Reply—Letter to the Editor: What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion
Drugs
Reply-Letter to the Editor: What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion
Working Group Nientemale DEI 0 1 2 3 4 5 6
R. Vellucci 0 1 2 3 4 5 6
R. Pannuti 0 1 2 3 4 5 6
C. Peruselli 0 1 2 3 4 5 6
P. Romualdi 0 1 2 3 4 5 6
G. Fanelli 0 1 2 3 4 5 6
P. A. Cortesi 0 1 2 3 4 5 6
Dear Editor 0 1 2 3 4 5 6
0 SC Anestesia, Rianimazione e Terapia Antalgica, Azienda Ospedaliero-Universitaria di Parma , Parma , Italy
1 SOD Cure Palliative e Terapia del Dolore, Ospedale Universitario Careggi , Florence , Italy
2 & R. Vellucci
3 Dipartimento di Farmacia e Biotecnologie, Alma mater studiorum, Universita` di Bologna , Bologna , Italy
4 SC Cure Palliative, Ospedale di Biella , Ponderano, BI , Italy
5 Fondazione ANT Italia Onlus , Andria , Italy
6 Research Centre on Public Health (CESP), University of Milan-Bicocca , Monza , Italy
-
We would like to thank Raffaele Giusti and colleagues [
1
]
for their comments on our paper [
2
].
Consistent with the motto ‘‘Actions speak louder than
words’’, we have gathered a group of opinion leaders in
palliative care and pain treatment who, for several years,
have been committed to treat breakthrough cancer pain
(BTcP). Our experience, gained by close contact with
cancer pain sufferers, has allowed us to explore the
literature on BTcP and to transfer it into clinical practice. We
are convinced that the situation in Italy [
3, 4
], in Europe [5]
and in other countries [
6
], is far from encouraging.
In Italy, the phenomenon of under-treatment of cancer
patients [
7
] and BTcP [
3, 4, 8
] is still an important
problem.
It must be made clear that rapid-onset opioids (ROOs)
do not seem to be used very often in clinical practice [
5, 8
],
as can be indirectly deduced from the Italian sales data.
Specifically, about one-third of patients with BTcP did not
receive any kind of rescue therapy, even in cases of
patients with at least three attacks per day [8]. In terms of
the drugs prescribed, one-third received a World Health
Organization level I drug, while among the opioids,
immediate-release (IR) morphine is significantly more
frequently administered (71.2 %) than oral transmucosal
fentanyl citrate (18.3 %) [
8
]. Even if IR morphine and
fentanyl both act through the same mechanism of action,
the route of administration influences the bioavailability of
the drug, and the lipophilic future of fentanyl allows it to
reach the brain very quickly.
At first sight, IR morphine might appear to be less
expensive, but it has a pharmacokinetic profile, which is
inappropriate for most episodes of BTcP and becomes
more efficacious than placebo after only 45 min,
postbaseline [
9
].
That is not to say that morphine does not have a role in
the treatment of BTcP, but rather that it may be useful in
the management of breakthrough pain episodes lasting for
more than 60 min, and may be considered in the
preemptive management of volitional incident pain or
procedural pain [
10
].
One fact seems unequivocal: missing or inappropriate
treatment of BTcP results in an increase of BTcP-related
office visits, emergency department visits, and
hospitalizations [
11–14
], often with long hospital stays, and
oncologic restaging, all of which have a significant impact
on costs, much more relevant than the costs related to using
ROOs in place of IR morphine. On the contrary, the correct
utilisation of ROOs in clinical practice can reduce the
burden of BTcP. Better analgesic efficacy can be translated
into savings in health-care resources as well as an
improved quality of life for patients [11]. Nevertheless,
further studies are needed to better quantify the economic
impact of BTcP and the benefits of using ROOs instead of
IR morphine.
We think that the long-term viability of our health-care
system is closely linked to our clinical choices.
We are fully aware that BTcP exacts a significant toll on
patients, their families, caregivers, and social networks, the
health-care system, and society at large. To lessen these
effects, we have prepared a decalogue of ‘‘Five Things to
Do and Five Things Not to Do’’ in the diagnosis and
treatment of BTcP; but add that this is what we do every
day with patients in clinical practice. We are convinced
that this approach represents a solid basis for making the
necessary progress for clinical management of BTcP,
making our job easier.
Furthermore, considering the variable approach on
cancer pain management in the different Italian regions,
depending on the environment and local resource
availability, we considered it essential and more useful to share
and discuss opinions between a consistent number of
palliative care experts from all over the country and define
some shared methods, rather than working on standard
recommendations. In addition, we also paid close attention
to communication with patients and their caregivers, an
important issue often underestimated.
An interesting issue needing (...truncated)