Case Study

Cancer Pain Management–Matthew

Liz wrote the following segments of a single patient case study in order to thread these throughout four text modules designed designed to train pharmaceutical sales representatives in—among other things—the challenges involved in managing cancer pain. To comply with confidentiality agreements, Liz has changed the proprietary name of the product to “PainMed®.”


Module 1

Section 4.2: The Pain Pathway

Patient Case History: Matthew

Matthew is a 49-year-old writer and history professor with a 40-year-old wife, Sybil, and a six- year-old son, Josh. Things have been going extremely well for Matthew—his newly published biography of Frederick Douglass has been well received; Sybil just received a hefty bonus at work; and Thad is a happy, healthy first-grader with a boundless enthusiasm for reptiles and a headlamp he has taken to wearing even when the sun is bright.

What, then, accounts for the dull pain in Matthew’s stomach? he wonders. He can’t pin down when exactly the pain began, but it dawns on him that it never really goes away. In fact, the pain seems to be spreading. Last night, there was such an unrelenting ache in his lower back, it was hard to get comfortable and fall asleep.

“Stress,” says Sybil. “You’re worried about that grant proposal.”

“I’ve never felt less stressed in my life!” says Matthew.

“Then maybe you pulled a muscle.”

“It’s not like that, Sybil.”

“Then call Dr. Frame and check it out.”

Ten days later, standing on the scale outside Dr. Frame’s office, Matthew is alarmed to discover that he’s lost 15 pounds. “Been dieting?” the physician’s assistant asks him.

“Not really,” Matthew says. “But—before my stomach and back began to hurt—I was going quite regularly to the gym.”

Later, as Dr. Frame gently probes Matthew’s abdomen, he prompts Matthew to be more specific about the characteristics of the pain he feels. “Would you say it’s ‘dull,’ or ‘sharp’?”

“Dull. . . right there, toward the top of my stomach.”

“And you first noticed it how long ago?”

“I’m not sure. . . . September, maybe. . . . Yeah, September. I thought it was back-to-school ‘butterflies,’ but–”

“–But now it’s December.”

“Should I be alarmed about this?” asks Matthew, alarmed.

“Probably not. But your gallbladder is palpable and your liver slightly enlarged, so—to play it safe—I think we should follow up with a couple of tests. Are you taking anything for the pain, Matthew?”

“Extra-strength Tylenol® at bedtime. During the day, a little ginger ale seems to help.”

Throughout this Learning Program, Matthew’s case will illustrate issues in cancer pain management, including pain due to tumor progression, nerve damage, and therapeutic interventions.

Patient Case History: Matthew

Life has become surreal for Matthew and Sybil. A complete physical exam, laboratory tests, ultrasound, a difficult endoscopic procedure, and a needle biopsy confirmed Stage IV pancreatic cancer. A 6-centimeter mass in the head of the pancreas has metastasized to the liver; at least three lymph nodes are involved.

As gently as he can, Matthew’s oncologist, Dr. Rogan, outlines three harsh options for Matthew and Sybil.

  1. Don’t fight the cancer—just manage the pain and live maybe 6 months.
  2. Fight the cancer with daily radiation for 5 weeks and light chemotherapy, expect some side effects, and live—perhaps—one year.
  3. Wage an aggressive battle with heavy radiation and heavy chemotherapy, expect lots of side effects, and—with luck—live two years.

Matthew is so numbed by fear and disbelief, he can’t think straight. All he knows for sure is, he wants to spend as much time as possible with his wife and son.

When Dr. Rogan asks Matthew to describe his pain, Matthew says that it’s “not too bad.” The dull pain in his stomach and the ache in his back are only “slightly worse” than they were two weeks earlier, when he first saw Dr. Frame, his PCP. The only new development is a sharp, stabbing pain that occasionally “zaps” him in the middle of his back. “It’s the psychological and emotional pain that’s really bothering me,” he explains.

Dr. Rogan offers to prescribe something to ease Matthew’s mental anguish and refers Matthew, Sybil, and Thad to counselors specially trained to deal with terminally ill patients and their families. He also stresses that pain is not something Matthew has to learn to live with and says that just because Matthew has cancer, he does not have to accept pain as a way of life.

When Sybil asks if pancreatic cancer is very painful, Dr. Rogan says it runs the gamut, depending on where the cancer spreads and whether the tumor infiltrates certain tissues or presses against certain nerves. He adds that chemotherapy and radiation will also cause some pain.

Before Matthew and Sybil leave for the day, Dr. Rogan introduces them to Dr. Deutsch, who explains that her special expertise is pain assessment. She adds that she and Dr. Rogan work closely together, along with others on the oncology team.

Patient Case History: Matthew

Dr. Deutsch tells Matthew and Sybil that she wants to conduct a baseline pain assessment before Matthew begins chemotherapy and radiation. This, she says, will help her distinguish disease-related pain from any treatment-related pain that might later occur.

In the course of the interview, Dr. Deutsch learns that Matthew has taken a medical leave from the university, in order to spend more time with his family and “fight this disease.” When prompted by Dr. Deutsch, Matthew explains that he has lost his appetite for food, work, fun, and sex—not necessarily because he’s in physical pain, but because he feels “drained” and “blue.”

When asked where the pain is and how strong it feels, Matthew points to his upper abdomen and lower back and describes it as “not too bad,” though chronic and dull. Sybil disagrees. She tells Dr. Rogan that her husband is a stoic and that he now sleeps in the fetal position because, she believes, he’s experiencing pain.

“So the pain has gotten worse?” asks Dr. Deutsch. Matthew reluctantly agrees.

To help Matthew more precisely define the intensity of his pain, Dr. Deutsch asks him to indicate where on a 10-point numeric rating scale, his pain was a week earlier (when they first met), and where it is today. Matthew ranks last week’s pain a “3” and today’s pain a “4.”

When asked to rank his pain according to six categorical descriptors, ranging from “no pain” to “worst possible pain,” Matthew describes his pain as “moderate.” Dr. Deutsch says this is helpful, because she had interpreted “not too bad” to mean Matthew’s pain was “mild.” Dr. Deutsch gives Matthew a prescription for a stronger analgesic and says she will consult with Dr. Rogan about the possibility of palliative surgery—surgery designed to relieve Matthew’s pain.

Before Matthew leaves, Dr. Deutsch also gives him a pain diary and shows him how to log pain intensity scores throughout each day. She also asks him to note what things aggravate his pain, and what things bring relief. She reminds Matthew that she and Dr. Rogan intend to aggressively manage all of Matthew’s pain and that they are depending on Matthew to keep them regularly apprised of how he feels. Matthew agrees to be more forthcoming about his discomfort and they all agree to meet again in a week.

Module 2, Chapter 2

Patient Case History: Matthew

Despite the stronger oral analgesic prescribed by Dr. Deutsch, Matthew is in considerable distress from what oncologist Dr. Rogan explains is a tumor-related obstruction of his small intestine. Matthew’s symptoms include an increasingly uncomfortable array of digestive problems and an unrelenting pain in his gut.

Although the tumor in Matthew’s pancreas cannot be surgically removed, surgeons can perform a palliative bypass procedure, which should relieve Matthew’s symptoms and improve his quality of life. Dr. Rogan warns Matthew that if he opts for this surgery, he will experience some acute post-surgical discomfort. But because Matthew will experience greater, recurrent discomfort if he does not have the bypass, Dr. Rogan believes that the benefits of surgery outweigh the risks.

Matthew has also begun to meet regularly with Jo Ellen Brisco, a social worker specially trained to work with terminally ill patients and their families. Although nothing they do or discuss relieves the “overwhelming sadness” Matthew feels, some of the relaxation and visualization techniques she’s taught him are beginning to help him rein in “high anxiety” before it “spirals out of control.”

Section 2.2: Pharmacologic Management of Mild to Moderate Pain

Patient Case History: Matthew

Matthew and Sybil are meeting with surgical-oncology nurse Helen Yau to learn how to prepare for Matthew’s palliative bypass surgery scheduled for the following week. When Helen asks if Matthew has been taking any aspirin, Matthew says, “Sometimes, though mostly I take Advil® for the pain.”

Helen tells Matthew that aspirin’s anti-platelet activity could cause bleeding problems during surgery, and that he should immediately stop taking it. When Matthew tells her that the Advil® doesn’t always relieve his pain, Helen says she’ll talk to his physicians about prescribing something stronger. In the meantime, though–until Matthew hears from Dr. Rogan or Dr. Deutsch–he should use only the Advil® for pain relief.

Section 2.3 Pharmacologic Management of Moderate to Severe Pain

Patient Case History: Matthew

A day after the palliative surgery, Matthew experiences acute pain that he ranks “7” on a 10-point scale and describes as “moderately severe.” Dr. Rogan successfully manages this post-surgical pain by administering intramuscular (IM) morphine on a scheduled basis for 2 days, then as needed.

Matthew spends the next two months at home, recovering from this surgery. The incision heals beautifully, and because the bypass has successfully relieved much of Matthew’s gastrointestinal distress, he gradually regains some weight. All these things boost Matthew’s spirits. Now that he’s not feeling and looking so bad, he feels more in control of his life and slightly less “doomed.”

Section 2.5: Management of Chronic Pain

Patient Case History: Matthew

Matthew begins his first course of chemotherapy. These treatments give him flu-like symptoms and make him feel so miserable, even a teaspoon of clear broth makes him gag. Anti-nausea medication provides only minimal relief.

When subsequent CT scans show that the chemotherapy isn’t working–that the tumor in his pancreas has grown and that his cancer has spread—Matthew’s spirits crash. Matthew now describes the pain in his abdomen and lower back as “intense.” When it’s at its very worst–when “breakthrough pain” prevents him from standing or walking–he ranks the pain a “10.”

Dr. Rogan prescribes morphine suppositories for when Matthew is nauseated from the chemotherapy and the sustained-release oral morphine formulation MS Contin® to manage Matthew’s chronic pain when he’s not nauseated. He also prescribes liquid morphine as needed to control the breakthrough pain.

Although Matthew says that he hates the pain, he is reluctant to comply with the pain management regimen Dr. Rogan prescribed. He explains that it’s important for him to remain “fully conscious,” but that the morphine makes him “fuzzy.” He says, “I don’t want to sleep all day and miss out on everything. I want to spend time with my wife and child.”

Module 3, Chapter 2

Section 1. 2

Patient Case History: Matthew

When Dr. Rogan confirms that Matthew’s pancreatic cancer has metastasized to his hip and spine, Matthew decides to discontinue chemotherapy. He doesn’t tolerate it well, and he knows it won’t cure him. Instead, Matthew asks Dr. Rogan and Dr. Deutsch to do what they can to enhance the quality of his life by managing his pain with minimal sedation.

When Dr. Deutsch meets with Matthew to reevaluate the treatment plan, Matthew describes the pain in his hip, back, and neck as “constant” and “radiating.” He adds that this pain can increase in intensity so quickly that it “wracks” his entire body. At its worst, the pain is “nearly intolerable,” he says. When Dr. Deutsch asks Matthew and Sybil how closely they have been following the twice-daily schedule of 60 mg of MS Contin® and how often Matthew requires the 10 mg of liquid morphine for breakthrough pain, Matthew says that he has been compliant with the fixed- schedule MS Contin®, but has been trying to “tough out” the breakthrough pain, only sometimes taking the awful-tasting liquid morphine. He repeats what he told Dr. Rogan earlier—that as bad he feels, he doesn’t always take the breakthrough medication because he’d rather be “in pain and alert” than “comatose on morphine.” He adds that not only does the MS Contin® make him sleep more than he likes, it also seems to have caused serious constipation.

With some emotion, Sybil describes her own ambivalence toward morphine. She worries that she’ll “somehow overdose” her husband. She wants to be sure she is providing maximum relief without causing harm.

Dr. Deutsch listens carefully, then emphasizes how important it is to prevent pain—or at least to catch it as early as possible—because once pain begins or the more it progresses, the harder it is to control. Dr. Deutsch then suggests that they try a new medication designed to relieve moderate to severe oncology pain—a product called PainMed®. She explains that PainMed® is a combination of morphine and dextromethorphan (a well-known compound used in cough medications), and that the beauty of PainMed® is that it provides equal analgesia at about one- half to three-fourths the morphine dose. Dr. Deutsch adds that because smaller doses of PainMed® are likely to achieve equivalent pain control, PainMed® may provide equally effective pain relief with less sedation.

When Sybil asks if the PainMed® will also help Matthew’s constipation, Dr. Deutsch explains that the effects of PainMed® on the GI tract are probably similar to equal doses of morphine, but that because Matthew will be taking fewer milligrams of morphine in each PainMed® dose, there’s a chance that this side effect will also be ameliorated. Dr. Deutsch adds that because constipation is associated with all opioids, she’ll prescribe a stool softener, as well.

Module 3, Section 1.3: Dosage and Administration

Patient Case History: Matthew

As Dr. Deutsch calculates the appropriate starting dose of PainMed®for Matthew, she takes into consideration the fact that he is currently using two opioid analgesics—MS Contin® 60 mg BID and liquid morphine 10 mg p.r.n. (ie, “as needed”). Although Dr. Deutsch suspects that Matthew’s MS Contin® dose may be too low to adequately control the pain he is currently experiencing, and although Matthew has told her he only sometimes uses the liquid morphine for breakthrough pain, Dr. Deutsch uses Matthew’s currently prescribed opioid doses as the best basis for her PainMed®dose calculations.

Dr. Deutsch’s Pain Med Dose Calculations

According to Dr. Deutsch’s calculations, Matthew’s current total morphine-equivalent daily dose is:

  • 60 mg MS Contin® BID plus 10 mg liquid morphine BID = 140 mg morphine (ie, 60 mg + 60 mg + 10 mg + 10 mg = 140 mg morphine)

When Dr. Deutsch refers to the PainMed® Dosing Chart (see Table 8), she finds that 140 mg morphine falls within the 111 mg – 160 mg current total morphine-equivalent daily dose range, so that Matthew should now receive:

  • Two 15:15 mg PainMed® capsules TID plus one 15:15 mg PainMed® capsule for breakthrough pain = 105 mg morphine (ie, six 15 mg capsules of PainMed® per day on a fixed schedule plus one 15 mg PainMed®capsule for breakthrough pain = 105 mg morphine)

Because Dr. Deutsch realizes that the basis for these calculations may represent inadequate pain control and because Matthew may have some hepatic impairment, she advises Matthew and Sybil to call her in 1 week to report how well he is tolerating the new medication and whether this dosage is adequately controlling his pain.

In prescribing PainMed®, Dr Deutsch underscores the fact that in addition to reducing the amount of sedating and constipating morphine Matthew will be taking each day, there is another key advantage of this new regimen: PainMed® provides comprehensive pain control. Not only can PainMed® be used on a fixed schedule (three times a day), it can also be used to treat breakthrough pain (as early as 1 hour after the fixed dose). Sybil says she likes the simplicity of this plan and is relieved to learn there will be no need for additional opioid analgesics. Matthew is pleased because the liquid morphine tastes awful and using a capsule for breakthrough pain will be more palatable.

“I hope this PainMed® makes a difference,” Sybil tells Dr. Deutsch, when the two of them have a moment alone. “I want Matthew to be ‘present,’ but I can’t bear to see him in pain. Watching him suffer these past few months has been the most painful experience of my life.”

Module 4

Section 2.2: Pain Management Settings of Care

Patient Case History: Matthew

Eleven months after his diagnosis, Matthew is so weakened by advanced pancreatic cancer that he tells Jo Ellen Brisco, the social worker who has been working with him, that he believes that this will be his last visit. With a tremor in his voice, he expresses his gratitude to her—not just for teaching him practical, coping techniques and offering a “sympathetic ear,” but—indirectly—for helping his wife and son, Thad. Jo Ellen had referred Thad to a child psychologist to assess how well he was coping with his father’s terminal illness, and also had urged Sybil and Thad to join a support group for kids of parents with cancer—a group that will continue to meet after Matthew has died. Matthew explains that these outside support systems have been a great comfort to him and his family.

After Matthew says good-bye to Jo Ellen, he meets with pain specialist Dr. Deutsch, who wants to reassess Matthew’s treatment regimen and learn whether PainMed® is continuing to provide satisfactory analgesia. Matthew explains that the past four months on PainMed® have been “pretty good (relatively speaking)” and that up to a week ago the revised dosing regimen of two 60:60 mg PainMed® capsules three times a day had been successfully controlling his chronic pain—and that a single 60:60 mg PainMed® capsule generally managed any pain that broke through. “But all oral medications are hard to ‘keep down’ these days,” he says, and he expresses the need for something stronger.

Sybil asks Dr. Deutsch about transdermal morphine patches and patient-controlled analgesia (PCA) pumps she’s heard about in the support group she’s been attending and wonders if either of these might be an option for Matthew.

“I want to die at home,” Matthew interjects.

Dr. Deutsch outlines the home-care and hospice services offered by Matthew’s health maintenance organization (ie, the individual practice association (IPA) HMO with which she and her physician group have a contract). She reassures Matthew and Sybil that the HMO-affiliated hospice nurses are expert at pain management, and that when the time comes for this next step, Matthew and his family will be in good hands.

Although Dr. Deutsch is supportive of Matthew’s wish to die at home, she cautions that some end-stage pancreatic cancer patients experience complications that require the more controlled environment of the hospital. Dr. Deutsch says that she will consult with oncologist Dr. Rogan before deciding on a new palliative treatment plan, and promises to follow up with Matthew and Sybil before the end of the day.

Module 4, Section 3.1: Managed Care Issues

Patient Case History: Matthew

Four days after his 50th birthday, 11 months after his diagnosis, Matthew dies of pancreatic cancer. Oddly enough, dealing with the nuts-and-bolts aftermath of her husband’s death, helps Sybil process her grief.

As Sybil reviews a statement from Matthew’s IPA HMO, she tells her best friend, Renee, that—all things considered—she’s in decent shape, financially. Matthew planned ahead for her and Thad, and—thankfully—his HMO covered the bulk of the medical expenses. Then she runs through the list of Benefit/Service and Coverage:

Inpatient acute hospital services (including a semi- private room and the final three days of intensive care):
Covered In Full

Hospital outpatient services (including anesthesia, endoscopic procedure, chemotherapy, radiation therapy, laboratory tests, and x-rays)
Covered In Full

Doctor’s office services (including administration of injections, chemotherapy, diagnostic screening tests, health education, nutritional counseling)
Covered In Full after a $20 copayment

Prescription drug rider
Prescription drugs covered up to a 30-day supply from a participating pharmacy covered in full after a $10 copayment for formulary drugs (eg, MS Contin®) and a $20 copayment for nonformulary drugs (eg, PainMed®)

Outpatient mental health services
Individual visits 1-8 covered in full after a $15 copayment per visit; individual visits after visit 8 covered in full after a $25 copayment per visit

Hospital emergency room treatment resulting in immediate admission
Covered In Full

Other health services (including ambulance services, hospice services)
Covered in full after applicable copayments up to a maximum of $3,000 per calendar year and a lifetime maximum of $10,000

Durable medical equipment (ie, the hospital bed delivered to Matthew’s home)
Covered in full after a copayment of 20%, not to exceed total expense of $1,000, up to a combined benefit maximum of $5,000 per calendar year

“That’s not too bad,” says Renee. “But what about those herbal tablets you had such high hopes for, and that short-lived experimental therapy that made Matthew so sick, and that final transfusion?”

“Those were ‘excluded,’” sighs Sybil. “We paid out of pocket for them.”


Photo Credit:
‘Me,’ Chris Warren, Flickr PhotoShare