BeCOn OWN Educational Program
Modules
Module 5
The multidisciplinary team in cancer pain management
Date of preparation: June 2015 HQ/EFF/15/0024d
Contents
Characteristics of a multidisciplinary team approach
Benefits of a multidisciplinary team approach
Patient journey
Appendix: additional interdisciplinary palliative care intervention: a practical example
Characteristics of a multidisciplinary team
approach
Word map of the patient experience
https://www.cancercare.on.ca/toolbox/pfac/form/experience/. Accessed 4 Jun 2015.
Physician communication styles
Physician-directed
Narrowly biomedical
Closed-ended medical
questions and
biomedical talk
(32%)
Patient-centred
Biopsychosocial
Balance of psychosocial and
biomedical
(20%)
Expanded biomedical
Moderate levels of
psychosocial discussion
(33%)
Roter DL, et al. JAMA. 1997;277(4):350-6.
Consumerist
Characterised primarily by
patient questions and
physician information
(8%)
Psychosocial
Psychosocial exchange
(8%)
Biopsychosocial factors involved in pain
Learning/memory
Gender
Attitudes/beliefs
Physical illness
Personality
Disability
BIOLOGY
Genetic vulnerability
PSYCHOLOGY
Behaviours
Emotions
Immune function
PAIN
Neurochemistry
Coping skills
Post trauma
Stress reactivity
Medication effects
SOCIAL
CONTEXT
Social supports
Family background
Cultural traditions
Social / economic status
Education
Pain is not just from physical disorders, but
results from combinations of physiological,
pathological, emotional, psychological,
cognitive, environmental and social factors
Holdcroft A, Power I. BMJ. 2003; 326(7390): 635-9.
A multidisciplinary approach to management of
cancer pain
A complex problem
A multidisciplinary solution
Oncologists
Pain specialists
BIOLOGY
PSYCHOLOGY
PAIN
Palliative care specialists
General practitioners
Psychologists
Radiotherapists
SOCIAL
CONTEXT
Nurses
Social workers
Rehabilitation specialists
Holdcroft A, Power I. BMJ. 2003; 326(7390): 635-9.
Pergolizzi JV, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12253. [Epub ahead of print].
Limitations in management of cancer pain
Survey of 2000 oncologists in the USA (overall response rate 32%)
The most important barriers to pain management were:
– poor assessment
– patient reluctance to take opioids or report pain
– physician reluctance to prescribe opioids
In response to vignettes describing challenging clinical scenarios, the majority endorsed
treatment decisions that would be considered unacceptable by pain specialists
Frequent referrals to pain or palliative care specialists were reported by only 14% and
16%, respectively
Additional efforts are needed to achieve meaningful progress in management
of cancer pain
Breuer B, et al. J Clin Oncol. 2011;29(36):4769-75.
Knowledge of cancer pain management among
specialists
Survey of 570 oncologists, 266 pain medicine specialists and 280 palliative
medicine specialists using 8 vignettes depicting challenging scenarios of patients
with poorly controlled pain
Average vignette score ranges were:
– 53.2−66.5 for oncologists
– 45.6−65.6 for pain medicine specialists
– 50.8−72.0 for palliative medicine specialists
Lower ratings were assigned to pain-related training in medical school (median 3) and
residency/fellowship (median 5)
Oncologists older than 46−47 years rated their training lower than younger oncologists
Oncologists and other specialists who manage cancer pain have knowledge deficiencies in
its management
Breuer B, et al. Oncologist. 2015;20(2):202-9.
Barriers to more widespread adoption of palliative
cancer care
Survey made available on the MASCC website for approximately 6 months:
183 responding institutions, 28% of ESMO designated centres
Most institutions had palliative care programs, and most programs consisted of an
inpatient consult service and outpatient clinics
A minority had inpatient palliative care beds and institution supported hospice services
Barriers to palliative care were largely financial
Integration of palliative care into oncology was highly desirable but only a minority of
respondents felt that their institution would financially support expanded services and
additional palliative care personnel
Designated centres were more likely to have expanded palliative care services
Palliative care integration into cancer care is largely through consulting services for
inpatients and outpatient clinics
Davis MP, et al. Support Care Cancer 2015 (epub ahead of print)
A multidisciplinary approach is preferred
in management of cancer pain
PAIN CLINICIAN
FAMILY MEDICINE
MEDICAL ONCOLOGIST
PALLIATIVE CARE
SPECIALIST
RADIATION ONCOLOGIST
Ideally, there should be communication among
the various specialists, with oncologists often
coordinating the patient’s care
Pergolizzi JV, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12253. [Epub ahead of print].
The evidence for multidisciplinary care teams in
improving outcomes
Patients with advanced cancer experience a complex web of problems, all of
which interact
Evidence from 8 randomised controlled trials and 32 observational or quasiexperimental studies suggests that:
– home, hospital and inpatient specialist palliative care significantly improved patient outcomes
in the domains of pain and symptom control, anxiety and reduced hospital admissions
Specialist palliative care should be part of care for cancer patients
There is a need to better understand the effects of different models
of palliative care and to use standardised outcome measurements
Higginson IJ, et al. Cancer J. 2010;16(5):423-35.
The need for timely multidisciplinary intervention:
a case report (i)
Woman in her 70s with metastatic NSCLC treated with chemo-radiation and
gamma knife surgery with pain secondary to mucositis and fatigue
History of back pain related to previous T5 and T10 compression fractures, plus new diagnosis of
T11 fracture
Presented with emotional distress, uncontrolled pain on fentanyl patch and ATC hydromorphone
Admitted to acute palliative care unit
Started on hydromorphone infusion and a multidimensional approach including a pharmacological
and interdisciplinary team was employed for management of her complex chronic pain.
Methylphenidate was started for management of depression, opioid-induced sedation, and fatigue:
also started naproxen as an adjunctive analgesic
Counsellor, chaplain and social worker spent considerable time with her and provided supportive
counselling and offered coping strategies, and underwent physical and music therapy
Discharged home with 60% reduction in MEDD
Didwaniya N, et al. Palliat Support Care. 2015;13(2):389-94.
The need for timely multidisciplinary intervention: a
case report (ii)
Patient-reported symptoms on the ESAS scale at the time of admission versus discharge
from the APCU
Admission
Discharge
10
9
8
7
6
5
4
3
2
1
0
0
0
0
0
0
0
Prompt intervention in an acute palliative care unit can be a powerful tool in the
management of complex symptom burden
Didwaniya N, et al. Palliat Support Care. 2015;13(2):389-94.
Pharmacological options for the management of
refractory cancer pain—what is the evidence?
The management of patients with refractory pain remains a challenge
Treatment options include opioid manipulation (parenteral delivery, rotation,
combination, methadone and buprenorphine), non-opioids and co-analgesics
(paracetamol, non-steroidal anti-inflammatory agents, antidepressants and
anticonvulsants), NMDA receptor antagonists, cannabinoids, lignocaine and
corticosteroids
The evidence of benefit for any of these agents is weak, and each additional agent
increases the risk of adverse events: evidence-based guidelines cannot, therefore, be
developed at present
New approaches are recommended including targeted opioid therapy, multimodal
analgesia, a goal-oriented approach to pain management and increasing use of the
multidisciplinary team and support services
Afsharimani B, et al. Support Care Cancer. 2015; 23(5): 1473-81.
Understanding the differences between hospice and
palliative care
For palliative care to be used appropriately, clinicians, patients, and the general
public must understand the fundamental differences between palliative care
and hospice care
The hospice provides hospice care exclusively to patients who are willing to forgo
curative treatments and who have a physician-estimated life expectancy of 6 months or
less
In contrast, palliative care is not limited by a physician’s estimate of life expectancy or a
patient’s preference for curative medication or procedures
Palliative care is appropriate at any age and at any stage in a serious illness, and
can be provided together with curative treatment
Parikh RB, et al. N Eng J Med. 2013; 369: 2347-51.
Traditional vs. early palliative care
Traditional Palliative Care
Palliative care to
manage symptoms
and improve quality
of life
Life-prolonging or curative treatment
DIAGNOSIS
DEATH
Early Palliative Care
Life-prolonging or curative treatment
Palliative care to manage symptoms and improve quality of life
DIAGNOSIS
DEATH
In the traditional care model, palliative care is instituted only after life-prolonging or
curative treatment is no longer administered
In the integrated model, both palliative care and life-prolonging care are provided
throughout the course of disease
Parikh RB, et al. N Eng J Med. 2013; 369: 2347-51.
The benefits of early palliative care
Patients with Mood Symptoms (%)
Assessment of mood at 12 weeks
50
Standard care
40
30
Palliative care to
symptoms
Early palliativemanage
care
and improve quality
of life
HADS, Hospital Anxiety and
Depression Scale (HADS), which
consists of two subscales, one for
symptoms of anxiety (HADS-A) and
one for symptoms of depression
(HADS-D).
PHQ-9 evaluates symptoms of
major depressive disorder
according to DSM-IV criteria.
20
10
0
HADS-D
HADS-A
PHQ-9
Patients metastatic non–small-cell lung cancer assigned to early palliative care had a
better quality of life than did patients assigned to standard care
Early palliative care led to significant improvements in both quality of life and mood
Temel JS, et al. N Engl J Med. 2010;363(8):733-42.
ASCO: the integration of palliative care into standard
oncology care
Provisional Clinical Opinion
Substantial evidence demonstrates that palliative care—when combined with standard
cancer care or as the main focus of care—leads to better patient and caregiver
outcomes: these include improvement in symptoms, QoL and patient satisfaction, with
reduced caregiver burden
Earlier involvement of palliative care also leads to more appropriate referral to and use
of hospice, and reduced use of futile intensive care
Combined standard oncology care and palliative care should be considered early in the
course of illness for any patient with metastatic cancer and/or high symptom burden
Smith TJ, et al. J Clin Oncol. 2012;30(8):880-7.
ALIADO*: a multidisciplinary working group to
improve management of oncological pain (i)
Guideline recommendations for patients
The physicians that are treating your cancer are also concerned about your pain – do
not hesitate to inform them about your pain experience
Following diagnosis - measurement and evaluation, your pain will be treated monitored and certainly controlled in the vast majority of cases
Every cancer patient has a right to receive adequate treatment and follow–up for
his/her pain
All health professionals of the multidisciplinary team in charge of your case are
concerned about your pain: family doctors, hospital specialists, nurses, psychologists,
social worker, etc. - do not hesitate to inform them also about your pain experience
“Sustained” cancer pain of “severe” intensity (>7/10) deserves to be considered a
medical emergency, and should be managed accordingly
*Alliance Against Oncological Pain
González-Escalada JR, et al. Medicina Paliativa. 2011; 18(2): 63-79.
ALIADO*: a multidisciplinary working group to
improve management of oncological pain (ii)
If you are suffering from a “difficult pain case” you might be referred to different pain
specialists for consultation. Do not delay the consultation as it is in your best interest to
control effectively your pain as soon as possible
For example, you might be referred for consultation to:
– a palliative medicine specialist for early palliative care
– a pain clinician specialist for an invasive procedure
– a radiation oncologist for palliative radiotherapy
– a medical oncologist for palliative chemotherapy
– a radiologist for an invasive procedure
All the physicians involved in your care have an ethical mandate to alleviate your pain:
you can expect that they will not allow you to suffer unnecessarily and unremittingly
*Alliance Against Oncological Pain
González-Escalada JR, et al. Medicina Paliativa. 2011; 18(2): 63-79.
Benefits of a multidisciplinary team approach
Assessing the effectiveness of cancer care teams
Systematic review of literature published between 2009 and 2014
Teams for screening and follow-up improved screening use and reduced time to followup colonoscopy after an abnormal screen
Discussion of cases within MDTs improved the planning of therapy, adherence to
recommended preoperative assessment, pain control and adherence to medications
There is no convincing evidence that MDTs affect patient survival or cost of care, or
studies of how or which MDT processes and structures were associated with success
Taplin SH, et al. J Oncol Pract. 2015; 11(3): 239-46.
Possible education interventions by a
multidisciplinary team
General population
Oncological patients
Patients’ family
Oncological voluntary
General practitioners
Oncologists
Expert of pain treatment
Druggists
Nurse in oncological wards
Psychologists
Social workers
Generic
brochure
Web site
Media coverage
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Questions and
answers booklet
General population
Oncological patients
Patients’ family
Oncological voluntary
General practitioners
Oncologists
Expert of pain treatment
Druggists
Nurse in oncological wards
Psychologists
Social workers
1D Congress
Press
conference
Toll-free line
Lay people and
hoc brochure
Myths and fact
lectures
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One-to-one visits
Topical workshop
Professional ad
hoc brochure
Pocket-sized
reference book
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Apolone G, et al. J Ambul Care Manage. 2006;29(4):332-41.
Prevalence and treatment of cancer pain in Italian
oncological wards
Cross-sectional survey of 2,655 patients admitted to oncological wards
34% of patients reported pain
Higher pain levels were observed in inpatients, in the presence of bone metastases, and
with low levels of ECOG status
The number of patients receiving strong opioids increased with the highest levels of
pain
A significant proportion of patients with moderate-severe pain were not receiving
appropriate medication as they were being predominantly administered non-opioid
drugs
This survey indicates the need for continuing educational and informative programmes in
pain management for oncologists and any physician dealing with cancer patients
Mercadante S, et al. Support Care Cancer. 2008;16(11):1203-11.
Cancer pain management in an oncological ward with
an established palliative care unit (PCU)
Cross-sectional survey in an oncological department with a dedicated palliative
care unit
Of 385 patients, 69.1%, 19.2%, 8.6% and 3.1% had no pain, or mild, moderate and
severe pain, respectively
128 patients with pain or receiving analgesics were analysed by pain management index
(PMI)
– Only a minority of patients had a negative PMI score, which was significantly associated with
inpatient admission (p = 0.011)
– 50 of these 128 patients had breakthrough pain (BTP), and all were receiving medication for BTP
It is likely that the presence of PCU team providing consultation and offering admissions
for difficult cases has a positive impact on the use of analgesics compared with previous
similar oncological settings where a PCU was unavailable
Mercadante S, et al. Support Care Cancer. 2013;21(12):3287-92.
Characteristics of a palliative care consultation
service with a focus on pain
Retrospective analysis of a palliative care consultation service documentation over 3
years in a German university hospital
Cancer entities
Lung
Colorectal
Head and neck
Urological
Others
Breast
Haematological
Pancreas
Gynaecological
Oesophagus
Unknown primary site
Liver
n
45
32
29
29
28
27
21
21
18
8
6
5
%
16
12
11
11
10
10
8
8
7
3
2
2
72% were inpatients, 28% were outpatients; almost all PCCS patients suffered from cancer
(98%, n=267)
The most common cancer entity was lung, followed by colorectal
Erlenwein J, et al. BMC Palliat Care. 2014; 13: 45.
Characteristics of a palliative care consultation
service with a focus on pain
Recommended opioids and their galenic preparation (% of all recommended opioids)
Overall opioids
Prolonged-release
preparations
Immediate–release
preparations
Morphine
87%
70%
25%
Hydromorphone
33%
18%
20%
Fentanyl
31%
37%
1%
Oxycodone
14%
5%
11%
Tramadol
10%
5%
6%
Tilidine
1%
1%
1%
Levomethadone
1%
1%
-
Buprenorphine
1%
1%
-
For 76% (n=208) of all PCCS-patients, modifications of the analgesic regimen were recommended
Of the consultations concerning analgesics, in 96% (n=197/208) opioids were used: 70% (n=186) of
all patients were recommended to receive an on-demand/breakthrough-pain analgesic, which was
an opioid in most cases (97% of all on-demand medications).
Erlenwein J, et al. BMC Palliat Care. 2014; 13: 45.
A multi-disciplinary approach
A multi-professional approach that requires a team with the respective qualifications is
necessary to meet the complex needs in the end-of-life care and to adequately support
patients, their families and the referring departments
Timely and possibly early integration of palliative expertise may lead to improved
symptom control and advice to patients, carers and their families
Erlenwein J, et al. BMC Palliat Care. 2014; 13: 45.
Patient journey
3 dimensions of the complex patient journey
Guiding Questions
1
2
3
Why it Matters
Healthcare journey
Which people & organisations
does the patient interact with on
his or her journey?
Determine what communication
channels can be used to reach
patients at their inflection points
Disease & Therapy journey
How and why do the specific
diagnostic & monitoring tests, and
classes & brands of treatment
change through the journey?
Identify opportunities to drive
optimal use of your therapy
Human journey
What are the physical, cognitive,
emotional, behavioural and social
experiences the patient goes
through?
Understand the medical and selfmanagement needs that impact
the course of the patient journey
The ideal patient journey and MDT
3
Oncologist + surgeon + radiotherapist
Treatment planning
2
4
Work-up and diagnosis
Specialist referral
1
Oncologist + pain specialist + palliative care
+ neurologist (if NeP)
Follow-up
Symptoms
General practitioner
Oncologist-led
MDT assessment
5
Pain diagnosis and assessment
6
Oncologist-led
MDT follow-up
Follow-up
Successful
management
of pain and
other symptoms
Summary
Cancer pain is a complex problem that can best be approached with a multidisciplinary
approach, even if not widely adopted in routine practice
Early palliative care and a multidisciplinary approach has been recommended by several
expert associations and working groups
The benefits of a multidisciplinary approach in terms of increased adherence to therapy
and improvement in pain have been clearly demonstrated
The patient journey is complex, and patients need to be assured that all health
professionals of the multidisciplinary team are concerned about their pain
Appendix: additional interdisciplinary palliative
care intervention practical example
Interdisciplinary palliative care intervention: a
practical example
Patient with complex and refractory cancer pain who responded poorly to increasing
doses of systemic and intrathecal analgesia, but improved after interdisciplinary
palliative care intervention
– Unclassified myxoid sarcoma excised 9 months prior followed by chemotherapy
– Developed progressive disease with uncontrolled right lower extremity pain
– At presentation to the palliative care team was receiving oral methadone (30 mg) every eight hours and oral
hydromorphone (12 mg) every four hours as needed for BTcP, along with intrathecal hydromorphone (2.8
mg/day) and bupivacaine (5.6 mg/day)
– Patient rated pain as 10/10, admitted to acute palliative care unit
– Assessment and counselling by a physician, fellow, mid-level provider, chaplain, social worker, case manager,
counsellor, child life specialist, physical therapist, occupational therapist, clinical pharmacist, nurses and
volunteers
– Medications changed gradually to wean off intrathecal medications with no withdrawal symptoms
– Patient returned to community with pain 5/10
An interdisciplinary approach to address total pain in patients with
advanced cancer may alleviate the need for invasive interventions
Reddy A, et al. J Pain Symptom Manage 2012;44(1):124-30.
Considerations on pain management and intrathecal
pumps
It is not always possible to completely eliminate cancer pain
– the goal of pain management in some patients may not be to reduce the pain expression to a 0,
but to make the pain more tolerable so that the patient can maintain function and quality of life
A checklist for intrathecal pumps
– Is the pain expression because of nociception? Have the non-nociceptive factors like
somatization related to depression and anxiety, delirium, and chemical coping been ruled out?
– Did the patient have an adequate trial of opioid titration and rotation along with addition of
adjuvants?
– Is the patient able to be discharged to the community or hospice setting for further care? If not,
have the patient and family been informed that an ideal discharge will be unlikely?
A thorough interdisciplinary approach to address total pain in patients with
advanced cancer may alleviate the need for invasive interventions, such as intrathecal
opioids, and facilitate a safe discharge to the community
Reddy A, et al. J Pain Symptom Manage 2012;44(1):124-30.