Overcoming barriers in cancer pain management

Research priorities for the pan-Canadian Oncology Symptom Triage and Remote Support practice guides: a modified nominal group consensus

Introduction

The pan-Canadian Oncology Symptom Triage and Remote Support (costars) team is studying how to improve the quality and consistency of cancer symptom management.

Methods

A 1-day invitational meeting was held 24 October 2017 in Ottawa, Ontario, to review the current evidence from costars projects and to establish research priorities for a future largescale implementation study. The meeting included 36 participants who were clinicians from adult oncology, pediatric oncology, and homecare; policymakers from national, provincial, and regional organizations; researchers; and a patient. Half the day involved summarizing evidence from four costars studies and experiences with implementing the costars symptom practice guides. The second half of the day used a modified nominal group technique to generate research questions within small groups, presentation of research questions to all participants, and two rounds of voting to reach consensus on research priorities.

Results

Participants proposed 4 research categories:■ User-centred augmentation to enhance usability (for example, designing a mobile costars solution)■ Outcome measurement (for example, determining key competencies for clinicians)■ Regular renewal of costars to keep pace with evolving evidence (for example, updates for novel therapies)■ Integration into clinical practice (for example, meaningful engagement of patients and caregivers in study design).

Conclusions

Across categories, the top 3 priorities were effect on health services use, competency development, and a mobile costars solution. Future research will address identified priorities, reflecting the needs and perspectives of diverse stakeholders. Stakeholder collaboration will continue to guide our approach to operationalizing this priority research agenda.

Toward a Conceptual Model of Affective Predictions in Palliative Care

CONTEXT

Being diagnosed with cancer often forces patients and families to make difficult medical decisions. How patients think they and others will feel in the future, termed affective predictions, may influence these decisions. These affective predictions are often biased, which may contribute to suboptimal care outcomes by influencing decisions related to palliative care and advance care planning.

OBJECTIVES

This study aimed to translate perspectives from the decision sciences to inform future research about when and how affective predictions may influence decisions about palliative care and advance care planning.

METHODS

A systematic search of two databases to evaluate the extent to which affective predictions have been examined in the palliative care and advance care planning context yielded 35 relevant articles. Over half utilized qualitative methodologies (n = 21). Most studies were conducted in the U.S. (n = 12), Canada (n = 7), or European countries (n = 10). Study contexts included end of life (n = 10), early treatment decisions (n = 10), pain and symptom management (n = 7), and patient-provider communication (n = 6). The affective processes of patients (n = 20), caregivers (n = 16), and/or providers (n = 12) were examined.

RESULTS

Three features of the palliative care and advance care planning context may contribute to biased affective predictions: 1) early treatment decisions are made under heightened emotional states and with insufficient information; 2) palliative care decisions influence life domains beyond physical health; and 3) palliative care decisions involve multiple people.

CONCLUSION

Biases in affective predictions may serve as a barrier to optimal palliative care delivery. Predictions are complicated by intense emotions, inadequate prognostic information, involvement of many individuals, and cancer's effect on non-health life domains. Applying decision science frameworks may generate insights about affective predictions that can be harnessed to solve challenges associated with optimal delivery of palliative care.

An in-hospital clinical care pathway with integrated decision support for cancer pain management reduced pain intensity and needs for hospital stay

PURPOSE

A clinical care pathway for pain management in a palliative care unit was studied with outcomes related to patients, physicians, and health care service. Mandatory use of patient-reported outcome measures (PROMs) and physician-directed decision support (DS) were integrated parts of the pathway.

METHODS

Adult cancer patients with pain intensity (PI) ≥ 5 (NRS 0-10) at admission were eligible. The patients reported average and worst PI at admission, day four, and discharge. The physicians completed the DS at admission and day four. The DS presented potential needs for treatment changes based on pain severity and pathophysiology. The physicians reported treatment changes due to input from the DS system. The two primary outcomes were average and worst PI changes from admission to discharge. Hospital length of stay (LOS) was registered.

RESULTS

Of 52 included patients, 41 were discharged alive. For those, the mean average PI at admission and at discharge was 5.8 and 2.4, respectively, a reduction of 3.4 points (CI 95% 2.7-4.1). The corresponding worst pain intensities were 7.9 and 3.8, a reduction of 4.1 points (CI 95% 3.4-4.8). The physicians completed DS forms for all patients. Fifty-five percent (CI 95% 41-69) of the patients had pain intervention changes based on the DS. A significant reduction in LOS (4.4 days, CI 95% 0.5-8.3) was observed during the study period.

CONCLUSIONS

The interventions were implemented according to the intentions and PI was reduced as hypothesized. For evaluation of generalizability, the interventions should be studied in other settings and with a controlled design.

Risk Assessment and Monitoring of Patients with Cancer Receiving Opioid Therapy

To provide safe and effective management of cancer pain, a thorough risk assessment is needed when conducting a comprehensive pain evaluation. This information provides the basis for decisions about appropriate pain relief interventions and for measures that can be taken to mitigate the potential for misuse of opioids and other substances.

The primary objective of this article is to assist oncologists and advanced practice prescribers to safely and effectively minimize risk when providing opioids for cancer pain relief. The majority of people with cancer are unlikely to misuse or divert opioid medications, yet the prescriber is often unaware of those who are at risk for these behaviors. To provide skillful pain management to each patient in the oncology setting, while limiting harm to the community, all prescribers must consider the potential for risk of misuse, addiction, or diversion. To minimize this risk to the greatest degree possible, it is imperative to include a thorough risk assessment when conducting a comprehensive pain evaluation. This information is then used to triage pain relief interventions based upon the degree of risk, including whether or not to incorporate opioids into the plan of care. Risk mitigation strategies, incorporating universal precautions, are implemented to assess, monitor, and reduce the potential for opioid misuse. Universal precautions include strategies such as the use of urine toxicology, state prescription drug monitoring programs, and agreements. Ongoing monitoring is conducted with the goal being to identify aberrant behaviors early so that they can be addressed and managed appropriately. Referral to addiction specialists may be warranted when substance use disorder precludes safe use of opioids.

Implications for Practice.

Throughout the trajectory of cancer care, opioid use is often indicated, and, in fact, it may be unethical to limit or prohibit the use of opioids when pain is severe. Oncologists face the significant challenge of providing cancer pain control that is safe and effective, while limiting individual risk for abuse or overdose and keeping the community free of diverted substances. Most oncology providers report inadequate training in chronic pain principles and in managing addiction. Risk assessment and mitigation measures can be incorporated within oncology care to enhance effective pain management while reducing the potential for harm.

Strategies of complementary and integrative therapies in cancer-related pain-attaining exhaustive cancer pain management

PURPOSE

Complementary integrative therapies (CITs) correspond to growing demand in patients with cancer-related pain. This demand needs to be considered alongside pharmaceutical and/or interventional therapies. CITs can be used to cover certain specific pain-related characteristics. The objective of this review is to present the options for CITs that could be used within dynamic, multidisciplinary, and personalized management, leading to an integrative oncology approach.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Most CITs only showed trends in efficacy as cancer pain was mainly a secondary endpoint, or populations were restricted. Physical therapy has demonstrated efficacy in motion and pain, in some specific cancers (head and neck or breast cancers) or in treatments sequelae (lymphedema). In cancer survivors, higher levels of physical activity decrease pain intensity. Due to the multimorphism of cancer pain, certain mind-body therapies acting on anxiety, stress, depression, or mood disturbances (such as massage, acupuncture, healing touch, hypnosis, and music therapy) are efficient on cancer pain. Other mind-body therapies have shown trends in reducing the severity of cancer pain and improving other parameters, and they include education (with coping skills training), yoga, tai chi/qigong, guided imagery, virtual reality, and cognitive-behavioral therapy alone or combined. The outcome sustainability of most CITs is still questioned.

CONCLUSIONS

High-quality clinical trials should be conducted with CITs, as their efficacy on pain is mainly based on efficacy trends in pain severity, professional judgment, and patient preferences. Finally, the implementation of CITs requires an interdisciplinary team approach to offer optimal, personalized, cancer pain management.

Cancer Pain Assessment and Classification

More than half of patients affected by cancer experience pain of moderate-to-severe intensity, often in multiple sites, and of different etiologies and underlying mechanisms. The heterogeneity of pain mechanisms is expressed with the fluctuating nature of cancer pain intensity and clinical characteristics. Traditional ways of classifying pain in the cancer population include distinguishing pain etiology, clinical characteristics related to pain and the patient, pathophysiology, and the use of already validated classification systems. Concepts like breakthrough, nociceptive, neuropathic, and mixed pain are very important in the assessment of pain in this population of patients. When dealing with patients affected by cancer pain it is also very important to be familiar to the characteristics of specific pain syndromes that are usually encountered. In this article we review methods presently applied for classifying cancer pain highlighting the importance of an accurate clinical evaluation in providing adequate analgesia to patients.

Healthcare professionals' perceptions on the use of opioid analgesics for the treatment of cancer-related pain in Cyprus: A mixed-method study

OBJECTIVES

Pain is considered the most common and debilitating symptom reported by patients affected by cancer, and opioids are at the front line for its effective management. However, the appropriate use of opioids can be limited by healthcare professionals' perceptions on opioids. Therefore, the aim of this study was to explore their perceptions on the use of opioids medication.

METHODS

This was a study of sequential mixed-method design conducted in Cyprus. As part of the quantitative phase of the study, the Barriers to Opioid Analgesic Availability Test questionnaire was completed by 73 physicians randomly selected. In the qualitative phase, 28 healthcare professionals working in primary and secondary healthcare centers participated in two focus groups. They were asked to express their perceptions on the use of opioid analgesics for the treatment of cancer-related pain. Data were analyzed according to Colaizzis' seven-stage phenomenological analysis.

RESULTS

The quantitative analysis showed that 69.85% of physicians acknowledge opiophobia as a main barrier to appropriate pain relief but also explicitly for cancer pain which is not adequately managed (45.19%). In terms of opioids availability, physicians stated that moderate to severe problems in opioids availability were mainly caused by their reluctance to prescribe opioids (49.3%) followed by the laws/regulations in place (41.08%). The qualitative analysis yielded the following six main themes: inadequate training of healthcare professionals in the use of opioid analgesics, inadequate patient/caregivers' awareness of opioid analgesics, opiophobia in healthcare professionals, opiophobia of patients/caregivers, poor management of opioid analgesics by healthcare professionals and patients/caregivers, and ineffective pain relief with opioids.

CONCLUSIONS

The lack of appropriate education is a significant barrier to opioids use in Cyprus. This is compounded by the attitudes and phobias of both healthcare professionals and the general public. In addition, there are barriers to opioid availability and unsatisfactory cancer pain relief.

Cancer Pain Management at Oncology Units: Comparing Knowledge, Attitudes and Perceived Barriers Between Physicians and Nurses

Pain is a major symptom that causes suffering among patients diagnosed with cancer. Identifying physicians' and nurses' knowledge, attitudes, and their perceived barriers of cancer pain management is considered an essential step in improving cancer pain relief. The purposes of this study are to compare physicians' and nurses' knowledge and attitudes toward cancer pain management (CPM) and describe their perceived barriers to CPM at oncology units. A descriptive cross-sectional design was utilized to obtain data through self-report questionnaire. The total number of sample size was 207 participants (72 physicians and 135 nurses). Findings revealed that both physicians and nurses had fair knowledge and attitudes toward CPM. Physicians had significantly higher knowledge and better attitudes than nurses (62.3 vs. 51.5%, respectively). Physicians were knowledgeable about pharmacological pain management and opioid addiction but had negative attitudes toward pain assessment. Nurses' knowledge was better in regard of CPM guidelines, while they had poor knowledge about pharmacological pain management and opioid addiction. Physicians and nurses perceived knowledge deficit, lack of pain assessment, opioid unavailability, and lack of psychological interventions as the most common barriers to CPM. It is recommended to integrate recent evidence-based guidelines about CPM in oncology units that aim to improve practice. Offering continuing education courses in hospitals guided by pain teams is another essential recommendation for effective CPM.

Factors That Hinder and Facilitate Cancer Patients' Knowledge About Pain Management-A Qualitative Study

CONTEXT

Pain management education may improve pain control for some patients, whereas individual differences exist.

OBJECTIVES

To evaluate possible critical components, facilitators, and hindrances for improved knowledge about pain management, in not hospitalized adult oncology patients with pain from bone metastasis participating in a pain management intervention.

METHODS

This substudy is a qualitative evaluation of the PRO-SELF Pain Control Program, tested in a randomized controlled trial. During six weeks, 87 participants in the intervention group received tailored coaching encounters by a trained oncology nurse. Three encounters for each patient were audio recorded. The encounter between patient's with the largest (n = 12) and lowest (n = 8) change in knowledge about pain management from before to after the intervention was transcribed verbatim and analyzed with qualitative content analysis.

RESULTS

The critical components of the intervention were repetition of information, struggling with resistance, use of peer experiences, and keeping track of variations. Facilitators of improvement were patients' trust and preparedness to try new procedures, the patient's self-awareness and body awareness, and taking active role in own care. Difficulties in processing complex information, culturally conditioned behaviors, fear, and lack of knowledge were the most important barriers to the success of the intervention.

CONCLUSION

Education in pain management in cancer patients requires repeated information, allowing time for overcoming resistance related to dysfunctional beliefs and fear. To facilitate the patient's involvement in their pain management, tailored and person-centered education is needed.

Cancer-Related Neuropathic Pain

Neuropathic pain in cancer is common and debilitating. It is important to differentiate neuropathic pain from other cancer-related pains as it is associated with worse pain outcomes and requires different treatment strategies. This review summarises recent updates to pain classification, aetiology, pain assessment and current recommendations for treatment in patients with cancer-related neuropathic pain.

Current management of breakthrough cancer pain according to physicians from pain units in Spain

PURPOSE

Current evidence suggests the need to improve the management of breakthrough cancer pain (BTcP). For this reason, we aimed to assess the opinion of a panel of experts composed exclusively of physicians from pain units, who play a major role in BTcP diagnosis and treatment, regarding the key aspects of BTcP management.

METHODS

An ad hoc questionnaire was developed to collect real-world data on the management of BTcP. The questionnaire had 5 parts: (a) organizational aspects of pain units (n = 12), (b) definition and diagnosis (n = 3), (c) screening (n = 3), (d) treatment (n = 8), and (e) follow-up (n = 7).

RESULTS

A total of 89 pain-unit physicians from 13 different Spanish regions were polled. Most of them agreed on the traditional definition of BTcP (78.9%) and the key features of BTcP (92.1%). However, only 30.3% of participants used the Davies' algorithm for BTcP diagnosis. Respondents preferred to prescribe rapid-onset opioids [mean 77.0% (SD 26.7%)], and most recommended transmucosal fentanyl formulations as the first option for BTcP. There was also considerable agreement (77.5%) on the need for early follow-up (48-72 h) after treatment initiation. Finally, 65.2% of participants believed that more than 10% of their patients underused rapid-onset opioids.

CONCLUSIONS

There was broad agreement among pain experts on many important areas of BTcP management, except for the diagnostic method. Pain-unit physicians suggest that rapid-onset opioids may be underused by BTcP patients in Spain, an important issue that need to be evaluated in future studies.

Testing a pain self-management intervention by exploring reduction of analgesics' side effects in cancer outpatients and the involvement of family caregivers: a study protocol (PEINCA-FAM)

Background

Pain is one of cancer patients’ most frequent and distressing symptoms; however, analgesics’ side effects often increase symptom burden. Further, with the home rapidly becoming the primary cancer care setting, family caregivers (FCs) commonly play central roles in patients’ pain self-management, but with little or no preparation. One US-tested intervention, the PRO-SELF© Plus Pain Control Program (PCP), designed to support cancer outpatients and their FCs in pain self-management, is currently being tested in the Swiss multi-centre PEINCA study. The current PEINCA-FAM study is a sub-study of PEINCA. The aims of PEINCA-FAM are: a) to test the efficacy of the adapted German PRO-SELF © Plus PCP to reduce side effects of analgesics; b) to enhance patients’/FCs’ knowledge regarding cancer pain; and c) to explore FCs’ involvement in patients’ pain self-management.

Methods

This mixed methods project combines a multi-centre randomized controlled clinical trial with qualitative data collection techniques and includes 210 patients recruited from three oncology outpatient clinics. FCs involved in patients’ pain self-management are also invited to participate. After baseline evaluation, eligible participants are randomized to a 6-week intervention group and a control group. Both groups complete a daily pain and symptom diary. Intervention group patients/FCs receive the weekly psychoeducational PRO-SELF© Plus PCP interventions; control group patients receive usual care. After completing the six-week study procedures, a subsample of 7–10 patients/FCs per group and hospital (N = 42–60) will be interviewed regarding their pain management experiences. Data collection will take place from April 2016 until December 2018. An intent-to-treat analysis and generalized linear mixed models will be applied. Qualitative data will be analysed by using interpretive description. Quantitative and qualitative results will be combined within a mixed method matrix.

Discussion

In clinical practice, specially trained oncology nurses in outpatient clinics could apply the intervention to reduce side effects and to enhance patients’/FCs’ self-efficacy and pain management knowledge.

Trial registration

The PEINCA study is registered in the Clinical Trials.gov site (code: NCT02713919, 08 March 2016).

Treatment of Pain in Cancer: Towards Personalised Medicine

Despite increased attention to cancer pain, pain prevalence in patients with cancer has not improved over the last decade and one third of cancer patients on anticancer therapy and half of patients with advanced disease still suffer from moderate to severe pain. In this review, we explore the possible reasons for the ongoing high prevalence of cancer pain and discuss possible future directions for improvement in personalised pain management. Among possible reasons for the lack of improvement are: Barriers for patients to discuss pain with clinicians spontaneously; pain measurement instruments are not routinely used in daily practice; limited knowledge concerning the assessment of undertreatment; changes in patients’ characteristics, including the ageing of the population; lack of significant improvement in the treatment of neuropathic pain; limitations of pharmacological treatment and lack of evidence-based nonpharmacological treatment strategies. In order to improve cancer pain treatment, we recommend: (1) Physicians proactively ask about pain and measure pain using assessment instruments; (2) the development of an optimal tool measuring undertreatment; (3) educational interventions to improve health care workers’ skills in pain management; (4) the development of more effective and personalised pharmacological and nonpharmacological pain treatment.

Cancer pain: where are we now?

Increasing numbers of those living with and beyond cancer presents a clinical challenge for pain specialists. A large proportion of these patients experience pain secondary to their disease or its treatment, impeding rehabilitation and significantly impacting upon their quality of life. The successful management of this pain presents a considerable challenge. This review aims to outline current concepts and treatment options, while considering nuances within pain assessment and the use of large-scale data to help guide further advances.

Therapeutic Patient Education in Cancer Pain Management: from Practice to Research: Proposals and Strategy of the French EFFADOL Program

In the field of cancer pain, therapeutic patient education (TPE) allows patients to develop skills to better manage their pain. In the Lower Normandy region of France, the management of pain is based on networking, thus allowing proximity and accessibility for all concerned. We have thus designed and initiated a broad five-stage research program that includes the following: (1) training for caregivers in TPE; (2) identifying the educational expectations of patients and their relatives with regard to cancer pain; (3) the design of a TPE program; (4) the evaluation of its quality; and (5) the evaluation of its effectiveness by comparative randomization. This article presents this approach and more particularly the research phases (stages 2, 4, 5) for which the objectives, the methodology, and the expected results are justified. Among the key points, particular attention is paid to the evaluation of the educational dimension that provides patients with self-efficacy to participate actively in the management of their pain, their perception of changes in relation to it and its impact. The choice of a specific assessment criterion (subscale 9 of the Brief Pain Inventory) and of the step-wedge design are thus argued. This approach, which is based on a partnership between health care professionals and researchers, aims to demonstrate the benefits provided by TPE to patients in order to enable them to better manage their pain on a daily basis.

Contribution of psychiatric diagnoses to extent of opioid prescription in the first year post-head and neck cancer diagnosis: A longitudinal study

PURPOSE

The purpose of this study was to determine, within the first-year post-head and neck cancer (HNC) diagnosis, the contribution of past and upon HNC psychiatric diagnoses (ie, substance use disorder, major depressive disorder, and anxiety disorder) to the extent (ie, cumulated dose) of opioid prescription.

METHODS

Prospective longitudinal study of 223 consecutive adults (on 313 approached; 72% participation) newly diagnosed (<2 weeks) with a first occurrence of primary HNC, including Structured Clinical Interviews for DSM-IV disorders, validated psychometric measures, and medical chart reviews. Opioid doses were translated into standardized morphine milligram equivalents (MME) using CDC guidelines. A model of variables was tested using multiple linear regression.

RESULTS

Fifty-five percent (123/223) of patients received opioids at some point during the first 12 months post-HNC diagnosis, 37.7% (84/223) upon HNC diagnosis (pre-treatment), 40.8% (91/223) during treatments, and 31.4% (70/223) post-treatment. The multiple linear regression indicated that an AD (P = 0.04) upon HNC diagnosis in early stage contributes to cumulated MME dose in the first year post-HNC diagnosis.

CONCLUSION

This study underlines how anxiety has important repercussions on the management of pain and illustrates the importance of screening for AD upon HNC diagnosis to allow for early prophylactic treatment and support.

[Elaboration and evaluation of a therapeutic education program in cancer pain management]

Pain, one of the most feared symptoms for patients with cancer, remains insufficiently alleviated and impairs quality of life. Therapeutic patient education (TPE) is a relevant approach to this problem while allowing patients to develop skills to better manage their pain. In the "Basse-Normandie" French region, the management of pain relies on two organized networks, thus allowing proximity and accessibility for all concerned. In this context, our team has begun a broad five-step research program that is part of a regional health policy: (1) training in TPE of 10 doctor/nurse pairs; (2) identification of educational expectations of patients and their relatives in the field of cancer pain; (3) design and optimization of a TPE program dedicated to cancer pain; (4) regional pilot study aiming to assess the feasibility, quality and transferability of the program; (5) evaluation of the TPE program by interventional comparative randomization at the national level. This article aims to present the program which originality and strengths are based on collaborative work between health stakeholders. Objectives, methodology and expected results of the research phase (stages 2, 4, 5) are notably developed. The main expected outcomes are to prove the effectiveness of the program in improving the knowledge and skills of patients in the field of pain cancer in order to promote their adherence to treatment and, consequently, to enable them to better manage it. The long-term objective is to disseminate the educational approach by modifying practices that provide a mutual benefit for caregivers and patients.

Family caregivers for adult cancer patients: knowledge and self-efficacy for pain management in a resource-limited setting

Adult cancer patients (ACPs) in resource-limited settings disproportionately suffer from inadequate pain control despite advancements in pain management. Family caregivers (FCGs) can support optimal pain control for ACPs in these settings if they are knowledgeable and confident about the needed care. However, the status of FCGs' knowledge and self-efficacy (SE) for pain management in developing countries is not well established.

PURPOSE

To assess the FCGs' knowledge and SE levels for pain management among ACPs while at home in a resource-limited setting.

METHODS

Using a questionnaire that comprised a Family Pain Questionnaire and Chronic Pain Self-efficacy Scale, data were collected from 284 FCGs of ACPs receiving care from two cancer care centres.

RESULTS

The FCGs had moderate knowledge (mean = 41.70 ± 14.1) and SE (mean = 795.95 ± 301.3) levels for pain management at home for ACPs. Majority of the FCGs had low knowledge (52.1%), but expressed higher SE (52.5%). Poor self-rated health among FCGs was significantly associated with low knowledge levels (OR = 1.75; 95% CI 1.024-2.978, p = 0.041). SE was significantly associated with perceiving a low impact of caregiving on health (OR = 1.55; 95% CI 1.074-2.239, p = 0.019), hours of caregiving per week (OR = 0.52; 95% CI 0.315-0.854; p = 0.01) and receiving organisational support (OR = 0.388; 95% CI 0.222-0.679; p = 0.001).

CONCLUSION

The results show a need for deliberate interventions to enhance FCG knowledge and SE for pain management at home as one of the ways of improving cancer pain management in resource-limited settings.

Apoyo con Cariño (support with caring): RCT protocol to improve palliative care outcomes for Latinos with advanced medical illness

Latinos are more likely to experience uncontrolled pain, and institutional death, and are less likely to engage in advance care planning. Efforts to increase access to palliative care must maximize primary palliative care and community based models to meet the ever-growing need in a culturally sensitive and congruent manner. Patient navigator interventions are community-based, culturally tailored models of care that have been successfully implemented to improve disease prevention, early diagnosis, and treatment. We have developed a patient navigation intervention to improve palliative care outcomes for seriously ill Latinos. We describe the protocol for a National Institute of Nursing Research-funded randomized controlled trial designed to determine the effectiveness of the manualized patient navigator intervention. We aim to enroll 240 Latino adults with non-cancer, advanced medical illness from both urban and rural clinical sites. Participants will be randomized to the intervention group (five palliative care patient navigator visits plus bilingual educational materials) or control group (usual care plus bilingual educational materials). Outcomes include quality of life (Functional Assessment of Chronic Illness Therapy), advance care planning (Advance Care Planning Engagement survey), pain (Brief Pain Inventory), symptom management (Edmonton Symptom Assessment Scale-revised), hospice utilization, and cost and utilization of healthcare resources. This culturally tailored, evidence-based, theory-driven, innovative patient navigation intervention has significant potential to improve palliative care for Latinos, and facilitate health equity in palliative and end-of-life care.

Opioid Analgesics Prescription to End-of-Life Cancer Patients: Characteristics, Attitudes, and Practices of French General Practitioners

Background: Pain management, especially at the end of life, varies depending on the prescriber's characteristics and attitudes. Little is known about the practices of general practitioners (GPs) regarding end-of-life management for patients with cancer. Objectives: To provide an overview of the characteristics associated with GPs' attitudes and practices regarding opioids prescribing and to explore GPs' perceived role and difficulties in managing end-of-life care for patients with cancer. Design: A cross-sectional study (December 2015 to March 2016). Subjects and Analyses: Data were collected from a representative sample of 376 GPs in southeastern France recruited to participate in a survey on medical practices and opinions regarding cancer patient management. Descriptive analyses and multivariate logistic regressions were conducted to study the characteristics, attitudes, and practices associated with GPs' opioids prescribing attitudes. Results: Almost 97% of GPs stated that they prescribe opioids to end-of-life cancer patients. Among these, 77% said that they prescribe opioids on their own initiative, while 23% declared doing so in coordination with a specialist team. Female GPs, GPs working in solo practices, and GPs reporting more difficulties in managing end-of-life cancer patients were significantly less likely to prescribe opioids on their own initiative. Conclusion: Our results suggest that GPs' characteristics and practices influence the prescribing attitudes at the end of life. Given the dearth of studies on this topic, further research is recommended to better understand the impact of GPs' characteristics on their prescriptive attitudes. The possible interactions between patients' and physicians' characteristics-in particular gender-should also be investigated.

The perceptions and experiences of osteopathic treatment among cancer patients in palliative care: a qualitative study

PURPOSE

This research aimed to explore the perceptions and experiences of cancer patients receiving osteopathic treatment as a complementary therapy when it is used in addition to conventional treatment for cancer pain.

METHODS

This qualitative study employed semi structured interviews of cancer patients in a palliative care unit in Lyon, France, who received treatment from an osteopath alongside their conventional cancer treatment. We analysed data using grounded theory and qualitative methods.

RESULTS

We interviewed 16 patients. The themes identified through the analysis included a low awareness of osteopathy among the population and an accompanying high level of misconceptions. The benefits of osteopathy were described as more than just the manual treatments with participants valuing osteopathy as a holistic, meditative, and non-pharmaceutical approach. Participants also described the osteopathic treatments as assisting with a range of cancer-related health complaints such as pain, fatigue, and sleep problems. Offering osteopathic treatment at an accessible location at low or no cost were identified by participants as enablers to the continued use of osteopathy.

CONCLUSIONS

The findings of this study provides preliminary data which suggests, when delivered alongside existing medical care, osteopathy may have health benefits for patients with complex conditions such as cancer.

A survey of perceptions, attitudes, knowledge and practices of medical oncologists about cancer pain management in Spain

PURPOSE

To monitor oncologists' perspective on cancer pain management.

METHODS

An anonymized survey was conducted in two waves. First, over a convenience sample of oncologists known to be particularly concerned with the management of pain. Second, using a random sample of oncologists.

RESULTS

In total, 73 and 82 oncologists participated in the first and second wave, respectively. Many oncologists reported to have good knowledge of analgesic drugs (95.9%), the mechanism of action of opioids (79.5%), and good skills to manage opioid-related bowel dysfunction (76.7%). Appropriate adjustment of background medication to manage breakthrough pain was reported by 95.5% of oncologists. Additionally, 87.7% (68.3% in the second wave, p = 0.035) of oncologists reported suitable opioid titration practices, and 90.4% reported to use co-adjuvant medications for neuropathic pain confidently. On the other hand, just 9.6% of oncologists participated in multidisciplinary pain management teams, and merely 30.3 and 27.1% reported to routinely collaborate with the Pain Clinics or involve other staff, respectively. Only 26.4% of the oncologists of the second wave gave priority to pain pathophysiology to decide therapies, and up to 75.6% reported difficulties in treating neuropathic pain. Significantly less oncologists of the second wave (82.9 vs. 94.5%, p = 0.001) used opioid rotation routinely.

CONCLUSIONS

Unlike in previous surveys, medical oncologists reported in general good knowledge and few perceived limitations and barriers for pain management. However, multi-disciplinary management and collaboration with other specialists are still uncommon. Oncologists' commitment to optimize pain management seems important to improve and maintain good practices.

Pain Management in Cancer Center Inpatients: A Cluster Randomized Trial to Evaluate a Systematic Integrated Approach-The Edinburgh Pain Assessment and Management Tool

Purpose Pain is suboptimally managed in patients with cancer. We aimed to compare the effect of a policy of adding a clinician-delivered bedside pain assessment and management tool (Edinburgh Pain Assessment and management Tool [EPAT]) to usual care (UC) versus UC alone on pain outcomes. Patients and Methods In a two-arm, parallel group, cluster randomized (1:1) trial, we observed pain outcomes in 19 cancer centers in the United Kingdom and then randomly assigned the centers to either implement EPAT or to continue UC. The primary outcome was change in the percentage of study participants in each center with a clinically significant (≥ 2 point) improvement in worst pain (using the Brief Pain Inventory Short Form) from admission to 3 to 5 days after admission. Secondary outcomes included quality of analgesic prescribing and opioid-related adverse effects. Results Ten centers were randomly assigned to EPAT, and nine were assigned to UC. We enrolled 1,921 patients and obtained outcome data from 93% (n = 1,795). Participants (mean age, 60 years; 49% women) had a variety of cancer types. For centers randomly assigned to EPAT, the percentage of participants with a clinically significant improvement in worst pain increased from 47.7% to 54.1%, and for those randomly assigned to continue UC, this percentage decreased from 50.6% to 46.4%. The absolute difference was 10.7% (95% CI, 0.2% to 21.1%; P = .046) and it increased to 15.4% (95% CI, 5.8% to 25.0%; P = .004) when two centers that failed to implement EPAT were excluded. EPAT centers had greater improvements in prescribing practice and in the Brief Pain Inventory Short Form pain subscale score. Other pain and distress outcomes and opioid adverse effects did not differ between EPAT and UC. Conclusion A systematic integrated approach improves pain outcomes for inpatients in cancer centers without increasing opioid adverse effects.

Optimal pain management for patients with cancer in the modern era

Pain is a common symptom among patients with cancer. Adequate pain assessment and management are critical to improve the quality of life and health outcomes in this population. In this review, the authors provide a framework for safely and effectively managing cancer-related pain by summarizing the evidence for the importance of controlling pain, the barriers to adequate pain management, strategies to assess and manage cancer-related pain, how to manage pain in patients at risk of substance use disorder, and considerations when managing pain in a survivorship population. CA Cancer J Clin 2018;68:182-196. © 2018 American Cancer Society.

Improving the management of pain from advanced cancer in the community: study protocol for a pragmatic multicentre randomised controlled trial

INTRODUCTION

For patients with advanced cancer, research shows that pain is frequent, burdensome and undertreated. Evidence-based approaches to support cancer pain management have been developed but have not been implemented within the context of the UK National Health Service. This protocol is for a pragmatic multicentre randomised controlled trial (RCT) to assess feasibility, acceptability, effectiveness and cost-effectiveness for a multicomponent intervention for pain management in patients with advanced cancer.

METHODS AND ANALYSIS

This trial will assess the feasibility of implementation and uptake of evidence-based interventions, developed and piloted as part of the Improving the Management of Pain from Advanced Cancer in the Community Programme grant, into routine clinical practice and determine whether there are potential differences with respect to patient-rated pain, patient pain knowledge and experience, healthcare use, quality of life and cost-effectiveness. 160 patients will receive either the intervention (usual care plus supported self-management) delivered within the oncology clinic and palliative care services by locally assigned community palliative care nurses, consisting of a self-management educational intervention and eHealth intervention for routine pain assessment and monitoring; or usual care. The primary outcomes are to assess implementation and uptake of the interventions, and differences in terms of pain severity. Secondary outcomes include pain interference, participant pain knowledge and experience, and cost-effectiveness. Outcome assessment will be blinded and patient-reported outcome measures collected via post at 6 and 12 weeks following randomisation.

ETHICS AND DISSEMINATION

This RCT has the potential to significantly influence National Health Service delivery to community-based patients with pain from advanced cancer. We aim to provide definitive evidence of whether two simple interventions delivered by community palliative care nurse in palliative care that support-self-management are clinically effective and cost-effective additions to standard community palliative care.

TRIAL REGISTRATION NUMBER

ISRCTN18281271; Pre-results.

Strong opioid prescription in cancer patients in their final year of life: A population-based analysis using a Taiwanese health insurance database

AIM

Pain assessment and management have been important criteria in hospital accreditation in Taiwan since 2007. We used a Taiwanese health insurance database to determine factors influencing patterns of strong opioid use in cancer patients in their final 12 months of life.

METHODS

Data from patients with cancer in Taiwan outpatient clinics with cancer-related deaths between 2008 and 2011 were included in the analysis. Strong opioid prescription data from the last 12 months of each patient's life, as well as patient, physician, and hospital characteristics, were collected from the National Health Insurance Research Database.

RESULTS

Among 162 679 patients, more were male (63.6%) than female (36.4%) and almost half (49.3%) were ≥70 years old. Most (44.9%) patients had gastrointestinal cancer. More than one-third (35.4%) of patients were prescribed strong opioids during the 12 months before death, and more than half (53.2%) of those prescribed opioids received them in the 3 months before death. Median duration of strong opioid use was 81 days before death. Patients with head/neck cancer (52.8%) or who were treated in hematology and oncology departments (45.8%) were most likely, and patients with gastrointestinal cancer (hazard ratio = 0.65; 95% confidence interval, 0.64-0.67) or treated in gastroenterology departments (hazard ratio = 0.88; 95% confidence interval, 0.84-0.93) were least likely to be prescribed strong opioids.

CONCLUSION

Strong opioid prescriptions varied among patients with different cancer diagnoses and physicians. Information from this study can guide efforts to improve patient and physician education about cancer pain management.

Pain Management: Time to Minimize Variations in Practice

There continue to be great variations in the management of pain in palliative care. Efforts need to be made within the field develop strategies to address this to avoid undue distress in patients.

Cancer pain management and the opioid crisis in America: How to preserve hard-earned gains in improving the quality of cancer pain management

Cancer pain remains a feared consequence of the disease and its treatment. Although prevalent, cancer pain can usually be managed through the skillful application of pharmacologic and nonpharmacologic interventions. Unfortunately, access to these therapies has been hampered by interventions designed to contain another serious public health problem: the opioid misuse epidemic. This epidemic and the unintended consequences of efforts to control this outbreak are leading to significant barriers to the provision of cancer pain relief. Oncologists and other professionals treating those with cancer pain will require new knowledge and tools to provide safe and effective pain control while preventing additional cases of substance use disorders (SUDs), helping patients in recovery to maintain sobriety, and guiding those not yet in recovery to seek treatment. How do these 2 serious epidemics intersect and affect oncology practice? First, oncology professionals will need to adopt practices to prevent SUDs by assessing risk and providing safe pain care. Second, oncology practices are likely to see an increased number of patients with a current or past SUD, including opioid misuse. Few guidelines exist for the direct management of pain when opioids may be indicated in these individuals. Third, modified prescribing practices along with the education of patients and families are warranted to prevent the exposure of these medications to unintended persons. Finally, advocacy on behalf of those with cancer pain is imperative to avoid losing access to essential therapies, including opioids, for those who might benefit. Cancer 2018;124:2491-7. © 2018 American Cancer Society.

Opioid utilization among pediatric patients treated for newly diagnosed acute myeloid leukemia

Purpose

A cohort of pediatric patients with AML treated at hospitals contributing to the Pediatric Health Information System was used to evaluate differences in opioid utilization by sex, age, race, and insurance.

Methods

Billing data were used to compute the prevalence of opioid exposure and to quantify rates of utilization among those exposed to opioids as days of use per 1000 inpatient days. Multivariable regressions were used to compare opioid prevalence, and rates of utilization among those exposed.

Results

On average across courses, 95.2% of patients were exposed to analgesics, 84.7% were exposed to non-opioid analgesics and 77.7% were exposed to opioids. The proportion of opioid-exposed patients increased with age, but did not differ by gender, race, or insurance status. Analyses limited to patients exposed to opioids revealed modest differences in days of opioid use among female patients (adjusted rate ratio (aRR) = 1.19, 95% CI: 1.11, 1.28), patients <1 year (aRR = 1.37, 95% CI: 1.21, 1.55) or ≥10 years of age (aRR = 1.63, 95% CI: 1.46, 1.82), whereas Asian patients received fewer days of opioids compared with white patients (aRR = 0.76, 95% CI: 0.61, 0.95). There was moderate hospital-level variability in both the prevalence of opioid utilization overall and preference for specific opioid medications. There was greater inconsistency in practice concerning choices for supplemental and alternative opioids than in first-line opioid utilization.

Conclusion

Additional work is needed to discern whether observed differences in opioid utilization by age and race reflect a difference in treatment or a difference in the experience of pain. Future studies should also explore the factors which guide decisions on opioid selections in an attempt to explain the variability across institutions.

Cancer Pain With a Neuropathic Component: A Cross-sectional Study of Its Clinical Characteristics, Associated Psychological Distress, Treatments, and Predictors at Referral to a Cancer Pain Clinic

CONTEXT

In patients with cancer pain, identifying a neuropathic pain component (NPC) may inform the selection of subsequent therapeutic interventions.

OBJECTIVES

The objective of this study was to determine the prevalence, clinical characteristics, associated psychological distress, pre-referral treatment, and predictors of cancer pain with an NPC in patients referred to a cancer pain clinic.

METHODS

Participants had standard assessments and documentation: Brief Pain Inventory ratings, presence of an NPC, based on a Douleur Neuropathique 4 (DN4) (neuropathic pain screening scale) score ≥4 combined with a physician's clinical assessment (blinded to DN4 result), the Hospital Anxiety Depression Scale, and Emotion Thermometer scores. Logistic regression analyses were used to determine predictors associated with an NPC.

RESULTS

Of 371 study participants, 120 (32.3%) had a designated NPC. Overall, psychological distress indices were similar in the NPC and nociceptive pain groups, except for a Hospital Anxiety and Depression Scale >7 score that was proportionately higher (74% vs. 63%, P = 0.03) in the nociceptive group. The final multivariable logistic regression model generated the following NPC predictors and their respective odds ratios (95% CIs): recent chemotherapy, 2.93 (1.63-5.26); recent surgery, 3.65 (2.03-6.59); adjuvant analgesic use, 2.93 (1.66-5.17); episodic incident pain, 2.63 (1.44-4.84); episodic breakthrough pain, 3.67 (2.00-6.73); pain duration three or more months, 2.35 (1.36-4.06); higher pain intensity, 1.47 (1.24-1.74); and pelvic or perineal pain location, 2.75 (1.09-6.96).

CONCLUSION

One in three patients with cancer have an NPC, which is independently associated with recent chemotherapy, surgery, adjuvant analgesic use, episodic incident and breakthrough pain, longer pain duration, higher pain intensity, and pelvic or perineal pain location.

Knowledge and attitudes of nurses toward pain management

Background:

Pain control is a vitally important goal because untreated pain has detrimental impacts on the patients as hopelessness, impede their response to treatment, and negatively affect their quality of life. Limited knowledge and negative attitudes toward pain management were reported as one of the major obstacles to implement an effective pain management among nurses. The main purpose for this study was to explore Saudi nurses’ knowledge and attitudes toward pain management.

Methods:

Cross-sectional survey was used. Three hundred knowledge and attitudes survey regarding pain were submitted to nurses who participated in this study. Data were analyzed with the Statistical Package for the Social Sciences software (SPSS; version 17).

Results:

Two hundred and forty-seven questionnaires were returned response rate 82%. Half of the nurses reported no previous pain education in the last 5 years. The mean of the total correct answers was 18.5 standard deviation (SD 4.7) out of 40 (total score if all items answered correctly) with range of 3–37. A significant difference in the mean was observed in regard to gender (t = 2.55, P = 0.011) females had higher mean score (18.7, SD 5.4) than males (15.8, SD 4.4), but, no significant differences were identified for the exposure to previous pain education (P > 0.05).

Conclusions:

Saudi nurses showed a lower level of pain knowledge compared with nurses from other regional and worldwide nurses. It is recommended to considered pain management in continuous education and nursing undergraduate curricula.

A Psychometric Evaluation of the Chinese Version of the M.D. Anderson Symptom Inventory-Heart Failure in Chinese Cancer Patients With Concurrent Heart Failure

PURPOSE

The purpose of the study was to translate the M.D. Anderson Symptom Inventory-Heart Failure (MDASI-HF), a specific instrument to assess symptoms in cancer patients with concurrent heart failure (HF), into Mandarin Chinese and to examine its psychometric properties in Chinese cancer patients.

DESIGN

A translation and psychometric evaluation design was used.

METHODS

The translation of the MDASI-HF into Mandarin Chinese followed Brislin's model with the four steps: translation, monolingual assessment, backward translation, and comparison. The Chinese version MDASI-HF was tested among 135 cancer patients with concurrent HF from a cancer hospital in Tianjin, China. Psychometric properties of content validity, internal consistency, test- retest reliability, concurrent validity, and sensitivity of the instrument were evaluated.

FINDINGS

The Cronbach's α was .913 for the core items, .835 for the HF items, and .897 for the interference items. The test-retest reliability was satisfactory with intraclass coefficients > .9 and content validity index was .94. The Chinese version MDASI-HF was significantly correlated with the Eastern Cooperative Oncology Group performance grade (correlation coefficients .456-.600) and the New York Heart Association classification (correlation coefficients .477-.631), indicating the established concurrent validity of the translated instrument.

CONCLUSIONS

The Chinese version MDASI-HF is a valid and reliable instrument to assess the symptoms of Chinese cancer patients with concurrent HF.

CLINICAL RELEVANCE

Symptom assessment and management play important roles in cancer rehabilitation. The Chinese version MDASI-HF can assist appropriate and timely symptom assessment in cancer patients with concurrent HF and can promote communication between healthcare professionals and patients. On the basis of the assessment, the rehabilitation team could provide effective symptom management, evaluate the effectiveness of interventions, and improve patients' quality of life.

Effectiveness of acupuncture for cancer pain: protocol for an umbrella review and meta-analyses of controlled trials

INTRODUCTION

The National Comprehensive Cancer Network guidelines for adult cancer pain indicate that acupuncture and related therapies may be valuable additions to pharmacological interventions for pain management. Of the systematic reviews related to this topic, some concluded that acupuncture was promising for alleviating cancer pain, while others argued that the evidence was insufficient to support its effectiveness.

METHODS AND ANALYSIS

This review will consist of three components: (1) synthesis of findings from existing systematic reviews; (2) updated meta-analyses of randomised clinical trials and (3) analyses of results of other types of clinical studies. We will search six English and four Chinese biomedical databases, dissertations and grey literature to identify systematic reviews and primary clinical studies. Two reviewers will screen results of the literature searches independently to identify included reviews and studies. Data from included articles will be abstracted for assessment, analysis and summary. Two assessors will appraise the quality of systematic reviews using Assessment of Multiple Systematic Reviews; assess the randomised controlled trials using the Cochrane Collaboration's risk of bias tool and other types of studies according to the Newcastle-Ottawa Scale. We will use 'summary of evidence' tables to present evidence from existing systematic reviews and meta-analyses. Using the primary clinical studies, we will conduct meta-analysis for each outcome, by grouping studies based on the type of acupuncture, the comparator and the specific type of pain. Sensitivity analyses are planned according to clinical factors, acupuncture method, methodological characteristics and presence of statistical heterogeneity as applicable. For the non-randomised studies, we will tabulate the characteristics, outcome measures and the reported results of each study. Consistencies and inconsistencies in evidence will be investigated and discussed. Finally, we will use the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the quality of the overall evidence.

ETHICS AND DISSEMINATION

There are no ethical considerations associated with this review. The findings will be disseminated in peer-reviewed journals or conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42017064113.

Understanding patient requirements for technology systems that support pain management in palliative care services: A qualitative study

Approaches to pain management using electronic systems are being developed for use in palliative care. This article explores palliative care patients' perspectives on managing and talking about pain, the role of technology in their lives and how technology could support pain management. Face-to-face interviews were used to understand patient needs and concerns to inform how electronic systems are developed. A total of 13 interviews took place with a convenience sample of community-based patients with advanced cancer receiving palliative care through a hospice. Data were analysed using framework analysis. Four meta-themes emerged: Technology could be part of my care; I'm trying to understand what is going on; My pain is ever-changing and difficult to control; and I'm selective about who to tell about pain. Patients described technology as peripheral to existing processes of care. To be relevant, systems may need to take account of the complexity of a patient's pain experience alongside existing relationships with health professionals.

Patient-clinician relationship seems to affect adherence to analgesic use in cancer patients: a cross sectional study in a Taiwanese population

Objectives

Patient satisfaction can provide a measure of service quality and serve as a predictor of health-related behaviors. Little is known about how patients' satisfaction with clinician-patient interactions affects their adherence to taking analgesics. The purposes of this study were to (1) investigate the predictors of patients' satisfaction with clinicians, and (2) examine whether patients' satisfaction with their clinicians can improve adherence to analgesic use.

Design

A cross-sectional and descriptive design was used.

Setting

Outpatient oncology clinic at a medical center in Taiwan.

Participants

A convenience sample (N = 309) was recruited.

Main outcome measures

The Medical Interview Satisfaction Scale 21 - Chinese Version, Short Version of the Barriers Questionnaire - Taiwan Form, Taiwanese version of the Morisky Medication Adherence Measure, and Interpersonal Physician Trust Scale - Chinese version, and Brief Pain Inventory Chinese Version.

Results

Variables that could significantly predict patients' satisfaction were patient age and trust in clinicians, which together accounted for 33% of the total variance. Patients' satisfaction with their clinicians significantly predicted patients' adherence to medication use (OR = 3.10, P < 0.05). There was an interactive effect (OR = 0.12, P < 0.05) between patients' satisfaction and barriers to analgesic use. Correlation coefficients between barriers to analgesic use and patients' adherence are -0.52 (P < 0.001) and -0.13 (P = 0.20) in the higher satisfaction and lower satisfaction patients, respectively.

Conclusions

Patients' satisfaction with their clinicians can have a positive effect on changing analgesics adherence behaviors when patients hold incorrect beliefs about analgesics. Patients' satisfaction has an important role in enhancement of analgesics adherence behaviors.

The social and behavioral influences (SBI) study: study design and rationale for studying the effects of race and activation on cancer pain management

BACKGROUND

Racial disparities exist in the care provided to advanced cancer patients. This article describes an investigation designed to advance the science of healthcare disparities by isolating the effects of patient race and patient activation on physician behavior using novel standardized patient (SP) methodology.

METHODS/DESIGN

The Social and Behavioral Influences (SBI) Study is a National Cancer Institute sponsored trial conducted in Western New York State, Northern/Central Indiana, and lower Michigan. The trial uses an incomplete randomized block design, randomizing physicians to see patients who are either black or white and who are "typical" or "activated" (e.g., ask questions, express opinions, ask for clarification, etc.). The study will enroll 91 physicians.

DISCUSSION

The SBI study addresses important gaps in our knowledge about racial disparities and methods to reduce them in patients with advanced cancer by using standardized patient methodology. This study is innovative in aims, design, and methodology and will point the way to interventions that can reduce racial disparities and discrimination and draw links between implicit attitudes and physician behaviors.

TRIAL REGISTRATION

https://clinicaltrials.gov/ , #NCT01501006, November 30, 2011.