BACKGROUND: Cancer pain can be debilitating and 10-20% of patients will have refractory pain despite optimal medical management. Here, we present a cost comparison of treating terminal cancer patients with intravenous (IV) narcotics, anterolateral cordotomy, or intrathecal pain pump (ITPP) placement. CASE DESCRIPTION: We evaluated and treated 2 patients with metastatic breast cancer and expected survivals of <1 year. The first patient, a 53-year-old female, had tumor invasion of the right chest wall and had failed oral pain regimens; she was admitted to receive IV Dilaudid as patient-controlled analgesia (PCA). After 7 days of treatment without improvement, she underwent a left-sided C1-2 cordotomy. For her, the cost of the cordotomy was $18,462 and the expenses for 7 days hospital stay with PCA was $89,884; the total was $108,346. The second patient, a 60-year-old female, had severe somatic pain due to invasion by tumor of the left knee cap. She, too, has failed oral therapy and was receiving in-hospital IV Dilaudid PCA. Following 2 days of failed treatment, a morphine ITPP was placed and effectively treated her pain. In patient 2, the cost of the ITPP was $80,603 and the expenses for 8 days of the hospital stay with PCA came to $84,785; the total was $165,389. CONCLUSION: The treatment of refractory pain in cancer patients is challenging. It requires invasive procedures such as cordotomy or ITPP. Although procedures may yield comparable pain control, there was a significant cost savings for cordotomy versus ITPP ($57,043 saved). Copyright:
BACKGROUND: Cancer pain can be debilitating and 10-20% of patients will have refractory pain despite optimal medical management. Here, we present a cost comparison of treating terminal cancer patients with intravenous (IV) narcotics, anterolateral cordotomy, or intrathecal pain pump (ITPP) placement. CASE DESCRIPTION: We evaluated and treated 2 patients with metastatic breast cancer and expected survivals of <1 year. The first patient, a 53-year-old female, had tumor invasion of the right chest wall and had failed oral pain regimens; she was admitted to receive IV Dilaudid as patient-controlled analgesia (PCA). After 7 days of treatment without improvement, she underwent a left-sided C1-2 cordotomy. For her, the cost of the cordotomy was $18,462 and the expenses for 7 days hospital stay with PCA was $89,884; the total was $108,346. The second patient, a 60-year-old female, had severe somatic pain due to invasion by tumor of the left knee cap. She, too, has failed oral therapy and was receiving in-hospital IV Dilaudid PCA. Following 2 days of failed treatment, a morphine ITPP was placed and effectively treated her pain. In patient 2, the cost of the ITPP was $80,603 and the expenses for 8 days of the hospital stay with PCA came to $84,785; the total was $165,389. CONCLUSION: The treatment of refractory pain in cancer patients is challenging. It requires invasive procedures such as cordotomy or ITPP. Although procedures may yield comparable pain control, there was a significant cost savings for cordotomy versus ITPP ($57,043 saved). Copyright:
Cancer-related pain represents a challenge to manage medically, and most patients will require higher and higher doses of opioid analgesics due to receptor downregulation, which puts them at risk of opioid addiction and death.[6] Utilizing an optimal noninvasive medical treatment, about 30% of patients will have refractory pain, thus requiring invasive pain procedures to achieve partial or complete relief.[5] Different invasive pain procedural options include anterolateral cordotomy, spinal cord stimulation, and intrathecal pain pump (ITPP).[2,3] Here, we present a cost analysis of in-hospital intravenous (IV) narcotics, anterolateral cordotomy versus ITPP placement in two terminal cancer patients.
CASE DESCRIPTION
Case 1
A 53-year-old female with metastatic breast cancer presented with severe pain involving the right chest wall; her n expected survival was <1 year. She had failed oral narcotics and was admitted for 7 days of Dilaudid patient-controlled analgesia (PCA); nevertheless, this left her with a 5/10 residual pain score. She, therefore, underwent a left-sided C1-2 cordotomy which resulted in immediate pain relief. The PCA was weaned over 2 days and she was discharged home in stable condition. The total cost of her care was $108,346; $18,462 for the cordotomy, $89,884 for the hospital stay [Tables 1 and 2].
Table 1:
Patient demographics.
Table 2:
Details of the pain procedures cost.
Patient demographics.Details of the pain procedures cost.
Case 2
A 60-year-old female with metastatic breast cancer and an expected survival of <1 year presented with severe cancer- related pain involving the left knee cap. She failed oral narcotics and local nerve blocks. She was admitted for Dilaudid PCA, but her residual pain was 7/10 on the VAS, so she underwent ITPP placement. Immediately postoperatively she experienced partial pain relief and the PCA was weaned over 7 days (e.g., to titrate the intrathecal opioids), at which point she was discharged home. The total cost of her care totaled $165,389; $80,603 for the ITPP placement procedure (including the implants) and $84,786 for the hospital stay [Tables 1 and 2].
DISCUSSION
In 1986, the World Health Organization stated the following “to provide relief from pain to the patient’s satisfaction, so that [they] may function effectively and eventually die free from pain” in regard to cancer-related pain.[8] Yet, multiple reports have shown that a significant percentage of patients with cancer pain is undertreated and suggest that the majority of these patients may benefit from interventional pain procedures.[4] Percutaneous cervical cordotomy provides immediate and long-lasting relief of unilateral somatic pain in about 90% of patients, with a low complication rate of <5%.[3] ITPP acts by delivering minute doses of opioids intrathecally, which causes pain relief without the untoward side effects of IV and oral opioids. A recent randomized controlled trial showed that 85.7% of patients randomized to receive a cordotomy experienced >33% reduction in pain intensity (≥4 points), while none randomized to palliative care achieved a similar reduction in pain.[7] Corrado et al. found that ITPP resulted in a 4.2-point reduction of the pain score (9.1–4.9 on 10-point pain scale) in two-thirds of their cancer patients, while Brogan et al. showed that ITPP achieved cost-effectiveness at 7.6 and 10.7 months versus high and low conventional opioid therapy, respectively.[1] In this report, the cost of the cordotomy ($18,462) was 22.9% of the cost of ITPP ($80,603) and 27% that of in-hospital PCA for ITTP titration.
Cost summary
In a cancer patient with expected survivals of <1 year, cordotomy saved about $57,053 in total cost versus ITPP. Therefore, for patients with estimated survivals of under 1 year, cordotomy was the most cost-effective versus ITPP in which is a better option in cancer patients with survival estimated at >1 year.
CONCLUSION
There is an obvious need for cost effective and adequate treatment for cancer-related pain. This study documented the lesser costs but comparable efficacy of utilizing cordotomy to treat patients with estimated survivals of <1 year versus the recommendation to consider ITPP for those with >1 year to live.