Ask the Experts
Q: My loved one was recently diagnosed with cancer, and is now suffering through quite a bit of pain. Is there anything you can recommend that may help?
A: When a loved one is diagnosed with cancer, one of the first questions on everyone’s mind is, “How much pain will they have?” Cancer pain can be very difficult to treat for three reasons.
First, because there are so many different kinds of cancer and they vary in stages, cancer pain comes in many different forms and levels of severity. Every patient experiences pain in a different way. Some people have no pain with cancer, while others suffer with severe pain.
Second, the progressive nature of cancer means that the pain can change throughout the course of the disease. Cancer doctors and pain doctors must closely monitor the patient and adjust therapies as needed.
Third, aggressive treatment is needed to destroy cancer. In addition to destroying cancer cells, cancer treatments can also destroy nerves. Cancer and the treatments used to treat it can cause pain or can worsen pre-existing pain.
Because of these factors, it is vitally important to come to a correct pain diagnosis to guide pain treatment therapies. Happily, there have been a huge number of advances made in the treatment of cancer pain in the last several years that can provide a great deal of relief for those suffering with pain.
An example of a significant advancement in cancer pain treatment is vertebroplasty (vertebral augmentation or kyphoplasty). Cancer that occurs within the spine can weaken the bone, which can result in spinal fractures. These vertebral body fractures can be incredibly painful. Often patients with these fractures are unable to walk or even move in a chair or bed without severe pain.
These painful fractures can be fixed by using a minimally invasive technique called vertebroplasty. During a vertebroplasty, a small needle is placed inside the bone and a special bone cement is injected into the fracture. The cement hardens quickly and is actually stronger than the bone itself. Patients often notice immediate pain relief, and most feel the pain relief is far superior to the pain medicines they were taking before the vertebroplasty.
Yet another technique is destruction of the nerves that sense pain. Some cancer pain does not respond well to narcotic pain medicines. In these cases, the nerves that carry pain signals can be specifically targeted and destroyed, allowing movement and skin sensation to remain unaffected. In pancreatic cancer, for instance, the abdominal pain can be excruciating. Using a technique called splanchnic nerve neurolysis, the nerves carrying the pain signals to the pancreas are destroyed. The pain relief is often significant, and can last up to 6 months.
The goal of treating cancer pain, just as in non-cancer pain, is to allow the patient to regain the ability to perform life’s everyday tasks and to relieve pain. Often, patients with cancer pain are placed on high levels of narcotic medicine such as morphine and OxyContin. While these medicines are often of benefit, they do have serious side effects that must be watched for carefully. Side effects of these medicines include difficulty breathing, nausea, vomiting, disorientation, constipation, and hallucinations. Strangely enough, very high doses of these medicines can cause an increase in pain through hyperalgesia. Because of these risks, the patient’s greatest chance for success in treating pain comes from a balanced approach of minimally invasive therapy, narcotics, and non-narcotic medicines.
In addition to these therapies, patients benefit from a strong support network. Depression and other psychiatric problems are common in the cancer pain patient as these patients are literally fighting for their lives. At Arizona Pain Specialists, we believe that treatment of the whole patient is crucial. We offer counseling services, group therapy, cognitive behavioral therapy, prayer, and other psychological services in our office to help patients cope with their illness. We also strongly recommend that patients see a psychiatrist for depression and other psychiatric problems.
New techniques to treat pain are in development, and existing techniques are being refined. The physicians at Arizona Pain Specialists are involved in several research studies in an effort to develop new techniques to improve pain control for all patients.
While dealing with a cancer diagnosis can be very frightening for a patient, there is hope for achieving a better quality of life and alleviating pain.
Q: Can you update me on the latest in pain management news? A: Absolutely. A recent change to health care coverage has been proposed, in which Medicare would cease paying for Vertebroplasty (vertebral augmentation), a treatment that has helped millions with painful, debilitating spinal fractures.
A:When insurance companies, especially Medicare, decide to quit reimbursing doctors for treatments, the end result is that patients lose access to those treatment options. Although paying for the procedure with out-of-pocket dollars is still available, many patients on Medicare live on fixed incomes.
Medicare’s Arizona carrier, Noridian, is proposing a policy of total non-coverage for vertebroplasty. This is a procedure that pain doctors and spine surgeons use to stabilize painful spinal compression fractures. Compression fractures of the spine are the most common complication of osteoporosis. These painful and debilitating fractures adversely affect quality of life and physical function.
In the United States alone, there are about 700,000 spinal compression fractures every year. The majority of these fractures do not cause symptoms, and improve with conservative therapy (braces, pain medications, rest, etc.). However, for some patients the fractures can cause severe debilitating pain which can lead to hospitalization and death. Those with vertebral compression fractures have a 23% higher mortality rate than those who do not. These patients are frequently candidates for vertebroplasty, a procedure which involves stabilizing the painful fractures using medical-grade bone cement introduced with a minimally invasive needle.
Noridian is basing their proposed policy on flawed studies that suffered from patient selection bias (only 32% of the patients studied were even ideal candidates for vertebroplasty), a low number of patients in the sample size, and lack of a control group. These studies caused uproar within the medical community, as it is a procedure that is performed for those in severe pain and doctors have seen long-term, dramatically positive results from the procedure.
Pain Doctors Hogan, Lynch, McJunkin and Pico are all active members of the Arizona Society of Interventional Pain Physicians, an organization dedicated to preserving patients’ rights to quality pain management care. AZSIPP drafted a letter to Noridian detailing the flawed aspects of these studies and highlighting a new, well-designed study that confirmed the benefits of vertebroplasty for compression fractures. This study is called the VERTOS II trial and was published in the journal Lancet in August, 2010. VERTOS II clearly shows that the procedure is not only safe, but that patients demonstrated very favorable outcomes. VERTOS II specifically refuted the flawed studies cited by Noridian in their draft proposal for non-coverage of vertebroplasty.
Pain physicians and patients across the United States are now awaiting the decision from Noridian as to whether Medicare patients will have access to this procedure. Patients are encouraged to post comments regarding this issue to http://www.vcfprocedureswork.com, as well as to contact Noridian and their elected officials.
Vice-President, Arizona Society of Interventional Pain Physicians
