Opioids in pain management of mesothelioma and lung cancer patients

Our plain-English summary of Opioids in pain management of mesothelioma and lung cancer patients, by E.K. Salminen, M. Silvoniemi, K. Syrjänen, et al (Acta Oncologica, 2013).

The study

• Authors: E.K. Salminen, M. Silvoniemi, K. Syrjänen, S. Kaasa, M. Kloke, P. Klepstad
• Journal: Acta Oncologica
• Published: 2013;52(1):30-7
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Lung cancer and mesothelioma are malignant tumors with generally dismal prognosis and therefore palliative pain treatment constitutes a challenge for the clinician.

Objectives: The aim of this study was to compare the outcomes of pain treatment with opioids among mesothelioma and lung cancer patients treated for palliation and assess factors which confound to optimal treatment.

Patients And Methods: A sub-cohort of 373 lung cancer and 22 mesothelioma patients was identified in multi-center European Pharmacogenetic Opioid Study (EPOS) cohort. A nested case-control (1:4) setting was designed to estimate the pain and other covariates distinguishing 22 mesothelioma- (= cases) and 88 lung cancer patients (controls), analyzed using univariate- and multivariate conditional (fixed-effects) logistic regression models.

Results: The mean total daily dose of opioids varied from 30.0 to 960.0 mg (mean 275, median 160 mg, SD 293) in mesothelioma, and from 10 to 5072 mg (mean 414, median 175, SD 788) in lung cancer patients (p = 0.420). In both groups, pain was mostly experienced as moderate and severe and it was frequently accompanied by depression, poor sleep, anxiety and fatigue. Four mesothelioma patients (18%) and seven lung cancer patients (10%) experienced complete pain relief with opioids by self-assessment. Assessments of pain severity by the patients and their physicians deviated significantly in mesothelioma (p = 0.039 McNemar test), as well as in lung cancer (p = 0.0001). In conditional logistic regression, no significant differences were found in distribution of pain covariates between lung cancer and mesothelioma patients.

Conclusion: Pain perception by the patients was associated frequently with other symptoms and complete pain control with opioids was achieved only with minority of patients both with mesothelioma and advanced lung cancer. Adequate pain control requires continuous monitoring and tailoring the dose to patient's individual needs and tolerance, recognition of accompanying symptoms such as depression and poor sleep, and their management.

In plain English

This study drew on the European Pharmacogenetic Opioid Study (EPOS), which enrolled 2294 cancer patients from 11 European countries. The authors compared 22 mesothelioma patients with 88 age- and sex-matched lung cancer patients receiving opioids in palliative care. Asbestos exposure was not studied. Pain was mostly moderate or severe in both groups. Mean total daily opioid dose, in oral morphine equivalents, was 275 mg for mesothelioma and 414 mg for lung cancer patients, not a statistically significant difference. Four mesothelioma patients (18%) reported complete pain relief; the article reports seven lung cancer patients (10%), without stating the denominator. Patients' and physicians' pain ratings often disagreed, and physicians frequently underestimated pain. Among lung cancer patients, younger age, poorer performance status, sleeplessness and breakthrough pain were linked to moderate to severe pain. Among mesothelioma patients, none of these factors reached statistical significance. The two groups did not differ significantly in pain-related symptoms. The authors concluded that only a minority in either group achieved complete pain relief. They noted the study was cross-sectional and included few mesothelioma patients.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Nested case-control analysis (1 mesothelioma case to 4 lung cancer controls) within a sub-cohort of the EPOS study. The authors describe it as cross-sectional and say it addressed secondary outcomes of a study with another original aim.
• Who was studied: 22 mesothelioma patients (cases) and 88 lung cancer patients (controls), matched strictly by age and gender. The controls were chosen from 374 lung cancer patients. All came from the EPOS cohort of 2294 cancer patients in 11 European countries, recruited from 17 centers. Patients were in palliative care and treated with opioids. Mean age was 63 years, and each group was about 73% male.
• Exposure: Opioid pain treatment, converted to equivalent daily oral morphine doses. Most patients took oral opioids (morphine, oxycodone, methadone, hydromorphone). Some used a fentanyl skin patch, and a few lung cancer patients received opioids under the skin or into a vein. The study compared two cancer types, mesothelioma and lung cancer. Asbestos is mentioned only in the introduction and was not studied.
• Main results:
  • Doses are given as equivalent daily oral morphine doses. Mesothelioma patients had a mean total daily dose of 275 mg (median 160 mg, range 30.0 to 960.0 mg). Lung cancer patients had a mean of 414 mg (median 175 mg, range 10 to 5072 mg). The difference (p = 0.420) was not statistically significant.
  • Four of 22 mesothelioma patients (18%) reported complete pain relief with opioids on self-assessment. The article reports seven lung cancer patients (10%) with complete relief but does not state the denominator. Seven of all 88 controls would be about 8%, and only 69 of 88 lung cancer patients completed the patient pain questionnaire. In the discussion, the authors said complete pain control was achieved in less than 20% of patients.
  • Pain was mostly moderate or severe in both groups.
  • Patients' and physicians' ratings of pain severity differed significantly in both groups.
• Mesothelioma: ratings matched in 12 of 22 patients (p = 0.039, McNemar test); Kappa agreement was 0.203.
• Lung cancer: ratings matched in 31 of 70 patients (p = 0.0001); Kappa agreement was 0.188.

The physician frequently underestimated pain severity.

• Among lung cancer patients, four factors were significantly associated with moderate to severe pain:
• younger age (OR 2.7, 95% CI 1.1-6.7)
• poor Karnofsky performance score (OR 3.50, 95% CI 1.2-9.9)
• sleeplessness (OR 3.40, 95% CI 1.4-8.4)
• breakthrough pain (OR 2.92, 95% CI 1.2-7.3)
  • Among mesothelioma patients, the same four factors appeared most apparent. None reached statistical significance because of the small number of patients.
  • In conditional logistic regression comparing mesothelioma cases with lung cancer controls, no pain-related factor differed significantly. The largest difference was for fatigue:
• Crude OR 3.44 (95% CI 0.5-24.4).
• Adjusted OR 5.22 (95% CI 0.8-32.1, p = 0.075) as given in the text.
• Table V gives the adjusted OR as 5.16 (95% CI 0.8-31.3, p = 0.074).
• The authors' conclusion: The authors concluded that pain in both mesothelioma and advanced lung cancer patients was not optimally controlled, because only a minority in each group achieved complete pain relief. They concluded that patients' own assessments and pain-related symptoms such as depression and poor sleep should get more attention. They also concluded that treatment should be tailored to the individual.
• Limitations the authors state:
  • The study was cross-sectional.
  • The small number of mesothelioma patients limited the power of the conclusions.
  • Time since starting opioid treatment differed between the groups. Opioids were started more recently in lung cancer patients, which may influence the outcome.
  • The analysis addressed secondary outcomes; the original EPOS study had another aim.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mesothelioma, Lung Cancer, Prognosis, Palliative Care.

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