Opioid rotation is now considered
standard practice in the
management of cancer pain.
The rationale for the approach has
been well summarized by Estfan and
colleagues. Rotation should be viewed
as one strategy among many to deal
with patients who demonstrate relatively
poor responsiveness to an opioid.[
1] Application of well accepted
clinical guidelines for opioid administration,
beginning with those originally
promulgated by the World
Health Organization, emphasize
the need to individualize the opioid
dose through a process of gradual
dose titration, irrespective of the specific
drug. Most cancer patients attain
an adequate balance between
analgesia and side effects, at least
initially. Some, however, experience
treatment-limiting toxicity, the sine
qua non of “poor responsiveness.”
This response reflects an outcome that
is related to a specific drug, route of
administration, set of patient-related
variables, and time.
Russell K. Portenoy, MD
Opioid rotation is now considered
Dyspnea is an extremely common symptom among cancer patients. Like pain, it is inherently subjective and is best defined as the perception of difficulty in breathing, or an uncomfortable awareness of breathing. Although it may be associated with one or more physiologic disturbances (such as hypercapnia, hypoxia, obstructive or restrictive patterns on pulmonary function tests, or various abnormalities on chest imaging studies), it is not strongly associated with any specific abnormality and may occur in the absence of any. Patient self-report is the gold standard for assessment and may range from mild breathlessness on exertion to a terrifying sense of suffocation.
In their article, Drs. Choi and Billings address a number of strategic areas in palliative care. These topics include the definition and scope of the evolving field, the complexities involved in the use of modalities that carry burden or risk (such as artificial nutrition and bowel decompression), and the underappreciated importance of communication skills and a capacity for ethical reasoning.
Fatigue is one of the most common symptoms experienced by patients with cancer and other progressive diseases. Although reported to be a major obstacle to maintaining normal daily activities and quality of life, remarkably few studies of this syndrome have been conducted.
Neuropathic pain may be defined as pain related to abnormal somatosensory processing in either the peripheral or central nervous system. This pathophysiologic label is typically applied when the painful symptom is associated
It is a propitious time for the publication of Dr. Wein’s thoughtful paper on sedation in the imminently dying. Although this intervention has been accepted by most palliative care specialists for many years, it seems to be unfamiliar to many oncologists. The numerous surveys[1-7] and published guidelines that have informed discussions of the technique have not appeared in the oncology literature and probably have been read by few of the front-line clinicians who care for dying cancer patients. Like the broader model of palliative care of which it is part, sedation in the imminently dying must be “mainstreamed”—ie, understood in all its complexity by clinicians whose patients may benefit most from its skillful application.
As a result of a burgeoning science and an intensive educational campaign that began more than a decade ago, oncologists
Dr. Peter Staats presented the case of a 15-year-old, 40-kg boy with a primitive neurectodermal tumor located in
Large surveys of populations with cancer pain indicate that as many as 90% of patients can attain adequate relief of pain using optimal, systemic, opioid-based pharmacotherapy. Skilled clinicians should be able to achieve
Michael H. Levy, MD: This 38-year-old white male first came to his physician in January of 1993 complaining of epigastric and low back pain. In March of 1993, he was diagnosed with pancreatic cancer that was metastatic to his