Assessment and management of adult cancer pain: a systematic review and synthesis of recent qualitative studies aimed at developing insights for managing barriers and optimizing facilitators within a comprehensive framework of patient care

Factors influencing fidelity to guideline implementation strategies for improving pain care at cancer centres: a qualitative sub-study of the Stop Cancer PAIN Trial

BACKGROUND

The Stop Cancer PAIN Trial was a phase III pragmatic stepped wedge cluster randomised controlled trial which compared effectiveness of screening and guidelines with or without implementation strategies for improving pain in adults with cancer attending six Australian outpatient comprehensive cancer centres (n = 688). A system for pain screening was introduced before observation of a 'control' phase. Implementation strategies introduced in the 'intervention' phase included: (1) audit of adherence to guideline recommendations, with feedback to clinical teams; (2) health professional education via an email-administered 'spaced education' module; and (3) a patient education booklet and self-management resource. Selection of strategies was informed by the Capability, Opportunity and Motivation Behaviour (COM-B) Model (Michie et al., 2011) and evidence for each strategy's stand-alone effectiveness. A consultant physician at each centre supported the intervention as a 'clinical champion'. However, fidelity to the intervention was limited, and the Trial did not demonstrate effectiveness. This paper reports a sub-study of the Trial which aimed to identify factors inhibiting or enabling fidelity to inform future guideline implementation initiatives.

METHODS

The qualitative sub-study enabled in-depth exploration of factors from the perspectives of personnel at each centre. Clinical champions, clinicians and clinic receptionists were invited to participate in semi-structured interviews. Analysis used a framework method and a largely deductive approach based on the COM-B Model.

RESULTS

Twenty-four people participated, including 15 physicians, 8 nurses and 1 clinic receptionist. Coding against the COM-B Model identified 'capability' to be the most influential component, with 'opportunity' and 'motivation' playing largely subsidiary roles. Findings suggest that fidelity could have been improved by: considering the readiness for change of each clinical setting; better articulating the intervention's value proposition; defining clinician roles and responsibilities, addressing perceptions that pain care falls beyond oncology clinicians' scopes of practice; integrating the intervention within existing systems and processes; promoting patient-clinician partnerships; investing in clinical champions among senior nursing and junior medical personnel, supported by medical leaders; and planning for slow incremental change rather than rapid uptake.

CONCLUSIONS

Future guideline implementation interventions may require a 'meta-implementation' approach based on complex systems theory to successfully integrate multiple strategies.

TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; number: ACTRN 12615000064505; data: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspxid=367236&isReview=true .

Physical activity and pain in people with and without cancer

BACKGROUND

Performing physical activity may provide analgesic benefit, although this effect is more established for noncancer pain rather than cancer pain. The relationship between physical activity and pain outcomes in adults with and without a history of cancer was examined.

METHODS

Totals of 51,439 adults without a cancer history and 10,651 adults with a cancer history from the Cancer Prevention Study II Nutrition Cohort were included. Exposures included self-reported moderate to vigorous physical activity (MVPA) as well as 2-year change in MVPA. Pain outcomes included pain intensity (primary outcome) and analgesic use (secondary outcome).

RESULTS

MVPA was inversely associated with pain intensity for adults with (odds ratio [OR], 0.84 [≥15 metabolic equivalent of task (MET) h/week vs. <7.5 MET h/week]; 95% confidence interval [CI], 0.76-0.93) and without (OR, 0.79; 95% CI, 0.75-0.82) a history of cancer. Compared to remaining inactive, participants who became sufficiently active (cancer: OR, 0.76; 95% CI, 0.68-0.86; no cancer: OR, 0.73; 95% CI, 0.69-0.77), became inactive (cancer: OR, 0.79; 95% CI, 0.71-0.88; no cancer: OR, 0.84; 95% CI, 0.80-0.89), or remained sufficiently active (cancer: OR, 0.66; 95% CI, 0.60-0.72; no cancer: OR, 0.62; 95% CI, 0.60-0.65) also reported less pain. Physical activity was not related to analgesic use.

CONCLUSIONS

The relationship between physical activity and pain intensity was not substantially different between people with and without a history of cancer. Cancer survivors who perform more activity, or who increase their activity, may experience less pain than cancer survivors who consistently perform less.

PLAIN LANGUAGE SUMMARY

People who have had cancer often experience ongoing pain. Being physically active may help reduce the intensity of the pain they experience.

Physical activity and pain in people with cancer: a systematic review and meta-analysis

PURPOSE

Physical activity can provide analgesic benefit but its effect on cancer-related pain is unclear. This review synthesised and appraised the evidence for the effect of physical activity on pain in people living with or beyond cancer.

METHODS

A systematic search of Ovid Medline and Embase was performed to identify randomised controlled trials (RCTs), randomised cross-over studies (RXTs), and prospective observational studies that examined physical activity and pain outcomes in adults living with or beyond cancer. Meta-analyses were performed to generate effect estimates. Risk of bias was assessed, and the GRADE system was used to assess evidence quality.

RESULTS

One hundred twenty-one studies (n = 13,806), including 102 RCTs, 6 RXTs, and 13 observational studies, met the criteria for inclusion. Meta-analyses of RCTs identified a decrease in pain intensity (n = 3734; standardised mean difference (SMD) - 0.30; 95% confidence interval (CI) - 0.45, - 0.15) and bodily pain (n = 1170; SMD 0.28; 95% CI 0.01, 0.56) but not pain interference (n = 207; SMD - 0.13, 95% CI - 0.42, 0.15) following physical activity interventions. Individual studies also identified a reduction in pain sensitivity but not analgesic use, although meta-analysis was not possible for these outcomes. High heterogeneity between studies, low certainty in some effect estimates, and possible publication bias meant that evidence quality was graded as very low to low.

CONCLUSION

Physical activity may decrease pain in people living with and beyond cancer; however, high heterogeneity limits the ability to generalise this finding to all people with cancer or to specific types of cancer-related pain.

Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits

Cancer pain is an important challenge in treatment and requires a rapid onset of action for its control. In particular, breakthrough cancer pain (BTcP) should be adequately controlled with a stable dose of a short-acting oral opioid. Fentanyl is a synthetic, highly selective opioid with many advantageous chemical properties, including high lipophilicity and distinct pharmacokinetic properties. It is recommended for pain management in a variety of settings, including acute pain, chronic pain and BTcP. To date, its variously designed formulations allow non-invasive administration; amongst others, sublingual fentanyl has proven useful in the management of BTcP and in improving the quality of life of patients with cancer. This review provides an update on the management of BTcP with fentanyl, with consideration of safety, as it remains an important tool in the treatment of cancer pain.

Quality of life beyond measure: Advanced cancer patients, wellbeing and medicinal cannabis

Experiences of advanced cancer are assembled and (re)positioned with reference to illness, symptoms and maintaining 'wellbeing'. Medical cannabis is situated at a borderline in this and the broader social domain: between stigmatised and normalised; recreational and pharmaceutical; between perception, experience, discourse and scientific proof of benefit. Yet, in the hyper-medicalised context of randomised clinical trials (RCTs), cancer, wellbeing and medical cannabis are narrowly assessed using individualistic numerical scores. This article attends to patients' perceptions and experiences at this borderline, presenting novel findings from a sociological sub-study embedded within RCTs focused on the use of medical cannabis for symptom relief in advanced cancer. Through a Deleuzo-Guattarian-informed framework, we highlight the fragmentation and reassembling of bodies and propose body-situated experiences of wellbeing in the realm of advanced cancer. Problematising 'biopsychosocial' approaches that centre an individualised disconnected patient body in understandings of wellbeing, experiences of cancer and potential treatments, our findings foreground relational affect and embodied experience, and the role of desire in understanding what wellbeing is and can be. This also underpins and enables exploration of the affective reassembling ascribed to medical cannabis, with particular focus on how it is positioned within RCTs.

Supporting Pain Self-Management in Patients With Cancer: App Development Based on a Theoretical and Evidence-Driven Approach

BACKGROUND

To inform the development of an intervention, it is essential to have a well-developed theoretical understanding of how an intervention causes change, as stated in the UK Medical Research Council guidelines for developing complex interventions. Theoretical foundations are often ignored in the development of mobile health apps intended to support pain self-management for patients with cancer.

OBJECTIVE

This study aims to systematically set a theory- and evidence-driven design for a pain self-management app and specify the app's active features.

METHODS

The Behavior Change Wheel (BCW) framework, a step-by-step theoretical approach to the development of interventions, was adopted to achieve the aim of this study. This started by understanding and identifying sources of behavior that could be targeted to support better pain management. Ultimately, the application of the BCW framework guided the identification of the active contents of the app, which were characterized using the Behavior Change Technique Taxonomy version 1.

RESULTS

The theoretical analysis revealed that patients may have deficits in their capability, opportunity, and motivation that prevent them from performing pain self-management. The app needs to use education, persuasion, training, and enablement intervention functions because, based on the analysis, they were found the most likely to address the specified factors. Eighteen behavior change techniques were selected to describe precisely how the intervention functions can be presented to induce the desired change regarding the intervention context. In other words, they were selected to form the active contents of the app, potentially reducing barriers and serving to support patients in the self-management of pain while using the app.

CONCLUSIONS

This study fully reports the design and development of a pain self-management app underpinned by theory and evidence and intended for patients with cancer. It provides a model example of the BCW framework application for health app development. The work presented in this study is the first systematic theory- and evidence-driven design for a pain app for patients with cancer. This systematic approach can support clarity in evaluating the intervention's underlying mechanisms and support future replication.

Beliefs and Narratives Associated with the Treatment of Chronic Pelvic Pain in Women

STUDY OBJECTIVE

Female patients with chronic pelvic pain (CPP) face complicated healthcare journeys, but narrative perspectives on CPP treatment are lacking.

DESIGN

We collected data in English and Spanish from discussion groups and individual interviews with stakeholders around female CPP.

SETTING

A tertiary care center for gynecologic care.

PATIENTS

Patients with CPP who self-identified as women/female, community healthcare workers, and providers who care for women with CPP.

INTERVENTIONS

We conducted discussion groups with all 3 types of stakeholders and individual interviews with female patients who have CPP.

MEASUREMENTS AND MAIN RESULTS

Patient participants completed condition specific validated questionnaires. De-identified transcripts were coded with NVivo software. We contrasted patient characteristics and codes between patients with CPP who did and did not report opioid use in the last 90 days. The mean pain score of patient participants was 6/10 ± 2/10, and 14 of 47 (28%) reported recent opioid use, without significant differences between patients with and without recent opioid use. Thematic saturation was achieved. Five main themes emerged: the debilitating nature of CPP, emotional impacts of CPP, challenges in CPP healthcare interactions, treatment for CPP, and the value of not feeling alone. Common threads voiced by stakeholders included difficulty discussing chronic pain with others, a sense of inertia in treatment, interest in alternative and less invasive treatments before more involved treatments, and the need for individualized, stepwise, integrated treatment plans. Participants agreed that opioids should be used when other treatments fail, but women recently using opioids voiced fewer concerns about addiction and positive experiences with opioid efficacy.

CONCLUSIONS

These findings among female patients with CPP and also among community healthcare workers and providers advocate for a move toward patient-centered care, particularly the acknowledgment that every woman experiences pain in a singular way. Furthermore, stakeholders voice a deep need for development of individualized treatment plans.

T-pattern detection in the scientific literature of this century: A systematic review

Introduction

Scientific literature contains mainly systematic reviews focused on substantial aspects, but there are also approaches that have combined both substantial and methodological aspects, which is our preferred option since it undeniably adds value. The aims of this study were: (1) to carry out a systematic review of the literatura on T-Pattern analysis (TPA), and (2) to explore the possible contribution of mixed methods research to the integration of qualitative and quantitative elements on a synthesis level.

Methods

Based on PRISMA guidelines, searches were carried out in the Scopus, PsycINFO, and Web of Science databases. The general search syntax was: "THEME" AND ("T-Patterns" OR "T Patterns") carried out in title, keywords and abstract. In addition, we included empirical articles on THEME and T-Patterns collected in other sources based on citations in several empirical works and consultations with different authors. This selection process resulted in 125 primary documents making up this systematic review.

Results

The results showed that the detection of structures in behavior patterns forms a nexus between studies carried out in very diverse fields and contexts. Most studies are observational, whilst the applicability and power of T-Pattern detection are extraordinary. It allows the researcher to go deeper in a robust analysis that responds to the integration of qualitative and quantitative elements which constitutes the leit motive of mixed methods; and also to discover the deep, hidden structure that underlies the respective databases, regardless of the methodology used in each study. The possibilities in assigning parameters notably increase the options for obtaining results and their interpretation.

Discussion

It is relevant the extraordinary strength and applicability of T-pattern detection. There is a high presence of T-pattern detection and analysis in studies using observational methodology. It is necessary commit to consolidating the methodological analysis of selected works, as taking individual and collective responsibility for improving methodological quality of TPA studies, taking advantage of the resources provided by the THEME program.

Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial

BACKGROUND

About 70% of patients with advanced cancer experience pain. Few studies have investigated the use of healthcare in this population and the relationship between pain intensity and costs.

METHODS

Adults with advanced cancer and scored worst pain ≥ 2/10 on a numeric rating scale (NRS) were recruited from 6 Australian oncology/palliative care outpatient services to the Stop Cancer PAIN trial (08/15-06/19). Out-of-hospital, publicly funded services, prescriptions and costs were estimated for the three months before pain screening. Descriptive statistics summarize the clinico-demographic variables, health services and costs, treatments and pain scores. Relationships with costs were explored using Spearman correlations, Mann-Whitney U and Kruskal-Wallis tests, and a gamma log-link generalized linear model.

RESULTS

Overall, 212 participants had median worst pain scores of five (inter-quartile range 4). The most frequently prescribed medications were opioids (60.1%) and peptic ulcer/gastro-oesophageal reflux disease (GORD) drugs (51.6%). The total average healthcare cost in the three months before the census date was A$6,742 (95% CI $5,637, $7,847), approximately $27,000 annually. Men had higher mean healthcare costs than women, adjusting for age, cancer type and pain levels (men $7,872, women $4,493, p<0.01) and higher expenditure on prescriptions (men $5,559, women $2,034, p<0.01).

CONCLUSIONS

In this population with pain and cancer, there was no clear relationship between healthcare costs and pain severity. These treatment patterns requiring further exploration including the prevalence of peptic ulcer/GORD drugs, and lipid lowering agents and the higher healthcare costs for men.

TRIAL REGISTRATION

ACTRN12615000064505. World Health Organisation unique trial number U1111-1164-4649. Registered 23 January 2015.

A direct observation of pain scale use in five video-recorded palliative care consultations: Using conversation analysis to show how practitioners support patients to describe pain

OBJECTIVE

Assessing pain intensity is an important palliative care task. Self-report pain intensity scales are frequently used within assessment. In contrast to formal studies of validity and reliability, we examine administration of, and responses to these scales in everyday palliative care.

METHODS

We searched episodes of pain scale use in a dataset of (video/audio-recorded) UK palliative care consultations involving five doctors, 37 terminally ill patients and their companions. We found five, and applied the techniques and tools of conversation analysis to characterise scales' administration and functioning.

RESULTS

Generally, the patients responded to scales by reporting multiple aspects of pain; the doctors supported and encouraged this. In two episodes, the scales generated misunderstandings. The doctors worked to resolve these in ways that avoided implying the patient was at fault.

CONCLUSION

Pain intensity scales can yield richer information than just intensity. They can also generate misunderstandings and social friction which take skill and effort to resolve.

PRACTICE IMPLICATIONS

Patients tend to respond to pain intensity scales by reporting on multiple aspects of pain, professionals should support them in this. These scales sometimes generate misunderstandings. To preserve the therapeutic relationship, professionals should work to resolve these without implying the patient is to blame.

Making Pain Research More Inclusive: Why and How

Current knowledge about mechanisms and interventions for pain has largely been derived from samples that are healthier, wealthier, younger, and more likely to be White than the general population. Failure to conduct inclusive pain research not only restricts generalizability and application of findings, but also hampers the discovery of mechanisms and the development of measures and interventions that are valid across population subgroups. Most of all, inclusive practices are critical to ensure that underrepresented groups derive equitable benefit from pain research. Here, we provide guidance for the pain research community on how to adopt inclusive research practices. We define "inclusion" to encompass a range of identities and characteristics, including racialized group/ethnicity, disability status, gender identity, sexual orientation, and age. We first describe principles relevant to promoting inclusion in pain research, including attention to: 1) stakeholder engagement; 2) structural factors underlying inequities; 3) the limitations of "disparity" research; 4) intersectionality; and 5) universal design. Next, we provide checklists with practical strategies for making studies more inclusive at each stage of the research process. We conclude by calling for system-level changes to ensure that the future of pain research is socially just, scientifically productive, and responsive to the needs of all people. PERSPECTIVE: This paper offers guidance on promoting inclusion of underrepresented groups in pain research. We describe principles relevant to conducting more inclusive research; eg, attention to stakeholder engagement, structural factors, and universal design. We provide checklists with practical strategies for inclusion at each stage of the research process.

Cultural factors affecting Chinese migrants' perceptions and responses to cancer pain and its pharmacological management: A convergent mixed-method study

INTRODUCTION

Studies identified barriers of pain reporting and use of analgesics impeding Chinese cancer patients to achieve optimal pain relief. No research has yet explored these issues in Chinese migrants, where cultural differences may exacerbate the barriers.

OBJECTIVES

To explore cultural factors influencing Chinese migrants' perspectives to cancer pain and its pharmacological management.

METHOD

Informed by Leininger's Cultural Care Theory, focus groups and a short version of Barrier Questionnaire-Taiwan (S-BQT) were conducted in Mandarin or Cantonese, with 24 Chinese migrants receiving ambulatory cancer and/or palliative care services in Sydney, Australia. Integrated thematic analysis, descriptive statistics, and meta-inference were adopted for data analysis and integration.

RESULTS

Participants suffered uncontrolled cancer pain negatively affecting their physical and psychosocial well-being. Most experienced moderate to severe pain, but only a third used opioids. Most adopted non-pharmacological approaches and half used Traditional Chinese Medicine. Participants scored a mean S-BQT of 3.28 (standard deviation ± 0.89). Three themes and seven sub-themes contributed to higher barriers of pharmacological pain management: (1) Philosophical health beliefs (cancer pain are self-provoked and body can self-heal); (2) Cultural values and beliefs (cancer pain is inevitable, and Chinese people express pain differently to local people); and (3) Conflicting views on the use of opioids (culture-related negative medication beliefs, Western biomedical model-related opioid fears, and opioids extend life for people with terminal cancer pain).

CONCLUSIONS

Chinese migrants' responses to cancer pain and attitudes towards opioids are complex. Culturally congruent strategies are needed to overcome culture-related barriers and improve quality of cancer pain care in this population.

Pharmacologic Management of Persistent Pain in Cancer Survivors

Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges  associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered.

Effect of Cancer Pain Guideline Implementation on Pain Outcomes Among Adult Outpatients With Cancer-Related Pain: A Stepped Wedge Cluster Randomized Trial

IMPORTANCE

An evidence-practice gap exists for cancer pain management, and cancer pain remains prevalent and disabling.

OBJECTIVES

To evaluate the capacity of 3 cancer pain guideline implementation strategies to improve pain-related outcomes for patients attending oncology and palliative care outpatient services.

DESIGN, SETTING, AND PARTICIPANTS

A pragmatic, stepped wedge, cluster-randomized, nonblinded, clinical trial was conducted between 2014 and 2019. The clusters were cancer centers in Australia providing oncology and palliative care outpatient clinics. Participants included a consecutive cohort of adult outpatients with advanced cancer and a worst pain severity score of 2 or more out of 10 on a numeric rating scale (NRS). Data were collected between August 2015 and May 2019. Data were analyzed July to October 2019 and reanalyzed November to December 2021.

INTERVENTIONS

Guideline implementation strategies at the cluster, health professional, and patient levels introduced with the support of a clinical champion.

MAIN OUTCOMES AND MEASURES

The primary measure of effect was the percentage of participants initially screened as having moderate to severe worst pain (NRS ≥ 5) who experienced a clinically important improvement of 30% or more 1 week later. Secondary outcomes included mean average pain, patient empowerment, fidelity to the intervention, and quality of life and were measured in all participants with a pain score of 2 or more 10 at weeks 1, 2, and 4.

RESULTS

Of 8099 patients screened at 6 clusters, 1564 were eligible, and 359 were recruited during the control phase (mean [SD] age, 64.2 [12.1] years; 196 men [55%]) and 329 during the intervention phase (mean [SD] age, 63.6 [12.7] years; 155 men [47%]), with no significant differences between phases on baseline measures. The mean (SD) baseline worst pain scores were 5.0 (2.6) and 4.9 (2.6) for control and intervention phases, respectively. The mean (SD) baseline average pain scores were 3.5 (2.1) for both groups. For the primary outcome, the proportions of participants with a 30% or greater reduction in a pain score of 5 or more of 10 at baseline were similar in the control and intervention phases (31 of 280 participants [11.9%] vs 30 of 264 participants [11.8%]; OR, 1.12; 95% CI, 0.79-1.60; P = .51). No significant differences were found in secondary outcomes between phases. Fidelity to the intervention was low.

CONCLUSIONS AND RELEVANCE

A suite of implementation strategies was insufficient to improve pain-related outcomes for outpatients with cancer-related pain. Further evaluation is needed to determine the required clinical resources needed to enable wide-scale uptake of the fundamental elements of cancer pain care. Ongoing quality improvement activities should be supported to improve sustainability.

Randomized Clinical Trial to Evaluate a Cancer Pain Self-Management Intervention for Outpatients

Objective

Unrelieved pain is common in patients with advanced cancer. Although psychoeducational interventions were found to decrease pain, effects were moderate. The purpose of this study was to evaluate the efficacy of a pain self-management intervention compared with usual care and to explore participants’ experiences with pain management and study participation.

Methods

A multicenter randomized controlled trial design with post-trial interviews was used. Outpatients with cancer pain and their family caregivers were recruited from three Swiss university hospitals. The intervention group (IG) received the six-week intervention consisting of education, skills building, and nurse coaching. The control group (CG) received usual care. Outcome variables were analyzed using multilevel models. Interpretive description guided the qualitative study part.

Results

Twenty-one patients with advanced cancer and seven family caregivers completed the study. The group x time effect showed a statistically significant decrease in average pain (P ​= ​0.04), but no significant group x time effect for worst pain (P ​= ​0.06). Pain scores, pain-related knowledge, Pain Management Index, self-efficacy, and performance status improved in the IG (P ​< ​0.05). Almost all of the interviewed participants perceived the pain management diary, tailored intervention sessions, and weekly support as useful. None experienced study participation as burdensome.

Conclusions

This study was the first to test the efficacy of a psychoeducational cancer pain self-management intervention in a German-speaking context, with most patients receiving palliative care. Clinicians can recommend the use of pain management diaries. Tailoring interventions to an individual's situation and dynamic pain trajectory may improve patients' pain self-management.

Registration number

This study has been registered via ClinicalTrials.gov: NCT02713919.https://clinicaltrials.gov/ct2/show/NCT02713919?term=NCT02713919&amp;draw=2&amp;rank=1.

Pain Experiences of Adults With Sickle Cell Disease and Hematopoietic Stem Cell Transplantation: A Qualitative Study

OBJECTIVE

Despite increasing use of hematopoietic stem cell transplantation (HSCT) for adults with sickle cell disease (SCD), little is known about pain management experiences throughout this process. The objective of this study was to explore patients' experiences with pain and pain management during and after HSCT for SCD.

METHODS

We conducted a qualitative interview study with 10 patients who underwent HSCT for SCD. We transcribed interviews verbatim and inductively identified codes. We used thematic analysis alongside a constant comparative method to develop and refine a codebook that aided in the identification of themes.

RESULTS

Four key themes emerged. (1) The pain trajectory: patients described a fluctuating course of pain during HSCT, which often extended long afterwards and impacted all aspects of life, particularly affected by pre-HSCT experiences; (2) The role of opioids-a double-edged sword: patients described opioids as reducing pain but insufficiently to balance significant adverse effects and burden; (3) Patient-centered decision making in pain management: patients described insufficient agency in decisions about opioid use and weaning; and (4) Consequences of health-related stigma: patients described experiences with stigma, mainly related to opioid use and weaning, as similar to pre-HSCT.

CONCLUSIONS

From the perspective of patients who have undergone HSCT for SCD, clinicians should use a patient-centered approach, integrating non-opioid approaches into pain management, particularly psychosocial support. As transplant for SCD becomes increasingly available, incorporating patient perspectives may improve health care delivery and overall patient experiences.

Women's experiences of advanced breast cancer in a resource-limited Arab context: A Stakian multi-case study

OBJECTIVE

Breast cancer is the most common cancer for women, globally. Women are more likely to present with more advanced cancer and palliative care needs in low-resource contexts. There is limited research on Arab, Muslim and African women's experiences of advanced breast cancer. The aim of this study was to explore and understand the experiences of advanced breast cancer in the Islamic Republic of Mauritania.

METHODS

Using a constructivist Stakian multi-case study approach, eight cases were constructed with women with advanced breast cancer (n = 8), family members (n = 10) and health professionals (n = 9). Data were collected longitudinally (up to nine months per case) and included semi-structured interviews and audio-journals. Data from 58 interviews and 31 journal entries were thematically analysed.

RESULTS

Three key themes were identified: 1. Destiny: Maure women appreciate that Allah is all powerful and maintains control over their destinies and their breast cancer. 2. Patience & Acceptance: a fear of causing offence to Allah influences how women express their experiences of breast cancer and its treatments. 3. Journeying in search of a cure: Maure women have limitled access to information around their cancer and its treatments. Women use their own observations and interpretations to understand their breast cancer and guide their pursuit of treatment and a cure.

CONCLUSION

Maure women feel reassured that life and cure remain possible because of Allah's sustenance; but are aware that the gift of life is fragile. They experience restricted power over how they express negative experiences, access to information, and healthcare decisions.

Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis

Oxygen therapy is frequently prescribed for the palliation of breathlessness, despite lack of evidence for its effectiveness in people who are not hypoxaemic. This study aimed to compare and contrast patients', caregivers' and clinicians' experiences of palliative oxygen use for the relief of chronic breathlessness in people with advanced life-limiting illnesses, and how this shapes prescribing.A systematic review and meta-synthesis of qualitative data was conducted. MEDLINE, CINAHL and PsycINFO were searched for peer-reviewed studies in English (2000-April 2019) reporting perspectives on palliative oxygen use for reducing breathlessness in people with advanced illnesses in any healthcare setting. After data extraction, thematic synthesis used line-by-line coding of raw data (quotes) to generate descriptive and analytical themes.Of 457 articles identified, 22 met the inclusion criteria by reporting perspectives of patients (n=337), caregivers (n=91) or clinicians (n=616). Themes common to these perspectives were: 1) benefits and burdens of palliative oxygen use, 2) knowledge and perceptions of palliative oxygen use beyond the guidelines, and 3) longitudinal trajectories of palliative oxygen use.There are differing perceptions regarding the benefits and burdens of using palliative oxygen. Clinicians should be aware that oxygen use may generate differing goals of therapy for patients and caregivers. These perceptions should be taken into consideration when prescribing oxygen for the symptomatic relief of chronic breathlessness in patients who do not quality for long-term oxygen therapy.

Palliative Care's Role Managing Cancer Pain During the Opioid Crisis: A Qualitative Study of Patients, Caregivers, and Clinicians

CONTEXT

Patients with cancer face symptoms because of disease and treatment, and pain is common and complex. The opioid crisis may complicate patients' and clinicians' experiences of managing pain in cancer care.

OBJECTIVES

In our study of perceptions and experiences with palliative care (PC) at an outpatient cancer center, we examined communication around symptom management throughout cancer care, and pain and its management emerged as particularly salient. The objective of this article is to describe, from the perspectives of patients, caregivers, and oncology health care professionals, the role of PC in navigating the complicated dynamics of pain management amidst the opioid crisis.

METHODS

A qualitative descriptive study with grounded theory components was designed to investigate experiences with and perceptions of specialist PC and symptom management, including pain. Interviews were audiorecorded and transcribed, and focused coding identified themes related to pain and pain management from all three perspectives.

RESULTS

About 44 patients, caregivers, and non-PC health care professionals completed interviews. Patients with cancer and their caregivers had many concerns about pain management and were specifically concerned about opioid use and stigma. For patients, PC improved pain management and helped to destigmatize appropriate pain management. Oncology clinicians reported that partnering with PC facilitated complex pain management and also provided moral support around difficult opioid recommendations for patients.

CONCLUSION

PC offers the potential to uniquely support both patients and other oncology professionals in optimally navigating the complexity around pain management for cancer care in the midst of the opioid crisis.

Implementation of a nurse-led self-management support intervention for patients with cancer-related pain: a cluster randomized phase-IV study with a stepped wedge design (EvANtiPain)

Background

Pain self-management support interventions were effective in controlled clinical trials and meta analyses. However, implementation of these complex interventions may not translate into identical effects. This paper evaluates the implementation of ANtiPain, a cancer pain self-management support intervention in routine clinical practice according to the Reach Efficacy-Adoption Implementation Maintenance framework.

Methods

In this cluster randomized study with a stepped wedge design, N = 153 adult patients with cancer-related pain were recruited from 01/17 to 05/18 on 17 wards of 3 hospitals in Vienna, Austria. ANtiPain entailed a face-to-face in-hospital session by a trained nurse to prepare discharge according to key strategies, information on pain self-management, and skills building. After discharge, cancer-pain self-management was coached via phone calls. Patient-level data were collected at recruitment, and 2, 4 and 8 weeks after discharge via postal or online questionnaire. Primary outcome was pain interference with daily activities. Secondary outcomes included pain intensity, self-efficacy, and patient satisfaction. Organizational-level data (e.g., on implementation procedures) were collected by study or intervention nurses. The mixed model to analyze patient-level data included a random intercept and a random slope for individual and a random intercept for ward.

Results

Recruitment was slower than expected and unevenly distributed over wards and hospitals. The face-to-face session was clinically feasible (mean duration = 33 min) as well as the mean amount (n = 2) and duration of phone calls (mean = 17 min). Only 16 (46%) of 35 trained nurses performed the intervention on nine wards. To deal with the loss of power, analyses were adapted. Overall effects on pain interference were not significant. However, effects were significant in sub analyses of the nine wards that recruited patients in the intervention period (p = .009). Regarding secondary outcomes, the group-by-time effect was significant for self-efficacy (p = .033), and patient satisfaction with information on pain-self-management (p = .002) and in-hospital pain management (p = .018).

Conclusions

The implementation of ANtiPain improved meaningful patient outcomes on wards that applied the intervention routinely. Our analyses showed that the implementation benefited from being embedded in larger scale projects to improve cancer pain management and that the selection of wards with a high percentage of oncology patients may be crucial.

Trial registration

ClinicalTrials.gov Identifier: NCT02891785 Date of registration: September 8, 2016.

Innovations in framework synthesis as a systematic review method

Framework synthesis is one systematic review method employed to address health care practice and policy. Adapted from framework analysis methods, it has been used increasingly, using both qualitative and mixed-method systematic review methods. This article demonstrates a spectrum of approaches to framework synthesis that are dependent on the extent to which theory is tentative, emergent, refined, or established; and that stakeholder involvement may help to understand the topic's complexity where theory is more nascent. The choice of approach depends on the degree of match with existing theories and, in the absence of existing theory, the scale and heterogeneity of the literature to be managed.

Healthcare Decision-Making of African-American Patients: Comparing Positivist and Postmodern Approaches to Care

Healthcare decision-making (HCDM) may be a potentially challenging time for any person. When considered against the backdrop of being a minority, experiencing disparate care based on racial bias, and confronting the implications of advanced serious illness, the practices and processes of HCDM become increasingly complex. The purpose of this paper is to consider the HCDM of African-American patients with advanced serious illness through the lens of positivism and postmodernism and to make the argument that postmodern nursing is the ideal ethical and equitable approach to HCDM. Postmodernism reengages nurses to consider HCDM of African-American patients with advanced serious illness as an individualized, contextualized, whole-person process, requiring all ways of knowing. A postmodern nursing approach may promote sustainable and human-centered health interventions that will reposition an often marginalized group to the center of practice, policy, and research progress.

A mixed-methods systematic review of patients' experience of being invited to participate in surgical randomised controlled trials

RATIONALE

Randomised controlled trials (RCTs) of surgical interventions are increasing. Such trials encounter challenges that are not present in RCTs of non-surgical interventions because of the nature of the intervention. Several studies have explored patients' experiences of surgical trials to improve recruitment or identify barriers and facilitators to research in this setting. Synthesizing these studies may reveal further insights or confirm whether saturation of relevant themes has been achieved.

OBJECTIVE

This review aimed to understand the experiences of adults who are invited to participate in surgical RCTs.

METHOD

MEDLINE, Web of Science, and CINAHL were searched to identify articles meeting the inclusion criteria. Assessment of quality was conducted with studies given an overall quality rating of good, fair, or poor. A segregated approach was used to synthesize the data. This method included a thematic synthesis of the qualitative data and a narrative review of the quantitative data. The findings of both syntheses were then integrated.

RESULTS

Thirty-four articles reporting 28 trials were included. This review found that the decision to participate in a surgical trial is influenced by multiple factors including patients' individual circumstances and attitudes, and the characteristics of the trial itself. The study identified three themes which encompass both qualitative and quantitative findings. These themes reveal it was important for patients to i) make sense of the trial and trial processes, ii) weigh up the risks and benefits of their different treatment options and participation, and iii) trust the trial and staff.

CONCLUSIONS

A patient-centred approach to trial recruitment may help staff build trusting relationships with patients and address their individual concerns about the trial and the risks and benefits of participation.

Are Pain and Fatigue in Multiple Myeloma Related to Psychosocial Factors?: A Systematic Review

BACKGROUND

Fatigue, pain, and psychological distress have been found to be among the most significant quality of life concerns for patients with multiple myeloma. Strong links between these variables have been found in other cancer populations.

OBJECTIVE

The aim of this study was to systematically review the research literature on the associations between psychosocial factors and pain and/or fatigue in patients with multiple myeloma.

INTERVENTIONS/METHODS

The review followed PRISMA guidelines. A systematic search of 3 databases was conducted. Included studies were appraised for risk of bias. Data were extracted and combined in a narrative synthesis.

RESULTS

The review identified 11 studies for inclusion, reporting data from a total of 2432 participants. It found consistent evidence of a medium-sized relationship between both global distress and depression on the one hand and pain and fatigue on the other. The included studies were highly varied in the psychosocial factors they investigated.

CONCLUSIONS

There is good evidence that pain and fatigue are related to global distress and depression in patients with multiple myeloma. The evidence on relationships with other psychosocial factors is inconclusive. Research investigating the role of more specific psychosocial processes is called for.

IMPLICATIONS FOR PRACTICE

Assessment of pain and fatigue in patients with multiple myeloma should routinely include screening for psychological distress. Interventions for psychological distress may be considered as adjuvant intervention strategies for pain and fatigue in patients with multiple myeloma.

Risk of opioid misuse in people with cancer and pain and related clinical considerations: a qualitative study of the perspectives of Australian general practitioners

OBJECTIVE

To explore the perspectives of general practitioners (GPs) concerning the risk of opioid misuse in people with cancer and pain and related clinical considerations.

DESIGN

A qualitative approach using semistructured telephone interviews. Analysis used an integrative approach.

SETTING

Primary care.

PARTICIPANTS

Australian GPs with experience of prescribing opioids for people with cancer and pain.

RESULTS

Twenty-two GPs participated, and three themes emerged. Theme 1 (Misuse is not the main problem) contextualised misuse as a relatively minor concern compared with pain control and toxicity, and highlighted underlying systemic factors, including limitations in continuity of care and doctor expertise. Theme 2 ('A different mindset' for cancer pain) captured participants' relative comfort in prescribing opioids for pain in cancer versus non-cancer contexts, and acknowledgement that compassion and greater perceived community acceptance were driving factors, in addition to scientific support for mechanisms and clinical efficacy. Participant attitudes towards prescribing for people with cancer versus non-cancer pain differed most when cancer was in the palliative phase, when they were unconcerned by misuse. Participants were equivocal about the risk-benefit ratio of long-term opioid therapy in the chronic phase of cancer, and were reluctant to prescribe for disease-free survivors. Theme 3 ('The question is always, 'how lazy have you been?') captured participants' acknowledgement that they sometimes prescribed opioids for cancer pain as a default, easier option compared with more holistic pain management.

CONCLUSIONS

Findings highlight the role of specific clinical considerations in distinguishing risk of opioid misuse in the cancer versus non-cancer population, rather than diagnosis per se. Further efforts are needed to ensure continuity of care where opioid prescribing is shared. Greater evidence is needed to guide opioid prescribing in disease-free survivors and the chronic phase of cancer, especially in the context of new treatments for metastatic disease.

Development and implementation strategies of a nurse-led symptom self-management program in outpatient cancer centres: The Symptom Navi© Programme

PURPOSE

The Symptom Navi© Programme (SN©P) is a structured nurse-led intervention supporting symptom self-management in cancer patients. We describe the development and evaluation of the intervention, implementation strategy, and the evaluation of nurse training for the Symptom Navi© Pilot Study.

METHODS

The intervention was developed using multiple methods (e.g. literature synthesis, focus groups) to produce SN©P information leaflets (SN©Flyers in French and German) and standardised training for nurses to deliver semi-structured consultations. We evaluated the SN©P using online surveys, focus groups, interviews, and the Item-Content Validity Index (I-CVI). Nurse training was evaluated in relation to content, acceptability, and confidence in implementing the SN©P. We examined the association between scored on the Work-related Sense of Coherence (Work-SoC) scale and nurses' confidence in implementing the SN©P. Thematic analysis was used to analyse qualitative data. Quantitative data was descriptively analysed and the Kendall Tau test was employed for correlations.

RESULTS

Patients and health care professionals confirmed that SN©Flyers and semi-structured consultations facilitated symptom self-management. Nurses considered training content/format acceptable and appropriate and felt confident in implementing the SN©P. Overall Work-SoC scores were correlated with nurses' confidence in implementing the SN©P (r_π = .47, p = .04).

CONCLUSIONS

Health care professionals and cancer patients perceived the SN©P as a useful support. Successful implementation of the SN©P depends on centre-specific factors including time, resources and workflow.

CLINICAL TRIAL REGISTRY

NCT03649984 and SNCTP000002381.

The Influence of a Home-Based Education Intervention on Family Caregivers' Knowledge and Self-Efficacy for Cancer Pain Management in Adult Patients Within a Resource-Limited Setting

Cancer-related pain is prevalent and has debilitating effects on patients and their family. The effects of cancer pain can be curtailed if the family members caring for the patient receive essential support to enhance their capabilities for cancer pain management. Little has been done to study the available support to family caregivers (FCGs) towards pain management in adult cancer patients (ACPs) living in resource-limited countries where the burden of cancer is on the rise. This study evaluated the influence of an education intervention delivered in the home setting on FCGs' knowledge and self-efficacy (SE) for pain management in ACPs. One-group pre-/post-test design was used in a sample of 54 FCGs who had been caring for ACPs suffering from pain for at least 1 month. Data were collected using the Family Pain Questionnaire and Caregiver Pain Management SE Scale. The FCGs' mean knowledge score post-intervention (26.69 ± 10) was higher than the baseline (45 ± 12.9), and the difference was statistically significant (t = 10.382, p = 0.000, CI = 17.12-25.43). Additionally, the FCGs' mean SE score post-intervention (1003.30 ± 191) was higher than the baseline (648.3 ± 273.4), and the difference was statistically significant (t = - 8.52, p = 0.000, CI = - 438.6-- 271.4). The home-based education intervention significantly and positively influenced the FCGs' knowledge and SE for pain management while at home. Cancer pain management educational interventions delivered at home should be considered as one of the strategies for enhancing cancer care in resource limited settings.

High sensitive detection of circulating tumor cell by multimarker lipid magnetic nanoparticles and clinical verifications

Tumor cells with heterogeneity and diversity can express different markers. At present, positive separation of circulating tumor cells (CTC) taking EpCAM as the marker was used in most cases which could be one-sided, while this study successfully prepared four antibody-modified magnetic immunoliposomes (MIL) by using the self-assembled liposome with antibody derivatives. This study aims to explore the separation efficiency and clinical detection feasibility of single or combined use of MIL with multi-tumor markers on different tumors. Captured CTC were stained with CK-FITC, CD45-PE and DAPI, and fluorescence microscope was used for the observation, analysis and calculation. The result indicated that the CTC number positive rate in blood samples of four different magnetic balls on the same patient could be up to 87.5% in 32 patients with 14 different kinds tumors. While the effect of directly mixed separation by four kinds of magnetic balls was not satisfying. It suggested that the MIL of multi-tumor markers could be a powerful tool for CTC separation in application of tumor screening and prognosis.

Testing the Implementation of a Pain Self-management Support Intervention for Oncology Patients in Clinical Practice: A Randomized Controlled Pilot Study (ANtiPain)

BACKGROUND

In oncology, pain control is a persistent problem. Significant barriers to cancer pain management are patient related. Pain self-management support interventions have shown to reduce pain intensity and patient-related barriers. Comparative effectiveness research is a suitable approach to test whether effects are sustained in clinical practice.

OBJECTIVE

In this pilot randomized controlled trial, the implementation of the ANtiPain intervention into clinical practice was tested to assess the effects on pain intensity, function-related outcomes, self-efficacy, and patient-related barriers to pain management to prepare a larger effectiveness trial.

METHODS

Within 14 months, 39 adult oncology patients with pain scores of 3 or higher on a 10-point numeric rating scale were recruited in an academic comprehensive cancer center in Southern Germany. Patients in the control group (n = 19) received standard care. Patients in the intervention group (n = 20) received ANtiPain, a cancer pain self-management support intervention based on 3 key strategies: provision of information, skill building, and nurse coaching. An intervention session was performed in-hospital. After discharge, follow-up was provided via telephone calls. Data were collected at baseline and 1 and 6 weeks after discharge. Effect sizes were calculated for all outcomes.

RESULTS

Large effects were found for activity hindrance (Cohen d = 0.90), barriers (d = 0.91), and self-efficacy (d = 0.90). Small to moderate effects were found for average and worst pain (Cohen d = 0.17-0.45).

CONCLUSIONS

Key findings of this study involved function-related outcomes and self-efficacy.

IMPLICATIONS FOR PRACTICE

Because these outcomes are particularly meaningful for patients, the integration of ANtiPain to routine clinical practice may be substantial. A larger study will be based on these findings.

Dissemination and Implementation of Patient-centered Indicators of Pain Care Quality and Outcomes

BACKGROUND

Previous approaches to measuring and improving nursing-sensitive, patient-centered metrics of pain quality and outcomes in hospitalized patients have been limited.

METHODS

In this translational research study, we disseminated and implemented pain quality indicators in 1611 medical and/or surgical, step-down, rehabilitation, critical access, and obstetrical (postpartum) units from 326 US hospitals participating in the National Database of Nursing Quality Indicators. Eligible patients were English-speaking adults in pain. Trained nurses collected patients' perceptions via structured interview including 9 pain quality indicators, demographic, and clinical variables; these patient experience data were merged with unit and hospital level data. Analyses included geographic mapping; summary statistics and 3-level mixed effects modeling.

RESULTS

Hospitals in 45 states and District of Columbia participated. Of 22,293 screened patients, 15,012 were eligible; 82% verbally consented and participated. Pain prevalence was 72%. Participants were 59.4% female; ages ranged from 19 to 90+ (median: 59 y); 27.3% were nonwhite and 6.5% were Hispanic. Pain intensity on average over the past 24 hours was 6.03 (SD=2.45) on a 0-10 scale. 28.5% of patients were in severe pain frequently or constantly. Race (nonwhite), younger age, being female and nonsurgical were associated (P<0.001) with greater pain. Care quality indicators ranking lowest related to discussion of analgesic side effects and use of nonpharmacologic approaches.

CONCLUSIONS

Unrelieved pain remains a high-volume problem. Individual factors and unit type were significantly associated with pain outcomes. Hospitals can employ these quality indicators to direct continuous quality improvement targeting pain care quality.

Development of a cancer pain self-management resource to address patient, provider, and health system barriers to care

OBJECTIVE

The majority of self-management interventions are designed with a narrow focus on patient skills and fail to consider their potential as "catalysts" for improving care delivery. A project was undertaken to develop a patient self-management resource to support evidence-based, person-centered care for cancer pain and overcome barriers at the levels of the patient, provider, and health system.

METHOD

The project used a mixed-method design with concurrent triangulation, including the following: a national online survey of current practice; two systematic reviews of cancer pain needs and education; a desktop review of online patient pain diaries and other related resources; consultation with stakeholders; and interviews with patients regarding acceptability and usefulness of a draft resource.

RESULT

Findings suggested that an optimal self-management resource should encourage pain reporting, build patients' sense of control, and support communication with providers and coordination between services. Each of these characteristics was identified as important in overcoming established barriers to cancer pain care. A pain self-management resource was developed to include: (1) a template for setting specific, measureable, achievable, relevant and time-bound goals of care, as well as identifying potential obstacles and ways to overcome these; and (2) a pain management plan detailing exacerbating and alleviating factors, current strategies for management, and contacts for support.

SIGNIFICANCE OF RESULTS

Self-management resources have the potential for addressing barriers not only at the patient level, but also at provider and health system levels. A cluster randomized controlled trial is under way to test effectiveness of the resource designed in this project in combination with pain screening, audit and feedback, and provider education. More research of this kind is needed to understand how interventions at different levels can be optimally combined to overcome barriers and improve care.

Women's stories of living with breast cancer: A systematic review and meta-synthesis of qualitative evidence

RATIONALE

Globally, breast cancer is by far the most frequently occurring cancer amongst women. Whilst the physical consequences of the disease and associated treatments are well documented, a comprehensive picture of how breast cancer is experienced at all stages of disease progression is lacking.

OBJECTIVE

This systematic review aimed to synthesize qualitative studies documenting women's breast cancer narratives into an empirically based explanatory framework.

METHODS

Two investigators independently searched Academic Search Premiere, CINAHL, Health Source: Nursing/Academic Edition, MEDLINE, PsycARTICLES, PubMed, Science Direct, SCOPUS, Web of Science and three international dissertation repositories using a pre-specified search strategy to identify qualitative studies on women's breast cancer narratives across all geographic and income-level settings. Of the 7840 studies that were screened for eligibility, included in the review were 180 studies, which were assessed using the Critical Appraisal Skills Programme. Using a 'meta-study' approach, an explanatory model of the breast cancer experience was formulated. Finally, we assessed the confidence in the review findings using the 'Confidence in the Evidence from Reviews of Qualitative Research' (CERQual) guidelines.

RESULTS

Eight core themes were identified: the burden of breast cancer, existential ordeal, illness appraisal, sources of support, being in the healthcare system, the self in relation to others, changes in self-image, and survivor identity. Together, these form the proposed Trajectory of Breast Cancer (TBC) framework.

CONCLUSION

The Trajectory of Breast Cancer explanatory framework offers a theoretically defensible synthesis of women's experiences of breast cancer. This framework provides an empirical basis for future reviewers conducting qualitative and narrative breast cancer research.

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).

Screening and Audit as Service-Level Strategies to Support Implementation of Australian Guidelines for Cancer Pain Management in Adults: A Feasibility Study

BACKGROUND

Pain in people with cancer is common but often under-recognized and under-treated. Guidelines can improve the quality of pain care, but need targeted strategies to support implementation.

AIM

To test the feasibility of two service-level strategies for supporting guideline implementation: a screening system and medical record audit.

DESIGN

Multimethods.

SETTING

One oncology outpatient service, and one palliative care outpatient and inpatient service.

PARTICIPANTS

Patients with advanced cancer.

METHODS

Patients were screened in the waiting room with a modified version of the Edmonton Symptom Assessment System-revised either electronically or in paper-based format. Feasibility indicated the percentage of patients successfully screened from the total number attending the services. An audit assessed adherence to key indicators of pain assessment and management. Feasibility thresholds were set at 75% incidence for screening and a median of 30 minutes per patient for audit.

RESULTS

Of 452 patient visits, 95% (n = 429) were successfully screened, 34% (n = 155) electronically and 61% (n = 274) paper-based. Electronic pain screening was technically challenging and time-intensive for nurses. Thirty-one patients consented to have their records audited. The median audit time was 37.5 minutes (range 10-120 minutes). Variability arose from the number and type of record (outpatient or inpatient). Adherence to indicators varied from 63% (pain assessment at first presentation) to 94% (regular pain assessment and medication prescribed at regular intervals).

CONCLUSIONS

This study confirmed the need to implement evidence-based guidelines for cancer pain and generated useful insights into the feasibility of pain screening and audit.

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.

Protocol for a phase III pragmatic stepped wedge cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of screening and guidelines with, versus without, implementation strategies for improving pain in adults with cancer attending outpatient oncology and palliative care services: the Stop Cancer PAIN trial

BACKGROUND

Pain is a common and distressing symptom in people with cancer, but is under-recognised and under-treated. Australian guidelines for 'Cancer Pain Management in Adults' are available on the Cancer Council Australia Cancer Guideline Wiki. This study aims to evaluate the effectiveness and cost-effectiveness of a suite of guideline implementation strategies for improving pain outcomes in adults with cancer in oncology and palliative care outpatient settings.

METHODS

The study will use a stepped-wedge cluster randomised controlled design, with oncology and palliative care outpatient services as the clusters. Patients will be eligible if they are adults with cancer and pain presenting to participating services during the study period. During an initial control arm, services will routinely screen patients for average and worst pain over the past 24 h using a 0-10 numerical rating scale (NRS) and have unfettered access to online guidelines. During the intervention arm, staff at each service will be encouraged to use: 1) a patient education booklet and self-management resource; 2) an online spaced learning cancer pain education module for clinicians from different disciplines; and 3) audit and feedback of service performance on key indices of cancer pain screening, assessment and management. Service-based clinical change champions will lead implementation of these strategies. The trial's primary outcome will be the probability that patients initially screened as having moderate-severe (≥5/10 NRS) worst pain experience a clinically important improvement one week later, defined as  ≥ 30% reduction. Secondary outcomes will include patient empowerment and quality of life, carer experience, and cost-effectiveness. For the main analysis, linear mixed models will be used, accounting for clustering and the longitudinal design. Eighty-two patients per service at six services (N = 492) will provide > 90% power. A qualitative sub-study and analyses of structural and process factors will explore opportunities for further refinement and tailoring of the intervention.

DISCUSSION

This pragmatic trial will inform implementation of guidelines across a range of oncology and palliative care outpatient service contexts. If found effective, the implementation strategies will be made freely available on the Wiki alongside the guidelines.

TRIAL REGISTRATION

Registered 23/01/2015 on the Australian New Zealand Clinical Trials Registry ( ACTRN12615000064505 ).

Systematic development of CHEMO-SUPPORT, a nursing intervention to support adult patients with cancer in dealing with chemotherapy-related symptoms at home

Background

Given the great symptom burden associated with chemotherapy on the one hand and generally poor self-management of symptoms by cancer patients on the other hand, our aim was to develop a nursing intervention to reduce symptom burden in adult cancer patients treated with chemotherapy and to support them in dealing with their various symptoms at home.

Methods

Development of the intervention was guided by the Intervention Mapping Approach and included following steps: needs assessment, formulation of proximal programme objectives, selection of methods and strategies, production of programme components, and planning for implementation and evaluation of the intervention. A panel of multidisciplinary healthcare professionals (n = 12) and a panel of patients and family caregivers (n = 7) were actively involved developing the intervention at each stage.

Results

For the intervention, four patient performance objectives relating to self-management were advanced. Self-efficacy and outcome expectations were selected as key determinants of dealing with chemotherapy-related symptoms. As methods for supporting patients, motivational interviewing and tailoring were found to fit best with the change objectives and determinants. Existing patient information materials were re-designed after panel input to reinforce the new intervention approach.

Conclusion

The intervention mapping approach, including active involvement of the intervention providers and receivers, informed the design of this nursing intervention with two or more contacts. Further evaluation is needed to gain insight into the potential effects, feasibility and mechanisms of this complex intervention.

Electronic supplementary material

The online version of this article (10.1186/s12912-018-0297-8) contains supplementary material, which is available to authorized users.

Barriers and facilitators to implementation of cancer treatment and palliative care strategies in low- and middle-income countries: systematic review

OBJECTIVES

To appraise improvement strategies adopted by low- and middle-income countries to increase access to cancer treatments and palliative care; and identify the facilitators and barriers to implementation.

METHODS

A systematic review was conducted and reported in accordance with PRISMA statement. MEDLINE, CINAHL, and the Cochrane Library databases were searched. Bias was assessed using the Standards for Quality Improvement Reporting Excellence, and evidence graded using the Australian National Health and Medical Research Council system.

RESULTS

Of 3069 articles identified, 18 studied were included. These studies involved less than a tenth (n = 12, 8.6%) of all low- and middle-income countries. Most were case reports (58%), and the majority focused on palliative care (n = 11, 61%). Facilitators included: stakeholder engagement, financial support, supportive learning environment, and community networks. Barriers included: lack of human resources, financial constraints, and limited infrastructure.

CONCLUSIONS

There is limited evidence on sustainable strategies for increasing access to cancer treatments and palliative care in low- and middle-income countries. Future strategies should be externally evaluated and be tailored to address service delivery; workforce; information; medical products, vaccines, and technologies; financing; and leadership and governance.

A Randomized, Single-Blind Study Evaluating the Effect of a Bone Pain Education Video on Reported Bone Pain in Patients with Breast Cancer Receiving Chemotherapy and Pegfilgrastim

BACKGROUND

Mild-to-moderate bone pain is the most commonly reported adverse event associated with pegfilgrastim.

AIMS

To investigate the effect of bone pain education on pegfilgrastim-related bone pain in patients with breast cancer receiving chemotherapy and pegfilgrastim.

DESIGN

Randomized, single-blind study.

SETTINGS

Forty-eight community oncology clinics throughout the United States.

PARTICIPANTS

Three hundred women ≥18 years of age with newly diagnosed stage I -III breast cancer, who were planning ≥4 cycles of neoadjuvant or adjuvant chemotherapy with pegfilgrastim support starting in cycle 1.

METHODS

Patients were randomized 1:1 to view a general education DVD on chemotherapy side effects (GE-DVD) or a DVD on bone pain following chemotherapy and pegfilgrastim (BP-DVD). Patients recorded severity of bone pain on a scale of 0-10, location of pain, and use of bone pain medications (i.e., analgesics, antihistamines, and nonsteroidal anti-inflammatory drugs) for 5 days, beginning on the day of pegfilgrastim administration, in each of the first four chemotherapy cycles.

RESULTS

Patient-reported maximum bone pain was similar in the two groups (GE-DVD vs BP-DVD: cycle 1, 3.2 vs. 3.5, p = .3479; across all cycles, 4.1 vs. 4.6, p = .2196). Other measures of bone pain were also similar between the groups. Bone pain was highest in cycle 1 but decreased and then remained stable in subsequent cycles. Bone pain medication use was similar in both groups and was highest in cycle 1.

CONCLUSIONS

The bone pain-specific education evaluated here did not improve perceptions of bone pain reported in this patient population.

Going Forward Lightening the Shadow of Cancer: Experiences of Family Caregivers Toward Empowerment

This qualitative study was conducted to explore the empowerment experiences of family caregivers of patients with cancer. Empowerment consisted of 3 main categories: (1) seeking tranquility with the help of religious beliefs, (2) developing a positive attitude, and (3) restoring control over the situation. Results may help nurses for planning spiritual and supportive care.

Communicating Caregivers' Challenges With Cancer Pain Management: An Analysis of Home Hospice Visits

CONTEXT

Family caregivers (FCGs) of hospice cancer patients face significant challenges related to pain management. Addressing many of these challenges requires effective communication between FCGs and hospice nurses, yet little empirical evidence exists on the nature of communication about pain management between hospice nurses and FCGs.

OBJECTIVES

We identified ways in which FCGs of hospice cancer patients communicated their pain management challenges to nurses during home visits and explored nurses' responses when pain management concerns were raised.

METHODS

Using secondary data from audio recordings of hospice nurses' home visits, a deductive content analysis was conducted. We coded caregivers' pain management challenges and immediate nurses' responses to these challenges.

RESULTS

From 63 hospice nurse visits, 101 statements describing caregivers' pain management challenges were identified. Thirty percent of these statements pertained to communication and teamwork issues. Twenty-seven percent concerned caregivers' medication skills and knowledge. In 52% of the cases, nurses responded to caregivers' pain management challenges with a validating statement. They provided information in 42% of the cases. Nurses did not address 14% of the statements made by caregivers reflecting pain management challenges.

CONCLUSION

To optimize hospice patients' comfort and reduce caregivers' anxiety and burden related to pain management, hospice nurses need to assess and address caregivers' pain management challenges during home visits. Communication and educational tools designed to reduce caregivers' barriers to pain management would likely improve clinical practice and both patient- and caregiver-related outcomes.

A Systematic Review of the Patient- and Carer-Related Factors Affecting the Experience of Pain for Advanced Cancer Patients Cared for at Home

CONTEXT

Effective pain management is a priority in the palliative care of advanced cancer patients. A body of research is emerging examining the factors that influence the management and experience of pain for such individuals. Identifying such factors should allow for the development of targeted interventions to improve pain management in the home while ultimately reducing unnecessary suffering for the patient.

OBJECTIVES

The objective of this study was to identify relevant patient- and carer-related factors which have an effect on the pain experienced by advanced cancer patients cared for at home.

METHOD

This is a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement guidelines. Studies were retrieved from the CINAHL, MEDLINE, and Web of Science and assessed independently by two reviewers with discrepancies assessed by a third before quality assessment and data extraction. A narrative synthesis was produced.

RESULTS

Our search strategy produced 720 hits, of which 10 studies were retained for the final analysis. The factors identified included carer knowledge of cancer pain management, carer burden, carer and patient distress, pain rating disparity, patient well-being, patient depression, patient affective experience, patient body image, and satisfaction with palliative/medical care. All factors identified are supported by only some evidence with many having only been explored in single studies.

CONCLUSIONS

There is a lack of quantitative research in the area of factors influencing the experience of pain for advanced cancer patients cared for at home. Such findings would be useful in developing theories of change that would underpin interventions aimed at improving pain outcomes for this population.

Cancer pain management needs and perspectives of patients from Chinese backgrounds: a systematic review of the Chinese and English literature

Objective

More than half of all cancer patients experience unrelieved pain. Culture can significantly affect patients’ cancer pain-related beliefs and behaviors. Little is known about cultural impact on Chinese cancer patients’ pain management. The objective of this review was to describe pain management experiences of cancer patients from Chinese backgrounds and to identify barriers affecting their pain management.

Method

A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they reported pain management experiences of adult cancer patients from Chinese backgrounds. Five databases were searched for peer-reviewed articles published in English or Chinese journals between1990 and 2015. The quality of included studies was assessed using Joanna Briggs Institution's appraisal tools.

Results

Of 3,904 identified records, 23 articles met criteria and provided primary data from 6,110 patients. Suboptimal analgesic use, delays in receiving treatment, reluctance to report pain, and/or poor adherence to prescribed analgesics contributed to the patients’ inadequate pain control. Patient-related barriers included fatalism, desire to be good, low pain control belief, pain endurance beliefs, and negative effect beliefs. Patients and family shared barriers about fear of addiction and concerns on analgesic side effects and disease progression. Health professional–related barriers were poor communication, ineffective management of pain, and analgesic side effects. Healthcare system–related barriers included limited access to analgesics and/or after hour pain services and lack of health insurance.

Significance of results

Chinese cancer patients’ misconceptions regarding pain and analgesics may present as the main barriers to optimal pain relief. Findings of this review may inform health interventions to improve cancer pain management outcomes for patients from Chinese backgrounds. Future studies on patients’ nonpharmacology intervention-related experiences are required to inform multidisciplinary and biopsychosocial approaches for culturally appropriate pain management.

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.