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Spinal cord stimulation
Although the efficacy of SCS is supported primarily by small case reports and case series,8 the “Polyanalgesic Consensus Conference algorithm recommends its use for neuropathic cancer pain if symptom coverage can be achieved with a stable disease course,” according to the present review.
In an observational study of 15 patients with low back pain associated with colorectal cancer or angiosarcoma, SCS resulted in a >50% improvement in VAS scores at 12 months. Opioid discontinuation and reduction was observed in 8 and 5 patients, respectively.9 Similar outcomes were found in a case series of 14 patients with lung cancer and chest wall pain related to thoracotomy or postoperative radiation.10 Multiple case reports also support the effectiveness of SCS for pain after surgery, chemotherapy, and radiation in patients with several types of cancer.
Although large randomized trials are needed to further determine the benefits of and inform treatment guidelines pertaining to IDDS and SCS, these “therapies are increasingly utilized as tools in a multimodal strategy for pain control and should not necessarily be reserved for patients in extremis or those who have ‘failed’ more conservative therapies,” the authors of the current review concluded. Given the lack of high-quality evidence to date, the “rationale and choice of treatment must be individualized and relies upon careful weighing of risks and benefits that include shared decision-making with patients.”
Clinical Pain Advisor asked Krishnan V. Chakravarthy, MD, PhD, assistant clinical professor of anesthesiology and pain medicine at the University of California, San Diego, to weigh in on these findings, their clinical implications, and the remaining research needs.
Clinical Pain Advisor: What do the findings suggest thus far about the potential role of IDDS and SCS for cancer pain?
Dr Chakravarthy: It is clear that both IDDS and SCS may serve as excellent options for palliative care, and specifically for patients [with cancer]. Although spinal cord stimulation may have broad applicability outside of cancer pain, the 1 area that has good clinical indication for IDDS is in palliative care. This is mainly because of a shortage of viable intrathecal opioid-sparing alternatives. This is an area of future exploration and ongoing research.
Clinical Pain Advisor: What are the main clinical implications of these findings?
Dr Chakravarthy: I think these studies warrant greater reflection on the role of these therapies within the cancer pain treatment paradigm. Likely, as more randomized controlled data gathering is encouraged, there will be greater emphasis on these therapies as viable options.
Clinical Pain Advisor: What should future research in this area focus on?
Dr Chakravarthy: With regard to IDDS therapy, [research on] opioid-sparing intrathecal alternatives should be emphasized. Large randomized controlled trial data support [the notion] that long-term opioid therapy with no defined clinical end point leads to more adverse effects than benefits. We must [therefore] be cognizant of those findings when using this approach to manage cancer pain. However, the strongest support for IDDS therapy is in cancer pain, where patient life expectancy plays an important role in determining duration of therapy, and patient comfort is a vital consideration. SCS could represent an exciting alternative approach to cancer pain treatment and needs to be further explored.
References
1. Lee SK, Dawson J, Lee JA, et al. Management of cancer pain: 1. Wider implications of orthodox analgesics. Int J Gen Med. 2014;7:49-58.
2. Bray F, Jemal A, Grey N, Ferlay J, Forman D. Global cancer transitions according to the Human Development Index (2008-2030): a population-based study. Lancet Oncol. 2012;13(8):790-801.
3. Xing F, Yong RJ, Kaye AD, Urman RD. Intrathecal drug delivery and spinal cord stimulation for the treatment of cancer pain. Curr Pain Headache Rep. 2018;22(2):11.
4. Smith TJ, Staats PS, Deer T, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002;20(19):4040-4049.
5. Liu HJ, Gao XZ, Liu XM, Xia M, Li WY, Jin Y. Effect of intrathecal dexmedetomidine on spinal morphine analgesia in patients with refractory cancer pain. J Palliat Med. 2014;17(7):837-840.
6. Staats PS, Yearwood T, Charapata SG, et al. Intrathecal ziconotide in the treatment of refractory pain in patients with cancer or aids: a randomized controlled trial. JAMA. 2004;291(1):63-70.
7. Rauck RL, Wallace MS, Leong MS, et al. A randomized, double-blind, placebo controlled study of intrathecal ziconotide in adults with severe chronic pain. J Pain Symptom Manag. 2006;31(5):393-406.
8. Peng L, Min S, Zejun Z, Wei K, Bennett MI. Spinal cord stimulation for cancer-related pain in adults.Cochrane Database Syst Rev. 2015;6:CD009389.
9. Yakovlev AE, Resch BE. Spinal cord stimulation for cancer-related low back pain. Am J Hosp Palliat Care.2012;29(2):93-97.
10. Yakovlev AE, Resch BE, Karasev SA. Treatment of cancer-related chest wall pain using spinal cord stimulation. Am J Hosp Palliat Care. 2010;27(8):552-556.
This article originally appeared on Clinical Pain Advisor
