Acknowledgement: Thank you to Dr. John David Prologo, Interventional Radiologist, Pain Proceduralist, Obesity Physician and Author of The Catching Point Transformation.
Cryoablation in palliative care offers a new approach to manage pain. The number of palliative procedures available to the interventional radiologist has rapidly expanded in recent years, and the need for continued implementation and innovation in this space is at an all-time high. The overuse of opioid analgesics has created a serious public health crisis, and the CDC has called upon physicians to develop nonpharmacologic therapies for pain, stating clearly that procedures with adequate evidence of safety and efficacy are preferable to opioids for the management of chronic pain.
As interventional radiologists’ study new methods to control pain in palliative care, we consulted with Dr. John David Prologo to discuss it. Dr. Prologo is an Interventional Radiologist, Pain Proceduralist, Obesity Physician, and Author. He has completed studies in cryoablation of nerves responsible for pain, hunger and controlling pain in cancer-related pain. We spoke with Dr. Prologo about the use of cryoablation in palliative care to control pain.
What is cryoablation?
Cryoablation is a minimally invasive treatment that uses extreme cold to freeze and destroy diseased tissue, including benign and malignant cells. Using image guidance like ultrasound or computed tomography (CT), a small cryoprobe is guided into the tumor and using liquid nitrogen or high-pressure argon gas, extremely low temperatures are generated to turn the tumor into an ice-ball. A freeze-thaw-freeze cycle rapidly destroys the targeted tissue and leaves adjacent healthy tissue undamaged. The necrotic debris is eventually absorbed by the body. An advantage of cryoablation is that it has minimal pain, as the freezing process acts with the local anesthesia to numb the area.
“Cryoablation has really gained momentum in recent years as advancements in its technical simplicity, alongside reduced morbidity in contrast to surgery has opened up new opportunities for its use”, added Dr. Prologo.
Cryoablation in palliative care
Palliative care is care meant to improve the quality of life of patients who have a serious or life-threatening disease, such as cancer. The pain patients suffer as a result of metastasized cancer (that has spread to other parts of the body) often prevents them from living a full life. Opioids are often insufficient due to their high side effect profile which can negatively affect patients’ final days with their loved ones.
As the government urges physicians and researchers to develop alternatives to opioids, cryoablation provides a new approach to help prevent or treat, as early as possible, the often-painful side effects of metastatic tumors in the body.
How is cryoablation used to treat pain in cancer?
The use of palliative cryoablation therapy in oncology is expanding worldwide. Interventional radiologists use cryoablation devices for the ablation of metastatic disease which are causing painful symptoms but are not able to be surgically removed or do not respond to chemotherapy.
In recent years there has been a paradigm shift in the use and development of cryoablation for palliation of bony metastases, in which isolated, painful metastases to the bone are common in cancer patients. With an estimated up to 50% of patients with pelvic bone metastases not achieving adequate pain control with medications alone, cryoablation is helping fill a significant need for alternative approaches for pain management.
Cryoablation has also been used to deliberately apply cold to nerves to temporarily block nerve conduction along peripheral nerve pathways for therapeutic purposes. With its recent integration into the interventional radiologist’s skill set for pain relief, a myriad of opportunities has now been unlocked providing huge benefit in palliative care. Cryoablation’s unique ability to percutaneously access deep structures in the body with high accuracy and precision, enables interventional radiologists under CT-guidance to insert small probes to freeze target nerves causing pain with high accuracy.
According to Dr. Prologo, “patients with tumor-related intractable pain can benefit from lowering the body’s temperature in order to disrupt the pain signals. Whether the tumor is pressing on a nerve, is distal to the nerve, or is anywhere near the nerve, pain may be reduced.” Using this procedure, relief from pain can last for six months to a year and can be repeated again as needed after that time.
Controlling pain in cancer patients
Current methods for controlling pain in palliative care as described by John Hopkins Medicine include over-the-counter drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. This is followed by weak opioids, such as hydrocodone, then stronger opiates, including morphine and fentanyl, should the pain persist and worsen.
However, alongside their addictive risks, opioids are in many cases insufficient with debilitating side effects, such as constipation, nausea, confusion and drowsiness that provide a far from optimal quality of life:. Therefore, the possibility of intervening with cryoablation provides new approaches to help patients with no other options.
Controlling cancer pain without medication
A systemic review of 22 published papers found that cryoablation decreased mean pain scores by 62.5% at 24 hours post-cryoablation, by 70% at 3 months, and by 80.9% at 6 months. Cryoablation was associated with a 44.2% improvement in quality of life after 4 weeks and a 59.6% improvement at 8 weeks. The need for opioids decreased by 75% at 24 hours and by 61.7% at 3 months.
“The cryoablation procedure also provides many benefits versus traditional pharmacologic therapies. The cryoablation procedure is generally about 45 minutes, and recovery is quick, with a patient treated and pain relieved in one day,” says Dr.Prologo.
Moreover, cryoablation does not interfere with other treatments patients are undergoing. In order to receive cryoablation, patients do not have to interrupt their chemotherapy or any other treatment regimen, and they do not have to be at the end of their lives.
Cryoablation also accelerates patients’ discharge from the hospital. Often, patients are admitted to the hospital with intractable pain and undergo radiation treatments and narcotics while in the hospital. As an alternative, cryoablation may be performed as an outpatient procedure and patients can leave the hospital the following day.
Below is an example of a study on the evaluation of painful metastatic lesions of the bone and where cryoablation may be used to help control pain as an alternative for pain management.
Algorithm for the evaluation of a painful metastatic lesion outside of the spine.
Studies demonstrate success in metastatic bone tumors where cryoablation provided rapid and durable pain palliation, improved quality of life, and offered an alternative to opioids for pain control. Watch this video to see an example of a procedure to treat painful bone metastases using the ProSense liquid nitrogen cryoablation system.
The future of palliative cryoablation therapy
Cryoablation of painful tumors provides rapid and durable pain palliation, improved quality of life, and an alternative to opioids for pain control.
The potential future uses of cryoablation for palliative care are extensive, enabling potentially better control of neurological pain pathways and improved pain-symptom management from disease.
Recent studies have shown cryoablation’s use to control cancer pain in many fields, including bone metastases, pancreatic cancer, metastases to pleura and chest, esophageal cancer to name a few.
As research and experience expands, the potential applications are endless. With cancer becoming more of a chronic long-term illness to manage and treat, new options to better control pain at later stages of life will bring new hope to many patients.
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IceCure would like to give special thanks to Dr. Prologo for sharing his time, insight and experience to create this article. Dr. Prologo is also the author of a new book, The Catching Point Transformation, where he discusses cryoablation of the vagus nerve to aid weight loss and how this procedure can help change your lifestyle for the better in only 12 weeks. Read his book here.
