Neuromodulation for Cancer and Non-cancer Pain

Health Technology Assessment Committee Recommendations

  1. In alignment with the developing provincial Chronic Pain Strategy, improve access to both spinal cord stimulation and intrathecal pumps for patients who have exhausted all other pain management options and are deemed eligible by their care team.
  2. As models for new tertiary pain clinics that will improve access to neuromodulation across the province are developed within the Provincial Chronic Pain strategy, these models should consider:
    1. the full cost and implications, including what the additional cost of providing neuromodulation interventions would be;
    2. how neuromodulation would be provided within these models; and
    3. how geographically-equitable neuromodulation access would be improved.

Health Technology Assessment Committee Findings

  1. Evidence for intrathecal pumps indicates clinical effectiveness for both chronic cancer and non-cancer pain. Significant clinical effectiveness of SCS in chronic non-cancer pain was also found. Evidence for other forms of neuromodulation studied was limited.
  2. A cost-effectiveness analysis was completed for SCS and intrathecal pumps, only, due to the lack of strong evidence for the other technologies. For SCS, two main outcomes were included: optimal health and suboptimal health. Over a nine-year horizon (the average lifetime of the battery), SCS costs less than conventional medical management (CCM). Over a four-year horizon intrathecal pump resulted in greater cost and greater life years than CMM.
  3. The strength of the evidence was not uniform for all the technologies assessed. Evidence was stronger for SCS than intrathecal pumps and evidence for these two technologies were stronger than for the other technologies included in the HTA. Therefore, only SCS and intrathecal pumps were assessed by the Committee.
  4. The BC health professionals interviewed all felt that neuromodulation is highly effective for specific sub-groups of patients, making the assessment & trial processes an important component of neuromodulation programs. All respondents commented that neuromodulation is best embedded in a multi-disciplinary pain clinic/program and would be most successful if considered within the broader pain strategy being developed in collaboration with Pain BC and the Ministry. One common challenge noted was the limited expertise among physicians to do neuromodulation and the challenges to recruiting new physicians to this field. 
  5. Patients described trying many treatments and strategies to manage their pain, often over a period of many years, before becoming aware of neuromodulation as an option. Their experiences navigating through healthcare services to find their way to a pain clinic that could provide neuromodulation as an option was often challenging. The way people were treated at the pain clinic, including being listened to, believed, and treated with dignity, respect, and compassion, was described as very important.  For these patients, neuromodulation has made a huge positive difference to their quality of life; with most saying they are not sure they would still be living without it. The primary themes that emerged from a systematic review of patient experiences were:
    • The complexity of the experience of living and coping with chronic pain;
    • Adapting to and using neuromodulation as a strategy for better managing pain;
    • Positive impacts of neuromodulation with respect to both pain reduction and improving function and quality of life; and
    • The importance of the patient-surgeon relationship.

Those patients living with severe pain, where neuromodulation is an effective option have limited access to neuromodulation.

Health Technology Assessment Committee recommendations on Neuromodulation for Cancer and Non-Cancer Pain were accepted by a committee of senior health authority and ministry executives during September 2019. Please note health authorities determine how health technologies are implemented within their programs and services. Other relevant scientific findings may have been reported since the completion of the reference documents used to form the basis of the committee's recommendations.