2017 TJCC-癌症存活者自主照護管理學術研討會 癌症存活者的考驗:疼痛問題 臺北醫學大學附設醫院 郭淑柳

大 綱 存活者疼痛問題 疼痛原因及評估 疼痛處置

治療水平的提高，美國目前有1400萬癌症倖存者。其中2/3的人生存期已經超過5年 原文網址：https://kknews.cc/zh-tw/health/qo3zxo.html Cancer survivors should be followed by long-term/late effects of disease and/or treatment. Kurita & Sjogren (2015). Acta Oncologica, 54, 629-634

Pain prevalence 系統性回顧2005-2014 55% 病人在治療期間有疼痛問題 39.3% 病人(在治癒性治療之後)有疼痛問題 66.4% in advanced cancer van den Beuken-van Everdingen MH et al. (2016)J Pain Symptom Management. 51(6):1070–90 e9. 30% and 60% of cancer survivors Brown et al. (2014) British Journal of Pain, 8(4), 139-153 Paice, Judith. et al (2016). J Clin Oncol 34:3325-3345 25-50% breast cancer patients experience chronic pain after treatment. Andersen et al. (2011). J pain 12, 725-746

疼痛原因 Treatment-related pain syndromes Surgery—e.g. 運用改良式手術方式改善此問題 Post-mastectomy pain Phantom limb pain Chronic postoperative visceral pain syndrome-往往出現的問題: 沾黏, fistulae. 運用改良式手術方式改善此問題 Radiotherapy 頸部肌肉纖維化 Fistulae formation Osteoporosis

Chemotherapy-induced peripheral neuropathy (CIPN) 化學治療引發周邊神經病變 Chemotherapy-induced peripheral neuropathy (CIPN) 與接受 Oxaliplatin, Paclitaxel, & Vincristine化學藥物治療有關 此副作用跟藥物劑量多寡相關, 可逆性副作用 疼痛性質- 刺刺的, 刺痛, 麻, 燒灼感 本體感覺喪失及肌肉無力

各類化學藥物產生CIPN 藥物名稱 藥物種類 CIPN 發生率 發生時間 可能病理機轉 Cisplatin Carboplatin platinum 40-50% From 1 month Peak 3 months TRPV1, TRPA, TRPM8 NMDA receptor effects Mitotoxicity Oxaliplatin 90% Acute onset, 2-3 days membrane K+ channels Vincristine Vinca alkaloid 30-40% Within 3 months Changes Ca 2+ NMDA receptor effects Microtubule disruption Paclitaxel Docetaxel taxane 30-50% >50% after second dose Thalidomide Immunomo-dulator 20-70% Daily dose-related-not cumulative dose Not elucidated TRPV1-Transient receptor potential vanilloid type 1 ; TRPA-Transient receptor potential ankyrin; TRPMS-Transverse rectus abdomins myocutaneous

Neuropathic pain—IASP的定義 “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system(體感神經系統)” 自發性引起的疼痛 感覺不正常—hyposensitivity, hypersensitivity, or both 感覺異常Paraesthesia—abnormal sensation 感覺遲鈍Dysaesthesia---unpleasant abnormal sensation 痛覺敏感Hyperalgesia—increased response to a stimulus

Pain assessment 整體性評估 Comprehensive assessment 評估疼痛狀況 使用量表或是Semi-quantitative tool 評估多層面的疼痛 Pain descriptors Associated distress Functional impact Related physical, psychological, social, and spiritual factors Information about cancer treatment Psychosocial and psychiatric history Prior pain management Journal of Clinical Oncology(JOCO , 2016) ASCO-a guideline of Management of chronic pain in cancer survivors

存活者疼痛處置 JOCO(2016)建議 處置分為藥物處置及非藥物處置 治療目標: enhance comfort, improve function, limit adverse events, safety 治療計畫制定過程須將病人及家屬意見納入於計畫 根據病人需求, 提供完整的疼痛處置計畫 處置分為藥物處置及非藥物處置

藥物處置 Opioids Non-opioid analgesics & adjuvant analgesics NSAIDs Acetaminophen Adjuvant analgesics—antidepressants and anticonvulsants Neuropathic pain Muscle relaxants N-methyl-D-aspartate receptor (NMRD) blockers (such as ketamine) ɑ-2 agonists (such as tizanidine) Local anesthetics, compounded creams/gels Corticosteroids  not recommended for long-term used JOCO (2016) a guideline of Management of chronic pain in cancer survivors

Opioids 所關注的議題 Assess and stratify risk of opioid misuse Decide whether or not to prescribe Risk of diversion Risk of drug abuse Monitor drug-related behavior Adverse effects-constipation, mental clouding, GI symptom Adherence Respond to aberrant behavirors Reassess and diagnose Consider whether to continue prescribing

疼痛處置--心理情緒處置 Psychological factors related to cancer pain Depression- Aggravated pain, fatigue, sleep disruption Distress and anxiety- Pain Strongly associated with emotional distress Uncertainty Greater perceived illness uncertainly confers significant risk for pain, distress, intrusive thoughts, avoidance behaviors, and reduced quality of life PTSD Cancer-related PTSD is untreated, pain, treatment nonadherence, desire for hastened death, and disability increase

非藥物處置 Physical medicine and rehabilitation Integrative therapies Physical therapy, Occupational therapy, recreational therapy, individual exercise program, ultrasound, heat/cold Integrative therapies Massage, acupuncture, music Interventional therapies Nerve blocks, neuraxial infusion,(epidural/ intrathecal), vertebrobroplasty/kyphoplasty

Psychological approaches Cognitive behavioral therapy, distraction, mindfulness, relaxation, imagery Neurostimulatory therapies TENS, spinal cord stimulation, peripheral nerve stimulation, transcranial stimulation

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