Peeling the “onion”: Pain palliation’s developing role in cancer care

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cancer
Dimitrios Filippiadis

At this year’s Society of Interventional Oncology (SIO) annual conference (25–29 January, Long Beach, USA), Dimitrios Filippiadis (Athens, Greece) moderated and presented in a session focused on palliative interventions, an area of rising interest within interventional oncology (IO). Filippiadis is an associate professor of diagnostic and interventional radiology (IR) at the National and Kapodistrian University of Athens, whose practice centres on musculoskeletal (MSK) and oncologic interventions, and cancer pain management. Catching up with Interventional News, he gives an update on palliative care as it stands today, the treatments that work, and the broader significance of palliation in light of a global opioid crisis.

IN: What were the key takeaways from your presentation and the overall session at SIO?

My talk in this palliative session focused on injections for cancer patients, so the main focus was pain reduction, mobility improvement, and improvement of life-quality in cancer patients. The fact is that, currently, there is a very high percentage of cancer patients that experience pain. Almost 80% of patients will experience pain during the course of their disease, and the vast majority of these patients are not adequately treated for their pain today. Therefore, this is a very large patient pool that we need to help.

Specifically for nerves, we can inject a wide variety of different agents, ranging from corticosteroids, local anaesthetics, alcohol of phenol, and rarely, hyaluronate acid derivatives for intra-articular injections. For example, you have a patient who is suffering either from degenerative disease in the spine or from metastases in the spine, and the result is neuralgia going all the way down to the lower extremities. To help these patients, you can inject corticosteroids with local anaesthetic. If you want something more permanent, you can perform neurolysis. An alternative to that is temperature mediated neurolysis—which will use radiofrequency or cryoneurolysis—in order to destroy the nerves. When you are performing any type of neurolysis, you interrupt the pain signals from the periphery to the brain, providing the patient with immediate pain relief, which complements life quality improvement.

Let’s take, for example, pancreatic cancer—in the guidelines, neurolysis of coeliac plexus or splanchnic nerves is included for the management of pancreatic cancer-related pain. In the National Comprehensive Cancer Network (NCCN) guidelines from 2021, and in the revised version of 2023, IO techniques including injections, neurolysis, augmentation techniques and ablation, are included for the management of adult cancer pain. For too many years, myself and my colleagues believed that pain palliation is an extra fourth step in the well-known analgesic ladder from the World Health Organisation (WHO). But right now, everybody’s convinced that our techniques—IO percutaneous, minimally invasive techniques—are not an extra fourth step, but actually an intermediate step which should be performed before switching from weak to strong opioids. Thus, the earlier we perform this kind of therapeutic approach, the better the result we are seeing. By doing so, we can significantly reduce strong opioid administration and we can positively impact the global opioid overdose crisis.

IN: How significant is palliative care to your oncology practice?

Palliative care is a major part of our everyday clinical practice. In my hospital, we have weekly multidisciplinary board meetings to discuss pain management, which are held separately from the multidisciplinary team (MDT) tumour board meetings.

We have orthopaedic surgeons and neurosurgeons, medical and radiation oncologists, anaesthesiologists, interventional oncologists, and we speak about different cases with a clear focus on pain management. Therefore, for the last three years that we have been holding these meetings, running palliative procedures has become around 50% of our everyday clinical practice. There is also a wide variety of techniques that we can offer; as well as neurolysis, we offer ablation, vertebral augmentation, or bone augmentation techniques. For patients with lytic spinal or peripheral skeletal metastasis, which cause pain and mobility impairment, we can offer percutaneous ablation, which can result in both local tumour control, prolonged overall survival, and pain reduction followed during the same session by an augmentation technique for structural support.

Additionally, one of the greatest advantages of our percutaneous or transarterial approaches is that they can be combined in a single session. A patient can visit the hospital once and receive ablation, plus structural augmentation, and maybe transarterial embolization—whenever it’s necessary. This is not only beneficial for the patient, but for the hospital and its finances as well.

IN: What influences your judgement when deciding on a pain management pathway?

Following our weekly MDT meetings to decide which therapy should be performed, we consult with the patient to clearly explain what their expectations should be. Expectations differ case by case—you can have a patient with less extensive disease and the goal could be a combination of local tumour control, plus symptomatology improvement. You can have patients who have extensive metastatic disease and the goal there is to first identify the source of pain and treat it. In these cases, you will offer improvement of the symptomatology in terms of pain reduction and mobility improvement. And last but not least, you also have cancer patients who have been treated, but they’re suffering from pain as an adverse event of the treatment. For example, you can have breast cancer patients who have undergone mastectomy, or patients with lung cancer, who have undergone thoracotomy and, respectively, these patients after surgical operation might suffer from post-mastectomy or post-thoracotomy pain syndrome. We also help these patients with neurolysis by taking out specific nerves for each case.

Looking past pain, you can have patients suffering from other symptoms, such as breast cancer patients with hot flashes, or patients with abdominal malignancy that suffer from nausea or vomiting. Cryoneurolysis of specific nerve targets in specific cases can also help in improvement and resolution of these symptoms as well.

IN: Is every interventional oncologist equipped to provide pain palliation? What soft/hard skills are required to perform these techniques?

This is the million dollar question. As interventional oncologists, we are clinicians, we are fully fledged clinicians. And we should start by explaining to everybody that we are treating the patient and not the images. There is a long list of clinical skills that are required to first decide on the correct therapy and then perform this treatment. Interventional oncologists should be able to consult with the patient, analyse the medical and clinical record, see the list of drugs the patient is taking, identify the source of pain, the source of symptomatology in general—and this will happen if you combine clinical and physical examination with evaluation of the diagnostic imaging.

Once we have this ability—and trust me, interventional oncologists, we do have these abilities because we were trained for that—we can proceed for selection of an appropriate therapeutic technique. I strongly believe that interventional oncologists should be involved in the decision-making process, simply because we know better than anybody else, the advantages and disadvantages of our therapeutic approaches, and therefore we can offer an optimal utilisation of these therapies.

We should also be involved in the follow-up of the patient—in pain, I explain it to my patients through an example of an onion. There are lots of large layers on the outside which cover the smaller layers inside. When you remove these outer layers, you must check to see what effect this has had on the inner portion. Which is to say we should follow up with the patient to see whether additional treatments are necessary. In the era of personalised medicine, it’s not who owns the patient, but who is clinically responsible for a specific section of their disease.

Major interest in palliative treatments in IO has spiked in the last five to 10 years. This may perhaps be due to the opioid crisis, as previously mentioned, but also due to its inclusion in the 2019 NCCN guidelines. I have participated in a group of authors who published a paper in 2019 which has been referenced in The NCCN Adult Cancer Pain Guidelines. Pain has also had a major impact on cancer patients, and it can drive them away from systemic and local therapies. If you have a patient who is in pain, it’s not possible to expect them to sit still on the table during chemotherapy. So being able to offer them pain reduction is of utmost importance, and it has positive implications on many levels.


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