PAIN MANAGEMENT BY WHO STEP LADDER PATTERN PROTOCOL IN CASES OF CERVICAL CANCER

To assess pain in cases of cancer cervix and to evaluate the response to pain management according to WHO step ladder pattern in cases of cancer cervix, total 209 carcinoma cervix diagnosed and admitted case were recruited in the study. Baseline pain score was measured for each patient. For mild to moderate pain (VAS ≤ 7) , step 1 analgesic, NSAID, diclofenac sodium (50 mg TDS) was prescribed. Pain scores were reevaluated after 48 hrs and change of score was recorded. If pain persisted (same score), worsened (score increased) or score decreased but with a VAS score of > 4 , case was considered as non responder and patient was switched to step 2 analgesic. Step 2 was also applied directly to patients presenting with severe pain ( VAS >7) at the time of recruitment. Drugs used in step 2 was oral tramadol (50 mg QID ) along with Diclofenac ( 50 mg TDS) . VAS Score was reevaluated after 48 hrs. If score still remained above 4; adjuvant analgesics (Amitryptiline 25-75 mg OD, Prednisolone 5mg BD – 10 mg/day) were added to step 2. Step 2 non responders were treated with step3 protocol. In step 3, tab morphine (10 mg BD upto maximum 30 mg BD) was given after stopping all other drugs . After 48 hrs, scores were re evaluated; if scores remained >4; adjuvant analgesics ( Amitryptiline 25-75 mg OD, Prednisolone 5mg BD – 10 mg/day ) were added. After 48 hrs if still pain scores did not decrease to <4, case was declared as failure . The WHO algorithm was followed as per the response of the patients. Outcome showed decrease in pain score using Visual Analogue Scale Score. 209 patients were enrolled in the study. 60 patients had no pain at baseline. Out of 149 patients with pain, 44.9 % (67) patients achieved complete pain relief at step 1. Out of the remaining 82 patients , 5 were lost to follow up. 49.3 % (38) achieved complete relief at step 2 . Only 39 patients did not reach score of zero after step 2 but 35 (89.7%) out of them achieved complete relief after step 3. Out of 142 patients ( excluding lost to follow up ), 2 cases were declared as failure. Among these failure cases, one of them had metastasis of femur and symphysis pubis; bisphosphonates were started. Other patients had bladder and bowel involvement diagnosed on repeat cystoscopy. This WHO guideline implementation study supports use of algorithm in decision making for cancer pain management. Following the same we were able to achieve effective pain relief in 96% of our patients with failure rate of only 4%. It further helped to reduce patient's agony and improved the quality of life.