2. PATIENT CASE Module 1 Date of preparation: June 2015 HQ/EFF/15/0024h

3. Pain caused by cancer and cancer therapy Dr Carla Ida Ripamonti Oncologist / pharmacologist specialised expert in pain, palliative and supportive care Fondazione IRCCS, Istituto Nazionale Tumori, Milano, IT Routine care

4. Patient history Female, 66-years-old, retired school teacher, divorced, 2 sons, lives alone, no medical problem before 2004 2004: DIAGNOSIS OF invasive ductal carcinoma G3, pT1c, pNo, ER 95%, PgR 90%, Ki- 67 52%, HER2 2+ (gene non-amplified according to FISH) THERAPY: quadrantectomy dx + BLS + intraoperative RT + tamoxifene for 5 years 2014: DIAGNOSIS OF left breast nodule retroareolar, invasive ductal carcinoma and lobular component pT1c (2 cm), G3, diameter 2 cm, IV (>3 vessels involved), ER 95%, PgR 0%, HER2 1+, Ki-67 40%. Axilla sx 1/12 nodes; Axilla dx 9/22 nodes with massive mts THERAPY: Mastectomy sx + axilla dissection sx and dx + reconstruction with expander + adjuvant chemotherapy adriamycin + paclitaxel → CMF → RT supraclavicular dx → aromatase inhibitors No comorbidities

5. PAIN DUE TO CANCER THERAPY Patients refears pain in the hands and feet due to chemotherapy The pain is described as tingling, ringing, numbness and 2-3 times a day; stabbing The pain is of suspected neuropathic origin and the patient presents both neuropathy in the hands and feet because hands are weak and she has difficulties in holding a glass; she does not feel the presence of or painful neuropathy Stabbing pain arises sudden with an intensity of 10/10 on a NRS and a duration of 1-2 minutes

6. PAIN DUE TO CANCER 2015 February: Evaluated for the presence of osteopenia or osteoporosis. Osteopenia was confirmed at the femoural level and osteoporosis at the lumbar level February: Bone scan showed the presence of litic lesion (mts) at D7. The patient refered pain at rest and on moving at D7. Pain on moving is a type of predictable episodic pain

7. Current pain/illnesses As the patient presented sleeping problems and anxiety, she accepted the intervention of the psychologist and did not want drugs February 2015 At the first visit in my office she was on codeine + paracetamol t.i.d + gabapentin 100 mg t.i.d. The oncologist/chemotherapist sent the patient to me to assess and treat pain and to start with denosumab 120 mg IV every month The patient with sent for consultation to radiotherapist

8. Clinical examination and pain assessment Blood pressure: normal 120/80 mmHg Cardiovascular examination: normal limits Sensory examination: present of dysesthesia and paresthesia at the hands and feet + reduction in sensitivity at the fingers on the hand and feet ESAS administered to assess pain and other physical and emotional symptoms No specific tools used to assess for neuropathic pan

9. Clinical judgment By ESAS, pain at rest at D7 is 4/10, pain on moving is 7/10 Fatigue 6, nausea 0, depression 2, anxiety 3, drowsiness 0, short of breath 0, appetite 3, sleeping 8, feeling of well-being 5 Diagnosis of neuropathic pain was done with patient descriptions and physical examination Breakthrough cancer pain without a neuropathic component was present on moving due to bone metastases. The BTP with a neuropathic component (stabbing pain) was so sudden; the duration of 1-2 minutes made it impossible to consider

10. Ripamonti CI, et al. Support Care Cancer. 2014;22(3):783-93. Edmonton Symtom Assessment System (ESAS) Please circle the number that best describes: No Pain No Fatigue No Nausea No Depression No Anxiety No Dowsiness No Shortness Of Breath Best Appetite Best Sleep Best Feeling Of Well-being Worst Feeling of Well-being Imaginable 0 1 2 3 4 5 6 7 8 9 10 Worst Sleep Imaginable Worst Appetite Imaginable Worst Shortness of Breath Imaginable Worst Anxiety Imaginable Worst Dowsiness Imaginable Worst Depression Imaginable Worst Nausea Imaginable Worst Fatigue Imaginable Worst Pain Imaginable

11. Therapeutic approach Drugs for background pain changed from codeine to oxycontin 10 mg every 8 hours with a reduction of background pain to 2/10 and a reduction in neuropathic pain in the hands and feet by 30% Breakthrough pain medication: buccal fentanyl started at 100 mcg,as needed 200 mcg occasionally with reduction or absence of pain during movement, although somnolence reported Non-pharmacologic treatment: placed an orthopaedic brace (only when she had to travel) + psychological intervention for other symptoms (sleeping and anxiety)

12. Follow-up Pharmacological treatment for nociceptive pain (bone mets) and neuropathic pain (due to chemotherapy) Interval after initial consultation/change in pain meds, 2 weeks No complaint of AEs (after a laxative was added) Says medication alleviates most pain Says now able to sleep better because pain is under control and because the anxiety is reduced thanks to psychological intervention with no drugs

13. Conclusions Buccal fentanyl was effective in reducing breakthrough cancer pain and was well tolerated Collaboration between a palliative care specialist and a pain specialist was beneficial for proper therapy

14. Thank you