Page 32 Complete Your CE Test Online - Click Here ● ● External radiation therapy may be given in a single dose or divided into several smaller doses given over a period of time. The decision as to whether to have single or divided dose may depend on how easy it is to get the treatments and their cost. ● ● Radiopharmaceuticals may be used to relieve pain from bone metastases. A single dose of a radioactive agent given IV may relieve bone pain when there are too many areas to treat with external radiation therapy. Physical medicine and rehabilitation Patients with cancer and pain may lose their strength, freedom of movement, and ability to manage their daily activities. Physical therapy or occupational therapy may help. Physical medicine uses physical methods, such as exercise and machines to prevent and treat disease or injury. Physical methods to treat weakness, muscle wasting, and muscle and bone pain include: ● ● Exercise to strengthen and stretch weak muscles, loosen stiff joints, help coordination and balance, and strengthen the heart. ● ● Changing position (for patients who are unable to move on their own). ● ● Limiting movement of painful areas or broken bones. Some patients may be referred to a physiatrist (a doctor who specializes in physical medicine) who can develop a personal plan for them. Some physiatrists are also trained in procedures to treat and manage pain [146]. Complementary therapies Complementary and alternative therapies combined with standard treatment may be used to help treat pain. Acupuncture, support groups, and hypnosis are a few integrative therapies that have been used to help pain [146]. ● ● Acupuncture is an integrative therapy that applies needles, heat, pressure, and other treatments to one or more places on the skin. Acupuncture may be used as an adjunct to try and help control pain, including pain related to cancer. ● ● Hypnosis may help patients relax and is often combined with other thinking and behavioral methods. Hypnosis to relieve pain works best in people who are able to concentrate, use imagery, and who are willing to practice the technique. ● ● Support groups help many patients. Patients with religious affiliations may be helped by religious counseling. Pastoral counseling (non-denominational) may also help by offering spiritual care and social support. Cancer pain in older patients is managed more cautiously Elders must be started on lower doses of opioids and titrated slowly to allow for differences in pain thresholds and responses to the drugs. There are some recommendations against using NSAIDs and tricyclic antidepressants in geriatric patients [145]. Meperidine is contraindicated in chronic pain management. It can be especially harmful in patients with decreased renal function or dehydration, and can cause delirium in older patients [203]. After pain control medications and other measures are started, and especially after each modification or addition, the nurse and the cancer treatment team must continue to assess how well it is working, monitor for side effects, and make changes if needed. Mucositis (Stomatitis) and mouth pain Ulcerative mucositis occurs in about 40% of patients receiving chemotherapy, and typically starts seven to ten days after treatment starts, remaining for about two weeks after it is finished. Chemotherapy often damages healthy cells in the mouth and gut, causing problems with eating and drinking liquids. Pain and inflammation can also be caused by fungal infections (thrush), viral infections, radiation to the head and neck. Susceptibility to these infections can be caused by direct toxicity to the mucosa as well as neutropenia and dysfunction of the salivary glands. There are no agents that prevent this toxicity, although dental and periodontal infections can be treated. Some infections can be prevented by oral rinses with 0.12% chlorhexidine gluconate and gentle brushing and flossing. Peroxide rinses were once recommended to help remove bacteria but peroxide can damage fibroblasts and keratinocytes and delay mucositis healing [181]. Cancer treatment agents most commonly associated with mucositis are [145,302]: ● ● Cytarabine. ● ● Doxorubicin. ● ● Etoposide. ● ● 5-fluorouracil. ● ● Methotrexate. ● ● Epidermal growth factor receptor inhibitors (such as afatinib, cetuximab, erlotinib, gefitinib, lapatinib, panitumumab). ● ● Multitargeted tyrosine kinase inhibitors (such as cabozantinib, ceritinib, crizotinib, pazopanib, regorafenib, sorafenib, sunitinib, vendetanib). ● ● Mammalian target of rapamycin inhibitors (such as everolimus, temsirolimus). Complications can be acute (developing during treatment) or chronic (developing months to years afterward). In general, cancer chemotherapy causes acute symptoms that resolve following treatment, with recovery of damaged tissues [181]. Primary preventive measures should begin before chemotherapy starts; appropriate nutritional intake, effective oral hygiene practices, and early detection of oral lesions are important pretreatment interventions. Patients who smoke should be offered help with cessation before treatment begins, since smoking reduces microcirculation and delays healing and is known prolong mucositis after radiation therapy [181]. Dental consultation a few weeks before cancer chemotherapy starts can sometimes help prevent complications by treating problems and starting a program of oral hygiene. Specific interventions are directed at [181]: ● ● Mucosal lesions. ● ● Dental caries and endodontic disease. ● ● Periodontal disease. ● ● Ill-fitting dentures. ● ● Orthodontic appliances. ● ● Temporomandibular dysfunction. ● ● Salivary abnormalities. If the patient is already myelosuppressed at the time of dental treatment, some corrections or prophylaxis may be needed (e.g., platelet transfusions or antibiotics if ANC less than 2000). Mucositis should be managed by good oral hygiene, and avoidance of spicy, acidic, hard, and hot foods and drinks. Dental brushing and flossing should be performed daily with assistance from professional staff [181]: ● ● A soft nylon-bristled toothbrush should be used two to three times a day with techniques that specifically maintain the gingival portion of the tooth and periodontal sulcus and keeping them free of bacterial plaque. ● ● Rinsing the toothbrush in hot water every 15 to 30 seconds during brushing will soften the brush and reduce risk for trauma. ● ● Oral rinsing with water or normal saline three to four times while brushing will further aid in removal of dental plaque. ● ● Rinses containing alcohol should be avoided. ● ● Toothpaste with a relatively neutral taste should be considered because flavorings can irritate oral soft tissues. ● ● Brushes should be air-dried between uses. ● ● Ultrasonic toothbrushes may be substituted for manual brushes if patients are properly trained in their use. ● ● Patients skilled at flossing without traumatizing gingival tissues may continue flossing throughout chemotherapy administration. ● ● While toothbrush disinfectants have been suggested, their routine use to clean brushes has not been proven of value. The mouth should be cleaned after meals [181]: ● ● If xerostomia is present, plaque and food debris may accumulate secondary to reduced salivary function, and more frequent hygiene may be necessary. ● ● Dentures need to be cleaned with denture cleanser every day and should be brushed and rinsed after meals. ● ● Rinsing the oral cavity may not be sufficient for thorough cleansing of the oral tissues; mechanical plaque removal is often necessary. ● ● Care must be exerted in the use of the varied mechanical hygiene aids that are available; dental floss, interproximal brushes, and wooden wedges can injure oral tissues rendered fragile by chemotherapy. ● ● Foam toothbrushes have limited ability to clean teeth but may be useful for cleaning other areas of the mouth, palate, and tongue.