Is it possible to detect an improvement in cancer pain management? A comparison of two Norwegian cross-sectional studies conducted 5 years apart

Breakthrough and Episodic Cancer Pain from a Palliative Care Perspective

Cancer pain intensity (PI) fluctuates, but the relationship between pain flares and background pain with respect to pain management is not settled. We studied how flare and background PIs corresponded with treatment results for background cancer pain. Patients admitted to an acute palliative care unit with average and/or worst PI ≥ 1 on the 11-point numeric rating scale were included. Average and worst PI at admission and average PI at discharge were collected. We examined how the difference and ratio between worst and average PI and average PI at admission, were associated with average PI development during hospitalization. Positive differences between worst and average PI at admission were defined as pain flares. Ninety out of 131 patients had pain flares. The reduction in average PI for patients with flares was 0.9 and for those without, 1.9 (p = 0.02). Patients with large worst minus average PI differences reported the least improvement, as did those with large worst/average PI ratios. Patients with pain flares and average PI ≤ 4 at admission had unchanged average PI during hospitalization, while those with pain flares and average PI > 4 experienced pain reduction (2.1, p < 0.001). Large pain flares, in absolute values and compared to background PI, were associated with inferior pain relief.

End-of-life cancer patients' total pain: the necessity to supplement pharmacology with psycho-socio-spiritual treatments

Aim: To analyze pain considering its different bio-psycho-social-spiritual manifestations and to assess the effectiveness of the analgesic treatments in end-of-life cancer patients. Materials & methods: The study was cross-sectional. A total of 376 end-of-life cancer inpatients participated in the research. Their socio-demographic and clinical data were collected and, during the first psychological consultancy, they filled in a set of validated rating scales assessing pain, anxiety, depression and quality of life. Results: The results show that physical pain was well managed for almost all patients. Nevertheless, the majority showed clinically significant levels of psychological distress. Conclusion: Treating pain means caring for all its possible manifestations including psychological symptoms and reduced wellbeing. Thus, integrating pharmacological treatment with psycho-socio-spiritual interventions, in other words, psychological, social and spiritual support, could be effective and desirable.

Improvement of pain management in a comprehensive cancer center: a comparison of two cross-sectional studies 8 years apart

CONTEXT

In 2011, a multidisciplinary palliative team (MPT) was established at Rigshospitalet (DK) and a cross-sectional study in inpatients was carried out at the Departments of Oncology and Hematology. High symptom burden, high prevalence of pain (64%), and insufficient analgesic treatment were demonstrated. In 2019, a similar study was carried out.

OBJECTIVES

This study compares prevalence of symptoms including pain and analyzes analgesic treatment of adult in-patients in a comprehensive cancer center.

METHODS

Two cross-sectional studies (May-Jun 2011; Feb-Sep 2019).

INCLUSION CRITERIA

malignant diseases, age ≥ 18 y, able to understand Danish. EORTC QLQ-C30 and Brief Pain Inventory (BPI) were applied.

RESULTS

A total of 134 and 183 inpatients were included in 2011 and 2019, respectively. Differences in the two populations were seen; in 2019 more patients had advanced disease (P = 0.0096), lower performance status (P = 0.0028), and a palliative treatment plan (P = 0.0034). The prevalence of impairments and symptoms was high and similar in the 2 years with exception of severe pain (P = 0.0143) and neuropathic pain (P < 0.0001) which increased in 2019. Moreover, pain relief significantly improved, and significantly fewer patients with pain were left untreated. Significant increase in opioid and adjuvant analgesic prescription in 2019.

CONCLUSION

An overall unchanged high symptom burden was observed. However, improvement of pain management was observed in 2019. The establishment of a MPT may possibly have contributed to improved pain management.

Identification and Characteristics of the Three Subgroups of Pain in Chinese Children and Adolescents with Cancer

PURPOSE

Pain is a distressing symptom for children and adolescents with cancer and is experienced by individuals differently. This study sought to determine subgroups according to their pain experiences, and how demographic, clinical, and quality of life (QOL)-related characteristics might differ across subgroups.

DESIGN AND METHODS

This cross-sectional study recruited 187 pediatric patients with cancer aged 8 to 17 years old and asked them to complete measures of pain intensity, pain duration, pain interference and pain control using the Chinese translation of the validated questionnaire from the Pain Squad app, as well as 7 PROMIS measures assessing QOL-related outcomes. Latent profile analysis (LPA) was used to identify latent subgroups.

RESULTS

Three subgroups of children were identified: low-pain/low-duration (69.5%), moderate-pain/high-duration (19.8%), and high-pain/moderate-duration (10.7%). Hospitalized children were more likely to be in the moderate-pain/high-duration subgroup. Children in the high-pain/moderate-duration subgroup were more likely to be cared for by unemployed caregivers. Scores on depressive symptoms (p = 0.002), anger (p < 0.001), anxiety (p = 0.045), fatigue (p = 0.044), and mobility (p = 0.008) questionnaire were significantly worse in the high-pain/moderate-duration subgroup than the other two subgroup.

PRACTICE IMPLICATIONS

This study provides a scientific foundation for further studies exploring predictive factors related to pain experiences. More targeted treatment strategies targeting the specific characteristics of each subgroup will help improve patients' QOL and use of medical resources.

CONCLUSIONS

The 3 identified pain subgroups demonstrate the heterogeneity in pain experiences among pediatric patients with cancer. Knowledge of these subgroups can assist clinicians in better identifying and targeting pain treatment for children with cancer.

Interventions and symptom relief in hospital palliative cancer care: results from a prospective longitudinal study

PURPOSE

To study the use of interventions and symptom relief for adult patients with incurable cancer admitted to an acute palliative care unit providing integrated oncology and palliative care services.

METHODS

All admissions during 1 year were assessed. The use of interventions was evaluated for all hospitalizations. Patients with assessments for worst and average pain intensity, tiredness, drowsiness, nausea, appetite, dyspnea, depression, anxiety, well-being, constipation, and sleep were evaluated for symptom development during hospitalization. Descriptive statistics was applied for the use of interventions and the paired sample t-test to compare symptom intensities (SIs).

RESULTS

For 451 admissions, mean hospital length of stay was 7.0 days and mean patient age 69 years. More than one-third received systemic cancer therapy. Diagnostic imaging was performed in 66% of the hospitalizations, intravenous rehydration in 45%, 37% received antibiotics, and 39% were attended by the multidisciplinary team. At admission and at discharge, respectively, 55% and 44% received oral opioids and 27% and 45% subcutaneous opioids. For the majority, opioid dose was adjusted during hospitalization. Symptom registrations were available for 180 patients. Tiredness yielded the highest mean SI score (5.6, NRS 0-10) at admission and nausea the lowest (2.2). Significant reductions during hospitalization were reported for all assessed SIs (p ≤ 0.01). Patients receiving systemic cancer therapy reported symptom relief similar to those not on systemic cancer therapy.

CONCLUSION

Clinical practice and symptom relief during hospitalization were described. Symptom improvements were similar for oncological and palliative care patients.

Pain management index (PMI)-does it reflect cancer patients' wish for focus on pain?

BACKGROUND

The pain management index (PMI) was developed to combine information about the prescribed analgesics and the self-reported pain intensity in order to assess physicians' response to patients' pain. However, PMI has been used to explore undertreatment of cancer pain. The present study explores prevalence of negative PMI and its associations to clinical variables, including the patient-perceived wish for more attention to pain.

METHODS

A single-center, cross-sectional, observational study of cancer patients was conducted. Data on demographics and clinical variables, as well as patient-perceived wish for more attention to pain, were registered. PMI was calculated. Negative PMI indicates that the analgesics prescribed might not be appropriate to the pain intensity reported by the patient, and associations to negative PMI were explored by logistic regression models.

RESULTS

One hundred eighty-seven patients were included, 53% had a negative PMI score. Negative PMI scores were more frequent among patients with breast cancer (OR 4.2, 95% CI 1.3, 13.5), in a follow-up setting (OR 12.1, 95% CI 1.4, 101.4), and were inversely associated to low performance status (OR 0.14, 95% CI 0.03, 0.65). Twenty-two percent of patients with negative PMI scores reported that they wanted more focus on pain management, versus 13% among patients with a non-negative PMI score; the difference was not statistically significant.

CONCLUSION

A high prevalence of negative PMI was observed, but only 1/5 of patients with a negative PMI wanted more attention to pain by their physician. Our findings challenge the use of PMI as a measure of undertreatment of cancer pain.

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.

Pain Intensity Factors Changing Breakthrough Pain Prevalence in Patients with Advanced Cancer: A Secondary Analysis of a Cross-Sectional Observational International Study

INTRODUCTION

Different definitions of breakthrough pain (BTP) influence the observed BTP prevalence. This study examined BTP prevalence variability due to use of different cutoffs for controlled background pain, different assessment periods for background pain, and difference between worst and average pain intensity (PI).

METHODS

Cancer patients from the EPCRC-CSA study who reported flare-ups of pain past 24 h were potential BTP cases. BTP prevalence was calculated for different cutoffs for background PI on numeric rating scales (NRS 0-10) for the past week, past 48 and past 24 h period. Furthermore, BTP cases were categorized based on the difference between maximum and average PI past 24 h (range, 0 to > 2 points, NRS 0-10).

RESULTS

Of 696 respondents, 302 patients (43.4%) reported pain flares the past 24 h. The BTP prevalence when using a defined background PI ≤ 4 for the past week was 19.8%. This number varied for different defined cutoffs for background PI. Actual background PI and BTP prevalence also varied between the assessment periods "past week", "past 48 h", and "past 24 h" (PI 4.0, 3.6, and 3.4; BTP prevalence 19.8, 22.7, and 24.9% for background PI ≤ 4). For patients with background PI ≤ 4 past week, 105 had a difference between maximum and average PI ≥ one point and 48 had a difference > two points.

CONCLUSIONS

The reported BTP prevalence is dependent on the cutoff for background PI in the BTP definition, population background PI during the assessment period, and defined cutoff for the difference between worst and average PI.

FUNDING

NTNU, Norwegian University of Science and Technology.

A cross-sectional study examining the prevalence of cachexia and areas of unmet need in patients with cancer

PURPOSE

The semantics of defining cancer cachexia over the last decade has resulted in uncertainty as to the prevalence. This has further hindered the recognition and subsequent treatment of this condition. Following the consensus definition for cancer cachexia in 2011, there is now a need to establish estimates of prevalence. Therefore, the primary aim of the present study was to assess the prevalence of cachexia in an unselected cancer population. A secondary aim was to assess patient-perceived need of attention to cachexia.

METHODS

A cross-sectional study in hospital patients was undertaken. Key inclusion criteria were the following: age > 18 years, cancer diagnosis, and no surgery the preceding 24 h. Data on demographics, disease, performance status, symptoms, cachexia, and patients' perceived need of attention to weight loss and nutrition were registered.

RESULTS

Data were available on 386 of 426 eligible patients. Median age (IQR) was 65 years (56-72), 214 (55%) were male and 302 (78%) had a performance status of 0-1 (Eastern Cooperative Oncology Group). Prevalence of cachexia (inpatients/outpatients) was 51/22%. Prevalence was highest in patients with gastrointestinal cancer (62/42%) and lung cancer (83/36%). There was no major difference in prevalence between patients with metastatic (55/24%) and localized disease (47/19%). Twenty percent of inpatients and 15% of outpatients wanted more attention to weight loss and nutrition. Cachexia (p < 0.001), symptoms of mood disorder (p < 0.001), and male gender (p < 0.01) were independently associated with increased need of attention.

CONCLUSION

Cachexia is a prevalent condition, affecting both patients with localized and metastatic cancer. Clinical attention to the condition is a sizeable unmet need.

A feasibility study to determine the benefits of upper extremity virtual rehabilitation therapy for coping with chronic pain post-cancer surgery

BACKGROUND

Persistent pain in shoulder and arm following post-surgical breast cancer treatment can lead to cognitive and physical deficits. Depression is also common in breast cancer survivors. Virtual reality therapy with integrative cognitive and physical rehabilitation has not been clinically trialed for this population. The novel BrightArm Duo technology improved cognition and upper extremity (UE) function for other diagnoses and has great potential to benefit individuals coping with post-surgical breast cancer pain.

OBJECTIVES

The aim of this study was to explore the feasibility of BrightArm Duo therapy for coping with post-surgical chronic pain and associated disability in breast cancer survivors with depression.

METHODS

BrightArm Duo is a robotic rehabilitation table modulating gravity loading on supported forearms. It tracks arm position and grasping strength while patients play three-dimensional (3D) custom integrative rehabilitation games. Community-dwelling women (N = 6) with post-surgical breast cancer pain in the upper arm trained on the system twice a week for 8 weeks. Training difficulty increased progressively in game complexity, table tilt and session length (20-50 minutes). Standardized assessments were performed before and after therapy for pain, cognition, emotion, UE function and activities of daily living.

RESULTS

Subjects averaged upwards of 1300 arm repetitions and 850 hand grasps per session. Pain intensity showed a 20% downward trend (p = 0.1) that was corroborated by therapist observations and participant feedback. A total of 10 out of 11 cognitive metrics improved post-training (p = 0.01) with a significant 8.3-point reduction in depression severity (p = 0.04). A total of 17 of 18 range of motion metrics increased (p < 0.01), with five affected-side shoulder improvements above the Minimal Clinically Important Difference (8°). In all, 13 out of 15 strength and function metrics improved (p = 0.02) with lateral deltoid strength increasing 7.4 N on the affected side (p = 0.05).

CONCLUSION

This pilot study demonstrated feasibility of using the BrightArm Duo Rehabilitation System to treat cancer survivors coping with upper body chronic pain. Outcomes indicate improvement in cognition, shoulder range, strength, function and depression.