Curr Oncol, Vol. 20, pp. e307-310; doi: http://dx.doi.org/10.3747/co.20.

1404
PAIN ASSESSMENT IN hdr BRACHYTHERAPY
OR IGI NA L A RTICLE

Pain assessment during

conscious sedation for cervical
cancer high-dose-rate
brachytherapy
H. Bhanabhai md cm,* R. Samant md,*
C. E md,* L. Grenier rn con(c),*
and S. Lowry rn con(c)*
ABSTRACT Conclusions

Background We were able to demonstrate that patients undergoing

hdr brachytherapy for cervical cancer can achieve
This observational study set out to evaluate the effec- good pain control with conscious sedation.
tiveness of conscious sedation anesthesia for pain
control during high-dose-rate (hdr) brachytherapy KEY WORDS
using a ring-and-tandem applicator system for pa-
tients with cervical cancer. Cervical cancer, carcinoma of the cervix, conscious
sedation, high-dose-rate brachytherapy, pain and
Methods symptom assessment, incidental pain, recovery time

At the time of initiation of the hdr cervical cancer 1. INTRODUCTION

brachytherapy program at our institution, patients
received a detailed symptom assessment during the Cervical cancer is commonly treated with radio-
procedures. Brachytherapy was carried out using a therapy, and brachytherapy remains an essential
Smit sleeve, together with a ring-and-tandem appli- component of treatment1,2. Anesthesia during high-
cator. Midazolam and an opioid—hydromorphone, dose-rate (hdr) brachytherapy for cervical cancer is
morphine, or fentanyl—were the main agents used not well reported in the literature, and the modalities
to achieve conscious sedation. used in practice vary greatly3. Our goal was to see
if conscious sedation could be effectively used to
Results control pain or discomfort during hdr brachytherapy
for cervical cancer.
From January 2009 to October 2010, 20 patients Treatment plans for cancer of the cervix show
(median age: 45 years) underwent 57 procedures. an increasing prevalence of hdr brachytherapy.
All patients received chemoradiation with cura- Compared with low-dose-rate brachytherapy, the hdr
tive intent. The median duration of the procedures technique has well-documented logistics and patient
was 1.4 hours, and no significant cardiovascular comfort advantages2, including shorter treatment
events were noted. The total dose of intravenous times, reduced periods of immobilization or bed
midazolam used ranged from 0.5 mg to 8.5 mg rest, and less chance for movement of the applicator
(median: 2.5 mg). The total dose of intravenous during treatment. Those advantages translate into
morphine equivalent used ranged from 2.5 mg the potential for outpatient rather than inpatient
to 60 mg (median: 8 mg). The mean and median treatment and greater patient throughput, reducing
pain scores during the procedures were 1.4 and 1.1 the use of resources2.
respectively. Brief moments of moderate to severe For the advantages of hdr brachytherapy to be
incidental pain were noted at the time of certain realized, the method of analgesia must be effective4–7.
events during the procedure—specifically during According to the American Brachytherapy Society,
insertion of the ring-and-tandem applicator. The hdr brachytherapy for carcinoma of the cervix should
maximal pain score during the entire procedure utilize conscious sedation whenever possible2. Lower
ranged from 0 to 10 (median: 4.7). The period of complication rates with conscious sedation as op-
recovery from conscious sedation was relatively posed to general anesthetic during hdr brachytherapy
brief (median discharge time: 1 hour). of the cervix have also been reported3. Our centre

Current Oncology—Volume 20, Number 4, August 2013

Copyright © 2013 Multimed Inc. Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).
e307
 BHANABHAI et al.

stopped its low-dose-rate cervical brachytherapy nurses, who assessed pain in the communicative
program in 2007 and developed a new protocol and patients. Patients were evaluated at least every 10
new processes for hdr brachytherapy in 2008, which minutes and during certain procedural events such
were fully implemented by 2009. In keeping with as Foley catheter insertion, applicator insertion, and
American Brachytherapy Society guidelines and the applicator removal. The medications and doses were
advantages of hdr already mentioned, an outpatient- all recorded in addition to the procedure and recovery
based program incorporating conscious sedation was times. The dose in morphine equivalents was calcu-
developed at The Ottawa Hospital Cancer Centre. lated assuming the equivalency of either hydromor-
The aim of our retrospective observational study phone 2 mg or fentanyl 100 μg to morphine 10 mg8.
was to assess, throughout the developmental stage Qualitative notes kept by the nursing staff were also
of the hdr brachytherapy program at our institution, temporally correlated with the pain scoring system.
the patient’s experience under conscious sedation. Finally, in the recovery area after completion of the
We could then incorporate that feedback into the entire procedure, patients were asked by the nursing
evaluation of the sedation protocol and potentially staff how they felt about the procedure and whether
improve the experience for future patients. they were satisfied with the degree of pain control.

2. METHODS 3. RESULTS

Patients treated between January 2009 and October From January 2009 to October 2010, 20 patients
2010 with hdr brachytherapy for biopsy-proven cer- (median age: 45 years) underwent 57 procedures (me-
vical cancer at The Ottawa Hospital Cancer Centre dian: 3 procedures per patient). All patients received
were included in the study. All brachytherapy proce- chemoradiation with curative intent.
dures were conducted as part of an integrated treat- The median duration of the procedure was 1.4
ment plan that included external-beam radiation and hours (standard deviation: 0.5 hours), although the
concurrent weekly chemotherapy. Before the initia- actual brachytherapy treatment delivery time was
tion of brachytherapy, an examination under anesthe- generally only 10–20 minutes. The procedure time
sia and placement of a Smit sleeve were performed was calculated as the time from insertion of the Foley
under general anesthesia. The patients were treated to catheter to removal of the ring-and-tandem appara-
a dose of 8 Gy per treatment in 3 weekly fractions. A tus. No significant cardiovascular events occurred
ring-and-tandem applicator was used, with the patient during any of the procedures.
remaining on the same table throughout the entire The total dose of intravenous midazolam used per
procedure (applicator insertion, imaging, treatment procedure ranged from 0.5 mg to 8.5 mg (median:
planning, treatment delivery, and applicator removal) 2.5 mg; standard deviation: 2.0 mg). The total dose
so that no transfers were required. A rectal retractor of intravenous opioid, in morphine equivalents,
attachment was also used with the applicator so that ranged from 2.5 mg to 60 mg (median: 15 mg; stan-
no packing was required. Brachytherapy imaging dard deviation: 8.0 mg)8. Table i shows the medians
was performed with fluoroscopy and plain radiogra- and standard deviations for the procedure times and
phy, and computerized dosimetry was performed us- doses of medications used.
ing the Plato software (Elekta, Stockholm, Sweden). During the procedure, the mean pain score was 1.4,
The conscious sedation protocol used an intravenous and the median was 1.1. Before fentanyl was used as
opioid (morphine, hydromorphone, or fentanyl) in
addition to intravenous midazolam. An initial dose
table i Procedure duration, medication doses, and pain scores
was given to patients at the start of the procedure,
with repeated dosing every 5–10 minutes as needed Variable Median sd
based on reassessment of pain in communicative
patients throughout the procedure. The patients also Procedure duration (hours) 1.4 0.5
received premedication (acetaminophen or tramadol,
pregabalin, and metoclopramide) in addition to local Midazolam dose (mg) 2.0 2.0
anesthesia with lidocaine spray to the cervix. The Morphine or equivalent (mg) 15 8
whole procedure was performed in a brachytherapy
suite with dedicated and specialized staff, including Procedural paina (mean: 1.2) 1.0 1.1
registered nurses, radiation therapy technologists, Maximal scoreb 4.7 2.5
and physicists, together with the attending radiation
oncologist. In addition, members of the anesthesia Recovery time (hours) 1 0.8
staff were available on call in an adjacent part of the a Mean and median of the median pain score during each of the
hospital to assist as needed, although they were never 57 procedures.
actually in the brachytherapy suite itself. b Median of the maximal pain score during each of the 57
During the procedure, pain scores were recorded procedures.
on a linear analogue 11-point scale (0–10) by the sd = standard deviation.

Current Oncology—Volume 20, Number 4, August 2013

e308 Copyright © 2013 Multimed Inc. Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).
 PAIN ASSESSMENT IN hdr BRACHYTHERAPY

the opioid, the mean and median pain scores were 1.3 treatment. The low median doses of midazolam and
and 1.1 respectively (first 10 patients). Brief moments of opioids used likely aided in the ease of recovery. The
moderate-to-severe incidental pain were noted at spe- wide variability in the drug doses used demonstrates
cific events during the procedure, most notably during that it is possible to customize medication doses de-
insertion of the ring-and-tandem applicator. pending on each patient’s specific needs. The continu-
The maximal pain score during the procedure ous patient assessment and feedback is particularly
ranged from 0 to 10 (median: 4.7). Before use of useful in allowing for medication doses to be thus
fentanyl as the opioid, the median of maximal pain adjusted. The doses of midazolam used in our study
during each procedure was 4.5. Figure 1 shows the were less than those reported in colonoscopy9. How-
maximal pain level during each procedure as a fre- ever, the doses of opioid used were slightly greater
quency distribution. than those used in colonoscopy, likely reflecting the
The recovery period from the conscious sedation large difference in the length of the two procedures9.
was relatively brief, with minimal nausea and mild- The use of fentanyl rather than hydromorphone
to-moderate levels of pain. Median time to discharge or morphine did not result in a significant decrease
home after completion of treatment was 1 hour. in the mean or median of the maximal pain during
Analysis of qualitative data found that the maxi- the procedure. The 27 procedures conducted using
mal levels of pain during the procedure coincided intravenous fentanyl resulted in a mean maximal
with applicator manipulation during insertion and pain score of 4.8; the first 30 procedures, which used
removal. After completion of treatment, all patients intravenous hydromorphone or morphine, resulted
commented that they were satisfied with pain control in a mean maximal pain score of 4.7. Keeping in
during the procedure. mind the standard deviation of the maximal pain
score (see Table i), those results are not significantly
4. DISCUSSION different. However, fentanyl has now become our
analgesic of choice because of its fast onset of action
The patients observed in the present study represent and rapid clearance.
the initial cohort of patients with cervical cancer The maximal level of pain reported during the
treated with hdr brachytherapy at The Ottawa Hos- procedures was centred on the 4–5 range out of 10,
pital Cancer Centre. Overall, the patients—and the with a few incidents of 9–10 (Figure 1). That result
radiation oncologists and nurses—were satisfied with is consistent with a well-tolerated pain management
the level of pain and symptom management during system. In addition, the maximal pain occurred dur-
the procedure and did not feel that pain compromised ing a very brief period of time (during manipulation
the quality of the treatment. In addition, the conscious of the applicator), as demonstrated in Figure 2, which
sedation protocol allowed for a rapid consistent treat- shows the reported pain relative to time (in approxi-
ment time, as Table i shows. Although no other recov- mately 10-minute intervals) for one of the procedures.
ery times have been reported for the various methods Another indication that the pain management system
of sedation in hdr brachytherapy for cervical cancer, was well tolerated was the low mean and median
the short recovery times in the present conscious se- pain scores. Anecdotally, we also noticed that giv-
dation protocol shows its applicability to outpatient ing patients opioid boluses just before insertion and
removal of the applicator seemed to improve pain
control and tolerance of the procedure.
In the 20 patients treated, 3 treatments were
abandoned because the Smit sleeve fell out before

figure 1 Distribution of maximal pain scores over 57 brachy- figure 2 Temporal distribution of pain during a brachytherapy
therapy sessions. session, in 10-minute intervals.

Current Oncology—Volume 20, Number 4, August 2013

Copyright © 2013 Multimed Inc. Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).
e309
 BHANABHAI et al.

the final treatment (2 patients)and because of poor 6. CONFLICT OF INTEREST DISCLOSURES

medical wellness for the brachytherapy treatment (1
patient). During the research period, 1 patient was None of the authors has any financial conflict of
treated under general anesthesia and was therefore interest to declare.
excluded from the study. The general anesthesia was
a result of patient preference, because the individual 7. REFERENCES
was virginal, with an intact hymen, and the friability
of the cervical tumour made for an extremely difficult 1. Green JA, Kirwan JM, Tierney JF, et al. Survival and recur-
applicator insertion. rence after concomitant chemotherapy and radiotherapy for
When our data are compared with those from a cancer of the uterine cervix: a systematic review and meta-
similar study of conscious sedation in hdr brachyther- analysis. Lancet 2001;358:781–6.
apy for cervical cancer, the results are quite similar10. 2. Nag S, Erickson B, Thomadsen B, Orton C, Demanes JD,
The mean of the pain scores was still in the mild range, Petereit D. The American brachytherapy society recommenda-
and the mean of the maximal pain score was in the tions for high-dose-rate brachytherapy for carcinoma of the
moderate range. However, the doses of midazolam and cervix. Int J Radiat Oncol Biol Phys 2000;48:201–11.
opioid observed in our study were lower10. 3. Lim KH, Lu JJ, Wynne CJ, et al. A study of complications
A limitation of the present study is its lack of arising from different methods of anesthesia used in high-
assessment of the patient’s experience hours, days, dose-rate brachytherapy for cervical cancer. Am J Clin Oncol
or weeks after the procedure was completed. All the 2004;27:449–51.
pain data were obtained during the procedure, and so 4. Chen HC, Leung SW, Wang CJ, et al. Local vaginal anesthesia
we have not been able to assess the amnesic effects of during high-dose-rate intracavitary brachytherapy for cervical
the conscious sedation system. Particularly with the cancer. Int J Radiat Oncol Biol Phys 1998;42:541–4.
use of midazolam, the perceived pain well after the 5. Roessler B, Six LM, Gustorff B. Anaesthesia for brachy-
event may be significantly different from that assessed therapy. Curr Opin Anaesthesiol 2008;21:514–18.
during the procedure. Also, in future, as we develop 6. Cepni K, Gul S, Cepni I, Güralp O, Sal V, Mayadagli A.
better imaging and brachytherapy planning (based on Randomized trial of oral misoprostol treatment for cervical
computed tomography or magnetic resonance imaging ripening before tandem application in cervix cancer. Int J
data rather than plain radiography, which may require Radiat Oncol Biol Phys 2011;81:778–81.
patient transfers), we will have to determine whether 7. Velji K, Fitch M. The experience of women receiving
good pain control can still be maintained. brachytherapy for gynecologic cancer. Oncol Nurs Forum
2001;28:743–51.
5. CONCLUSIONS 8. Pereira J, Lawlor P, Vigano A, Dorgan M, Bruera E. Equi-
analgesic dose ratios for opioids. A critical review and
We have been able to successfully perform hdr proposals for long-term dosing. J Pain Symptom Manage
brachytherapy for cervical cancer with conscious 2001;22:672–87.
sedation. Most patients tolerated the procedures 9. Ulmer BJ, Hansen JJ, Overley CA, et al. Propofol versus
well, with just relatively brief periods of moderate- midazolam/fentanyl for outpatient colonoscopy: administra-
to-severe incidental pain at times of applicator tion by nurses supervised by endoscopists. Clin Gastroenterol
manipulation. With anticipation of uncomfortable Hepatol 2003;1:425–32.
events and continuous patient feedback, the system 10. Kwekkeboom KL, Dendaas NR, Straub M, Bradley KA.
allows for individualized analgesic dosing, which Patterns of pain and distress during high-dose-rate intra-
was demonstrated by the variability in the doses of cavity brachytherapy for cervical cancer. J Support Oncol
opioids and midazolam used in the present study. 2009;7:108–14.
In addition, the system allowed us to treat patients
efficiently, within a relatively consistent treatment
time. The consistency and short procedure time Correspondence to: Rajiv Samant, Division of
demonstrate adequate applicator placement on the Radiation Oncology, The Ottawa Hospital Cancer
initial attempt, because the patients are comfort- Centre, 501 Smyth Road, Ottawa, Ontario K1H 8L6.
able. The recovery times observed were also shorter E-mail: [email protected]
than would be expected with general anesthesia.
Importantly, this system allowed for all patients to * Division of Radiation Oncology, The Ottawa
avoid hospitalization for brachytherapy by receiving Hospital Cancer Centre, University of Ottawa,
outpatient treatment. Ottawa, ON.

Current Oncology—Volume 20, Number 4, August 2013

e310 Copyright © 2013 Multimed Inc. Following publication in Current Oncology, the full text of each article is available immediately and archived in PubMed Central (PMC).