The impact of demographic and disease-specific variables on pain in cancer patients

Pain experience of cancer patients receiving care in a multidisciplinary pain management clinic

BACKGROUND

Few longitudinal studies have focused on patients' cancer pain experience when receiving care in a multidisciplinary pain management clinic (MPMC). This study aimed to evaluate the experiences of a cohort of cancer patients newly engaged in a MPMC.

METHODS

This study was based on a longitudinal approach in which data were collected over a 6 months period at the King Hussein Cancer Centre in Jordan. The study adopted the Arabic version of the Brief Pain Inventory to identify the level and prevalence of cancer pain, and to identify the impact of receiving care at the MPMC on patients' pain experience. Data were collected over four time points, and the period between these points ranged from 2 to 3 weeks.

RESULTS

The majority of patients demonstrated improvement in their pain after receiving treatment at the MPMC, while a third still experienced severe pain. Significant improvement was reported at T1, and no further decline in pain was noted after this point. This indicates that exposure to the intervention provided by the MPMC generated, on average, an improvement in patients' pain experience.

CONCLUSION

The MPMC may be an effective pain management strategy in the treatment of cancer pain.

Pain among older adults with gastrointestinal malignancies- results from the cancer and aging resilience evaluation (CARE) Registry

PURPOSE

The impact of pain on functional status and mental health among older adults with cancer is a relevant, yet understudied. We sought to identify the prevalence of pain at diagnosis in older adults with gastrointestinal (GI) malignancies and evaluate the association of pain with functional status limitations, cognition, and mental health.

METHODS

This prospective cross-sectional study included older adults (age ≥ 60) with GI cancers enrolled in the CARE Registry. Pain measured in numeric rating scale from 0 to 10. We utilized the literature based cutoff for moderate-severe as ≥ 4. Logistic regression used to assess differences in functional status, falls, cognitive complaints, and depression/anxiety associated with moderate/severe pain, adjusted for sex, race, education, ethnicity, marital status, cancer type/stage, and treatment phase.

RESULTS

Our cohort included 714 older adults with an average mean age of 70 years and 59% male. Common diagnoses included colorectal (27.9%) and pancreatic (18%). A total of 43.3% reported moderate/severe pain. After multivariate adjusting for covariates, participants with self-reported moderate/severe pain were more likely to report limitations in instrumental activities of daily living (adjusted odds ratio [aOR] 4.3 95% confidence interval [CI] 3.1-6.1, p < .001), limitation in activities of daily living (aOR 3.2 95% CI 2.0-5.1, p < .001), cognitive complaints (aOR 2.9 95% CI 1.4-6.0, p < .004), anxiety (aOR 2.2 95% CI 1.4-3.4, p < 0.01), and depression (aOR 3.7 95% CI 2.2-6.5, p < .001).

CONCLUSIONS

Pain is common among older adults with GI cancers and is associated with functional status limitations, cognitive complaints, and depression/anxiety. Strategies to reduce pain and minimize its potential impact on function and mental health warrant future research.

Long-term opioid use in patients treated with head and neck intensity-modulated radiotherapy

PURPOSE

Acute and chronic pain during and after radiotherapy is an important driver of poor quality of life. We aimed to identify risk factors associated with increased chronic opioid use in head and neck squamous cell cancer survivors.

METHODS

We performed a retrospective cohort analysis on head and neck squamous cell cancer patients treated with definitive or adjuvant intensity-modulated radiotherapy. We tracked their oncologic opioid prescription profile from initial presentation to the last follow-up date. We determined the incidences of 1- and 2-year opioid use and performed multivariate logistic regression for both outcomes.

RESULTS

Our analytic cohort consisted of 403 head and neck squamous cell cancer survivors. The numbers of patients requiring opioids at 3 months, 6 months, and 1 year after treatment were 316 (78%), 203 (50%), and 102 (25%), respectively. On multivariate logistic regression, positive smoking history (95% CI 1.86 [1.03, 3.43], p = 0.04), unemployment (95% CI 2.33 [1.16, 4.67], p = 0.02), prior psychiatric illness (95% CI 2.15 [1.05, 4.40], p = 0.03), and opiate use before radiotherapy (95% CI 2.75 [1.49, 5.20], p = 0.01) were independently associated with significantly greater odds of opioid use at 1 year.

CONCLUSIONS

Our institutional analysis has shown that a substantial amount of head and neck cancer survivors are chronically dependent on opioids following radiotherapy. We have identified a cohort at highest risk for long-term use, for whom early interventions should be targeted.

Unravelling the heterogeneity of soft tissue and bone sarcoma patients' health-related quality of life: a systematic literature review with focus on tumour location

Patients with sarcoma experience many physical and psychological symptoms, adversely affecting their health-related quality of life (HRQoL). HRQoL assessment is challenging due to the diversity of the disease. This review aims to unravel the heterogeneity of HRQoL of patients with sarcoma with regard to tumour location and to summarise the used measures in research. English-language literature from four databases published between January 2000 and April 2019 was reviewed. Studies that described adult sarcoma HRQoL outcomes were included and classified according to primary sarcoma location. Eighty-seven articles met the inclusion criteria covering sarcoma of the extremities (n=35), pelvis and axial skeleton (n=9), pelvis and extremities (n=5), head and neck (n=4), retroperitoneum (n=2) and multiple sarcoma locations (n=33), respectively. Urogenital and thoracic sarcoma were lacking. Fifty-four different questionnaires were used, most often cancer-generic or generic HRQoL questionnaires. Patients with sarcoma reported lower HRQoL than the general population. Distinctive patterns of HRQoL outcomes according to tumour location regarding symptoms, physical functioning, disability and psychosocial well-being were identified. In metastatic sarcoma, mostly constitutional symptoms were present. To comprehensively assess HRQoL, a sarcoma-specific measurement strategy should be developed and used covering the heterogeneity of sarcoma including location-specific issues to improve personalised HRQoL assessment in future research and clinical practice.

Relationship between Pain Scores and EORTC QLQ-C15-PAL Scores in Outpatients with Cancer Pain Receiving Opioid Therapy

Cancer pain is one of the most frequent and distressing symptoms associated with cancer and has a serious impact on the QOL of patients. However, inadequate pain treatment has also been reported in outpatients with cancer pain. The aims of this study were (1) to evaluate the relationship between pain intensity using the Numerical Rating Scale (NRS) and QOL scores using the Japanese version of the European Organization for Research and Treatment of Cancer (QOL Questionnaire Core 15 for Palliative Care (QLQ-C15-PAL)), and (2) to investigate their association with various pain patterns, especially with baseline and breakthrough pain. Forty outpatients who were receiving opioid therapy and obtained informed consent participated. We collected a total of 222 pharmacist consultations during the study period. Global QOL scores and pain scores (PA) in the QLQ-C15-PAL (PA score, 0-100) at the first visit were significantly correlated with worst pain intensity. In addition, the scores for the worst pain were significantly correlated with not only physical functioning scores but also with emotional functioning scores. The correlations between the worst pain NRS and PA scores were positive. Specifically, patients tended to report large variability of NRS scores when the PA score was less than 40 and also when they exhibited pain patterns with "baseline and breakthrough cancer pain in the same day" or "baseline pain throughout the day." Reducing the worst pain NRS and relieving breakthrough pain appear to be important measures to improve the QOL of outpatients receiving opioid therapy for cancer pain.

Head and neck cancer survivors' pain in France: the VICAN study

PURPOSE

Pain is an increasing concern in the growing number of head and neck cancer survivors. This study aimed to analyze the 5-year prevalence of pain in French survivors of head and neck cancer and to identify associated factors.

METHODS

Analyses were performed among 296 5-year cancer survivors diagnosed in 2010. Using multivariable logistic regressions, we studied the associations between pain and factors collected in the French representative national "vie après le cancer" (VICAN) survey. Eligible participants were aged from 18 to 82 years; patients' living conditions, socioeconomic characteristics, and medical data were collected.

RESULTS

Pain was reported by 72.6% of the participants. In the multivariable analyses, decreasing level of physical activity was the only determinant of increased overall pain (OR= 2.77, CI= 1.48-5.17). The chronic pain prevalence was 62.3%. The main risk factors found were tumor localization in the oropharynx (OR= 2.49, CI= 1.27-4.88), education (at least a high school's degree) (OR= 0.33, CI= 0.13-0.9), and decreased physical activity (OR= 2.20, CI= 1.24-3.9).

CONCLUSIONS

Five years after diagnosis, pain is a very frequent sequelae that has a significant impact on quality of life in head and neck cancer survivors. Reduced physical activity, a low level of education, and tumor localization in the oropharynx are factors associated with pain.

IMPLICATIONS FOR CANCER SURVIVORS

Pain frequency and its impact on patients' lives imply that an adaptation must be made in terms of both pain diagnosis and management and the training of healthcare professionals.

CLINICAL TRIAL REGISTRATION

This is not a clinical trial. ISP number: INSERM C11-63.

To be in pain (or not): a computer enables outpatients to inform their physician

BACKGROUND

In the outpatient oncology clinic, pain management is often inadequate. Incorporating a systematic pain management program into visits is likely to improve this. We implemented an integrated program, including a structured pain assessment, pain treatment protocol and patient education module. In the present study, we investigated whether this intervention improved pain control.

PATIENTS AND METHODS

At seven oncology outpatient clinics, patients were asked to register their pain intensity on a touch screen computer. These scores were made available into their electronic medical records. Additionally, a hospital-wide treatment protocol for cancer-related pain and a patient education module were developed. A data warehouse system enabled us to extract patient data from the electronic medical record anonymously and to use them for analysis. The primary outcome of the study was the percentage of patients with moderate to severe pain [current pain (CPI), NRS > 4] measured during 2 weeks at the start and 6 months after implementation. As secondary outcomes, we studied the percentage of pain registrations in specific patient groups and the percentage of patients treated with a curative and a palliative intention with (moderate-severe) pain. Differences were tested with the χ(2) test.

RESULTS

During the first 6 months, 3407 of the 4345 patients (78%) registered their pain intensity on the touch screen computer. The percentage of patients with moderate to severe CPI decreased 32% (P = 0.021): from 12.5% at start to 8.5% after 6 months. More patients in the palliative phase than in the curative phase of their disease registered their pain intensity (82% versus 75%, respectively, P < 0.005), and more patients in the palliative phase experienced moderate to severe pain (23% versus 14%, respectively, P < 0.001).

CONCLUSION

Pain registration by patients themselves is feasible, provides insight into patients' pain intensity and may improve pain control in outpatients with cancer-related pain.

CLINICAL TRIAL NUMBER

Because this is an innovation project and not a primary research project, it has no clinical trial number. The protocol and all materials involved were approved by the Institutional Review Board of the Erasmus MC (MEC-2009-324).

Integrating Palliative Care Into the Care of Patients With Advanced Lung Cancer

Lung cancer is the leading cause of death due to malignancy. Although lung cancer mortality has been decreasing in recent years, it remains substantially higher than other causes of cancer death. Median survival for patients with locally advanced non-small cell lung cancer, defined as lung cancer involving regional lymph nodes, is estimated to be approximately 10 to 17 months, and median survival for patients with metastatic disease is only 6 to 9 months. In addition, patients with advanced lung cancer often experience debilitating symptoms and poor quality of life. Pain, dyspnea, and fatigue are most frequently reported and affect at least 65% of patients with advanced lung cancer. Given this burden of symptoms and high mortality, patients and their families facing a diagnosis of advanced lung cancer are in need of support. Palliative care, with its focus on addressing the emotional, physical, and spiritual sources of suffering utilizing the expertise of an interdisciplinary team, can provide this comprehensive support. This review describes the role of supportive and palliative care integrated into the treatment of patients with a diagnosis of advanced lung cancer with sections focused on the evaluation and treatment of pain and dyspnea, approaches to challenging communication tasks, and the support of caregivers who care for patients with advanced lung cancer.

Unresolved Pain Interference among Colorectal Cancer Survivors: Implications for Patient Care and Outcomes

OBJECTIVE

Using a large sample of colorectal cancer (CRC) survivors we 1) describe pain interference (PI) prevalence across the cancer continuum; 2) identify demographic and clinical factors associated with PI and changes in PI; and 3) examine PI's relationship with survivors' job changes.

METHODS

CRC participants of the Cancer Care Outcomes Research and Surveillance Consortium completed surveys during the initial phase of care (baseline, < 1 year, n = 2,961) and follow-up (about 1-year postdiagnosis, n = 2,303). PI was measured using the SF-12 item. Multiple logistic regression was used to identify predictors of PI. Model 1 evaluated moderate/high PI at baseline, Model 2 evaluated new/continued/increasing PI postdiagnosis follow-up, and Model 3 restricted to participants with baseline PI (N = 603) and evaluated predictors of equivalent/increasing PI. Multivariable logistic regression was also used to examine whether PI predicted job change.

RESULTS

At baseline and follow-up, 24.7% and 23.7% of participants reported moderate/high PI, respectively. Among those with baseline PI, 46% had equivalent/increasing PI at follow-up. Near diagnosis and at follow-up, female gender, comorbidities, depression, chemotherapy and radiation were associated with moderate/high PI while older age was protective of PI. Pulmonary disease and heart failure comorbidities were associated with equivalent/increasing PI. PI was significantly associated with no longer having a job at follow-up among employed survivors.

CONCLUSION

Almost half of survivors with PI during the initial phase of care had continued PI into post-treatment. Comorbidities, especially cardiovascular and pulmonary conditions, contributed to continued PI. PI may be related to continuing normal activities, that is, work, after completed treatment.

Pain is not systematically registered in Dutch medical oncology outpatients

BACKGROUND

Systematic pain registration and assessment with a visual analog scale (VAS) or numeric rating scale (NRS) at each visit are key recommendations in one of the most recent guidelines on cancer pain management. It is unclear whether this recommendation is applied.

OBJECTIVES

The aim was to explore registration of pain in medical records of patients visiting the medical oncology outpatient clinic.

METHODS

In a multicenter study in six Dutch hospitals, data were extracted from medical records of 380 outpatients with cancer. Data of the first three visits at the outpatient clinic were studied. Descriptive statistics were conducted.

RESULTS

In 23% of all 987 visits at the outpatient clinic, pain or absence of pain was registered, and in an additional 15%, a nonspecific symptom description was given. Regarding all other visits, (62%) pain or absence of pain was not documented at all. Pain measurement using a VAS or NRS was documented in only one visit. Pain was more often registered in medical records of patients with metastasis, as well as in those of patients with urogenital tumors.

CONCLUSION

Pain in medical oncology outpatients is not systematically registered in their medical records. With one exception, pain was not registered with a VAS or NRS. Yet, registration and assessment of pain to monitor pain are essential to evaluate and adapt pain treatment over time. Pain registration has not improved since 2001 and therefore implementing the recommendations regarding systematic monitoring of pain is needed.

The influence of personality on reported pain and self-efficacy for pain management in older cancer patients

This study examines the relationship of personality traits and affect on cancer-related pain in 150 older adults receiving outpatient treatment at a comprehensive cancer center. Regression analyses revealed extraversion as a significant predictor of current pain, with openness to experience as a significant indicator of average pain. Similarly, positive affect and negative affect were significant predictors of self-efficacy for pain management. Moderation models showed that conscientiousness and extraversion were significant moderators in the relationship between self-efficacy for pain management and worst pain. These findings suggest that different personality types may influence perceptions of pain severity.

A narrative literature review of older people's cancer pain experience

AIMS AND OBJECTIVES

To synthesise current evidence about the experience of older people with cancer pain and consider how exploration of this may inform clinical practice and research.

BACKGROUND

Cancer is more prevalent in older age. Evidence suggests that older people's pain is generally under-recognised and under treated. Pain is a significant concern for many people living and dying with cancer and may be of particular concern for older people who may have complex biopsychosocial needs. There is mounting evidence that older people and their families experience high level of unmet need generally and suboptimal pain in particular.

DESIGN

Narrative literature review.

METHOD

A comprehensive search of five electronic databases was undertaken between the years 1996-2010 inclusive. Inclusion criteria were primary research papers relating older peoples' experiences of cancer pain, incorporating the verbal report or narrative account of experience of cancer.

RESULTS

Seventeen papers met the criteria for inclusion in the review. Three major themes emerged from the literature: (1) emotional experience identified by older people with cancer pain, (2) effects of pain on life and living, and (3) how communication affects the experience or expression of cancer pain including subthemes of validating, trust and cultural effects on the communication of pain.

CONCLUSION

There is limited research about older people's cancer pain from the perspective of the person experiencing the pain. This review highlights the need for further research into living and dying with cancer pain which incorporates the unique and individual experience of older people.

RELEVANCE TO CLINICAL PRACTICE

Understanding the complexity and nature of older people's cancer pain experience should inform appropriate effective care that improves quality of life and promotes independence and dignity. Culturally sensitive training in communication may enhance understanding of the needs of older people with cancer pain.

Predictors of pain among patients with head and neck cancer

OBJECTIVE To determine predictors of pain 1 year after the diagnosis of head and neck cancer. DESIGN Prospective, multisite cohort study. SETTING Three academically affiliated medical centers. PATIENTS The study population comprised 374 previously untreated patients with carcinoma of the upper aerodigestive tract. MAIN OUTCOME MEASURES Participants were surveyed before treatment and 1 year thereafter. Multivariate analyses were conducted to determine predictors of the 36-Item Short-Form Instrument (SF-36) bodily pain score 1 year after diagnosis. RESULTS The mean SF-36 bodily pain score at 1 year was 65, compared with 61 at the time of diagnosis (P = .004), and 75, the population norm (lower scores indicate worse pain). Variables independently associated with pain included pretreatment pain score (P &lt; .001), less education (P = .02), neck dissection (P = .001), feeding tube (P = .05), xerostomia (P &lt; .001), depressive symptoms (P &lt; .001), taking more pain medication (P &lt; .001), less physical activity (P = .02), and poor sleep quality (P = .006). The association between head and neck cancer pain and current smoking and problem drinking did not reach significance (P = .07 and P = .08, respectively). CONCLUSIONS Aggressive pain management may be indicated for patients with head and neck cancer who undergo neck dissections, complain of xerostomia, require feeding tubes, and have medical comorbidities. Treatment of modifiable risk factors such as depression, poor sleep quality, tobacco use, and alcohol abuse may also reduce pain and improve quality of life among patients with head and neck cancer.

Symptom clusters among multiethnic groups of cancer patients with pain

OBJECTIVE

Considering recent inconsistent findings on ethnic differences in cancer pain experience, there is a need to clarify the association of ethnicity to cancer pain experience through diverse approaches. However, there currently exist only a small number of studies on ethnic differences in cancer pain experience in general, and few symptom cluster studies specifically related to ethnic differences in cancer pain experience. The purpose of this study was to cluster cancer patients who reported similar cancer pain experience, and to determine ethnic differences in the clusters.

METHOD

This was a secondary analysis of the data from a larger Internet study on cancer pain experience of four major ethnic groups of cancer patients in the United States. Only 388 subjects who responded to the questions on cancer pain, cancer symptoms, and functional status were included for this secondary analysis. The data were analyzed using hierarchical cluster analysis and multinomial logistic analysis.

RESULTS

A three-cluster solution was adopted: 1) Cluster 1 with low pain, low symptoms, and high functional status, 2) Cluster 2 with moderate pain, low symptoms, and moderate functional staus, and 3) Cluster 3 with high pain, moderate symptoms, and low functional status. In Cluster 2, there were ethnic difference in the cancer pain and funtional status scores; Asian Americans reported lower pain scores than did other ethnic groups, and African Americans had higher funtional status scores than did other ethnic groups. In Cluster 3, there were ethnic difference in the symptom scores (p < 0.05); African Americans reported higher symptom scores than did whites.

SIGNIFICANCE OF RESULTS

The results of this study add an important piece of information on ethnic differences in symptom clusters. This study suggests further national scope studies on clustering multiethnic groups of cancer patients by cancer pain experience.

Symptom prevalence and management of cancer patients in Lebanon

CONTEXT

Cancer patients experience a great number of distressing physical and psychological symptoms. In Lebanon, there are no available data on symptom prevalence and symptom management in adults with cancer.

OBJECTIVES

The aim of this study was to determine the prevalence of symptoms and the effectiveness of treatment received as reported by patients.

METHODS

The study used a cross-sectional, descriptive survey design. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the Memorial Symptom Assessment Scale were translated to Arabic and used; data were collected from adult Lebanese cancer patients at the American University of Beirut Medical Center.

RESULTS

A total of 200 cancer patients participated in the study; the majority were female with breast cancer and mean age was 54 years. The cognitive functioning domain of the EORTC QLQ-C30 scale was found to have the highest score and social functioning the lowest. The most prevalent symptom was lack of energy. Nausea and pain were the symptoms most treated. Males reported better quality of life (QoL), physical functioning, and role functioning than females; females reported more fatigue, pain, and appetite loss than males. Higher physical and psychological symptoms were correlated with lower health status, QoL, and functioning.

CONCLUSION

Although this sample reported a fair QoL and social functioning, many symptoms were highly prevalent and inadequately treated. Symptoms were found to negatively affect QoL and functioning. Based on these results, providing adequate symptom management and social support to Lebanese cancer patients is highly recommended.

Incidence of severe pain in newly diagnosed ambulatory patients with stage IV cancer

BACKGROUND

Pain is common among cancer patients.

OBJECTIVE

To characterize the incidence of severe pain among newly diagnosed patients with stage IV cancer in ambulatory care.

METHODS

A retrospective cohort of 505 ambulatory oncology patients with newly diagnosed stage IV solid tumours at a comprehensive cancer centre (Dana-Farber Cancer Institute, Boston, Massachusetts, USA) was followed from January 1, 2004, to December 31, 2006. Pain intensity scores were extracted from electronic medical records. The incidence of severe pain was calculated using the maximum monthly pain scores reported at outpatient visits.

RESULTS

Of the 505 patients included in the present study, 340 (67.3%) were pain-free at the initial visit, 90 (17.8%) experienced mild pain, 48 (9.5%) experienced moderate pain and 27 (5.4%) experienced severe pain. At least one episode of severe pain within one year of diagnosis was reported by 29.1% of patients. Patients with head and neck, gastrointestinal and thoracic malignancies were more likely to experience severe pain compared with patients with other types of cancer (52.6%, 33.9% and 30.5%, respectively). In the multivariable model, patients whose primary language was not English (OR 2.90 [95% CI 1.08 to 7.80]), patients who reported severe pain at the initial visit (OR 9.30 [95% CI 3.72 to 23.23]) and patients with head and neck (OR 10.17 [95% CI 2.87 to 36.00]) or gastrointestinal (OR 4.05 [95% CI 1.23 to 13.35]) cancers were more likely to report severe pain in the following year.

CONCLUSIONS

The incidence of severe pain was high in ambulatory patients with newly diagnosed stage IV cancer.

Assessing the quality of pain care in ambulatory patients with advanced stage cancer

CONTEXT

Pain is common among patients with advanced cancer despite the dissemination of clinical pain care guidelines.

OBJECTIVES

We sought to assess the quality of pain care among patients with advanced disease.

METHODS

We reviewed the records of 85 adult ambulatory patients with advanced breast, lung, and gastrointestinal cancer treated in 2004-2006. Patients' screening pain intensity scores were at least 7 of 10. Nurse reviewers completed medical record reviews of care rendered at the index visit and over the subsequent 30 days based on the 2004 National Comprehensive Cancer Network pain guideline. An expert panel then rated the quality of the evaluation, treatment, and overall pain care. We used a multivariable model to analyze guideline compliance and resolution of severe pain.

RESULTS

Among advanced cancer patients with severe pain, clinicians adjusted pain medications only half the time and made few timely referrals for pain-related consultations. By 30 days after the index visit, 34% of patients continued to report severe pain. The expert panel judged the overall quality of pain care as "fair" or "poor" in about two-thirds of cases because more timely and effective intervention could have reduced the severity and duration of pain. Resolution of severe pain was associated with adjustment of pain medications at the index visit (adjusted odds ratio 3.8, 95% CI 1.3-10.6).

CONCLUSION

There is room for improvement in the pain care of patients with advanced cancer. Additional research is needed to understand the reasons for poor performance.

Factors associated with pain among ambulatory patients with cancer with advanced disease at a comprehensive cancer center

PURPOSE

The prevalence and severity of pain have not been well described among oncology patients in ambulatory care. To better understand the burden of pain among patients with advanced cancer, we examined the prevalence of pain reported during office and treatment visits.

METHODS

A retrospective study of 4,014 patients with advanced disease (stage 4 at diagnosis or metastatic progression) who completed an ambulatory visit between 2004 and 2006 was conducted at a comprehensive cancer center in Boston, Massachusetts.

RESULTS

At their first visit during the study period, 74% of patients reported no pain (0 score); 12%, low pain (1 to 3 score); 9%, moderate pain (4 to 6 score); and 5%, severe pain (7 to 10 score). The prevalence of pain was highest among patients who were younger than 60 years of age, were nonwhite, did not speak English as their primary language, or were covered by Medicaid, received free care, or paid their own health care costs. Patients with thoracic, breast, and head and neck cancers had higher pain scores than those with other diseases. Pain was reported more frequently among patients whose diagnosis or metastatic progression occurred less than 3 months before the reported pain score. In multivariable regression analysis, age, race, cancer type, and time since diagnosis/progression were identified as important factors associated with severe pain.

CONCLUSION

Younger age, minority race, and recent onset of advanced disease are associated with severe pain among patients with cancer. Recognizing these high-risk groups could inform targeted interventions to address pain care in ambulatory patients with advanced cancer.

Cancer patient attitudes toward analgesic usage and pain intervention

OBJECTIVES

Although pain is commonly experienced by cancer patients, many receive inadequate pain management. Little data exist quantifying analgesic usage among oncology patients. This study evaluates perceived causes of pain and investigates reasons why oncology patients fail to receive optimal pain management.

METHODS

An institutional review board-approved questionnaire assessing pain control and analgesic usage was posted on OncoLink. Between November 2005 and July 2008, 1107 patients responded. Respondents were female (73%), white (74%), educated beyond high school (64%), and had surgery (69%), chemotherapy (64%), and radiation (47%). Most had breast (30%), gastrointestinal (12%), gynecologic (11%), and lung (8%) malignancies.

RESULTS

Sixty-seven percent of respondents reported pain, with 48% reporting pain directly from their cancer and 47% reporting pain from their cancer treatment. Among patients in pain, 25% did not use analgesics. Analgesic usage was significantly less in men (44% vs. 52%, P=0.023), minorities (42% vs. 53%, P=0.001), and patients with lower education levels (45% vs. 53%, P=0.013). Usage varied by cancer diagnosis and was higher among patients who received chemotherapy (56% vs. 40%, P<0.001) and radiation (53% vs. 47%, P=0.058). Reasons for not taking analgesics included: health care provider not recommending medications (85%), fearing addiction/dependence (80%), and inability to pay (76%). Many patients reporting pain, not taking analgesics, pursued alternative therapies (94%).

DISCUSSION

Most cancer patients perceive pain from their disease or treatment, regardless of therapy received. Many, however, did not use analgesics due to concerns of addiction, cost, or lack of health care provider endorsement. Providers should regularly discuss pain symptoms and management with cancer patients.

Pain in patients attending a specialist cancer service: prevalence and association with emotional distress

CONTEXT

We know little about how many outpatients of a modern cancer center suffer from clinically significant unrelieved pain and the characteristics of these patients to guide better care.

OBJECTIVES

To determine the prevalence of clinically significant pain (CSP) in the outpatients of a regional cancer center and the association with distress and other variables.

METHODS

A secondary analysis of cross-sectional, self-reported and clinical data from 2768 patients reattending selected clinics of a regional National Health Service cancer center in the U.K. Pain was measured using the pain severity scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, emotional distress was measured by the Hospital Anxiety and Depression Scale, and demographic and clinical data were taken from medical records.

RESULTS

Fifty-four percent (95% confidence interval [CI] 52-56) of patients reported pain at least "a little" in the previous week and 18% (95% CI 17-20) at least "quite a bit" (CSP). The strongest independent associations of CSP were active disease (odds ratio [OR] 1.95, 95% CI 1.5-2.5) and emotional distress (OR 4.8, 95% CI 4-6).

CONCLUSION

CSP is surprisingly common in outpatients of specialist cancer services, and it is strongly and independently associated with emotional distress. Better symptom management should consider pain and distress together.

A combined pain consultation and pain education program decreases average and current pain and decreases interference in daily life by pain in oncology outpatients: a randomized controlled trial

Pain education programs (PEP) and pain consultations (PC) have been studied to overcome patient-related and professional-related barriers in cancer pain management. These interventions were studied separately, not in combination, and half of the studies reported a significant improvement in pain. Moreover, most PEP studies did not mention the adequacy of pain treatment. We studied the effect of PC combined with PEP on pain and interference by pain with daily functioning in comparison to standard care (SC). Patients were randomly assigned to SC (n=37) or PC-PEP (n=35). PEP consisted of patient-tailored pain education and weekly monitoring of pain and side effects. We measured overall reduction in pain intensity and daily interference over an 8-week period as well as adequacy of pain treatment and adherence. The overall reduction in pain intensity and daily interference was significantly greater after randomization to PC-PEP than to SC (average pain 31% vs 20%, P=.03; current pain 30% vs 16%, P=.016; interference 20% vs 2.5%, P=.01). Adequacy of pain management did not differ between the groups. Patients were more adherent to analgesics after randomization to PC-PEP than to SC (P=.03). In conclusion, PC-PEP improves pain, daily interference, and patient adherence in oncology outpatients.

Sleep problems in cancer patients: prevalence and association with distress and pain

BACKGROUND

Although it is increasingly recognized that cancer patients often have sleep problems, we lack data on their prevalence and associations in representative clinical populations. We aimed to determine (i) the prevalence of sleep problems amongst outpatients of a cancer centre and (ii) the association with medical variables, emotional distress and pain.

METHODS

Secondary analysis of self-report and medical data on 2862 cancer centre outpatients. Sleep problems were identified using the sleep item from the Patient Health Questionnaire-9: 'Over the last two weeks, how often have you been bothered by trouble falling or staying asleep or sleeping too much?' scored on a four-point frequency scale. Emotional distress was measured using the Hospital Anxiety and Depression Scale and pain using the subscale of the European Organisation for Research and Treatment of Cancer Quality of Life Core 30 questionnaire. Medical data were obtained from the cancer centre clinical database.

RESULTS

Sleep problems (bothered more than half the days during the previous 2 weeks) were reported by 30.2% (865/2862, 95% CI = 28.5 to 31.9) of the patients. They were common in both patients with active cancer (34.5%) and in cancer survivors (28.0%). There was only a modest association with cancer site and treatment status, but there was a strong association with pain (odds ratio = 2.7, 95% CI = 2.2 to 3.4) and emotional distress (odds ratio = 4.5, 95% CI = 3.7 to 5.6).

CONCLUSIONS

Sleep problems are common in cancer outpatients and are strongly associated with pain and emotional distress. A combined approach to the management of sleep, pain and emotional distress is indicated. Copyright © 2011 John Wiley & Sons, Ltd.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The Relationship Between Symptom Prevalence and Severity and Cancer Primary Site in 796 Patients With Advanced Cancer

Knowledge of differences in symptom experience between cancer sites may help better understand symptom pathophysiology. A total of 38 symptoms in 796 consecutive patients with advanced cancer were retrospectively analyzed. Symptom prevalence and severity were compared among the 12 primary site groups (PSGs) by the chi-square test. Pairwise comparisons determined which sites differed. Pain, fatigue, weakness, lack of energy, and anorexia had the highest overall prevalence but did not differ among PSGs. The 3 most common neuropsychological symptoms (insomnia, depression, and anxiety) also did not vary among PSGs. Nineteen (50%) symptoms varied significantly between PSGs, in prevalence (17), severity (14), or both (12). Nine of 17, 6 of 14, and 6 of 12 were gastrointestinal symptoms. Symptoms which varied by PSGs can be included in cancer site-specific symptom assessment instruments.

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

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

PERSPECTIVE

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

A systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: a critical appraisal

The aim of this paper is to identify the major barriers hindering adequate pain management and critically review interventions aiming to overcome them. We searched relevant literature on PubMed published between January 1986 and April 2007. The most frequently mentioned barriers for both patients and professionals were knowledge deficits, inadequate pain assessment and misconceptions regarding pain. Four interventions were identified: patient education, professional education, pain assessment and pain consultation. These interventions were never combined in multidisciplinary study protocols. Most RCTs included small groups of patients and reported no power analysis. Studies on professional education and pain assessment did not evaluate patients' outcomes. In 5 of 11 RCTs on patient education, pain intensity decreased statistically significantly. In two RCTs on pain consultation, patients' pain decreased statistically significantly, although the adequacy of pain treatment did not change. In conclusion, international guidelines on multidisciplinary interventions in pain management are partly substantiated by clinical trials.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

The effects of analgesic prescription and patient adherence on pain in a dutch outpatient cancer population

Insufficient awareness of cancer pain, including breakthrough pain, inadequate analgesic prescriptions, and nonadherence contribute to inadequate cancer pain management. There are insufficient data about the contribution of each of these factors. In a cross-sectional survey among 915 adult cancer outpatients, pain was assessed by the Brief Pain Inventory. Breakthrough pain was defined as a worst pain intensity rated as "7 or more" and an average pain intensity rated as "6 or less" in patients on "around-the-clock" (ATC) analgesics. The Pain Management Index (PMI) was calculated to measure the quality of treatment. Adherence was considered inadequate when below 100% of the dose prescribed. Pain was present in 27% of patients. Worst pain was rated as moderate in 26%, and as severe in 54%. Breakthrough pain was present in 45% of patients with ATC medication. The PMI indicated inadequate treatment in 65% of patients. The proportions of patients adherent to ATC analgesics varied from 59% (tramadol) to 91% (Step 3 opioids). The management of cancer pain will benefit most from improving analgesic prescriptions and patient adherence.

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

At present, no definite conclusions can be drawn about the real extent of the pain suffered by cancer patients. A population-based study was conducted to obtain reliable information about the prevalence and severity of pain in cancer patients (all phases) and about predictors of pain. A representative sample of cancer patients was recruited in the area from a cancer registry. Pain was assessed by the Brief Pain Inventory (BPI). Adequacy of pain treatment was assessed with the Pain Management Index (PMI). We found that 55% of the 1429 respondents had experienced pain past week; in 44% (n=351), the pain was moderate to severe (BPI score>or= 4). Total prevalence of pain/moderate to severe pain was present in 49%/41% in patients with curative treatment >or=6 months ago, 57%/43% in patients with current curative treatment or treatment <6 months ago, 56%/43% in patients with current palliative anti-cancer treatment and in 75%/70% in patients for whom treatment was no longer feasible. Positive predictors of the prevalence of pain were lower education level, more advanced disease and haematological (excluding (non)-Hodgkin lymphoma), gastro-intestinal, lung, or breast malignancies. According to the PMI, analgesic treatment was inadequate in 42% of the patients. Negative predictors of adequate treatment were current curative anti-cancer treatment and low education level.

CONCLUSION

A substantial proportion of cancer patients does suffer from moderate to severe pain and does not receive adequate pain treatment.

Gender and ethnic differences in cancer pain experience: a multiethnic survey in the United States

BACKGROUND

Inconsistent findings on ethnic differences in cancer pain experience suggest the need for further studies on this topic for adequate cancer pain management.

OBJECTIVES

To determine ethnic differences in cancer pain experience of four ethnic groups in the United States.

METHODS

A feminist perspective was used as the theoretical basis. This was a survey of a multiethnic sample of 480 cancer patients asking questions on sociodemographic characteristics and health or illness status, 3 unidimensional cancer pain scales, 2 multidimensional cancer pain scales, the Memorial Symptom Assessment Scale, and the Functional Assessment of Cancer Therapy Scale. The data were analyzed using descriptive and inferential statistics including ANOVA and hierarchical multiple regression analyses.

RESULTS

The results indicated certain ethnic differences in types of pain and symptoms that patients experienced. Also, the results demonstrated significant ethnic differences in cancer pain and functional status.

DISCUSSION

The findings suggest further in-depth qualitative exploration on cultural values and beliefs related to cancer pain in each ethnic group and national studies with a larger number of ethnic minorities on this topic.

Prevalence of pain in patients with cancer: a systematic review of the past 40 years

BACKGROUND

Despite the abundant literature on this topic, accurate prevalence estimates of pain in cancer patients are not available. We investigated the prevalence of pain in cancer patients according to the different disease stages and types of cancer.

PATIENTS AND METHODS

A systematic review of the literature was conducted. An instrument especially designed for judging prevalence studies on their methodological quality was used. Methodologically acceptable articles were used in the meta-analyses.

RESULTS

Fifty-two studies were used in the meta-analysis. Pooled prevalence rates of pain were calculated for four subgroups: (i) studies including patients after curative treatment, 33% [95% confidence interval (CI) 21% to 46%]; (ii) studies including patients under anticancer treatment: 59% (CI 44% to 73%); (iii) studies including patients characterised as advanced/metastatic/terminal disease, 64% (CI 58% to 69%) and (iii) studies including patients at all disease stages, 53% (CI 43% to 63%). Of the patients with pain more than one-third graded their pain as moderate or severe. Pooled prevalence of pain was >50% in all cancer types with the highest prevalence in head/neck cancer patients (70%; 95% CI 51% to 88%).

CONCLUSION

Despite the clear World Health Organisation recommendations, cancer pain still is a major problem.

Barriers to pain management in the rehabilitation of the surgical oncology patient

Virtually every surgical oncology patient faces pain, and it can become a major barrier to rehabilitation and quality of life. Pain must be assessed as to its severity, etiology (somatic, visceral, or neuropathic), causation (directly from malignancy or from treatment side effects), and its impact on daily function. Treatments can include physical modalities, exercise, opioids, adjuvant medications, and interventional techniques. Barriers to treatment may include side effects, finances, and attitudes. New technologies in medication delivery systems, intrathecal pumps, injections, and surgery have greatly strengthened the armamentarium available to manage pain.

Prevalence of pain in hospitalised cancer patients in Norway: a national survey

PURPOSE

Pain severely impairs health-related quality of life and is a feared symptom among cancer patients. Unfortunately, patients often do not receive optimal care. We wanted to evaluate the quality of cancer pain treatment in Norwegian hospitals.

PATIENTS AND METHODS

A one-day prevalence study targeting hospitalised cancer patients above 18 years of age was performed. A questionnaire based on the Brief Pain Inventory was used, and additional information regarding sex, age, diagnosis, break through pain (BTP), and treatment was included.

RESULTS

Fifty two percent of the included patients stated having cancer related pain (n=453), and mean pain during the previous 24 hours for these patients was NRS 3.99 (Numeric Rating scale 1-10). Presence of metastasis, occurrence of BTP, and abnormal skin sensibility in the area of pain were associated with higher pain scores. Forty two percent of all patients used opioids. However, these patients still had higher pain scores, more episodes of BTP, and more influence of the pain on daily life functions than average. Thirty percent of patients with severe pain (NRS>or=5) did not use opioids, and some of these patients did not receive any analgesics at all.

CONCLUSION

Although most cancer patients receive an acceptable pain treatment in Norwegian hospitals, there are patients who are not adequately managed. Lack of basic knowledge and individual systematic symptom assessment may be reasons for the underuse of analgesics and the resulting unnecessary suffering among the cancer patients.

The WHO analgesic ladder for cancer pain control, twenty years of use. How much pain relief does one get from using it?

INTRODUCTION

Pain is a major problem in the treatment of patients with cancer. This article reviews studies concerning evaluation of patients with cancer pain treated according to The World Health Organization (WHO) analgesic ladder.

MATERIALS AND METHODS

Systematic search of PUBMED, MEDLINE, EMBASE, LILACS, BDENF, and OVID and a hand search of reference lists and textbooks from 1982 to 2004 were performed.

RESULT

Analgesia was considered adequate in 45 to 100% of patients analyzed in the studies.

CONCLUSION

However, the evidence that they provide is insufficient to grant the effectiveness of the WHO guidelines because a controlled clinical trial of this intervention has never been published.

Predictors of quality of life in oncology outpatients with pain from bone metastasis

The relationship between pain and quality of life (QOL) in cancer patients is complex due to the number and the diversity of factors that can influence pain and QOL. The aims of this study of oncology outpatients with pain from bone metastasis were: 1) to determine the extent to which pain characteristics (i.e., severity, duration, meaning of pain, and perceived availability and efficacy of pain relief), psychological distress (i.e., depression), physical functioning, social functioning and QOL are intercorrelated, and 2) to determine which of these variables are important predictors of QOL. A total of 157 oncology outpatients completed questionnaires that evaluated pain, QOL, depression, physical functioning, and social functioning at the time of enrollment into a randomized clinical trial that evaluated the effectiveness of a psychoeducational intervention to improve cancer pain management. Pearson product moment correlation coefficients were calculated to examine the relationships among the study variables. A blockwise, hierarchical multiple regression analysis was performed to determine which variables were the most important predictors of QOL. Meaning of pain was significantly correlated with all the other variables, in particular pain intensity and duration. The most important factors that predicted QOL were depression, social functioning, and physical functioning. Depression proved to be the most important predictor of QOL.