Reviving Interventional Therapies for Cancer Pain Management

[MUSIC PLAYING] One of the things we often forget about when we're treating cancer is the pain that patients with cancer experience. There's been a lot of challenges lately in terms of getting appropriate pain management, much more restriction of the use of opioids, what other therapies are out there, and how do we pay enough attention to people's pain, especially when it comes to cancer.

Well, joining me today is Dr. Michael Byas-Smith. He's the medical director of Capital Caring's Schoufield Family Advanced Pain Clinic to talk about some of the latest advances. Dr. Byas-Smith, thanks for joining me.

Oh, glad to be here. When we talk about the latest advantages, we have to first talk about where we are in how we conceptualize management of pain and cancer patients. So we went through a period in our culture where we thought morphine was the answer to all pain, especially cancer pain. And so if you develop cancer pain, all you needed was morphine or Dilaudid or some other morphine compound. And end the story.

Well, it turns out that the opiate medications, while a godsend for patients with severe pain, are not the panacea for managing a lot of the syndromes that we see in cancer patients. And so we've actually gone back to some of the older treatments that were developed in the '50s and '60s for managing pain. These are the interventional therapies that we offer at our pain clinic. So often, patients, anywhere from 10% to 20% of patients will experience uncontrolled pain despite being on heavy doses of opioid medications.

And so we come in, and we provide the alternatives to try and wall off the pain. And so we try to make it so that the brain, the consciousness doesn't experience the pain. And we do that through a number of different ways.

I want to go back for a second, Dr. Byas-Smith, and talk about even-- you mentioned how we really felt that opioids was the mainstay therapy. We realized the side effects that often had, even on patients with cancer. And then the environment has made it more difficult, in some ways, for people to get appropriate pain management. Is that accurate?

That would be accurate. And the way we regulate the use of opioid medications certainly has made it more difficult for patients to get all the medication that they need in the opioid class. But we also recognize that those medications are not a panacea for managing all cancer pain.

Tell us how you think about treating pain. And is it different whether it's acute pain or chronic pain?

MICHAEL BYAS-SMITH: I'm an old fashioned doctor, and we always start with what is the mechanism that's causing the underlying primary pain problem. And then what other confounding issues are magnifying that symptom. So for example, if a patient has huge anxiety because they just recently been diagnosed with the cancer problem, and maybe they haven't been told that they have a short time to live. And then they develop this pain problem. You have to bring-- factor that in to manage that pain.

So it's not just the pain by itself, it's how the patient is experiencing their clinical diagnoses, how they're responding to the medications that have been tried, et cetera. So a number of different parameters have to be considered in coming up with the appropriate treatment plan for the individual patient.

And often, cancer patients have more than one source of pain. And so we can't just think, oh, they've got cancer, they have pain. So therefore, morphine is the answer. There may be neuropathic pain syndromes involved. There may be bone, yeast destruction that's involved, there may be visceral expansion and compression that's causing the pain. So we have to think about all of these different systems in the same patient.

So tell us what some of these advances are. You've got a lot of machinery behind you. That's not what we might have thought about as we were going to talk about pain today. So what should consumers know, what should caregivers know, patients know, about some of the advances in pain management?

MICHAEL BYAS-SMITH: So the advance that we put forward is that when patients get to the end of their treatments for cancer, but their symptoms persist or magnified, they still need to understand we need to understand the source of their discomfort. And some of the equipment behind me or the imaging tools that we use to try to understand why a problem exists to begin with because if we don't know, then we can't properly apply interventional therapies.

So if the patient has a big cyst growing out of their kidney, and we just give them morphine, probably not going to get good relief. But the images can tell us quickly precisely what's going on with that kidney. So often, patients who are at the end of treatments, they're also in their diagnostic workup for problems that occur. So for patients with advanced disease, it's important that we continue to investigate every new occurrence of stress and exacerbation of pain in our patients.

And what are the specific type of interventions that you perform?

So if you look from a governmental standpoint as say, Dr. Byas-Smith, what are you doing in your clinic? We have 50 different procedures plus that we do in our clinic. But they can all be crystallized into just a few categories. So I mentioned earlier that if you have a severe pain syndrome involved in your head, then there are techniques that we can apply to knock out all the pain signals that are coming from that hip.

Can't fix the hip, can't get rid of the cancer. But there's no reason for that patient to suffer with signals coming from that hip. And so one of the things that we do is we call it neural lysis where we inject the nerves that are serving the painful part so that that information can be conducted.

The other thing that we do is we augment the signal once it gets into the central nervous system. So when information, painful information, even other since information, finds its way back to the spinal cord, the spinal cord then thinks, what is going on, what should we do with this information. Is an important enough to magnify it and send it up to the brain, or should we suppress it because it's not that important? And constantly, your nervous system is making these adjustments.

And so what we do is we help it to make the adjustment to turn the signal down so that pain signals are not transmitted to the brain as easily. Sometimes completely obliterated.

How do you do that?

So there are certain medications like morphine, like dilaudid. And there's some other fancier medications that we put into the spinal fluid which absorbs into the spinal cord, goes to the Centers that do this modulation of the pain signal and shut that signal off. And so through injections and through catheter insertions.

For some patients, we put pumps in because we need to give that medication 24/7. We implant a subcutaneous pump that we can refill periodically to deliver a very small amount of medications to the spinal cord, which block the pain signals or modulate the system so that the person doesn't experience severe pain.

One criticism in pain management that patients often bring up is that they're often chasing the pain, right? They have pain, they take a medication, it's relieved, then it returns. This strategy is somewhat different, isn't it?

Very different. Our goal is to-- and it's not that often that we miss-- that we want to eliminate all pain. So the patient doesn't have to think about it, doesn't have to anticipate, eight hours from now, I need to be taking a pill, or I need to get an injection. We try to make it so that the exacerbation of pain is very infrequent.

And so using this approach, not only do we get a longer duration of relief, but we eliminate the need to take the pills on a scheduled or prem basis so that patients don't have to think so much about the symptom management and can have a higher quality of life.

Now many patients watching may be thinking, well, I never heard of this. I never heard about these types of therapies. How did they find out about it? Because even their cancer doctor, their other doctor, may not tell them about it, it may not be available in their area. What's your advice to viewers?

So luckily, we have the internet. And so if you just go on to your browser, type in cancer pain management intervention, you will get a plethora of sites that will describe to you the kind of techniques that we are using in our clinic. The issue could be that your doctor that you're seeing every day is so focused, rightfully so, on trying to cure the problem that these kind of interventions are overlooked sometimes.

So if you go to your standard pain management clinic, they're working usually with an orthopedic surgery service and they're helping to manage their patients. They're doing a lot of spinal injections. Or people who are going to get back to skiing and get back to working-- that sort of thing. They will know about doctors like me in their midst and certainly all of the major oncology systems will be aware of docs like me we work with all of the major systems in the DC Metropolitan area for example. So when they come across difficult to manage problems. We will get those calls

I want to ask you-- has the COVID pandemic restricted people's access to these types of therapies? Either they're not coming in because they're fearful of going into a hospital or medical setting or maybe they're just saying, you know what, pain is a natural part of the disease, and I'm just going to live with it. What's your response to that?

Well, there's no question that the COVID has had a negative impact on all facets of medicine-- cardiology, neurology, pain management-- because especially in my field, I can't do my work without me seeing the patient, touching the patient, doing imaging studies on patients. We can do an interview over the Zoom call to get a sense of what kind of treatments we might be able to offer. But until we touch those patients, we cannot adequately assess those patients.

So it has impacted my practice significantly. But even through the pandemic, we have made a way for patients to get in to see us. And things are starting to ease up now. We're going out into the hospitals more. They're easier to get in. Hospitals were locked down. And so I think the COVID impact is going to be lessened. But we still have the issue of the community not being aware that these kinds of therapies are readily-- can be available to them.

Dr. Byas-Smith, I want to thank you for taking the time today, educating us about what are some of these new therapies that patients with cancer can utilize to relieve their pain.

Glad to be here. Thank you so much.

If you have questions, drop us a line. You can email me [email protected]. Thanks for watching.

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