid prescribing in each of these countries.

Sharing experiences as to the achievements and obstacles in the field of palliative care in the region Annual international palliative care courses organised by Palliative Care Department of in Puszczykowo near Poznan have been a splendid opportunity for that during the last decade

Influencing government institutions in mentioned countnes if the situation seems to be inadequate to the needs of people dying from cancer (and non malignant terminal illnesses) - setting national policies in cancer pain management and palliative care Charitable organisations do not seem to provide sufficient funding in developing countnes of the region, there is an urgent need to obtain some basic resources from the state for palliative care service

Organising training and courses for palliative care professionals from Eastern and Central Europe There are already some centres in Eastern and Central Europe which provide high quality education in palliative care These should support the countries in which palliative care is still at its beginnings specialist training in Western Europe (i e Great Britain) is also taken into account - if only funds will make that possible The idea of multidisciplmary holistic approach should be emphasised.

Setting standards of palliative care specific for local needs and circumstances That applies both to the standards of providing and teaching palliative care As to the latter it is planned to work out an agreement on curricula for students and postgraduates. ECEPT opts for compulsory comprehensive training for all medical students and family medicine trainees (Poznan experience gives some strong arguments for that)

Raising awareness of the problems of palliative care not only among medical professionals but also in whole societies of the countnes involved in ECEPT Eastern and Central European countnes lag behind the West very badly in the field of death education There are still taboos and myths associated with dying from cancer even among health professionals. Collusion, opiophobia and futile aggressive treatment cast their shadows on the quality of life of the dying patients. Changing attitudes is a difficult task but the example of Poland adds some optimism - social awareness changed immensely after last year's media campaign Still there is a great deal to be done in that field

WHAT HAS BEEN DONE SO FAR ?

ECEPT has been registered as an association based in Poznan Poland capable of accepting foreign citizens as members. During the extraordinary general meeting in Geneva (Sept 1999) representatives of East European countnes were accepted as members of the Management Committee and the Audit Committee of ECEPT Meetings are usually appointed dunng international courses in Puszczykowo near Poznan Twice a year delegates representing the countnes grouped in ECEPT meet to discuss current problems and plan future activities In May 2000 the issues of education are on the agenda of the meeting while in September legal problems and funding palliative care shall be discussed

At this moment ECEPT is gathenng funds for further action Support is sought from non-government charitable organisations (e g Open Society Institute Stefan Batory Foundation) and from pharmaceutical companies (substantial help from Janssen-Cilag Poland) ECEPT is planning co operation with European Association for Palliative Care and Polish Hospices Fund (a chantable organisation based in the UK deeply involved in co-ordinating training for palliative care professionals in the placements in the best Bntish hospices)

MEMBERSHIP

On a wntten declaration by the interested person the Management Committee shall take a decision in a form of a resolution whether this person may be granted a full membership The interested person may appeal from the decision to refuse him a full membership to the General Meeting which will pass a final resolution on this issue

Palliative care professionals (physicians nurses, psychologists, social workers and so on) from Eastern and Central Europe are meant to be the core of ECEPT When delegates from countnes as exotic as Mongolia applied for membership the issue was raised of whether to accept or not representatives from outside Europe It was decided to accept them considering their pioneenng role in palliative care Representatives of organisations supporting ECEPT may also apply for membership.

According to the Articles of ECEPT full membership may be granted to :

a/ Adults, Polish citizens or foreigners residing in the territory of Republic of Poland who support the cause of ECEPT and declare active involvement in the fulfilment of its objectives. b/ Foreigners who are not residents of Republic of Poland.

A supporting member may be a physical or legal person, irrespective of the person's residence or registered address in Poland or abroad, who agrees to be granted a membership of ECEPT for his/her contribution to the fulfilment of its objectives.

An honorary membership may be conferred to any physical person, irrespective of the person's residence, in recognition of special services for ECEPT. The General Meeting shall decide on the granting of supporting and honorary membership by adopting a resolution. A full member of the ECEPT shall have :

1/ Active and passive electoral rights in the elections of ECEPT bodies. 2/ The right to attend any activities related to the fulfilment of the objectives of ECEPT.

A full member of the ECEPT is required to :

a/ Take part in the activities of ECEPT.

b/ Comply with the Articles of Association and the resolutions of ECEPT bodies.

c/ Pay an annual membership fee subject to the decision of the General Meeting (10 EURO has been decided to be the annual fee).

A supporting member shall pay the fee in the amount the member has declared.

Addresses for correspondence : Palliative Care Dept. Ul. Lakowa 1 / 2. 61-878 Poznan, Poland. Tel. /Fax : 0048-61-8530-106 E-mail: President of the Management Committee, Prof. Jacek Luczak : jluczak@usoms. poznan. pi Secretary, Maciej Kluziak : mkluziak@polbox. corn

• Published in : European Journal of Palliative Care, Volume 6, Number 2, March/April 1999

THE IMPORTANCE OF PALLIATIVE HOME CARE SERVICES WROCLAW'S EXPERIENCES

Anna Oronska, Wroclaw, Poland

At years 1980-84 an enormous interest in developing palliative / hospice care started in Poland. At the very beginnig it was focused on the home care. The first hospice home care teams were based on the voluntary workers : doctors, nurses, psychologists, non - professional people, often connected with church. In Wroclaw the first voluntary home hospice, "St. Veronica's Hospice" was organised in 1984. It has possibility to take care of about 50-60 patients / year. It was highly insufficient (Wroc?aw has 650. 000 inhabitans, about 1200 death from cancer every year. )

In 1994 it became possible to establish the Palliative Care Team connected with Lower Silesia Oncology Centre, providing home care in the structures of NHS.

At the beginning 8 doctors, 8 nurses, 2 physiotherapist, 2 social workers, 1 psychologist and 1 medical secretary were employed. Several volunteers helped from the beginning. 2 volunteer chaplains provided spiritual care.

At the first year (1994) we took care of 569 patients. We performed 6879 home visits, 286 consultations of the patients in the clinic, and 2102 consultations for families.

The mean time of care for the patient was 1 month 25 days. 68% of patients died at home. From this first experiences we have recognised, that palliative home care is very important and needed in our health service. The district doctors and nurses were not prepared to take care of terminally ill and dying patients. Pain management was inadequate, and the aspects of "total pain" was hot taking in account. At the beginning patients and their families received information about our Team mainly from other people, sometimes from district nurses (in spite of the fact, that all hospitals and policlinics got information about our activity).

The team provides multidisciplinary care for terminally ill cancer patients. As a rule, every patient has his "own" doctor and nurse. Psychologist, social worker, physiotherapist, occupational therapist, chaplains and volunteere help, when needed. Doctors and nurses perform regular visits, at least once a week, and more often (even a few times a day) if necessary.

Families visit the Team to borrow some aids (wheel chairs, mattresses, nebulisers. oxygen concentrators) and simply - to talk with members of the Team, sometimes cry...

We try to take care not only of somatic problems of our patient. We send Christmas and Easter cards, and for specially poor, lonely patients - parcels with fruits, sweets.

Twice a year a holy service for died patients is celebrated. Now it takes place in one of the biggest churches in Wroclaw, as more then thousand bereaved family members are attending.

For the patients being in better condition and bereaved families we arrange concerts. Christmas and Eastern meetings and very well accepted - bus excursions.

We also offered several education and training courses and conferences for doctors, nurses and volunteers.

The demand for our service is still growing. In 1999 we took care of 1067 patiens, the team performed 13. 687 visits, 1281 patients consultations in the polyclinic and 4290 families consultations.

We also counted phone consultations - 1740. The mean time of patient's care is now longer - 3 month, that corresponds with greater number of patients visits in the polyclinic.

Patients are refereed to our care earlier in the course of the disease, now very often by hospital doctors and oncologists.

Our team has grown also : now we are 12 nurses, 12 doctors, 3 physiotherapists, 2 social workers, 2 psychologists (one works as occupational therapists) medical secretary, 2 volunteer chaplains. The number of volunteers is also growing.

We find that our work is very useful. The holistic care that we provide as a multidisciplinary team is very important for terminally ill and dying cancer patients, allowing them to sped their last days and to die at home. with theirs loved ones.

CANCER PAIN MANAGEMENT AND PALLIATIVE CARE IN THE CZECH REPUBLIC

D. Vondrackova, M.D., Pain Management Centre, Teaching Hospital "Na Bulovce". Institute for Postgraduate Medical. Education. Prague, Czech Republic.

The Second World Conference of Cancer Organisations published a study on the status of mortality ratio for malignant diseases. The Czech Republic has been indicated as one of countries with increasing number of cancer and high mortality ratio related especially to lung, breast, and colorectal cancer, as well as other types of cancer. Today, most of oncological patients can be successfully treated or at least their lives can be substantially prolonged as a result of continuing medical progress. This means that many of cancer patients are maintained with relatively progressed oncological disease for a long time. It should be a duty of medical personnel to secure good quality of life for such terminally ill patients. Pain management should be an important part of palliative care.

In the Czech Republic the concept and importance of cancer pain management has not been widely accepted by oncologists and medical public yet. There was not a single paper dealing with pain published in any Czech oncological journal in 1999. The Czech Pain Society tries to fill the gap with its own journal called "Bolest" (Pain). It published a series of survey articles on palliative care of preterminally and terminally ill patients along with other articles on cancer pain. A recent study shows that oncologists are not interested too much in patients in terminal stage of cancer Nearly 60% of the Czech oncologists believe that general practitioners should take over the care for patients not treated oncologically any longer Perhaps as a result of intensive lecturing activities of members ot the Czech Pain Society, 34% of oncologists think that terminally ill patients with cancer pain belong to the care of algesiologists The same number of oncologists (33%) thinks outpatient oncologists should treat those patients

In pain management centres the oncological patients form 5 8% of all chronic pain patients A recent survey (one month study) in 48 centres confirms this number 669 oncological patients (5 8%) were treated along with 10 824 non oncological ones Opioids were given to 75% of cancer patients while only 6,4% of others were treated by opioids More and more pretermmally and terminally ill patients are treated in hospices and at home under the support of home care services

The recent opening of five hospices with total capacity of 126 beds is a significant step forward in the Czech palliative care Almost a thousand patients were accepted during 1999, most of them treated by opioids along with other medication Patients were mostly accepted in pretermmal stage of cancer and more than 50% died Hospices pay special attention to the palliative care that is being developed in close co operation with the Czech Pain Society Outlines of the new specialisation Algesiology and Palliative Care have been jointly formulated Two textbooks on palliative care for patients in pretermmal and terminal stages were published in the last two years (Voriicek et al Jakoubkova et al) Since 1995 Days of Palliative Care are annually organised in Brno

For seriously ill cancer patients, who for various reasons are not placed in a hospice and stay home, it is possible to provide home care services Nurses working in this service are specially trained not only in palliative care but also in providing care to patients with the established analgesic neural blocks or other analgesic methods applied for pain management, such as subcutaneous opioid infusion and/or PCA However, most of those patients are treated by oral opioids or transdermally applied fentanyl

The opioid consumption can be considered as a criterion for the level of cancer pain management Opioid therapy for non malignant pain is used rather exceptionally Therefore, numbers of the country analysis showing the opioids consumption can be use as a direct measure of the of cancer pain management level In 1996 the consumption of morphine in injection was 4 58 mg per person and year, in 1998 already increased by 37 7% to 6 31 mg/person/year The total amount of morphine in a slow release form used in the Czech Republic (10 million inhabitants) was 66 mil mg (6,60 mg/person/year) while in 1996 it was by about 20 million mg less - 44 4 million mg (4,44 mg/person/year) - again the increase of 48,6% Transdermal fentanyl started to be used only since end of 1997 In 1998 2 890 packages were prescribed, i e 627 625 /ug Several tens of analgesic neurosurgical treatments including delivery of morphine in ventricles have been performed at neurosurgical departments There are no legislative obstacles for prescribing opioids, the main problem, mainly for general practitioners remains high price Also the introduction of oral therapy during hospitalisation is impossible due to high cost Therefore mostly oncologists and algesiologists routinely prescribe oral and transdermal opioids, much less by other doctors Lack of information fear of opioids fear of addiction, fear of sufficient dose, and other prejudices also hinder the opioid therapy The solution is in continuous education of both medical personnel and patients

The Department for Pain Management in co operation with the Czech Pain Society organises seminars, courses and discussions for physicians, publishes articles in press and professional journals Also stays at specialised departments under the supervision of the Department are used to tram algesiologists and oncologists for Pain Management Members of the Czech Pain Society are preparing a Supplement to the ]oumal Pain for publication in 2000 containing also chapters on cancer pain management and palliative care including home and hospice care We are convinced that the level of the care for terminally ill patients in the Czech republic comes near to European standards as the choice is concerned The main drawbacks are still the high cost of slow released forms of opioids and the lack of information In helping to solve those problems by informing medical and general public on principles of cancer pain management, opioid therapy, and palliative care the Departments for Pain Management and the Czech Pain Society see future potentials for further improvements of the difficult situation of seriously ill cancer patients and their families

References

(1) Jakoubkova J Palliative Medicine Prague Galen 1998 (In Czech)

(2) Voriicek J Adam Z et al Palliative medicine Prague Grada Publishing 1998 (In Czech)

(3) Opioids — Treatment of Cancer Pain Marketing Study Prague Exmarket and Associates Int Ltd Ad hoc Division November 1999 (In Czech)

(4) Durogesic Treatment of Cancer Pain Marketing Study Prague Exmarket and Associates Int Ltd Ad hoc Division March 2000 (In Czech)

(5)BeskaF Tvrdik J Lorenc J Exploitation of the cancer registry tor the evaluation ot the diagnostic and treatment care Klimcka onkologie (Clinical Oncology) Special Number 1999 (In Czech)

(6) Zaioudik J Report on The Second World Conference of Cancer Organisations Atlanta, 1999 Klimcka onkologie (Clinical Oncology) 1999 No 12 139

(7) Bolest (Pain) Journal of the Czech Pain Society (Quarterly) Vol 1 3 1998 1999 2000 (In Czech)

A PROSPECTIVE STUDY EVALUATING THE RESPONSE TO THE INITIATION OF PARENTERAL OPIOIDS FOR CANCER PAIN

 Roelien H Enting'. Wendy Oldenmenger¹, Carin CD van der Rijt²³, Eric H Wilms⁴, Manin van den Bent', Ema Elfrink³, Ineke Elswijk³, Peter Sillevis Smitt'

Dept of Neuro-oncology', Dept of Internal Oncology², the Palliative Care Unit³, and Dept of Pharmacology, Daniel den Hoed Cancer Center, PO Box 5201, 3008 AE Rotterdam, NL

Aim of investigation: To evaluate the routine use of parenteral opioids before the use of spinal analgesia.

Methods: Since December 1997, parenteral opioids have been started in patients (pts) who have severe pain despite non-parenteral opioid administration or who suffer intolerable side effects (SE). Pts were prospectively evaluated for pain intensity (PI) and SE three times daily. The primary endpoints were 'adequate pain control' (= decrease of > 2 points in PI, and PI < 6, or decrease of > 1 category of PI (mild = 0-4, moderate = 5-6, severe = S 7) and change in proportion of pts with >. 1 SE.

Results: The series included 28 men, and 22 women, with a mean age of 54 yr, and lung carcinoma (22%), breast carcinoma (16%), head and neck cancer (16%) or other (46%). Median survival was 43 (7 >750) days. Mean PI was 6.7 (range 4-9), 94% had moderate or severe pain. Prior opioid use consisted of oral morphine (44%), transdermal fentanyl (46%), weak opioids (8%), or none (2%). Mean dose was 507 mg daily oral morphine equivalent dose. 39 pts (78%) experienced > 1 SE. Adequate pain control was reached in 38 pts (76%). Mean PI decreased from 6.7 to 4.0 (p<0.001). The number of pts with < mild pain increased from 3 (6%) to 28 (56%) (p<0.001). SE occurred in 39 pts (78%) at baseline, and in 31 pts (62%) on parenteral opioids (p=0.07).

Conclusions: In 76% of 50 pts, the start of parenteral opioids was initially successful for pain control with a trend towards fewer SE.

INCIDENCE AND METHODS OF TREATMENT OF CANCER PAIN IN POLAND

Wozniak Slawomir Pawel. Luczak J, Department Palliative Care Wroclaw , Poland

Introduction & objectives: Pain is common symptom for many people with cancer. Clinical experience suggests that optimal palliative care can effectively mange the symptoms of cancer patients during most of the course of the disease. The aim of this retrospective study was to assess the effectiveness and acceptability of management of pain in patients with malignant disease.

Material & methods : There is approximately 1500 cancer death each year in our town (600 000 inhabitants). 956 pts was registrated in Palliative Care Unit of Oncology Centre for symptom control in 1994 and 1995.

Results: Assessment of pain was based on VAS- Visual analogue Scale ( 0-10) and on 5-step verbal Scale. In our data only 7,4% pts were free of pain. At the start of symptom therapy. 6%used only NSAI drugs., 36% used weak opioid Tramadol 50-lOOmg every 4 hours orally in monotherpy or in combination with NSAI. 11% was treated with codein combination with NSAI. In 30% of case cancer pain was treating with Morphine (MF) 10-300mg every 4 h orally or control releasing morphine. In the last week of therapy 61% pts use MF, in 19% of them. MF was administrated s.c. Neuropathic pain was diagnosed in 28% of pts with pain.

Conclusions: Cancer pain responds to pharmacological measures, and successful treatment is based on simple principles that have been promoted by the World Health Organisation.

PERSPECTIVES OF CANCER PAIN TREATMENT IN RUSSIA

Georgy Novikov. Bons Prokhorov, Sergey Rudoy, Mark Vaismam, Konstantin Velikulug

Center Of Cancer Pain Relif, Scientific Oncology Institut of Moscow; Training course for palliative care, Medicine Academy named after Sechenov, Box 137, Moscow, 127018, Russia

The improvement of quality of life of patients suffering advanced cancer remains and important issue in Russia. The solution to this problem depends on efficient treatment and adequate pain relief first The problem is even worse because of lack of medical staff special knowledge since. Medical universities do not have palliative care subjects in their programs This situation has been changing lately.

The system for palliative care in Russia for cancer patients has appeared and developed Active scientific investigations take place im the area of improvement of quality of life for such patients. Most important is pharma treatment of pain relief. Modem non-opioid analgetic Xefocam (Nycomed) use has been investigated in Russia as well as oral morfine (Mundipharma) with 12-24 hours of activity, fentanyl transdermal system (Janssen Pharmaceutica) and so on. If conservative care is not effective, neural blockades are used. The first Russian training course for palliative care was organzed Medicine Academy named after Sechenov. Most of doctors working in the system of palliative care for cancer patients were trained here Unification of federal trainingstandard is being finished This will let to unify palliative care training throughout Russia.

The issue of training for nurses and assistances still remains very important. Further improvement of training system and usage of modem methods of treatment of cancers pains will provide improvement of palliative care in Russia. Such improvement will help to raise the bad cancer patient's quality of life to a higher level

USE OF LOCAL ANAESTHETIC CONTINUOUS INFUSION IN CANCER PAIN TREATMENT BY SPINAL PERMANENT DEVICES

 Gennaro Savoia. Gennaro Scibelli, Elvira Gravmo, Lucia Maio, Giovanni Giannoni

Buon Consiglio Hosp, Dept of Anaesthesia, 80123. Naples, Italy.

Aim of investigation. The treatment of the mixed cancer pain (nociceptive, incident and/ or neuropathic) requires to deal with many difficulties: resistance to opioids, long time-term home-management, home-dispensing of resources like local anaesthetics, possible use of triple association (morphine, a2-agomsts, local anaesthetics).

Methods. We perspectively studied for 6 years 85 patients, resistant to the analgesic ladder recommended by OMS, for which was set indication to a testing period (15-30 days) of drugs infusion by epidural catheter and, subsequently, to a spinal permanent device with subcutaneous port. 58 patients were affected with cervicothoracic (21) or lumbo-sacral plexopathy (37); multiple bone metastases were in 51/ 85 patients. In all the patients the pain was mixed, incident, with integrated VAS 24 h > 100 using a middle dose of oral morphine > 180 mg/die and full doses of adjuvants. During the testing period by epidural catheter a continuous infusion of 10-40 mg/die of morphine, equal to 1/10 of the oral dose, was performed. Sequentially clonidme 75-150 mcg/die and bupivacaine 15-120 mg/die were added. After 15-30 days, if necessary, a spinal device (44 patients) was applied with initial infusion of morphine equal to 1/10 of the epidural dose, clonidme 30 mcg/die and bupivacaine 10 mg/die (max 12 ml/die)

Results. Thev are synthesized in the Table.

	N of patients (epidural/spmal)	Spinal route
Morphine	85/44	1 -30 mg/die
Clonidme	64/44	30-150 mcg/die
Bupivacaine	69/44	5-60 mg/die
Integrated VAS<50		42/44
Complications		5/44

Conclusions. The employed technique appears optimal in the middle term-treatment of cancerous patients, resistant to the action of the oral opioids, according to the recommendations of OMS

ANALGESIA AND OTHER EFFECTS OF NON. INVASIVE TRANSCRANIAL ELEROSTIMULA-TION (TES) OF THE BRAIN ENDORPHINERGIC STRUCTURES (BES) FOR CANCER PAIN PALLIATIVE CARE.

 Valery P.Lebedev. Electroanalgesia Lab., Pavlov Institute of Physiology, St.-Petersburg 199034, Russia, e-mail :lebedev@infran.ru

Aim of investigation: The analgesic effect of the TES of BES is well known. To estimate the applicability of TES of BES for analgesia in cancer patients it was necessary to define TES effects upon the tumor growth and liver antitoxic ability.

Methods: TES effects upon implanted tumor growth were estimated experimentally in rats with 6 different solid and ascitic tumor strains with and without cyto-static drugs combination. TES effect upon the liver antitoxic ability was determined in rats with acute CC14 liver damage. 1080 patients with heavy cancer pain (with metastasis - after surgery or irradiation (radiation treatment), during and after chemotherapy) were treated by TES. Treatment consists of 10 daily sessions 30 min each.

Results: The statistically significant naloxone re-versible TES inhibition of implanted tumor growth in rats was demonstrated. Among several cytostatics TES potentiated the effects of vinblastine and 5-fluorouracil. In CC14 poisoned rats TES dramatically reduced the events of hepatocyte cytolysis, improved the liver antitoxic loading tests, and liver metabolic activity. These TES effects were also naloxone reversible and potentiated by D-leucine. In patients TES of BES was used as a replacement of morphine-like analgesics. During and after treatment pain was abolished or significantly reduced in 56.5% of patients with analgesic aftereffect of about two or more months duration. In 29.2% of patients the analgesic aftereffect was shorter than two months. In 14.3% the analgesic effect was rather insignificant. In all patients treated the improvement of mood and reduction of depression were observed.

Conclusions: TES of BES is effective nonpharmaer insignificant. In all patients treated the improvement of mood and reduction of depression were observed.

FENTANYL TTS (DUROGESIC) IN THE TREATMENT OF THE ADVANCED CANCER PAIN

G. Russo, M. del Giudice, P. L. Viscidi, D. Viscidi, A. Cuomo. Division of pain therapy. National Cancer Institute of Naples, Via M. Semmola, 80131 Naples, Italy

Aim of investigation: To evaluate the role of transdermic Fentanyl in the medium-high intensity cancer pain in patients pretreated only with FANS , when the pain intensity and the stage disease have such characteristics to consider suitable the treatment with strong opioids.

Methods: We enrolled 25 in consent adult patients of both sexes affected by cancer pain in treatment, till then, with FANS and with inadeguate pain relief. All the patients have been treated for 30 days with Fentanyl TTS at the beginning dose of 25 mcg/hour. In case of persistence of pain, from the third day of treatment the dose has been adapted to the individual needs. Non opioid analgesics and adjuvant drugs were administered. We measured the pain intensity through VAS in mm every day for the first fifteen days of treatment and then every three days. For the duration of the study, it was pointed out the tolerability and the outbreak of side effects.

Results: The average VAS lowered from a pre-treatment value of 57+/-22 to 48+/-18 the first day, 39+/-16 the third day, 19+/-9 the seventh day and 15+/-10 during the remaining period of treatment. The average drug dose was 6,2+/-4,5 mg/die. Two patients had stipsi, one patient had nausea and vomit and one had rush in the application seat.

Conclusions: The analgesia values, were very satisfactory. The patient compliance, thanks to the rare side effects, was excellent

FENTANYL TTS (DUROGESIC) AND QUALITY OF LIFE

 A Cuorno⁰. M del Giudice°, G Russo°, P L Viscidi⁰, D Viscidi", F De Faico*, D Barbeno* ° Division of pain therapy, * Service of Psychology National Cancer Institute of Naples Via M Semmola 80131 Naples Italy

Aim of investigation: To evaluate the acceptance grade of the therapy with Fentanyl TTS and the quality of residual life in patients with cancer pain

Methods: 54 in consent adult patients of both sexes affected by cancer pain were treated with Fentanyl TTS For each patient it was evaluated a) the terapy acceptance grade through a semi structured interview at basal time and after 30 days of treatment,b) the quality of residual life through the evaluation of the Performance Status, QL Index of Spitzer and Functional Living Index Cancer (FLIC) at basal time and every seven days for four weeks

Results: The therapy acceptance grade was excellent, as showed by the semistructured interview The quality of residual life was satisfactory in proportion with the individual evolution of neoplastic disease

Conclusions: The results obtained on the therapy acceptance grade have to be correlate with the analgesic efficacy, the rare side effects and the simple use of the system, as well as with the psicological correlation with other transdermic systems utilized to treat benign pathologies The data on the quality of residual life must be considered in addition to the analgesic efficacy also because the patients treated with Fentanyl TTS showed poor side effects

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p.107, 108, 109, 110, 111, 116, 118, 119, 284, 287, 280, 298, 316, 317