Nearly one in three people with cancer, both with those with active cancer and cancer survivors, report  having trouble falling asleep, staying asleep, or sleeping too much.

Pain and emotional distress were often associated with sleep problems.

When researchers in Scotland asked 2,862 patients “Over the last two weeks, how often have you been bothered by trouble falling or staying asleep or sleeping too much?”

• 34.5 percent with active cancer said yes.
• 28.0 percent of cancer survivors also answered yes.

In addition, patients who said they had sleep problems were almost three times as likely to to have pain (odds ratio 2.7) and nearly five times as likely to have emotional distress (odds ratio 4.5).

The team at the Universities of Edinburgh and Glasgow concluded,

Sleep problems are common in cancer outpatients and are strongly associated with pain and emotional distress. A combined approach to the management of sleep, pain and emotional distress is indicated.

SOURCE

Sharma N. et al, Psycho-Oncology, Early View, July 1, 2011.  doi: 10.1002/pon.2004

Listening to just thirty minutes of music significantly reduced pain and distress for cancer patients.

The patients were receiving medication, but still had pain.

Music reduced pain scores by more than 50 percent for almost half of them compared to fewer than 1 in 10 similar patients who just rested in bed.

Nurses randomly assigned Taiwanese patients to listen to their choice of music for 30 minutes or to rest without music.  They measured pain at the beginning and end of the time using a visual scale.

42 percent who listened to music had their pain scores fall by 50 percent or more, compared to 8 percent of those who merely rested.  A statistical test showed a large effect of the music for both changes in the sensation of pain and changes in the distress patients felt.

Patient had their choice of folk songs, Buddhist hymns , or American harp and piano music.  Although 7 out of 10 chose the Taiwanese music, the American music was also enjoyed and effective.

Writing in the International Journal of Nursing Studies, lead author Shih-Tzu Huang said,

Offering a choice of familiar, culturally appropriate music was a key element of the intervention.  Soft music was safe, effective, and liked by participants. It provided greater relief of cancer pain than analgesics alone. Thus nurses should offer calming, familiar music to supplement analgesic medication for persons with cancer pain.

SOURCE:  Huang et al, International Journal of Nursing Studies, Volume 47, Number 11, November 2010.

What This Means for Patients

Sometimes the simple things that we do intuitively prove to be effective scientifically.

In this study music was not offered instead of medication, but in addition to it.

Patients also got to choose the music that they liked from culturally appropriate choices.

This simple method may help cancer patients both in the hospital and at home.

The Food and Drug Administration has approved a new opiate drug for severe breakthrough cancer pain.  However, Onsolis® will only be available through a restricted distribution program.

As part of an FDA-required Risk Evaluation and Mitigation Strategy, or REMS, only health care providers, pharmacies, and patients registered with the FOCUS program will be able to prescribe, dispense, and use the medicine.

The FOCUS program will:

• Provide training and educational materials to health care providers and pharmacists about the drug’s risks and appropriate uses.
• Make a counseling call to patients to be sure they have receive proper education about the drug’s use.
• Only allow prescriptions to be filled by pharmacies that send the drug directly to the patient’s home.

Onsolis delivers fentanyl through an absorbable film that sticks to the inside of the mouth.  It can only be prescribed for patients who are already taking another opiate medicine around the clock, considered tolerant to opiates and can safely take high doses of fentanyl.

The drug has a boxed warning that it should not be used for migraines, dental pain, or pain after surgery or by patients who only use it on an as-needed basis. It also warns that it must be kept out of the reach of children and not substituted for other fentanyl products.

Bob Rappaport, MD, director of the Division of Anesthesia, Analgesia and Rheumatology Products in the FDA’s Center for Drug Evaluation and Research (CDER) said,

Onsolis can provide strong pain relief to patients who are opioid tolerant. But for patients who are not opioid tolerant, it can lead to overdose, sudden serious breathing difficulties and death. For this reason, Onsolis should be prescribed only under the safeguards provided by the FDA-required REMS and by health care professionals knowledgeable about Onsolis and the use of potent opioid medications.

Farrah Fawcett died on Thursday, June 25, 2009 of anal cancer that had spread to her liver.  She was 62.  Anal cancer is much more rare than either colon or rectal cancer, affecting about 5,300 Americans in 2009. 710 will die from it.

In other headlines, the Caterpillar company works with Peoria hospitals and doctors to ensure quality colonoscopy for their employees and a Swiss laboratory will be the first to offer a blood screening test for colorectal cancer.

In research, MRI colonography is useful for patients who can’t have a full colonoscopy before surgery, screening colonoscopies are increasing for Medicare enrollees, and scientists have found factors in tumors that make nerves more sensitive to pain.

Research Reports

• Magnetic resonance colonography was successful before surgery for patients with colon or rectal cancer who hadn’t yet had a complete colonography.  Done either the night before in surgery in the hospital or a week before as an outpatient procedure, it revealed lesions, both cancers and polyps, in 4 out of 47 patients tested, changing the surgical strategy for 3 of them.  One flat adenoma and 5 small polyps were missed and found later on colonoscopy. Although bowel cleansing is necessary, there is no radiation or sedation.  Michael P. Achiam and his team in Copenhagen report on the feasibility and potential benefits of MRC in the July 2009 issue of Academic Radiology.
• Since 1998 when Medicare first began paying for colonoscopy, its use has increased each year for Medicare enrollees, and use of other screening tests including FOBT, flexible sigmoidoscopy, and barium enema has decreased.  Percentage of people on Medicare who have been screened for colorectal cancer has increased each year, but still less than half (47 percent) had been tested in 2005.  Only a third of people 50 to 64 who are covered by Medicare because of a disability had an appropriate screening test.  Anna Schenk in North Carolina and a team at the National Cancer Institute report findings in the American Journal of Prevention Medicine, July 2009.
• Working with mice, German scientists have discovered two substances secreted by tumors that make nerve fibers more sensitive to pain, increase nerve endings in the skin, and cause the growth of tumors.  Blocking the signals of granulocyte- and granulocyte-macrophage colony-stimulating factors (G-CSF and GM-CSF) may lead to a more effective way of controlling cancer pain.  Matthias Schweizerhof discusses the research in a letter to Nature Medicine published online June 7, 2009. Science Daily had an article about the studies on June 25.

Other Headlines

• The Caterpillar company, headquartered in Peoria, IL, provides free cervical, breast, prostate, and colorectal cancer screening to its 45,000 US employees.  To manage costs and ensure quality, they met with hospital and doctors in their area and proposed a program for Caterpillar employees that caps costs for colonoscopy at $1,000 and also grades doctors on how many of eight colonoscopy quality-indicators  they meet. That information is shared with the program doctors.  All doctors who do colonoscopies in the Peoria region are now part of the program.  Health reporter Julie Steenhuysen covers the story for Reuters Health.
• Voillier, a private Swiss testing lab will be the first in Europe to offer a blood test for colorectal cancer based changes in DNA. The test looks for methylation of DNA in the SEPT9 gene which ordinarily keeps tumors from developing.  Cancer cells shed this altered DNA into the bloodstream.  The test was developed by German molecular diagnostics firm Epigenomics, which plans to offer the test in the United States later this year.  Currently a study is underway with 7,500 people who who will have the blood test done before their colonoscopy to find out if changes in blood DNA are reflected in colonoscopy results.

One of the most important fears after a cancer diagnosis is suffering during chemotherapy. But patients also are afraid that the cancer will cause suffering  from pain that can’t be treated. Almost all patients with cancer are most afraid of pain and controlling it.

It is so important that cancer patients and their caregivers know how to manage pain because patients in pain do not eat, do not drink do not exercise, and do not interact. One of the major misconception for pain control is that the patient will become addicted. Patients may want to save medicine for it when it gets really bad. It needs to be very clear that the best pain control is early intervention. When pain is developing is the time take a painkiller. Don’t wait til it reaches 10/10.

In fact studies have shown that when you wait too long, the benefit is much less and you may end up taking more because it is much more difficult to control pain when it is out of control. The problem of addiction for cancer patients is really not a clinical problem. Over the last 17 years I have seen very few patients where we had problems getting them off pain medication. The benefit is bigger by far than these few issues. Patients have more energy, eat better, avoid dehydration, and are emotionally better off, all of which are basic for better treatment outcomes.

Patient with pain are usually exhausted. They feel drained and can’t sleep at night, and, because of the pain, don’t eat and lose weight.

It is absolutely critical to communicate clearly with your oncologist to make sure your pain is adequately treated. There are basic principles and steps which should be followed to have the best outcome. We usually start with over-the-counter painkillers such as Advil®, Aleve®, or Tylenol.  But they may not be enough. Then we use stronger combinations such as Percocet®, Vicodin®, or Lortab®.

It is critical for pain control to take the pain medication on a regular time schedule. To try to save these medications and wait until the pain peaks is absolutely wrong. Take them as they are prescribed every 4 or 6 hours. It is also important to have a medication for breakthrough pain in case you still have pain despite taking your prescribed medicine on a regular schedule. If pain still continues, sometimes increasing the dose may help. In other cases you may need a stronger breakthrough drug.

With NSAIDs such as Aleve or Advil, you need to watch out for your stomach. It can get upset, particularly if you have a history of gastritis or ulcer. Make sure your oncologists knows about your history.

If pain is difficult to control with these measures and you need breakthrough medicine more than four or five times a day, you may need a longer acting morphine agent. In recent years significant advances have been made to develop highly active morphine medications, such as patches or lollipops. These patches only need to changed every three days and deliver small doses of pain medicine through the skin. Interestingly, some patients develop pain on the third day, and studies have shown that some patients need to change the patch every two days because they are detoxifying the drug faster.

Document how often you take breakthrough pain medication and the pattern of your pain to allow your doctor to make more effective recommendations.

There are a couple of important fact you need to know: When you put on a patch it takes at least 10 hours to reach levels which can be effective and the absorption through the skin varies significantly among patients. If you get sick with nausea, vomiting or feeling dizzy or woozy, take the patch off immediately and consult with your oncologist. If you suddenly don’t need any breakthrough drugs, you may need to reduce the dose of the patch, perhaps due to the effect of chemotherapy or radiation.

Pain management is not easy and requires often a pain management team which has special expertise in pain medications and technologies such as nerve blocks to handle patients whose problems continue.

The most common side effect of pain medications is constipation which should be handled with stool softener right away.  Constipation needs to be monitored and discussed with your oncologist.

The most important issues are if your pain is not well-controlled or if you are having side effects from the pain medicine, you need to contact your doctor’s office to make sure that you don’t need adjustments or interventions.

Are men and women with severe cancer pain treated in the same way?

Although both sexes reported the same level of worst pain in a past week, men were more likely to have a prescription for high-potency pain medicine and receive higher doses of morphine.

Women being first evaluated at a cancer pain clinic reported more pain “right now” and higher average pain during the past week.  However, a review of their medical charts showed they were getting  less morphine and had higher average pain scores than men.  They were more likely to say that their pain was poorly controlled.

Men’s records from their primary oncologist showed an average daily dose of opiate of 130 milligrams, while women were getting 66 milligrams each day.  In addition, only 33 percent of women had a prescription for high potency pain medicine compared to 51 percent of men.

Writing in the Journal of Pain and Symptom Management, Kristin A. Donovan PhD, and her team at the Moffit Cancer Center in Tampa, Florida, concluded,

Females were significantly less likely to have been prescribed high potency opioids by their primary oncology team and significantly more likely to report inadequate pain management as measured by Pain Management Index scores. These results suggest a sex bias in the treatment of cancer pain and support the routine examination of the effect of sex in cancer pain research.

SOURCE: Donovan et al., Journal of Pain and Symptom Management, Volume 36, Number 2, August 2008.