Percutaneous cervical cordotomy for cancer-related pain: national data

Our plain-English summary of Percutaneous cervical cordotomy for cancer-related pain: national data, by M. Poolman, M. Makin, J. Briggs, et al (BMJ Supportive & Palliative Care, 2020).

The study

• Authors: M. Poolman, M. Makin, J. Briggs, K. Scofield, N. Campkin, M. Williams, M.L. Sharma, B. Laird, C.R. Mayland, INPIC Group
• Journal: BMJ Supportive & Palliative Care
• Published: 2020;10(4):429-434
• Cited by: 17 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objectives: Percutaneous cervical cordotomy (PCC) is an interventional ablative procedure in the armamentarium for cancer pain treatment, but there is limited evidence to support its use. This study aimed to assess the effectiveness and safety of PCC.

Methods: Analysis was undertaken of the first national (UK) prospective data repository of adult patients with cancer undergoing PCC for pain treatment. The relationship between pain and other outcomes before and after PCC was examined using appropriate statistical methods.

Results: Data on 159 patients' PCCs (performed from 1 January 2012 to 6 June 2017 in three centres) were assessed: median (IQR) age was 66 (58-71) years, 47 (30%) were female. Mesothelioma was the most common primary malignancy (57%). The median (IQR) time from cancer diagnosis to PCC assessment was 13.3 (6.2-23.2) months; PCC to follow-up was 9 (8-25) days; and survival after PCC was 1.3 (0.6-2.8) months. The mean (SD) for 'average pain' using a numerical rating scale was 6 (2) before PCC and 2 (2) at follow-up, and for 'worst pain' 9 (1) and 3 (3), respectively. The median (IQR) reduction in strong opioid dose at follow-up was 50% (34-50). With the exception of 'activity', all health-related quality of life scores (5-level version of EuroQol-5 Dimension) either improved or were stable after PCC. Six patients (4%) had PCC-related adverse events.

Conclusions: PCC is an effective treatment for cancer pain; however, findings in this study suggest PCC referrals tended to be late in patients' disease trajectories. Further study into earlier treatment and seeking international consensus on PCC outcomes will further enhance opportunities to improve patient care.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

In plain English

This study analysed the first UK national register of adults with cancer pain treated with percutaneous cervical cordotomy (PCC). PCC is a procedure that uses heat lesions to interrupt pain pathways in the upper spinal cord. The register covered 159 patients treated between 1 January 2012 and 6 June 2017 at three centres (Liverpool, Portsmouth and Warwick). Malignant pleural mesothelioma was the most common diagnosis (90 patients, 57%). There was no comparison group. On a 0 to 10 scale, mean average pain fell from 6 before the procedure to 2 at follow-up, and mean worst pain fell from 9 to 3 (both p less than 0.001). Follow-up came a median of 9 days after the procedure. The median daily strong opioid dose fell from 200 mg to 140 mg (morphine equivalent). Six patients (4%) had procedure-related adverse events. Median survival after the procedure was 1.3 months. The authors concluded that PCC is an effective and safe treatment for cancer-related pain, but that patients were often referred late in their illness. They noted modest numbers, no control group and missing data as limitations.

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: Observational study of a prospective national (UK) data register (registry) of patients undergoing PCC, analysed mainly descriptively, with exploratory non-parametric tests
• Who was studied: 159 adult patients with cancer-related pain who had PCC at three UK interventional pain centres (Liverpool, Portsmouth and Warwick) between 1 January 2012 and 6 June 2017. The median age was 66 and 47 (30%) were female. Diagnoses were malignant pleural mesothelioma in 90 (57%), primary lung cancer in 43 (27%) and other cancers in 26 (17%).
• Exposure: The intervention studied was percutaneous cervical cordotomy: radiofrequency heat lesions placed in the lateral spinothalamic tract of the upper cervical spinal cord, done under X-ray guidance. The study did not report asbestos or other occupational exposure.
• Main results:
  • Across all 159 patients, mean (SD) average pain on a 0 to 10 scale was 6 (2) before cordotomy and 2 (2) at follow-up, p less than 0.001.
  • Mean (SD) worst pain was 9 (1) before cordotomy and 3 (3) at follow-up, p less than 0.001.
  • Median (IQR) strong opioid dose (morphine equivalent daily dose) was 200 mg (100 to 400 mg) at baseline and 140 mg (20 to 300 mg) at follow-up, p less than 0.001. The median reduction was 50% (IQR 34 to 50).
  • Median time to follow-up was 9 (IQR 8 to 25) days, and 137 (87%) patients were alive at that point. Median survival after the procedure was 1.3 (IQR 0.6 to 2.8) months.
  • On the EQ-5D quality-of-life measure (figure based on n=110), the results section reported an improvement in activity (p=0.018) and a reduction in sleep (p less than 0.01). Other scores improved or were stable.
  • Six patients (4%) had PCC-related adverse events: urinary retention (2), opioid toxicity (1), impaired balance (1), dyspnoea (1) and pain at the PCC site (1).
• The authors' conclusion: The authors concluded that their findings support PCC as an effective and safe treatment for cancer-related pain. They also concluded that patients were often referred late in their disease, so the full benefit may not have been realised, and they proposed considering PCC at the earliest opportunity.
• Limitations the authors state:
  • Modest numbers: 159 procedures over 5 years.
  • Observational design with no comparison or control group. For example, there was no comparison by pain location.
  • Whether pain was nociceptive or neuropathic was not consistently recorded.
  • Missing data, for example on pain quality, non-opioid painkillers and non-drug strategies.
  • Patients were not referred using any formal criteria.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma, Quality of Life.

Related studies

• Cordotomy in mesothelioma-related pain: a systematic review — B.D. France, R.A. Lewis, et al. (2014)
• Ultrasound guided continuous erector spinae plane block for pain management in pulmonary malignancy — T. Aydın, O. Balaban, et al. (2018)
• Long-term continuous erector spinae plane block for palliative pain control in a patient with pleural mesothelioma — J. Ramos, P. Peng, et al. (2018)
• Peritoneal cystic mesothelioma: are surgery and HIPEC optimal first-line treatments? — F. Coccolini, R. Manfredi, et al. (2012)
• Anterior cingulotomy improves malignant mesothelioma pain and dyspnoea — E.A. Pereira, M. Paranathala, et al. (2014)
• Pleural malignant mesothelioma causing cord infiltration through the nerve root. Case report — H. Okura, Y. Suga, et al. (2009)

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