Intrathecal Morphine in Postoperative Analgesia for Colorectal Cancer Surgery: A Retrospective Study.

BACKGROUND: Colorectal cancer surgery is commonly performed with adequate analgesia essential for patient recovery. This study assessed the effectiveness of intrathecal morphine and patient-controlled analgesia (ITM + PCA) vs patient-controlled analgesia alone (PCA) for postoperative pain management in colorectal cancer surgery. METHODS: This retrospective study extracted and analyzed data covering a 4-year period (2014-2018) from a clinical database with 24- and 48-hour postsurgery follow-up. Primary outcomes included pain scores, median opioid consumption (oral morphine equivalence dose), sedation, nausea and vomiting, and length of admission. Outcomes were analyzed for ITM + PCA vs PCA alone, overall and stratified by laparotomy or laparoscopy procedures. RESULTS: In total, 283 patients were included: ITM + PCA (163) and PCA alone (120). Median opioid consumption in the first 24 hours for ITM + PCA vs PCA alone was lower for laparotomy (-32.7 mg, P<0.001) and laparoscopy (-14.3 mg, P<0.001). Median pain score (worst pain) within the first 24 hours for ITM + PCA vs PCA alone was similar for laparotomy (P>0.05) and lower for laparoscopy (-1 unit, P=0.031). Sedation occurred less frequently for ITM + PCA vs PCA at 24 hours (3.5% vs 11.4%, P=0.031), with nonsignificant reduction at 48 hours (4.8% vs 18.8%, P=0.090) for laparotomy, but with no difference for laparoscopy (P>0.05). Incidence of nausea and vomiting and length of admission were similar for ITM + PCA vs PCA alone for laparotomy or laparoscopy (P>0.05). CONCLUSION: This retrospective study demonstrated that ITM + PCA can achieve similar analgesic effects after laparotomy and laparoscopy colorectal cancer surgery compared with PCA alone while resulting in a reduction of oral opioid consumption and lower incidence of sedation.

Corrigendum to: Cancer patients' use of and attitudes towards medicinal cannabis.

ObjectivesAccess to medicinal cannabis is a timely and important issue in cancer care. Recent legislative changes in Australia have increased access to medicinal cannabis, but the views of people with cancer on this topic are poorly understood. The aim of this study was to explore the prevalence of the use of and attitudes towards medicinal cannabis among people with cancer.MethodsA cross-sectional study was performed using an anonymous, 15-item study-specific paper-based survey. The survey was administered over a 2-week period in August 2017 in the waiting rooms of a specialist cancer hospital.ResultsIn all, 339 patients completed the survey (mean (±s.d.) age 59±15 years; 52% male). Fourteen respondents (4%) were currently using cannabis medicinally. Only one of these respondents had a prescription for their cannabis product. Most respondents would consider using a medicinal cannabis product if recommended by their doctor (n=271; 80%).ConclusionThis study is the first of its kind to survey the use of and attitudes towards medicinal cannabis in a broad sample of Australian people with cancer. Few respondents were currently using cannabis for medicinal purposes, but an overwhelming majority were in favour of increasing access and would consider using a prescribed product.What is known about the topic?Cannabis may have a wide variety of medicinal uses, particularly in the cancer setting. Currently, people with cancer in Victoria have limited access to medicinal cannabis despite recent legislative changes.What does this paper add?In a general sample of people with cancer, few were using cannabis for medicinal purposes, but most were in favour of widening access and would consider using a product their doctor prescribed.What are the implications for practitioners?Despite supporting access, patients indicated that the recommendations of doctors and increasing the evidence base are necessary requirements to their use of medicinal cannabis.

Parecoxib as an adjunct therapy for the treatment of refractory non-surgical cancer pain.

BACKGROUND: Evidence for the use of short-term daily parenteral parecoxib for refractory or uncontrolled non-surgical cancer pain is limited. This study aimed to characterise the real-world off-label use and report on clinical experiences in an Australian cancer cohort. METHODS: Eligible patients received at least one dose of parecoxib of an intended three-day course between October 2015 and December 2018. Data were collected to characterise the parecoxib treatment cohort (cancer diagnosis, metastases, sites and types of pain and prior analgesia). Parecoxib-related adverse events, pain scores (worst and median), and concurrent opioid use were assessed at 24 h pre (T0) and 24 (T1), 48 (T2), 72 (T3) and 96 h (T4) post first parecoxib dose. RESULTS: Sixty-five patients (39 males and 26 females) and 68 courses of parecoxib (three patients treated twice) were included in analyses: metastatic disease (86%), bone pain (54%) and taking ≥3 classes of analgesic medications (69%). Pain types varied (46% non-specific, 22% neuropathic and 32% other). Most (94%) received parecoxib by subcutaneous administration. Following parecoxib, median 24-h pain scores and worst pain scores improved for 59% (40/68) and 50% (34/68) of patients, respectively. In the first 24 h (T0 to T1), median (4 vs. 2, p < 0.01) and worst (6 vs. 5, p < 0.01) pain scores were reduced and sustained to T4 (4 vs. 2.5, p = 0.01). Breakthrough analgesia requirements reduced for 63% (43/68) of patients, while total concurrent opioid use remained constant. Mean/median oral morphine equivalence for T0 vs. T1 was 111 mg/75 mg vs. 162 mg/90 mg, (p > 0.8). Two patients ceased parecoxib due to renal/liver function abnormalities and two experienced mild injection-site reactions. CONCLUSIONS: In this real-world study, parecoxib was utilised as adjunctive therapy in a select patient cohort to contribute to reduced pain scores with no new safety signals. Prospective randomised studies in larger cohorts would improve understanding of the effects of parecoxib.

Cancer patients' use of and attitudes towards medicinal cannabis.

Objectives Access to medicinal cannabis is a timely and important issue in cancer care. Recent legislative changes in Australia have increased access to medicinal cannabis, but the views of people with cancer on this topic are poorly understood. The aim of this study was to explore the prevalence of the use of and attitudes towards medicinal cannabis among people with cancer. Methods A cross-sectional study was performed using an anonymous, 15-item study-specific paper-based survey. The survey was administered over a 2-week period in August 2017 in the waiting rooms of a specialist cancer hospital. Results In all, 339 patients completed the survey (mean (±s.d.) age 59±15 years; 52% male). Fourteen respondents (4%) were currently using cannabis medicinally. Only one of these respondents had a prescription for their cannabis product. Most respondents would consider using a medicinal cannabis product if recommended by their doctor (n=271; 80%). Conclusion This study is the first of its kind to survey the use of and attitudes towards medicinal cannabis in a broad sample of Australian people with cancer. Few respondents were currently using cannabis for medicinal purposes, but an overwhelming majority were in favour of increasing access and would consider using a prescribed product. What is known about the topic? Cannabis may have a wide variety of medicinal uses, particularly in the cancer setting. Currently, people with cancer in Victoria have limited access to medicinal cannabis despite recent legislative changes. What does this paper add? In a general sample of people with cancer, few were using cannabis for medicinal purposes, but most were in favour of widening access and would consider using a product their doctor prescribed. What are the implications for practitioners? Despite supporting access, patients indicated that the recommendations of doctors and increasing the evidence base are necessary requirements to their use of medicinal cannabis.

Paroxetine for the treatment of intractable and persistent cough in patients diagnosed with cancer.

INTRODUCTION: Intractable and persistent cough is experienced by more than a third of patients with advanced cancer, with a significant negative impact on quality of life. Pharmacological treatment has been of little help in some patients. Limited evidence suggests novel agents such as paroxetine may reduce cough severity. This retrospective study aimed to assess effectiveness and tolerability of paroxetine for the treatment of intractable cough in patients with cancer. METHODS: Single-centre medical record review of paroxetine use in patients with advanced malignancy and cough treated at an Australia tertiary referral cancer centre between 1 October 2012 and 1 October 2017. Data relating to cough type and severity, response and adverse events were extracted from medical records. Cough type was described as non-productive dry cough, productive chesty cough or cough exhibiting both non-productive and productive features (mixed cough). RESULTS: Overall, 24/34 patients (71%) experienced a major or moderate reduction in their cough severity after treatment with paroxetine. Nearly half (47%) described a major improvement and a quarter (24%) moderate improvement. Of the 34 patients, nearly half had a lung primary cancer (16/34, 47%) and nearly all (17/18) of those without lung cancer had lung metastases from another primary cancer. Patients with dry cough reported greater benefit from paroxetine. Of the 56% (19/34) of patients with non-productive dry cough, 80% (15/19) reported an improvement in symptoms post paroxetine. The remaining 15 patients, 44% of the group, presented with either a productive chesty cough (9/34, 27%) or mixed cough (6/34, 18%). Of these patients, 60% (9/15) reported an improvement in symptoms. Two thirds of patients were commenced on paroxetine 10 mg (22/34, 65%), with the remainder starting at 20 mg (14/34, 35%). CONCLUSION: Paroxetine may be an effective, novel, off-label treatment for intractable and persistent cough in patients with advanced cancer.

Subcutaneous Lidocaine Infusion for Pain in Patients with Cancer.

BACKGROUND: Intravenous lidocaine is effective in treating pain. Limited studies have assessed the effectiveness and safety of subcutaneous lidocaine infusions. METHODS: We conducted a retrospective review of patients with cancer who received subcutaneous lidocaine infusions for pain. Patient characteristics, pain scores and opioid doses before and after lidocaine, and details of infusions were recorded. We identified three time periods of interest. T0 is defined as the 24-hour period immediately before commencing lidocaine treatment. T1 is defined as the 24-hour period before lidocaine was ceased. T2 is defined as the first 24-hour period after lidocaine was ceased. In addition, the overall impression of the effectiveness of lidocaine was subjectively evaluated by the authors. RESULTS: Twenty patients (13M;7F) received lidocaine. Two patients received it twice, totaling 22 episodes. The median lidocaine dose was 0.67 mg/kg/h with the median duration being 5.5 days. The median worst pain score at T0 and T1 was 8.5 and 5.5, respectively. The difference in the mean pain scores was 3.2 95% CI (2.1, 4.4; p < 0.001). In 15/22 episodes (68%), patients experienced a decrease in pain scores of more than 2. The median morphine oral equivalent (MOE) daily doses at T0, T1, and T2 were 425, 362.5, and 275 mg, respectively. The difference in the mean MOE between T0 and T1 was -126 (95% CI [-281, 28]; p = 0.13). The difference in the mean MOE between T0 and T2 was -207 (95% CI [-370, -44]; p = 0.025). Lidocaine was subjectively deemed effective in 10/22 episodes (45%). There were no documented adverse events attributed to lidocaine. Univariate analyses did not identify any subgroups likely to benefit from lidocaine. CONCLUSION: Subcutaneous lidocaine infusions may be used safely in cancer pain management and is effective in some patients.

Carmustine infusion reactions are more common with rapid administration.

PURPOSE: Carmustine is a nitrosurea alkylating agent predominantly used at Peter MacCallum Cancer Centre as part of the autologous stem cell transplant induction regimens Stanford BCNU and BEAM. Acute infusion reactions were anecdotally reported to be higher than the reported rates of 10%, and it was suggested that the rate of infusion being employed was excessive. Some references suggest maximum infusion rates of 3 mg/m(2)/min for carmustine, a rate which is exceeded in the 2-h infusions used for Stanford BCNU, but not with BEAM. METHODS: A retrospective audit was conducted in 64 patients (57 Stanford BCNU, 7 BEAM) who had received these regimens between January 2009 and November 2010. RESULTS: Rates of infusion reaction to carmustine were higher than literature values, with reactions in Stanford BCNU (94.7%) being significantly higher than for BEAM (28.6%; P = 0.0003). These findings have resulted in a change of administration of carmustine in Stanford BCNU from 2 to 3 h. Further studies plan to compare the incidence of infusion reactions before and after the change in administration rates. CONCLUSION: Patients receiving rapid infusion of carmustine in the Stanford BCNU regimen for stem cell conditioning have a high rate of infusion reaction. A maximum rate of 3 mg/m(2)/min is recommended.