Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC.
Department of Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC.
JCO Oncol Pract. 2020 Feb;16(2):e166-e174. doi: 10.1200/JOP.19.00206. Epub 2020 Jan 7.
Approximately 30% of patients with cancer who have pain have symptomatic improvement within 1 month using conventional pain management strategies. Engaging clinical pharmacists in palliative medicine (PM) and use of pharmacogenomic testing may improve cancer pain management.
Adult patients with cancer with uncontrolled pain had baseline assessments performed by PM providers using the Edmonton Symptom Assessment Scale. Pharmacotherapy was initiated or modified accordingly. A subset of patients consented to pharmacogenomic testing. The first pharmacy assessment occurred within 1 week of baseline and a second assessment was done within another week if intervention was required. Each patient's final visit was at 1 month. Pain improvement rate (a reduction of two or more points on a 0-to-10 pain scale) from baseline to final visit was compared applying the Fisher exact test to published historical control data, and between patients with and without pharmacogenomic testing. Multivariate logistic regression identified pain improvement covariates.
Of 142 patients undergoing pharmacy assessments, 53% had pain improvement compared with 30% in historical control subjects ( < .001). Pain improvement was not different between those who received (n = 43) and did not receive (n = 99) pharmacogenomics testing (56% 52%; = .716). However, of 15 patients with an actionable genotype, 73% had pain improvement. Higher baseline pain (odds ratio [OR], 1.79; 95% CI, 1.43 to 2.24; < .001), black or other race (OR, 0.42; 95% CI, 0.18 to 0.95; = .04), and performance status 3 or 4 (OR, 0.18; 95% CI, 0.04 to 0.83; = .03) were associated with odds of pain improvement, but pharmacogenomic testing was not ( = .64).
Including pharmacists in PM improves pain management effectiveness. Although pharmacogenomics did not statistically improve pain, a subset of patients with actionable genotypes may have benefited, warranting larger and randomized studies.
约 30%的癌症疼痛患者在使用常规疼痛管理策略后 1 个月内疼痛症状得到改善。临床药师参与姑息治疗（PM）和使用药物基因组学检测可能会改善癌症疼痛管理。
患有未控制疼痛的成年癌症患者由 PM 提供者使用埃德蒙顿症状评估量表进行基线评估。相应地开始或修改药物治疗。一部分患者同意进行药物基因组学检测。第一次药房评估在基线后 1 周内进行，如果需要干预，则在另一个星期内进行第二次评估。每位患者的最后一次就诊时间为 1 个月。从基线到最后一次就诊，疼痛改善率（疼痛评分从 0 到 10 的评分降低两个或更多点）通过应用 Fisher 精确检验与已发表的历史对照数据进行比较，并与进行和未进行药物基因组学检测的患者进行比较。多变量逻辑回归确定了疼痛改善的协变量。
在接受药房评估的 142 名患者中，53%的患者疼痛得到改善，而历史对照患者为 30%（ <.001）。接受（n = 43）和未接受（n = 99）药物基因组学检测的患者之间的疼痛改善无差异（56% 52%； =.716）。然而，在 15 名具有可操作基因型的患者中，有 73%的患者疼痛得到改善。较高的基线疼痛（优势比 [OR]，1.79；95%置信区间，1.43 至 2.24； <.001）、黑种人或其他种族（OR，0.42；95%置信区间，0.18 至 0.95； =.04）和体力状态 3 或 4（OR，0.18；95%置信区间，0.04 至 0.83； =.03）与疼痛改善的可能性相关，但药物基因组学检测无关（ =.64）。
将药剂师纳入 PM 可提高疼痛管理的效果。尽管药物基因组学并未在统计学上改善疼痛，但具有可操作基因型的患者亚组可能从中受益，需要更大规模和随机研究。
