Kanser Ağrısına Yaklaşım
Özet
Kanser, dünya genelinde önemli bir mortalite ve morbidite nedeni olup hastaların büyük kısmında psikolojik acıyı da tetikleyen ağrılara yol açmaktadır. Ağrı; nosiseptif, nöropatik ve psikojenik olarak sınıflandırılmakta; etiyolojik olarak ise kanserin kendisine, cerrahi, kemoterapi, radyoterapi gibi tedavi süreçlerine veya kanser dışı nedenlere bağlı olarak gelişebilmektedir. Ağrı yönetiminde temel amaç hastanın yaşam kalitesini artırmaktır. Bu doğrultuda Dünya Sağlık Örgütü (DSÖ), ağrının şiddetine göre non-opioid, zayıf opioid ve güçlü opioidlerin adjuvan ilaçlarla kombine edildiği üç basamaklı bir analjezik merdiven tedavisi şablonu önermektedir. Hafif ağrılarda parasetamol ve NSAİD'ler tercih edilirken, dirençli ve şiddetli vakalarda morfin, fentanil gibi güçlü opioidlere geçilmektedir. Ayrıca nöropatik ve kemik ağrılarında antidepresan, antikonvülsan, kortikosteroid ve bifosfonat gibi adjuvan analjezikler tedaviye eklenmektedir. İlaç tedavisine dirençli olgularda ise epidural/intratekal kateterler, sinir blokları ve kordotomi gibi invaziv yöntemler uygulanabilmektedir. Kanser ağrısı farmakolojik yöntemlerle %80-90 oranında çözülebilse de bilgi eksikliği ve opioid bağımlılığı korkusu gibi nedenlerle pratikte başarı oranı %30-40'ta kalmaktadır; bu yüzden doktor, hasta ve hasta yakınları arasında güvene dayalı multidisipliner bir yaklaşım gereklidir.
Cancer is a leading cause of mortality and morbidity worldwide, causing pain that also triggers psychological distress in a large portion of patients. Pain is classified into nosiceptive, neuropathic, and psychogenic types, and etiologically, it can develop due to the cancer itself, treatment processes such as surgery, chemotherapy, and radiotherapy, or non-cancer causes. The primary goal of pain management is to improve the patient's quality of life. Accordingly, the World Health Organization (WHO) recommends a three-step analgesic ladder treatment template in which non-opioids, weak opioids, and strong opioids are combined with adjuvant drugs based on the severity of the pain. While paracetamol and NSAIDs are preferred for mild pain, strong opioids like morphine and fentanyl are utilized in resistant and severe cases. Furthermore, adjuvant analgesics such as antidepressants, anticonvulsants, corticosteroids, and bisphosphonates are added to the treatment for neuropathic and bone pain. In cases resistant to pharmacotherapy, invasive methods like epidural/intrathecal catheters, nerve blocks, and cordotomy can be applied. Although cancer pain can be effectively treated at a rate of 80-90% with pharmacological methods, the success rate remains around 30-40% in practice due to reasons such as lack of knowledge and fear of opioid addiction; therefore, a multidisciplinary approach based on trust among the doctor, patient, and patient's relatives is required.
Referanslar
1.Chapman CR, Casey KL, Dubner R, Foley KM, et al. Pain measurement: an overview. Pain 1985; 22(1): 1-31.
Van Everdingen MH, Hochstenbach LM, Joosten EA et al. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. J Pain Symptom Manage. 2016;51:1070–90
Hall AJ, Sykes NP. Analgesia for patients with advanced disease. Postgrad Med J 2004; 80: 148-154
4.Sarıhan E, Kadıoğlu E, Artıran İğde F. Kanser Ağrısı, Tedavi Prensipleri ve Dünya Sağlık Örgütü Ağrı Basamak Tedavisi. Nobel Med 2012;8(1): 5-15.
Eti Z. Kansede ağrı tedavisi. Üroonkoloji Bülteni 2005;2: 16-20.
6.Mitra R, Jones S. Adjuvant analgesics in cancer pain: a review. Am J Hosp Palliat Car 2012;29(1):70-9.
7.Coyle N, Layman-Goldstein M. Pharmacologic management of adult cancer pain. Oncology (Williston Park) 2007;21(2): 10-22.
Ripamonti CI, Bandieri E, Roila F; ESMO Guidelines Working Group. Management of cancer pain: ESMO Clinical Practice Guidelines.Ann Oncol 2011; 22 (6): 69-77
9.McNicol E, Strassels SA, Goudas L et al. NSAIDS or paracetamol, alone or combined with opioids, for cancer pain. Cochrane Database Syst Rev 2005 25;(1):CD005180
Davis MP, Lasheen W, Gamier P. Practical guide to opioids and their complications in managing cancer pain. What oncologists need to know. Oncology (Williston Park) 2007;21(10):1229-38.
Marinangeli F, Ciccozzi A, Leonardis M et al. Use of strong opioids in advanced cancer pain: a randomized trial. J Pain Symptom Manage 2004; 27(5):409- 16.
Mercadante S, Porzio G, Ferrera P et al . Low morphine doses in opioid-naive cancer patients with pain. J Pain Symptom Manage 2006;31(3):242-47.
Ripamonti C, Bandieri E. Pain therapy. Crit Rev Oncol Hematol 2009;70(2):145-59.
Messina J, Darwish M, Fine PG. Fentanyl buccal tablet. Drugs Today (Barc) 2008;44(1):41-54.
Mercadante S, Bruera E. Opioid switching: a systematic and critical review. Cancer Treat Rev 2006; 32: 304- 315.
Tan P, Barry S, Reken S et al. Pharmacological management of neuropathic pain in non-specialist settings: summary of NİCE guidance. BMJ 2010; 340: c1079
SaartoT, WiffenP. Antidepressants for neuropathic pain (Cochrane Review) Cochrane Syst Rev 2007; 2: CD002068
Wiffen P, Mcquary H, Edwards J t al. Gabapentin for acute and chronic pain (Cochrane Review) Cochrane Syst Rev 2005; 2:CD005452
Wiffen P, Collins S, Mcquary H et al . Anticonvulsant drugs for acute and chronic pain.(Cochrane Review) Cochrane Syst Rev 2005; 3:CD001133
Mercadante SL, Berchovich M, Casuccio A et al. A prospective randomized study of corticosteroids as adjuvant drugs to opioids as adjuvant drugs to opioids in advanced cancer patients. Am J Hosp Palliat Care. 2007; 24: 13-19
Shih A, Jackson KC. Role of corticosteroids in palliat,e care. J Pain Palliat Care Pharmacother. 2007; 21: 69-76
Aapro M, Abrahamsson PA Body JJ et al. Guidance on the use of bisphosphonats in solid tumors: recommendations of an international expert panel. Ann Oncol 2008; 19: 420-432.
Nguyen H, Garber JE, Hassenbusch SJ. Spial analgesics. Anesthesiology Clin N Am 2003; 21: 805-816
De Leon-Casasola OA. İnterventional procedures for cancer pain management: are they indicated ? Cancer İnvest 2004; 22: 630- 642
