Transcription:
Managing Cancer Pain


John Leonard, MD (Host): Welcome to Weill Cornell Medicine, Cancer Cast, conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today on the podcast, we'll be talking about pain management for cancer patients. Our guest for this episode is Dr. Abhilasha Solanki. She's an interventional pain management physician and anesthesiologist at Weill Cornell Medicine and NewYork-Presbyterian hospital. Dr. Solanki specializes in treating a variety of acute and chronic pain conditions with the goal to provide her patients with optimal pain relief, improved function, wellbeing, and quality of life.

Her clinical practice focuses on cancer patients, geriatric care, and sports medicine. And so today I'm looking forward to focusing our conversation on how pain management and symptom relief are an important part of multidisciplinary approaches to cancer care. So, Dr. Solanki thank you for joining us today. It's great to have you. And this is a really important topic for our patients and I'm sure those in our audience will be very interested in learning more about how we can address these issues for patients.

Dr. Abhilasha Solanki: Thank you very much Dr. Leonard for such a generous introduction.

John Leonard, MD (Host): I want to start by asking you, how did you end up focusing in this area, specifically the area of pain medicine and management of pain and specifically cancer related pain? How did you zero in on this area for your clinical and research efforts?

Dr. Abhilasha Solanki: A series of events through my life have essentially led me to this career choice. During my residency in anesthesiology, in Boston at the Beth Israel Deaconess Medical Center, I worked at an Institute called the Arnold Pain Management Center. That was essentially my first introduction to pain. And that is exactly where I started developing a very keen interest in pain and more so, the science and the art of pain management. Alleviating patients of their pain and suffering has been by far the most gratifying experience for me as a physician.

And just seeing the joy on their faces of their family members when they were free of this agony, left such a huge impression on my mind that it kind of just made me realize that this is what I was meant to do. And since then, there has been no looking back. I decided to make this my chosen field of specialization and I moved to New York City to pursue a fellowship in interventional pain at Weill Cornell.

John Leonard, MD (Host): Well, it's great to have you here. And our patients certainly benefit from your background and your skill. And I think anybody dealing with cancer, whether it's themselves, their loved one or in their clinical practice, the issue of pain tends to come up fairly frequently, not for everyone with cancer, but certainly in some cases the pain that the patient is suffering is the dominant issue that they have in many ways.

Whereas others it's perhaps a smaller, but still important part of cancer care and the experience of the patient. So maybe we can start by thinking a little bit about how we define pain in the context of cancer care?

Dr. Abhilasha Solanki: Pain is actually one of the most common, as well as complex symptoms in cancer patients. The prevalence is extremely high in not only patients who are newly diagnosed with cancer and undergoing treatment for it, but also in cancer survivors. Usually what happens is that they have pain during cancer treatment and that could be as a result of the cancer itself, or it could be due to surgery or radiation therapy or chemotherapy that is needed to treat the cancer. Understandably, this has a huge impact on their lives. Their ability to function, their quality of life, their mood.

And there are quite a few studies that mention that acute pain is an important predictor of chronic pain after cancer treatment. So it's very important to be attentive to pain, frequent assessments and appropriate managements are key to getting this under control so that patients have an improved quality of life. And at the same time, it prevents them from developing chronic pain.

John Leonard, MD (Host): One factor that I think patients deal with and face in their care is the connection between the cancer-causing pain – whether it's a mechanical issue or a bony issue – and the need to treat the cancer itself to relieve that pain versus the symptoms and treating the symptoms. How can people think about that connection from the standpoint of treating the underlying process to manage the pain versus treating the symptom with analgesics or other areas? Is there a way you can encapsulate how people think about that or should think about that?

Dr. Abhilasha Solanki: Well, it's very important to remember that cancer pain management is a very integral part of cancer treatment plans. And this is actually given concurrently with the anti-cancer treatments. So, for example, if there is a patient with post-surgical pain they usually experience a combination of nociceptive and neuropathic pain. And then there is a role over there for pharmacological interventions and sometimes more invasive procedures. There are patients who have tumor related nerve compression which responds well to radiation therapy and sometimes steroid treatments as well.

So, our oncological services are very familiar with the basics of pain management that needs to be given concurrently with the anti-cancer treatment. And if they feel that they need more assistance that's when they actually consult us to weigh in on the pain management plan and make further recommendations.

John Leonard, MD (Host): So can you give us a little bit of a Breakdown of the key types of cancer related pain are the most common types of cancer related pain. it seems that part of it is related to the treatment and the treatment side effects. Some of it is the tumor itself. It may be other complications or other related issues, but what are the major categories of cancer related pain that you see?

Dr. Abhilasha Solanki: In my practice, I essentially treat all types of cancer pain. And most of my referrals come from our oncological teams over here at Weill Cornell. Having said that majority of these patients actually have breast cancer or prostate cancer, lung cancer, pancreatic cancer, colorectal cancer and gynecological cancer.

John Leonard, MD (Host): And are most of their scenarios related more to the tumor itself or the treatment? And we'll come back to the complications of something like neuropathy, which can be seen as a side effect of cancer therapy. If you could break down the percentages of your practice, does it end up being people dealing with severe pain directly from the cancer itself most commonly?

Dr. Abhilasha Solanki: It depends on the underlying cause of the cancer. In some patients, for example, the pancreatic cancer patients, pain is seen right at the time of diagnosis. And treatment starts almost right then, whereas in our breast cancer patients, a lot of these patients have post mastectomy pain or pain related to the chemotherapy drugs that they've had for treatments. Similarly, patients who are having colorectal cancer, in their case when they're getting ready for chemotherapy or chemo radiation or a combination of chemoradiation with surgery, pain can be a very big factor and they actually may need pain treatments prior to even starting the chemotherapy and the radiation therapy.

John Leonard, MD (Host): Let's get into the different ways that patients can address their pain issues. And before we get into medications and procedures, can you give us an overview first about the non-pharmacological ways that we deal with pain. Are there things that people can do with their exercise, their activities, or non-medical management of pain that for some scenarios can be very helpful that people could consider or look into?

Dr. Abhilasha Solanki: Over the years, there has been an increasingly important role of these non-pharmacological interventions in the management of cancer pain. And in fact, most of the cancer societies and cancer networks also recommend these. So, like I said, there is definitely a huge role. There are studies that show that music therapy or poetry sessions where patients learn breathing exercises and relaxation techniques have a very positive impact on their wellbeing and hence their pain control. Similarly, physical exercise and physical therapy has an equally important role. If you're not able to exercise then yoga and meditation techniques that one learns in yoga and just the relaxation breathing exercises, have a very positive impact on pain control.

Apart from that psychological interventions have a huge role to play in the treatment of the psychological aspect of pain treatment as well as cancer treatment. And mindful cognitive behavioral therapy, pain coping strategies, and just relaxation and guided imagery are some of the few interventions that pain psychologists can offer to patients in their journey of getting treated with cancer.

John Leonard, MD (Host): How would you recommend that patients identify that some of the things you just mentioned might be good options for them versus a more pharmacological based approach? Are there certain scenarios where the non-drug treatments might be more effective versus other scenarios where you say that's not going to work, you really need to go to a medication to control your pain?

Dr. Abhilasha Solanki: To begin with, the mainstay in cancer pain management continues to be pharmacological interventions and for good reason. The non-pharmacological interventions are very helpful, but it has to be very well understood that it's not an alternate approach when other approaches have failed. Instead, they should be considered as a complimentary therapy that provides and compliments the positive effect of other treatments. So, in my opinion, they both go hand in hand, the pharmacological interventions and the non-pharmacological interventions. And if you lean more towards the non-pharmacological that is completely all right.

John Leonard, MD (Host): So can you give us a sense of some of the major categories of pharmacological interventions that are available to patients? And I know many doctors or even oncologists are more or less familiar with certain categories, but the major areas of medications that you think are helpful and how you decide between them when you see a patient who's dealing with pain?

Dr. Abhilasha Solanki: Amongst the traditional painkillers, there are two big categories. There are the non-opioids such as nonsteroidal, anti-inflammatory drugs, like Motrin, Aleve, ibuprofen, Celebrex, and then paracetamol or Tylenol. And then there's the second big category: The opioids. Which have both weak opioids and the stronger opioids. And these have been traditionally used for the longest time. And during the initial stages of pain management, we typically use a combination of these medications.

And the type and the strength of these medication really depends on the clinical assessment and the pain severity. The goal is always to achieve rapid, effective and safe pain control. And in order to minimize the side effects of some of these medications, especially the opioids, there has been more interest in the use of adjuvant drugs such as steroids, anti-convulsant medications like Gabapentin, Lyrica, and then some anti-depressants which have pain, relieving effects such as Cymbalta and Amitriptylin, Notriptylin. Also, a separate class of drugs would be bisphosphonates, which are typically used for patients with metastatic bone pain.

Those are the big categories. And apart from that, it's also very important to remember that once the cause of the cancer pain is effectively addressed, it just follows that the use of these pain medications is no longer necessary. And so, we start tapering down these medications pretty effectively and safely with very close and regular assessment of our patients.

John Leonard, MD (Host): What are some of the side effects of different categories of these medicines that people need to think about as they're starting on them or choosing them? I know there are a lot of different drugs, but maybe just some of the high points of the things that need to be taken in consideration as one balances this all out?

Dr. Abhilasha Solanki: The non-steroidal anti-inflammatory medications are known to cause gastric discomfort or heartburn in simple terms. So, we need to remember to take it when they've had a meal, on full stomach. Opioids generally tend to have a variety of side effects and how a patient responds to these medications can be very different from another patient. The most common side effects that we see are nausea or gastric discomfort, again, sedation, and constipation. With the other adjuvant drugs, one of A number of patients that I've seen over the years have a lot of concern about being on opioids. And they're aware of the addictive potential in certain situations. Obviously, there's a lot of attention in the press and in the literature and in society about opioid addiction and all of those issues. I know that for cancer patients, while these may be concerns that they have personally, they are in a very different situation.

How do you tell patients to think about opioids? For someone who's concerned, they don't want to be addicted, they're worried about the stigma or just being connected to a medicine for a long term? How do you advise cancer patients specifically for whom you think opioids might be a good choice, but they may be reluctant?

Dr. Abhilasha Solanki: I spend a lot of time educating patients about these medications. And it's very natural for them to be worried about the stigma that comes with it. But having said that, this is also a very different subset of patients and typically, if somebody is not interested in pursuing opioids as a means of pain management, then I just work with them. And we do interventional pain procedures, which can actually provide abrupt reduction in pain such as interventional nerve blocks or neuroablative procedures. And if there are patients who are interested in taking opioids for pain control, then we start out at the lowest possible dose. And we titrate it to effect until they feel like they're comfortable and are not having any side effects.

John Leonard, MD (Host): You referenced a number of the interventional procedures that are available. I'm wondering if you could give the audience a little bit of an overview of the different categories of interventions that you and your colleagues are able to do and how you think about using more local therapy in these cases versus a systemic drug? What categories and what options of scenarios will these make a big difference for potentially?

Dr. Abhilasha Solanki: Amongst the interventional pain procedures some of the most common ones that we do are nerve blocks and neuroablative procedures. Patients who have neuropathic pain, which means, pain that comes because of nerve related irritation or compression are ideal candidates for this. Apart from this, we also do implants where we can do something called a spinal cord stimulator implant, or peripheral nerve stimulator implant. Once again, in patients who are having nerve related pain that is in a specific dermatome in their bodies.

What is a nerve block for the audience? How does that work? How do you physically do that?

So nerve block is, in simple terms, an injection that we do in the body to numb up the nerves that are causing pain. For example, if it's a patient who has pancreatic cancer, a procedure that we routinely do is called the celiac plexus block, which is basically a bunch of nerves that are supplying the pancreas. And we essentially put numbing medicine into these nerves so that they can stop the pain that the patient is experiencing. These procedures need to be done under imaging guidance. Sometimes it's under x-ray guidance, sometimes ultrasound guidance and sometimes CT guidance. And we are able to do these at Weill Cornell for all our patients.

John Leonard, MD (Host): The stimulator devices that you referenced, what's involved in those and what scenarios do you consider those procedures as an option?

Dr. Abhilasha Solanki: Well patients who have a single nerve related pain. For example, if somebody has compression of the sciatic nerve or the common peroneal nerve, these are big nerves in the leg. They might be actually very good candidates for a peripheral nerve stimulator, where essentially what we do is we implant a device that has small leads, which basically keeps stimulating the nerve and instead of feeling pain, the brain perceives those signals as vibration. So it's kind of reteaching the brain how to read those signals. And similarly, we have something called spinal cord stimulator implants, and they also do pretty much the same thing. These implants are also done on the imaging guidance.

John Leonard, MD (Host): What are some of the new things on the horizon in pain management? I know you and your colleagues do research. Where's the field moving? What are the new things that you think might be out there and available to patients in the coming years?

Dr. Abhilasha Solanki: We are using stimulators a lot now. And one of the things that has been around for a long time, but has been a little underutilized, is the intrathecal drug delivery system. This is something that we offer in patients who are not very good candidates let's say for oral analgesics and are not candidates for any localized treatment and are having generally a lot of pain. And it requires an implant in the body that basically continues to give them pain medication at a constant rate.

And it also minimizes the side effects that we would typically see with oral pain medications or transdermal pain medications. Apart from these implants there's increased usage of transcutaneous electrical nerve stimulation and acupuncture in the management of pain. We just need to do more clinical trials to show how effective these modalities are.

John Leonard, MD (Host): One of the key aspects of getting cancer care at an institution where you have multiple team members with different disciplinary expertise, such as at Weill Cornell and NewYork-Presbyterian is the idea that we have these multidisciplinary colleagues that are working together. Can you tell us a little bit about how that works in your area and how you interact with primary oncologists to identify the issues for patients and work together in managing them?

Dr. Abhilasha Solanki: The pain management division over here at Weill Cornell, collaborates with several oncological teams routinely. Most oncological services have meetings every once in a month, sometimes twice a month to discuss their patients. And if indicated they seek our services following which we basically see the patient, evaluate the patient and make our recommendations to them. This happens both in the inpatient setting, in the hospital, as well as in the outpatient clinics. And over the years, we have developed relationships with all these services. And we work very closely with them and we communicate on a regular basis about patients who may benefit from interventional pain procedures.

John Leonard, MD (Host): Before we finish, I wanted to ask you, what advice do you have for patients who may be having pain issues? What are the scenarios from the standpoint of patients being managed by their primary oncologist for their cancer, where you would say, gee you really should either ask your doctor or seek a referral to see a pain management specialist? What are the categories of scenarios where patients should really pursue specialized expertise in pain, if they're a cancer patient?

Dr. Abhilasha Solanki: For me, I think it's very important for patients to know that they should feel absolutely free to communicate with their cancer care teams, as well as their caregivers about any pain that they might be experiencing. Even if it doesn't seem like it's severe. You need to really talk about it. Because like we discussed, there are plenty of treatment options available to help treat their pain. And some of these options may not be very well known to their cancer care teams.

And in that scenario, they should feel free to request for the referral or consultation with us. And that can happen at any point during their cancer care. If it's earlier, it's better because then we are able to get the pain under better control quickly so that they're able to get back to functioning well and having a better quality of life.

John Leonard, MD (Host): Well, Dr. Solanki, thank you very much for joining us today. This has been a really useful and important discussion for this aspect of cancer care and management. So thank you for being here.

Dr. Abhilasha Solanki: Thank you very much.

John Leonard, MD (Host): I'd like to invite our audience to download subscribe, rate, and review CancerCast on Apple podcast, Google podcasts, Spotify or online at weillcornell.org.

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