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Clinician Article

Corticosteroids for the management of cancer-related pain in adults.



  • Haywood A
  • Good P
  • Khan S
  • Leupp A
  • Jenkins-Marsh S
  • Rickett K, et al.
Cochrane Database Syst Rev. 2015 Apr 24;(4):CD010756. doi: 10.1002/14651858.CD010756.pub2. (Review)
PMID: 25908299
Read abstract Read evidence summary
Disciplines
  • Oncology - Palliative and Supportive Care
    Relevance - 7/7
    Newsworthiness - 5/7
  • Oncology - General
    Relevance - 6/7
    Newsworthiness - 4/7
  • Hospital Doctor/Hospitalists
    Relevance - 5/7
    Newsworthiness - 4/7
  • Internal Medicine
    Relevance - 5/7
    Newsworthiness - 4/7
  • Special Interest - Pain -- Physician
    Relevance - 4/7
    Newsworthiness - 3/7

Abstract

BACKGROUND: One of the most feared symptoms associated with cancer is pain. Opioids remain the mainstay of pain treatment but corticosteroids are often used concurrently as co- or adjuvant analgesics. Due to their anti-inflammatory mechanism of action, corticosteroids are said to provide effective analgesia for pain associated with inflammation and in the management of cancer-related complications such as brain metastasis and spinal cord compression. However, corticosteroids have a wide range of adverse effects that are dose and time dependent.

OBJECTIVES: To evaluate the efficacy of corticosteroids in treating cancer-related pain in adults.

SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 4), MEDLINE (OVID) (1966 to 29 September 2014), EMBASE (OVID) (1970 to 29 September 2014), CINAHL (1982 to 29 September 2014), Science Citation Index (Web of Science) (1899 to 29 September 2014) and Conference Proceedings Citation Index - Science (Web of Science) (1990 to 29 September 2014).

SELECTION CRITERIA: Any randomised or prospective controlled trial that included patients over 18 years with cancer-related pain were eligible for the review. Corticosteroids were compared to placebo or usual treatment and/or supportive care.

DATA COLLECTION AND ANALYSIS: All review authors independently assessed trial quality and extracted data. We used arithmetic means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI).

MAIN RESULTS: Fifteen studies met the inclusion criteria, enrolling 1926 participants. The trial size varied from 20 to 598 patients. Most studies compared corticosteroids, particularly dexamethasone, to standard therapy. We included six studies with data at one week in the meta-analysis for pain intensity; no data were available at that time point for the remaining studies. Corticosteroid therapy resulted in less pain (measured on a scale of 0 to 10 with a lower score indicating less pain) compared to control at one week (MD 0.84 lower pain, 95% CI 1.38 to 0.30 lower; low quality evidence). Adverse events were poorly documented. Factors limiting statistical analysis included the lack of standardised measurements of pain and the use of different agents, dosages, comparisons and routes of drug delivery. Subgroup analysis according to type of cancer was not possible. The quality of this evidence was limited by the risk of bias of the studies and small sample size. The results were also compromised by attrition, with data missing for the enrolled patients.

AUTHORS' CONCLUSIONS: The evidence for the efficacy of corticosteroids for pain control in cancer patients is weak. Significant pain relief was noted in some studies, albeit only for a short period of time. This could be important for patients with poor clinical status. Further trials, with increased numbers of participants, are needed to evaluate the safety and effectiveness of corticosteroids for the management cancer pain in adults, and to establish an ideal dose, duration of therapy and route of administration.


Clinical Comments

Hospital Doctor/Hospitalists

Good subject, relevant to hospitalists; probably too broad a topic (steroids for ALL cancers) to get an answer, given that some cancers (Lymphomas) might respond very well while others do not; no conclusions reached. This is probably not needed for dissemination to hospitalists.

Oncology - General

The role of steroids in managing cancer pain in conjunction with opioids has been unclear. In this Cochrane review, the authors identified only a handful of eligible studies with most providing low level evidence. The authors concluded that; although, steroids may be a useful adjunct in some patients, the benefits may be short lived and are currently unsupported from high-level evidence. Further research is required.

Special Interest - Pain -- Physician

Clinically, many patients have a positive response to cancer pain when started on steroids. This study, like many Cochrane reviews, merely shows that there is not good data. It should not change practice. It will hopefully lead to be better studies.

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