Personalizing Pain Management and Palliative Care in Ovarian Cancer

A common goal for palliative care is pain management, where opioids like morphine are often on the frontline. Then, practitioners may build on medications from there, adding agents such as gabapentin and tricyclic antidepressants. But if those don’t work, Christopher J. Pietras, M.D. said that ketamine may be an option.
 
BY Brielle Urciuoli
PUBLISHED August 21, 2018
To add to the message that palliative care should be individualized for each patient, researchers are investigating this even further with a drug, ketamine – which is typically used to kickstart and maintain anesthesia use – for the difficult-to-treat pain associated with ovarian cancer.

Palliative care should be individualized for each patient being treated, and could even use ketamine – a drug that is typically used to kickstart and maintain anesthesia use – for patients with ovarian cancer whose pain is difficult to treat, according to.

“Treating patients’ symptoms, just like treating peoples’ cancers, is very individualized,” Christopher J. Pietras, M.D., director of Palliative Care and assistant clinical professor at the UCLA School of Medicine, said in an interview with OncLive, a sister publication of CURE.

“It’s very important to involve the oncologist, the primary care physician or a specialist in palliative care or pain so that they can assess where the symptoms are coming from and why,” he added.

Palliative care is a multidisciplinary approach focused on improving quality of life. Lately, advocates and experts alike have been trying to knock down the stigma that palliative care is meant only for people who are dying. In fact, when it comes to ovarian cancer treatment, some even say that palliative care is just as important as disease treatment.

Another misconception that people have is that being entered into palliative care means that their cancer treatment will stop.

“If someone was receiving a treatment for their cancer, and we know it’s either working or we’re waiting to see if it’s working, there is no reason to stop treatment. That is, unless it was directed by an oncologist in discussion with the patient,” Pietras said.

He mentioned that palliative care can help patients and their loved ones when facing difficult decisions, such as whether or not to stop chemotherapy or which chemotherapy option they should choose.

“It’s essential that we know what is important to them and how their symptoms affect their life, so they can receive the treatments that best match their goals,” he said.

A common goal for palliative care is pain management, where opioids like morphine are often on the frontline. Then, practitioners may build on medications from there, adding agents such as gabapentin and tricyclic antidepressants. But if those don’t work, Pietras said that ketamine may be an option.

“Although the data for ketamine do not include a large number of placebo-controlled trials, there are smaller studies suggesting that ketamine may be beneficial when used appropriately for patients with very difficult-to-control pain symptoms,” he said. “These patients would already be on very high doses of opioids and non-opioid adjuvant medicines, like gabapentin.”

During the OncLive State of the Science Summit on Ovarian Cancer, Pietras presented on the possible use of ketamine in palliative care for those with ovarian cancer. He said that while larger studies are needed, in the few that are available, it seems that ketamine may promising.

However, it is still too early for a conclusion to be made just yet.

“Therefore, ketamine should only be used in a select group of patients who have uncontrollable pain – despite highly escalated opioids and other medications – and in patients who do not have traits that would make them more likely to have side effects,” he said. “This includes patients who might feel confused and those who have anxiety, as those are the most common side effects with ketamine.”

Overall, pain management could look different for each patient.

“Although these are tough conversations, it’s important to know what patients want so that we can match treatments to their goals,” Pietras said. “That way, we can also lessen a caregiver’s depression and anxiety. We need to know if it’s better to have these conversations early or later in the disease course and what the effect on quality of life is.”

 
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