Pain in Malignant Pleural Mesothelioma: A Prospective Characterization Study

Our plain-English summary of Pain in Malignant Pleural Mesothelioma: A Prospective Characterization Study, by N. MacLeod, C. Kelly, J. Stobo, et al (Pain Medicine, 2016).

The study

• Authors: N. MacLeod, C. Kelly, J. Stobo, L. McMahon, D. Taggart, M. Fallon, B.J. Laird
• Journal: Pain Medicine
• Published: 2016;17(11):2119-2126
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Malignant pleural mesothelioma (MPM) is associated with severe pain. The underlying neurobiology of this is complex. The primary aim of this study was to characterize pain in MPM.

Methods: This study was undertaken as part of a trial examining radiotherapy for the treatment of pain in MPM (ISRCTN 10644347). Patients had MPM with associated pain for which radiotherapy was planned and a worst pain score ≥ 4/10. The following assessments were undertaken: clinical neuropathic pain assessment, Brief Pain Inventory (BPI), Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), Short form of the McGill Pain Questionnaire (SF-MPQ), and Quantitative Sensory Testing (QST). The relationship of these characteristics and response to radiotherapy was assessed. Unless stated, medians and interquartile range (IQR) are used.

Results: Thirty-seven patients were recruited. Average pain and worst pain was 4 (4-6) and 8 (6-8), respectively. Higher average pain and higher worst pain scores were associated with higher interference scores on the BPI, P < 0.001 and P < 0.0005. Twenty patients (54%) had a clinical diagnosis of neuropathic pain, and of these, only six patients (40%) screened positively for neuropathic pain using the LANSS. Patients with a high LANSS also had higher BPI and SF-MPQs. The presence of neuropathic pain (clinically or by LANSS) did not predict response to radiotherapy, P < 0.05. The SF-MPQ scores were higher in those with abnormal cool sensation on QST (P = 0.016).

Conclusion: Pain in mesothelioma varies among patients and may have neuropathic components. An adequate pain assessment is necessary to guide the clinician in the appropriate choice of analgesics.

© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected].

In plain English

This study described pain in people with malignant pleural mesothelioma. It was part of a UK trial of radiotherapy for mesothelioma pain, run at three cancer centres from June 2012 to December 2013. Forty patients consented and 37 completed the assessments before radiotherapy, though individual sensory tests had results for only 26 to 33 patients. The median average pain score was 4 and the median worst pain score 8 on a 0 to 10 scale. Both were moderately associated with how much pain interfered with daily life. Twenty patients had a clinical diagnosis of neuropathic (nerve) pain. The LANSS screening questionnaire missed many: 11 of 24 patients who screened negative had a clinical diagnosis, so the authors suggested it may not be an effective screening tool here. No pain characteristic predicted response to radiotherapy, though the authors noted the study was not large enough to test this. The authors concluded that pain in mesothelioma is common and severe, has a neuropathic component in some patients, and has mixed mechanisms. They called the small sample size a clear limitation.

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: Prospective pain characterization study carried out within a larger trial of radiotherapy for pain in malignant pleural mesothelioma (ISRCTN 10644347)
• Who was studied: Adults with malignant pleural mesothelioma and mesothelioma-related pain (worst pain 4/10 or more) for which radiotherapy was planned. They were recruited at three UK cancer centres (Glasgow, Edinburgh, Sheffield) from June 2012 to December 2013. Forty patients consented and 37 completed the assessments. Median age was 71.5 years, and 35 of the 40 were male.
• Exposure: Not reported. The article does not describe asbestos or any other exposure. Pain was assessed before planned radiotherapy using a clinical assessment, the Brief Pain Inventory (BPI), the LANSS, the short-form McGill Pain Questionnaire (SF-MPQ) and Quantitative Sensory Testing (QST).
• Main results:
  • Sensory-test (QST) results were incomplete. Out of 40 patients, Table 3 records missing results for 14 (brush), 7 (detection threshold), 7 (pain threshold), 8 (cool), 8 (warm), 10 (pin prick) and 10 (wind up). That leaves 26 to 33 patients with results for each test.
  • Across the patients assessed, the median average pain score was 4 (IQR 4 to 6) and the median worst pain score was 8 (IQR 6 to 8).
  • Worst pain score correlated with the mean BPI interference score (Spearman's coefficient 0.567, P < 0.001). The authors described this as a moderate positive association.
  • Average pain score correlated with the mean BPI interference score (Spearman's coefficient 0.556, P < 0.001).
  • The words patients most often chose to describe their pain were aching (32, 86.5%), tender (29, 78.4%) and sharp (27, 73%).
  • Twenty patients had a clinical diagnosis of neuropathic pain.
  • On the LANSS, 11 patients (31.4%) scored 12 or more, suggesting likely neuropathic pain, and 24 (68.6%) scored under 12.
  • Of the 24 patients with a LANSS under 12, 11 (45.8%) had a clinical diagnosis of neuropathic pain. The authors suggested the LANSS may not be an effective screening tool in this group given the high false negative rate.
  • Median total BPI was 52 (IQR 41.00 to 59.50) in patients with a LANSS under 12, versus 69.50 (IQR 61.00 to 84.00) in those with a LANSS of 12 or more (P = 0.004).
  • Median SF-MPQ was 10.00 (IQR 8.00 to 13.50) in patients with a LANSS under 12, versus 15.00 (IQR 12.00 to 18.00) in those with a LANSS of 12 or more (P = 0.012).
  • Median SF-MPQ was 12 (IQR 9.5 to 16.5) in patients with abnormal cool sensation on QST, versus 6.5 (IQR 5.0 to 11.5) in those with normal cool sensation (P = 0.016). No such relationship was found for hot sensation (P = 0.697).
  • Abnormal pin-prick sensation was found in all eight assessed patients with a LANSS of 12 or more, compared with 9 of 20 patients (45%) with a LANSS under 12 (P = 0.010).
  • There was no evidence that the LANSS or SF-MPQ determined the likelihood of response to radiotherapy (P > 0.05).
  • A clinical diagnosis of neuropathic pain did not predict response to radiotherapy. Six patients with the diagnosis responded and eight without it responded.
  • No QST characteristic was associated with a higher likelihood of response to radiotherapy.
  • At baseline, 32 patients (84.2%) were taking strong opioids.
• The authors' conclusion: The authors concluded that pain is a common and severe problem in malignant pleural mesothelioma, with a neuropathic component in some patients but a mixed mechanism overall. They found no specific factors that predicted response to radiotherapy.
• Limitations the authors state:
  • The small sample size, which the authors said limits the inferences that can be drawn.
  • The LANSS is a screening tool for neuropathic pain, not a diagnostic test.
  • There was no comparator group and no data over time.
  • The study was not powered to assess whether QST parameters predicted response to radiotherapy.

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: Pleural Mesothelioma, Mesothelioma.

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