High prevalence of pain in patients with cancer in a large population-based study in The Netherlands

Pain and inflammation in women with early-stage breast cancer prior to induction of chemotherapy

CONTEXT

Pain is a commonly experienced and distressing symptom in women with breast cancer (BCA), and recent evidence suggests that immune activation may be associated with pain and other co-occurring symptoms. However, no studies to date have explored the relationships among perceived pain and biomarkers of inflammation in women with early-stage BCA during the initial course of treatment.

OBJECTIVES

The purpose of this research study was to examine the relationships among pro- and anti-inflammatory biomarkers and the presence of pain and other symptoms (anxiety, depression, fatigue, and sleep disorder) prior to induction of chemotherapy.

METHOD

This was a secondary analysis of data that measured perceived symptoms, including the presence of pain and pain interference, and plasma levels of pro- and anti-inflammatory cytokines and C-reactive protein (CRP) in women with early-stage BCA (N = 32) at 1 month postsurgery but prior to induction of chemotherapy.

RESULTS

Women experiencing pain had significantly higher levels of CRP (p < .01), interleukin (IL) 13 (p < .02), and IL-7 (p < .02) and more pain interference (p < .01), depression (p < .01), and sleep disturbance (p < .01) compared to women reporting no pain.

CONCLUSION

The presence of pain during the initial course of treatment in women with early-stage BCA was associated with significantly higher levels of CRP, IL-7, and IL-13, suggesting a potential role of immune activation in perceived pain. Further research to examine the precise effects of these biological factors in modulating pain is needed. Perceived pain was also associated with multiple co-occurring symptoms, and this finding has important implications for symptom management.

A theory-based educational intervention targeting nurses' attitudes and knowledge concerning cancer-related pain management: a study protocol of a quasi-experimental design

Background

Pain is one of the most frequent problems among patients diagnosed with cancer. Despite the availability of effective pharmacological treatments, this group of patients often receives less than optimal treatment. Research into nurses' pain management highlights certain factors, such as lack of knowledge and attitudes and inadequate procedures for systematic pain assessment, as common barriers to effective pain management. However, educational interventions targeting nurses' pain management have shown promise. As cancer-related pain is also known to have a negative effect on vital aspects of the patient's life, as well as being commonly associated with problems such as sleep, fatigue, depression and anxiety, further development of knowledge within this area is warranted.

Methods/design

A quasi-experimental study design will be used to investigate whether the implementation of guidelines for systematic daily pain assessments following a theory-based educational intervention will result in an improvement in knowledge and attitude among nurses. A further aim is to investigate whether the intervention that targets nurses' behaviour will improve hospital patients' perception of pain. Data regarding nurses' knowledge and attitudes to pain (primary outcome), patient perception regarding pain (secondary outcome), together with socio-demographic variables, will be collected at baseline and at four weeks and 12 weeks following the intervention.

Discussion

Nursing care is nowadays acknowledged as an increasingly complicated activity and "nursing complexity is such that it can be seen as the quintessential complex intervention." To be able to change and improve clinical practice thus requires multiple points of attack appropriate to meet complex challenges. Consequently, we expect the theory-based intervention used in our quasi-experimental study to improve care as well as quality of life for this group of patients and we also envisage that evidence-based guidelines targeting this patient group's pain will be implemented more widely.

Trial Registration Number

ClinicalTrials.gov NCT01313234

The Relationship Between Cancer Pain and Quality of Life in Patients Newly Admitted to Wuhan Hospice Center of China

To evaluate the relationship between pain and quality of life (QoL) in patients newly admitted to Wuhan Hospice Center, China. A total of 1,634 patients were analyzed in this retrospective study. A Numerical Rating Scale and Chinese-QoL instrument were used to assess pain score and QoL, respectively. Most patients experienced moderate to severe pain, which significantly impaired QoL. The pain was significantly correlated with appetite, mood, sleep, fatigue, pain intensity, daily activity, side effect, general appearance, and support from family. But there was no correlation with support from society, understanding of cancer, or attitude toward treatment. In our study, the relationship between pain and QoL was found to be reciprocal. The staff can offer a multidisciplinary care perspective for improving hospice care for this special group of population.

How well is cancer pain treated?

There are currently two indicators, Morphine Consumption Data and the Pain Management Index, that have been widely used to assess the efficacy of cancer pain treatment. Both are based on the World Health Organization guidelines for cancer pain and both have limitations in their ability to assess the quality of pain care for cancer patients. The published studies that have used these methods all report that cancer pain is generally undertreated in a wide range of clinical settings and care models.

Attitude and knowledge of physicians about cancer pain management: young doctors of South Korea in their early career

OBJECTIVE

This study is aimed at evaluating the attitude and knowledge about the optimal use of opioids and finding out the barriers to cancer pain management especially for young doctors in South Korea.

METHODS

A survey through questionnaire form was conducted on 1204 physicians. Physicians were grouped by their medical specialties and personal characteristics. Specialties were grouped into internal medicine and family medicine doctors, surgeons, anesthesiologists, pediatricians, other board holders and general physicians. Personal characteristics were grouped by their past experiences and current surroundings.

RESULTS

Though many doctors thought that they were fairly well educated for pain management strategy, a large population of physicians showed a negative attitude and inadequate knowledge status about cancer pain management. The degree of attitude and knowledge status was different as their specialties and personal experiences. The factors that affected doctors' attitude and knowledge were: (i) medical specialty, (ii) past history of using practical pain assessment tool, (iii) self-perception of knowledge status about pain management, (iv) experience of prescribing opioids, (v) experience of education for cancer pain management. Although many physicians had a passive attitude in prescribing opioid analgesics, they are willingly open to use opioids for cancer pain management in the future. The most important perceived barriers to optimal cancer pain management were the fear for risk of tolerance, drug addiction, side effects of opioid analgesics and knowledge deficit about opioid analgesics.

CONCLUSIONS

From this study, we found that further education and practical training will be needed for adequate cancer pain management for young physicians in their early career.

Increasing 2-arachidonoyl glycerol signaling in the periphery attenuates mechanical hyperalgesia in a model of bone cancer pain

Metastatic and primary bone cancers are usually accompanied by severe pain that is difficult to manage. In light of the adverse side effects of opioids, manipulation of the endocannabinoid system may provide an effective alternative for the treatment of cancer pain. The present study determined that a local, peripheral increase in the endocannabinoid 2-arachidonoyl glycerol (2-AG) reduced mechanical hyperalgesia evoked by the growth of a fibrosarcoma tumor in and around the calcaneous bone. Intraplantar (ipl) injection of 2-AG attenuated hyperalgesia (ED(50) of 8.2 μg) by activation of peripheral CB2 but not CB1 receptors and had an efficacy comparable to that of morphine. JZL184 (10 μg, ipl), an inhibitor of 2-AG degradation, increased the local level of 2-AG and mimicked the anti-hyperalgesic effect of 2-AG, also through a CB2 receptor-dependent mechanism. These effects were accompanied by an increase in CB2 receptor protein in plantar skin of the tumor-bearing paw as well as an increase in the level of 2-AG. In naïve mice, intraplantar administration of the CB2 receptor antagonist AM630 did not alter responses to mechanical stimuli demonstrating that peripheral CB2 receptor tone does not modulate mechanical sensitivity. These data extend our previous findings with anandamide in the same model and suggest that the peripheral endocannabinoid system is a promising target for the management of cancer pain.

Cancer Health Empowerment for Living without Pain (Ca-HELP): effects of a tailored education and coaching intervention on pain and impairment

We aimed to determine the effectiveness of a lay-administered tailored education and coaching (TEC) intervention (aimed at reducing pain misconceptions and enhancing self-efficacy for communicating with physicians) on cancer pain severity, pain-related impairment, and quality of life. Cancer patients with baseline "worst pain" of ≥4 on a 0-10 scale or at least moderate functional impairment due to pain were randomly assigned to TEC or enhanced usual care (EUC) during a telephone interview conducted in advance of a planned oncology office visit (265 patients randomized to TEC or EUC; 258 completed at least one follow-up). Patients completed questionnaires before and after the visit and were interviewed by telephone at 2, 6, and 12 weeks. Mixed effects regressions were used to evaluate the intervention adjusting for patient, practice, and site characteristics. Compared to EUC, TEC was associated with increased pain communication self-efficacy after the intervention (P<.001); both groups showed significant (P<.0001), similar, reductions in pain misconceptions. At 2 weeks, assignment to TEC was associated with improvement in pain-related impairment (-0.25 points on a 5-point scale, 95% confidence interval -0.43 to -0.06, P=.01) but not in pain severity (-0.21 points on an 11-point scale, -0.60 to 0.17, P=.27). The improvement in pain-related impairment was not sustained at 6 and 12 weeks. There were no significant intervention by subgroup interactions (P>.10). We conclude that TEC, compared with EUC, resulted in improved pain communication self-efficacy and temporary improvement in pain-related impairment, but no improvement in pain severity.

Gender differences in predicting quality of life in cancer patients with pain

PURPOSE

Numerous studies have identified several factors influencing quality of life (QOL) in cancer patients. However, studies on gender differences in cancer-related physical symptoms and QOL levels have yielded inconsistent results. The present study examined common symptoms (i.e., pain intensity, fatigue, and depression) in regard to their ability to predict QOL in male and female oncology patients with cancer pain.

METHOD

A total of 114 oncology outpatients, including 34 males and 80 females, with pain completed a demographic questionnaire, the Multidimensional Quality of Life Scale - Cancer, the Lee Fatigue Scale, the Center for Epidemiological Studies - Depression Scale, and a numeric rating scale for pain intensity.

RESULTS

The female patients reported significantly lower psychological dimension of QOL than their male counterparts (p=0.009). Also for the females, a negative correlation was found between pain intensity and QOL (r=-0.504, p<0.0001), as well as positive correlations between pain intensity and fatigue (r=0.421, p<0.0001) and depression (r=0.368, p<0.0001). Stepwise linear regression analyses showed that among the females, QOL was significantly predicted by pain intensity as well as by depression (F((2,75))=52.62, p<0.0001, Adj. R(2)=0.57). However, among the males, depression was the only symptom found to predict QOL (F((2,30))=9.72, p<0.001, Adj. R(2)=0.39).

CONCLUSION

Therefore, it is concluded that gender should be considered as an additional feature for further characterizing QOL. Gender differences in factors predicting QOL warrant different clinical approaches to male and female patients, and identifying these differences may assist health care providers in tailoring treatment modalities to individual patients for optimal outcomes.

Acupuncture for cancer pain in adults

BACKGROUND

Forty percent of individuals with early or intermediate stage cancer and 90% with advanced cancer have moderate to severe pain and up to 70% of patients with cancer pain do not receive adequate pain relief. It has been claimed that acupuncture has a role in management of cancer pain and guidelines exist for treatment of cancer pain with acupuncture.

OBJECTIVES

To evaluate efficacy of acupuncture for relief of cancer-related pain in adults.

SEARCH STRATEGY

CENTRAL, MEDLINE, EMBASE, PsycINFO, AMED, and SPORTDiscus were searched up to November 2010 including non-English language papers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating any type of invasive acupuncture for pain directly related to cancer in adults of 18 years or over.

DATA COLLECTION AND ANALYSIS

It was planned to pool data to provide an overall measure of effect and to calculate the number needed to treat to benefit, but this was not possible due to heterogeneity. Two review authors (CP, OT) independently extracted data adding it to data extraction sheets. Quality scores were given to studies. Data sheets were compared and discussed with a third review author (MJ) who acted as arbiter. Data analysis was conducted by CP, OT and MJ.

MAIN RESULTS

Three RCTs (204 participants) were included. One high quality study investigated the effect of auricular acupuncture compared with auricular acupuncture at 'placebo' points and with non-invasive vaccaria ear seeds attached at 'placebo' points. Participants in two acupuncture groups were blinded but blinding wasn't possible in the ear seeds group because seeds were attached using tape. This may have biased results in favour of acupuncture groups. Participants in the real acupuncture group had lower pain scores at two month follow-up than either the placebo or ear seeds group.There was high risk of bias in two studies because of low methodological quality. One study comparing acupuncture with medication concluded that both methods were effective in controlling pain, although acupuncture was the most effective. The second study compared acupuncture, point-injection and medication in participants with stomach cancer. Long-term pain relief was reported for both acupuncture and point-injection compared with medication during the last 10 days of treatment. Although both studies have positive results in favour of acupuncture they should be viewed with caution due to methodological limitations, small sample sizes, poor reporting and inadequate analysis.

AUTHORS' CONCLUSIONS

There is insufficient evidence to judge whether acupuncture is effective in treating cancer pain in adults.

Evaluating the quality of psychosocial care in outpatient medical oncology settings using performance indicators

OBJECTIVE

An American Psychosocial Oncology Society workgroup has developed indicators of the quality of psychosocial care that can be measured through review of medical records. The present report describes the first large-scale use of these indicators to evaluate psychosocial care in outpatient medical oncology settings.

METHODS

Medical records of 1660 colorectal, breast and non-small cell cancer patients first seen by a medical oncologist in 2006 at 11 practice sites in Florida were reviewed for performance on indicators of the quality of psychosocial care.

RESULTS

Assessment of emotional well-being was significantly less likely to be documented than assessment of pain (52 vs 87%, p<0.001). A problem with emotional well-being was documented in 13% of records and evidence of action taken was documented in 58% of these records. Ten of eleven practice sites performed below an 85% threshold on each indicator of psychosocial care. Variability in assessment of emotional-well being was associated (p<0.02) with practice site and patient gender and age while variability in assessment of pain was associated (p<0.001) with practice site and cancer type.

CONCLUSIONS

Findings illustrate how use of the psychosocial care indicators permits identification of specific practice sites and processes of care that should be targeted for quality improvement efforts. Additionally, findings demonstrate the extent to which routine assessment of emotional well-being lags behind routine assessment of pain in cancer patients.

A multicenter assessment of the adequacy of cancer pain treatment using the pain management index

PURPOSES

Determine adequacy of management of pain secondary to bone metastases by physicians referring to specialized outpatient palliative radiotherapy (RT) clinics in Canada; compare geographic differences in adequacy of pain management and pain severity between these cohorts; compare results with published international literature.

METHODS

Prospectively collected data from three participating centers were used to calculate the Pain Management Index (PMI) by subtracting the patient-rated pain score at time of initial clinic visit from the analgesic score. Scores were 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively, on the Edmonton Symptom Assessment System or Brief Pain Inventory. Analgesic scores of 0, 1, 2, and 3 were assigned for no pain medication, nonopioids, weak opioids, and strong opioids respectively. A negative PMI suggests inadequate pain management.

RESULTS

Overall incidence of negative PMI and moderate to severe pain was 25.1% and 70.9% respectively for 2011 patients. Comparing the three participating centers, the incidence of negative PMI was 31.0%, 20.0%, and 16.8% (p < 0.0001), and severe pain was 55.5%, 48.2% and 43.4% (p < 0.0001), these correlated with a negative PMI. Patients referred to our clinics were less likely to be undertreated for their pain when compared to study results from international countries.

CONCLUSION

Geographic differences in adequacy of analgesic management for painful bone metastases exist between Canadian specialized outpatient palliative RT clinics and between centers globally. Investigating reasons for these differences may provide insight into solutions to improve quality of life for these patients.

Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the Pain Management Index

CONTEXT

The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization's "analgesic ladder" approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain.

OBJECTIVES

The aim of this study was to assess prevalence of inadequate pain management in an outpatient palliative radiotherapy clinic using the PMI.

METHODS

All patients with bone metastases referred for palliative radiotherapy from 1999 to 2006 were retrospectively analyzed for patient-rated pain scores (0-10 scale) and analgesic consumption. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients were prescribed no pain medication, nonopioids, "weak" opioids, and "strong" opioids, respectively. The PMI score was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain management by the prescriber. Descriptive statistics, Pearson's r correlation, and univariate and multivariate logistic regression analysis were used to determine the relationship of PMI over time, and the relationship with predictive factors.

RESULTS

One thousand patients were included from January 1999 to December 2006. A negative PMI was calculated for 25.8% of patients at initial consultation. Prevalence of negative PMI significantly increased over years (P<0.0001). Higher Karnofsky Performance Status (P<0.0001) and breast primary cancer site (P<0.0001) were significantly associated with negative PMI after adjusting for year variable.

CONCLUSION

Despite publication of numerous cancer pain management guidelines, undermedication appears to be a persistent problem for patients with painful bone metastases referred for radiotherapy.

Prevalence and correlates of pain in the Canadian National Palliative Care Survey

BACKGROUND

Pain is a common problem for people with cancer who are nearing the ends of their lives.

OBJECTIVE

In the present multicentre Canadian study of palliative cancer care, the prevalence of pain, its perceived severity and its correlates across a range of physical, social, psychological, and existential symptoms and concerns were examined.

METHODS

Semistructured interviews were conducted with 381 patients. In addition to inquiring about pain, the interview also assessed 21 other symptoms and concerns, and collected information about demographic characteristics, functional status and medication use.

RESULTS

Pain of any intensity was reported by 268 (70.3%) participants, although for 139 (36.5%), the severity was rated as minimal or mild. For 129 (33.9%) individuals, pain was reported as moderate to extreme, and considered by the respondents to be an important ongoing problem. Patients who reported moderate to extreme pain were younger than other participants, but had lower functional status and a shorter median survival duration. They were more likely than other participants to be treated with opioid medications (P<0.001) and, less reliably, with benzodiazepines (P=0.079). Compared with participants with no, minimal or mild pain, those with moderate to extreme pain had a higher prevalence of distressing problems on 11 of 21 other symptoms and concerns. The strongest correlations were with general malaise (rho = 0.44), suffering (rho = 0.40), nausea (rho = 0.34), weakness (rho = 0.31), drowsiness (rho = 0.29) and anxiety (rho = 0.29).

CONCLUSIONS

Pain continues to be a difficult problem for many patients who are receiving palliative cancer care, particularly younger individuals who are nearing death.

Symptoms and problems in a nationally representative sample of advanced cancer patients

Little is known about the need for palliative care among advanced cancer patients who are not in specialist palliative care. The purpose was to identify prevalence and predictors of symptoms and problems in a nationally representative sample of Danish advanced cancer patients. Patients with cancer stage 3 or 4 from 54 hospital departments (n = 1630) received the EORTC QLQ-C30 questionnaire. Mean scores were calculated according to the scoring manual and in addition a 'symptom/problem' and a 'severe symptom/problem' was defined and calculated. Multiple logistic regression was used to identify predictors. In total, 977 (60%) patients participated. The most frequent symptoms/problems were fatigue (57%; severe 22%) followed by reduced role function, insomnia and pain. Age, cancer stage, primary tumour, type of department, marital status and whether the patient had recently been hospitalized or not were associated with several symptoms and problems. This is probably the first nationally representative study of its kind. It shows that advanced cancer patients in Denmark have symptoms and problems that deserve attention and that some patient groups are especially at risk.

Quality of life and non-pain symptoms in patients with cancer

To measure the prevalence of non-pain physical symptoms and psychological symptoms in patients with cancer, to investigate the impact of physical and psychological symptoms on their quality of life (QoL), and to inquire whether treatment had been received for the complaints/symptoms, a representative sample of 1,429 cancer patients were recruited and classified according to tumor type and treatment status [i.e., (1a) curative treatment >6 months ago, (1b) curative treatment <or=6 months ago, (2) palliative antitumor treatment, and (3) treatment no longer feasible]. QoL and non-pain symptoms were measured by the European Organisation for Research and Treatment of Cancer (EORTC)-C30 version 3. We added two items: (1) Did you have a dry mouth? and (2) Did you feel listless? We also asked whether the patients had received treatment for their symptoms. Depression and anxiety were measured by the Dutch version of the Hospital Anxiety and Depression Scale. One-way analysis of variance (ANOVA) was used to detect differences in global QoL between patients with different types of cancer. When ANOVA was significant, post hoc tests (Tukey) were performed to identify significant differences among cancer types. Linear regression analyses (forced entrance procedure) were performed to investigate the influence of physical and psychological symptoms on global QoL. The prevalence of moderate-to-severe symptoms increased significantly with each disease group. Vomiting and irritability were the least prevalent symptoms, and fatigue and worries were the most prevalent symptoms in all groups. Patients in Group 1 (curative treatment) experienced symptoms that were independent of cancer type. Patients in Group 2 (palliative treatment) experienced symptoms that varied with cancer type. QoL decreased significantly each step from Group 1 through 3. Fatigue, appetite loss, constipation, dry mouth, depression, and anxiety had independent negative influences on QoL. Patients with gastrointestinal cancer, malignant lymphoma, and other hematological malignancies had significantly poorer QoL than patients with prostate cancer. In 45%-90% of patients, symptoms remained untreated. Non-pain physical symptoms and psychological symptoms are frequent in patients with cancer at all disease phases. Many symptoms remain untreated. Systematic recording of symptom intensity should be mandatory, irrespective of the phase of disease.

Sex, gender, and pain: a review of recent clinical and experimental findings

Sex-related influences on pain and analgesia have become a topic of tremendous scientific and clinical interest, especially in the last 10 to 15 years. Members of our research group published reviews of this literature more than a decade ago, and the intervening time period has witnessed robust growth in research regarding sex, gender, and pain. Therefore, it seems timely to revisit this literature. Abundant evidence from recent epidemiologic studies clearly demonstrates that women are at substantially greater risk for many clinical pain conditions, and there is some suggestion that postoperative and procedural pain may be more severe among women than men. Consistent with our previous reviews, current human findings regarding sex differences in experimental pain indicate greater pain sensitivity among females compared with males for most pain modalities, including more recently implemented clinically relevant pain models such as temporal summation of pain and intramuscular injection of algesic substances. The evidence regarding sex differences in laboratory measures of endogenous pain modulation is mixed, as are findings from studies using functional brain imaging to ascertain sex differences in pain-related cerebral activation. Also inconsistent are findings regarding sex differences in responses to pharmacologic and non-pharmacologic pain treatments. The article concludes with a discussion of potential biopsychosocial mechanisms that may underlie sex differences in pain, and considerations for future research are discussed.

PERSPECTIVE

This article reviews the recent literature regarding sex, gender, and pain. The growing body of evidence that has accumulated in the past 10 to 15 years continues to indicate substantial sex differences in clinical and experimental pain responses, and some evidence suggests that pain treatment responses may differ for women versus men.

Opioid use in an Israeli health maintenance organization: 2000-2006

OBJECTIVE

The objective of this study was to assess opioid use during 7 years (2000-2006) among Clalit Health Services (CHS) members.

DESIGN

Purchasing data of opioids authorized for use in Israel were obtained from the computerized databases of CHS. Patient demographics and cancer morbidity were also extracted. The data were analyzed by converting the purchased opioids to oral morphine equivalents (OMEs).

SETTING

CHS is the largest health maintenance organization in Israel (3,774,600) and insures almost 54% of the Israeli population.

PATIENTS

All CHS members who purchased an opioid at least once during the 7-year study period (2000-2006).

INTERVENTION

There were no interventions in this study.

OUTCOME MEASURES

The outcome measures of this study were total OME purchased per year, OME (mg) per capita/per year, and OME (mg) daily dose.

RESULTS

There were 119,562 patients who purchased an opioid at least once (3.2% of CHS population). Of them, 57.4% were women, 69.0% aged 65 years and above (average age 56.05 years +/- 26.7), 7.7% purchased opioids for more than 12 months, and 81.3% purchased opioids for only 1-4 months. A 96% increase in total OME purchased was found between 2000 and 2006 (from 56.4 kg to 110.6 kg). The annual OME purchased per capita increased from 15.7 mg in the year 2000 to 29.3 mg in 2006. The total number of patients who received at least one opioid prescription increased by 60%, while the growth in total number of CHS members was smaller (4.8%).

CONCLUSIONS

There is a growing use of opioids at CHS during the 7-year period, a potential indicator of the progress made in improving accessibility and availability of opioids in our health care organization in Israel.

Cancer pain as the presenting problem in emergency departments: incidence and related factors

GOALS OF WORK

Since emergency departments (ED) are designed to manage people with urgent and life-threatening conditions, cancer patients presenting with pain may not receive the appropriate care in the ED. The purpose of this study was to identify the incidence and factors related to ED visits by cancer patients with pain complaints.

MATERIALS AND METHODS

Medical charts selected by stratified random sampling were retrospectively reviewed to obtain information about ED visits by cancer patients during a 1-year period. The sample included 1,179 ED visits by 1,026 cancer patients.

MAIN RESULTS

Pain was the most common reason for ED visits by cancer patients. The incidence of ED visits for pain as a presenting problem was 27.8%. The 72-h ED return-visit rate was 8.2% for cancer patients who visited the ED with pain complaints. Patients with gastrointestinal and genitourinary cancers were more likely to visit the ED for pain. Patients who had received radiation therapy were less likely to visit the ED for pain.

CONCLUSION

Effective cancer pain management programs need to be developed and tested to reduce ED visits by cancer patients with pain. More research is needed to explore why cancer patients with pain visit the ED.

How effective are patient-based educational interventions in the management of cancer pain? Systematic review and meta-analysis

This review aimed to quantify the benefit of patient-based educational interventions in the management of cancer pain. We undertook a systematic review and meta-analysis of experimentally randomised and non-randomised controlled clinical trials identified from six databases from inception to November 2007.Two reviewers independently selected trials comparing intervention (formal instruction on cancer pain and analgesia on an individual basis using any medium) to usual care or other control in adults with cancer pain. Methodological quality was assessed, and data extraction undertaken by one reviewer with a second reviewer checking for accuracy. We used random effects model to combine the effect estimates from studies. Main outcome measures were effects on knowledge and attitudes towards cancer pain and analgesia, and pain intensity. Twenty-one trials (19 randomised) totalling 3501 patients met inclusion criteria, and 15 were included in the meta-analysis. Compared to usual care or control, educational interventions improved knowledge and attitudes by half a point on 0-5 rating scale (weighted mean difference 0.52, 95% confidence interval 0.04-1.0), reduced average pain intensity by over one point on 0-10 rating scale (WMD -1.1, -1.8 to -0.41) and reduced worst pain intensity by just under one point (WMD -0.78, -1.21 to -0.35). We found equivocal evidence for the effect of education on self-efficacy, but no significant benefit on medication adherence or on reducing interference with daily activities. Patient-based educational interventions can result in modest but significant benefits in the management of cancer pain, and are probably underused alongside more traditional analgesic approaches.

Health related quality of life in a nationally representative sample of haematological patients

OBJECTIVES

Knowledge of health related quality of life of haematological patients is limited. This study aimed at investigating the prevalence and predictors of symptoms and problems in a representative sample of haematological patients in Denmark.

METHODS

A random sample of patients with leukaemia, multiple myeloma and advanced lymphoma (n = 732) received the European Organisation for Research and Treatment of Cancer quality-of-life questionnaire (EORTC QLQ-C30). Mean scores were calculated. In addition, scores were dichotomised using two thresholds: patients reporting at least 'a little' of each EORTC QLQ-C30 symptom/problem were classified as having a 'symptom/problem', and patients reporting at least 'quite a bit' were classified as having a 'severe symptom/problem'. Multiple logistic regression was used to identify predictors.

RESULTS

In total, 470 (64%) patients participated. The most frequent symptoms/problems were fatigue (55%; severe 20%), reduced role function (49%; severe 23%), insomnia (46%; severe 15%), and pain (37%; severe 15%). Older patients and patients in active antineoplastic treatment had more symptoms and problems. There was only little evidence of social inequalities.

CONCLUSION

This is probably the first nationally representative study of symptoms and problems in haematological patients. These patients have symptoms/problems that deserve attention. Health related quality of life is an important issue in haematological malignancies.

Concerns of former breast cancer patients about disease recurrence: a validation and prevalence study

OBJECTIVE

The present study has three aims: first, to evaluate the psychometric properties of the Dutch version of the CARS (CARS-DLV). Second, to measure the prevalence of concerns about disease recurrence in former breast cancer patients and identify potential predictors and third, to establish how fear of recurrence was effecting quality of life.

METHODS

A prospective study was carried out on breast cancer patients (n=136) who had undergone curative treatment. Eligible patients completed an extensive questionnaire consisting of the CARS (fear of recurrence), HADS (anxiety and depression), BPI (pain), RAND (quality of life), LOT (optimism) and the PCS (catastrophizing).

RESULTS

This study confirmed the good internal consistency, test-retest stability and construct validity of the CARS (Dutch Language version). Moderate to high levels of fear of disease recurrence were found in 56% of 136 breast cancer survivors. Worries about health and death were the most prominent. Pain was a strong predictor of overall fear and of fear on the four sub domains of the CARS. The prevalence of fear decreased significantly with age. Education level, living arrangements and time since the last treatment did not predict the prevalence of overall fear. Fear of recurrence was negatively correlated with quality of life.

CONCLUSION

The CARS-DLV proved to be a valuable instrument to measure women's' concerns about breast cancer recurrence. More than half of former breast cancer patients indicated moderate to severe concerns about disease recurrence. Health and death worries were the most prominent. The levels of worry were independent of the time since diagnosis.

The pitfalls of profoundly effective analgesic therapies

OBJECTIVE

In essentially all areas of pain medicine, treatments with improved effectiveness are needed. Though gains have been made in recent years, suffering from acute postoperative pain, low back pain, cancer-related pain, and pain from other causes remains problematic. On the other hand, both science and industry are approaching the problem with ever more sophisticated techniques. Though not currently in our armamentarium, it seems likely that at some point we will be faced with the situation where profoundly effective broad-spectrum analgesic therapies are available to our patients. Depending on their mechanisms of action, there may be significant downsides to the use of these new medications. The objective of this report was to explore the consequences of developing profoundly effective analgesic agents.

METHODS

This report reviews some of the recent advancements in our march toward developing profoundly effective analgesics and some of the pitfalls we might anticipate will be associated with these agents. Specifically, the issue of pain as an essential protective mechanism is explored. The causes and consequences of inherited neuropathies associated with pain insensitivity are reviewed.

RESULTS

The ability to appreciate internal and external stimuli as painful is critical to humans. The loss of this ability has profound adverse consequences which in their extreme can be life threatening. Significant social issues might arise from the availability of profoundly effective analgesics. A structure for managing the introduction of these agents into clinical practice is suggested.

DISCUSSION

By anticipating the likely clinical properties of profoundly effective analgesics we place ourselves in best position to guide their development, assure their safety, and oversee their use. The early collaboration of industry, scientists, clinicians, and regulatory authorities may be the best course.

The situation-specific theory of pain experience for Asian American cancer patients

Studies have indicated the need for theories that explain and target ethnic-specific cancer pain experiences, including those of Asian Americans. In this article, I present a situation-specific theory that explains the unique cancer pain experience of Asian Americans. Unlike other existing theories, this situation-specific theory was developed on the basis of evidence, including a systematic literature review and research findings, making it comprehensive and highly applicable to research and practice with Asian American patients with cancer. Thus, this theory would strengthen the interconnections among theory, evidence, and practice in pain management for Asian American cancer patients.

Internet-based survey evaluating use of pain medications and attitudes of radiation oncology patients toward pain intervention

PURPOSE

Pain is a common symptom among cancer patients, yet many patients do not receive adequate pain management. Few data exist quantifying analgesic use by radiation oncology patients. This study evaluated the causes of pain in cancer patients and investigated the reasons patients fail to receive optimal analgesic therapy.

METHODS AND MATERIALS

An institutional review board-approved, Internet-based questionnaire assessing analgesic use and pain control was posted on the OncoLink (available at www.oncolink.org) Website. Between November 2005 and April 2006, 243 patients responded. They were predominantly women (73%), white (71%), and educated beyond high school (67%) and had breast (38%), lung (6%), or ovarian (6%) cancer. This analysis evaluated the 106 patients (44%) who underwent radiotherapy.

RESULTS

Of the 106 patients, 58% reported pain from their cancer treatment, and 46% reported pain directly from their cancer. The pain was chronic in 51% and intermittent in 33%. Most (80%) did not use medication to manage their pain. Analgesic use was significantly less in patients with greater education levels (11% vs. 36%, p = 0.002), with a trend toward lower use by whites (16% vs. 32%, p = 0.082) and women (17% vs. 29%, p = 0.178). The reasons for not taking analgesics included healthcare provider not recommending medication (87%), fear of addiction or dependence (79%), and inability to pay (79%). Participants experiencing pain, but not taking analgesics, pursued alternative therapies for relief.

CONCLUSIONS

Many radiation oncology patients experience pain from their disease and cancer treatment. Most study participants did not use analgesics because of concerns of addiction, cost, or failure of the radiation oncologist to recommend medication. Healthcare providers should have open discussions with their patients regarding pain symptoms and treatment.

Assessment of pain

Valid and reliable assessment of pain is essential for both clinical trials and effective pain management. The nature of pain makes objective measurement impossible. Acute pain can be reliably assessed, both at rest (important for comfort) and during movement (important for function and risk of postoperative complications), with one-dimensional tools such as numeric rating scales or visual analogue scales. Both these are more powerful in detecting changes in pain intensity than a verbal categorical rating scale. In acute pain trials, assessment of baseline pain must ensure sufficient pain intensity for the trial to detect meaningful treatment effects. Chronic pain assessment and its impact on physical, emotional, and social functions require multidimensional qualitative tools and health-related quality of life instruments. Several disease- and patient-specific functional scales are useful, such as the Western Ontario and MacMaster Universities for osteoarthritis, and several neuropathic pain screening tools. The Initiative on

METHODS

Measurement, and Pain Assessment in Clinical Trials recommendations for outcome measurements of chronic pain trials are also useful for routine assessment. Cancer pain assessment is complicated by a number of other bodily and mental symptoms such as fatigue and depression, all affecting quality of life. It is noteworthy that quality of life reported by chronic pain patients can be as much affected as that of terminal cancer patients. Any assessment of pain must take into account other factors, such as cognitive impairment or dementia, and assessment tools validated in the specific patient groups being studied.