Cancer patient attitudes toward analgesic usage and pain intervention

Advances in the use of local anesthetic extended-release systems in pain management

Pain management remains among the most common and largely unmet clinical problems today. Local anesthetics play an indispensable role in pain management. The main limitation of traditional local anesthetics is the limited duration of a single injection. To address this problem, catheters are often placed or combined with other drugs in clinical practice to increase the time that local anesthetics act. However, this method does not meet the needs of clinical analgesics. Therefore, many researchers have worked to develop local anesthetic extended-release types that can be administered in a single dose. In recent years, drug extended-release systems have emerged dramatically due to their long duration and efficacy, providing more possibilities for the application of local anesthetics. This paper summarizes the types of local anesthetic drug delivery systems and their clinical applications, discusses them in the context of relevant studies on local anesthetics, and provides a summary and outlook on the development of local anesthetic extended-release agents.

Different Outcomes According to Needling Point Location Used in Sham Acupuncture for Cancer-Related Pain: A Systematic Review and Network Meta-Analysis

Numerous acupuncture studies have been conducted on cancer-related pain; however, its efficacy compared to sham acupuncture remains controversial. We confirmed whether the outcome of acupuncture differs according to the needling points of sham acupuncture for cancer-related pain. We searched 10 databases on 23 May 2023 to screen acupuncture trials using sham acupuncture or waiting list as controls for cancer-related pain. Sham acupuncture was classified into two types, depending on whether the needling was applied at the same locations as verum acupuncture (SATV) or not (SATS). A network meta-analysis (NMA) was performed on the basis of a frequentist approach to assess pain severity. Eight studies (n = 574 participants) were included in the review, seven of which (n = 527 participants) were included in the NMA. The pain severity was not significantly different between SATV and verum acupuncture, but verum acupuncture significantly improved pain severity compared to SATS. The risk of bias affecting the comparisons between the verum and sham acupuncture was generally low. Previous acupuncture trials for cancer-related pain showed differing outcomes of sham and verum acupuncture, depending on the needling points of sham acupuncture. The application of SATV cannot be considered a true placebo, which leads to an underestimation of the efficacy of verum acupuncture.

Acupuncture for cancer pain: a scoping review of systematic reviews and meta-analyses

Background

Due to the effectiveness and safety, acupuncture, one of the traditional therapies of Chinese medicine, has been widely used in clinical practice globally. A few systematic review or meta-analyses have proved its effectiveness and safety towards patients with cancer pain, while there are no syntheses among those evidence. The aim of this scoping review is to summarize the evidence from systematic reviews of acupuncture for the treatment of cancer pain and evaluate the breadth and methodological quality of these evidence as well.

Methods

The scoping review process was guided by the methodology framework of Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA ScR) and "Arkseyand O'Malley six-stage framework". Electronic searches were carried out in several online databases from inception to Jan 2022. Systematic reviews and meta-analyses that involve any type of acupuncture for patients with cancer pain will be included. A pair of reviewers independently screened full texts. Moreover, review characteristics were extracted, and methodological quality was assessed using the AMSTAR 2 tool.

Results

Twenty-five systematic reviews and meta-analyses were included. Manual acupuncture is the most frequently included types of test group intervention (48%), followed by acupuncture + medicine (28%), and auricular acupuncture (12%). All the reviews have declared that acupuncture is an effective method for cancer pain treatment. Eleven reviews (44%) aiming at evaluating the safety also have confirmed that acupuncture is safe for treating cancer pain. However, most included studies were conducted in China. With certain geographical limitations, the findings were not representative within the region. The results of our review may owe to the synthesis of all kinds of cancer pain, and only 2 reviews described the type of cancer pain in detail.

Conclusions

This scoping review synthesizes and evaluates existing evidence of acupuncture for cancer pain. From this scoping review of systematic reviews and meta-analyses, there are clear recommendations for future studies: expanding the region of research in the world and trying to conduct the study of different types of cancer pain in details as much as possible. Evidences of acupuncture for cancer pain can inform clinical decision-making.

Systematic review registration

https://inplasy.com/inplasy-2022-1-0073/, identifier INPLASY202210073.

Pain-Related Gene Solute Carrier Family 24 Member 3 Is a Prognostic Biomarker and Correlated with Immune Infiltrates in Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma: A Study via Integrated Bioinformatics Analyses and Experimental Verification

The aim of this study was to explore cervical carcinoma and screen a suitable gene as the biomarker used for prognosis evaluation as well as pain therapy. Low expression levels of solute carrier family 24 member 3 (SLC24A3) was involved in the appearance and development of numerous malignancies. Nevertheless, the prognostic value of SLC24A3 expression with cervical squamous cell carcinoma and endocervical adenocarcinoma (CESC) patients remains uncertain. During the present study, SLC24A3 expression in CESC was retrieved from TCGA, GEO, and MSigDB databases. Based on TCGA and GEO profiles, we performed survival and difference analyses about SLC24A3 both in two GEO (GSE44001 and GSE63514) and TCGA-CESC cohorts (all p < 0.05), indicating that SLC24A3 was low expressed in tumors and associated with higher overall survival in CESC patients. Additionally, we programmed a series of analyses, including genomic profiling, enrichment analysis, immune infiltration analysis, and therapy-related analysis to identify the mechanism of the SLC24A3 in the process of cancer in CESC. Meanwhile, qRT-PCR was used to validate that the expression of SLC24A3 mRNA in Hela and SiHa cell lines was significantly lower than in PANC-1 and HUCEC cell lines. Our finding elucidated that the SLC24A3, a sodium-calcium regulator of cells, is an indispensable factor which can significantly influence the prognosis of patients with CESC and could provide novel clinical evidence to serve as a potential biological indicator for future diagnosis and pain therapy.

An Overview of Systematic Reviews and Meta-Analyses of Clinical Studies of Acupuncture for Cancer Pain

BACKGROUND

Systematic reviews (SRs) and meta-analyses (MAs) for the use of acupuncture for cancer pain have been increasing, but the evidence has not been systematically and comprehensively assessed. We aimed to perform an overview of the evidence quality of SRs/MAs of acupuncture for improving cancer pain.

METHODS

8 databases were systematically searched to identify SRs/MAs of acupuncture for improving cancer pain. The A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2), Risk of Bias in Systematic Reviews (ROBIS), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Grades of Recommendations, Assessment, Development, and Evaluation (GRADE), respectively, were applied by 2 independent reviewers to evaluate the methodological quality, risk of bias, reporting quality, and evidence quality.

RESULTS

A total of 14 SRs/MAs were included in the present study. By AMSTAR-2, two reviews were rated as having high methodological quality, while 12 were given a critically low rating. All SRs/MAs in Phase 1, Domain 1, and Domain 4, according to ROBIS, were at low risk. Furthermore, 4 reviews in Domain 2, twelve reviews in Domain 3, and ten SRs/MAs in Phase 3, were rated as having low risk of bias. With reporting quality, some reporting flaws were identified in the topic of protocol and registration, additional analyses, and search strategy. According to GRADE, the level of evidence quality was "critically low" to "moderate," and risk of bias was the most common downgraded factor.

CONCLUSION

Acupuncture may be beneficial in improving cancer pain. However, due to the identified limitations and inconsistent findings, we recommend further rigorous, and more standardized SRs/MAs to provide strong evidence for definitive conclusions.

Impact of NCCN Guideline Adherence in Adult Cancer Pain on Length of Stay

To improve the management of cancer related pain, the National Comprehensive Cancer Network (NCCN) publishes the Adult Cancer Pain guideline on an annual basis. However, a large majority of oncology patients still report inadequate pain control. Single-center, retrospective cohort study of adult patients admitted for uncontrolled pain or pain crisis between 3/1/19 and 06/30/20 were assigned to cohorts of either adherent or non-adherent to NCCN guideline recommendations for management of pain crises based on their initial opioid orders. Patients must have reported a pain score >/= 4 and received at least one dose of opioids within 24 hours upon admission. The length of stay (LOS), pain scores, and naloxone administration were compared between both groups. Patients in the adherent group had a shorter median LOS (3.7 days [range: 1 to 18.93] vs 5.4 days [range: 1.45 to 19.64 days], p = 0.04). Patients that received lower doses than recommended had longer LOS compared to adherent group (6.1 vs. 3.7 days; p = 0.009). When adjusted for confounders, this significance did not remain. The lowest reported pain score within 24 hours of admission was lower in the adherent group (median 3 vs 4, p = 0.04). Predictors of LOS included opioid tolerance and a pain or palliative care consult. Adherence to NCCN guidelines for acute pain crisis management in adult patients with cancer remains poor. Patients who received guideline adherent initial opioid regimens demonstrated a trend toward a shorter LOS. Opioid-tolerant patient outcomes remain inadequate; appropriate pain management for these patients need to improve.

Effects of a physician- and pharmacist-managed clinic on pain management in cancer patients in China

In China, pharmacists have started to manage cancer pain at outpatient clinics. This retrospective study performed at a tertiary teaching hospital was aimed to evaluate the effects of a physician-pharmacist joint clinic for cancer pain management. The study was performed between December 2016 and August 2019 and included 113 outpatients with moderate to severe cancer-related pain. Patients were divided into two groups according to the clinic each patient visited: the physician-pharmacist joint clinic (joint group, n = 59) or physician-only clinic (usual group, n = 54). Brief Pain Inventory (BPI) and Morisky Medication Adherence Measure (MMAM) were used to collect data on pain intensity, interference and medication adherence. Pain Management Index (PMI) was also calculated. BPI, MMAM and PMI were assessed at baseline (patients' first visit, week 0) and week 4 follow-up. The Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) was used to assess patients' health-related quality of life (HRQoL) at week 4. The primary outcomes were the improvement in pain intensity, adequacy of pain management and medication adherence. The secondary outcome was the improvement in HRQoL. At week 4, compared to the usual group, the BPI pain intensity categories except the pain right now were significantly lower in the joint group: worst pain, 4 (3-7) vs 6 (4-8), P = .020; least pain, 1 (0-2) vs 2 (1-3), P = .010; average pain, 3 (2-4) vs 4 (2-5), P = .023; pain right now, 2 (1-3) vs 2 (0-4), P = .796. For the seven pain interference categories, there were no significant improvements in the joint group (P > .05). Significantly more patients achieved adequate pain control in the joint group than the usual group ((P = .002). There was also a significant difference in medication adherence between the two groups (P = .001). There were no significant differences in HRQoL between the two groups. The study suggests that pharmacist participation in outpatient cancer pain management is associated with improvement of patients' pain control and medication adherence.

Acupuncture and Derived Therapies for Pain in Palliative Cancer Management: Systematic Review and Meta-Analysis Based on Single-Arm and Controlled Trials

Background: Acupuncture is a classical complementary therapy, but benefits in palliative cancer pain are still unclear due to lack of consistent evidence. Objectives: To comprehensively evaluate the effectiveness of acupuncture and derived therapies (such as electroacupuncture, laser acupuncture, and transcutaneous electrical nerve stimulation) for analgesia in palliative cancer care based on both single-arm and controlled trials. Design: Eight databases were searched from inception to August 31, 2020. Both single-arm trials and controlled trials were included. The primary outcome was the change in pain intensity, as evaluated by the numeric rating scale (NRS) and the visual analog scale. Subjects: Adults with cancer. Results: Forty-one controlled studies with 2685 participants and 18 single-arm studies with 1084 participants were included. For controlled trials, meta-analysis indicated that acupuncture and derived therapies in addition led to greater reductions in the NRS score than conventional analgesics alone (weighted mean difference [WMD]: 1.33 [0.85-1.82], p < 0.001). For single-arm trials, meta-analysis showed that both the immediate effect (WMD: 1.57 [1.43-1.71], p < 0.001) and long-term longitudinal effect (WMD: 1.81 [1.25-2.37], p < 0.001) of acupuncture on analgesia were positive, as evaluated by the NRS, respectively. The benefits of acupuncture and derived therapies were also seen in quality of life and the global improvement rate. LI4 (Hegu) was the most frequently used acupoint. Conclusions: This systematic review supported the application of acupuncture and derived therapies for managing pain during palliative cancer care from two dimensions. Further studies could explore the effect of acupuncture on other predominant symptoms in palliative cancer patients.

The Association Between Analgesic Treatment Beliefs and Electronically Monitored Adherence for Cancer Pain

OBJECTIVES

To determine whether clusters based on analgesic treatment beliefs among patients with cancer predict objective analgesic adherence.

SAMPLE & SETTING

207 patients with cancer in the outpatient setting who were aged 18 years or older, self-identified as White or African American, were diagnosed with solid tumor or multiple myeloma, and were prescribed at least one around-the-clock analgesic prescription for reported cancer pain.

METHODS & VARIABLES

This study is a secondary analysis of an existing dataset. General linear modeling with a backward elimination approach was applied to determine whether previously identified analgesic treatment belief clusters, as well as sociodemographic, clinical, and pain variables, were associated with adherence behaviors.

RESULTS

Significant explanatory factors were experiential in nature and included sociodemographic, clinical, and pain-related variables, explaining 21% of the variance in analgesic adherence. Analgesic belief clusters were not predictive of adherence.

IMPLICATIONS FOR NURSING

Future research should examine sociodemographic and other clinical factors, as well as the influence of analgesic treatment beliefs, to better understand adherence behaviors among patients with cancer.

Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis

Question

Is the use of acupuncture and acupressure associated with improved cancer pain management compared with sham intervention and/or analgesic therapy alone?

Findings

In this systematic review of 17 randomized clinical trials and meta-analysis of 14 trials in the current English-language and Chinese-language literature, a significant association was found between real (compared with sham) acupuncture and reduced pain, and acupuncture combined with analgesic therapy was associated with decreased analgesic use. However, heterogeneity lowered the level of certainty of the evidence.

Meaning

This study found a moderate level of evidence that acupuncture and/or acupressure was significantly associated with lower pain intensity in patients with cancer compared with a sham control, which suggests a potential for a combination of acupuncture and acupressure to help reduce opioid doses in patients with cancer.

Importance

Research into acupuncture and acupressure and their application for cancer pain has been growing, but the findings have been inconsistent.

Objective

To evaluate the existing randomized clinical trials (RCTs) for evidence of the association of acupuncture and acupressure with reduction in cancer pain.

Data Sources

Three English-language databases (PubMed, Embase, and CINAHL) and 4 Chinese-language biomedical databases (Chinese Biomedical Literature Database, VIP Database for Chinese Technical Periodicals, China National Knowledge Infrastructure, and Wanfang) were searched for RCTs published from database inception through March 31, 2019.

Study Selection

Randomized clinical trials that compared acupuncture and acupressure with a sham control, analgesic therapy, or usual care for managing cancer pain were included.

Data Extraction and Synthesis

Data were screened and extracted independently using predesigned forms. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. Random-effects modeling was used to calculate the effect sizes of included RCTs. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach.

Main Outcomes and Measures

The primary outcome was pain intensity measured by the Brief Pain Inventory, Numerical Rating Scale, Visual Analog Scale, or Verbal Rating Scale.

Results

A total of 17 RCTs (with 1111 patients) were included in the systematic review, and data from 14 RCTs (with 920 patients) were used in the meta-analysis. Seven sham-controlled RCTs (35%) were notable for their high quality, being judged to have a low risk of bias for all of their domains, and showed that real (compared with sham) acupuncture was associated with reduced pain intensity (mean difference [MD], −1.38 points; 95% CI, −2.13 to −0.64 points; I² = 81%). A favorable association was also seen when acupuncture and acupressure were combined with analgesic therapy in 6 RCTs for reducing pain intensity (MD, −1.44 points; 95% CI, −1.98 to −0.89; I² = 92%) and in 2 RCTs for reducing opioid dose (MD, −30.00 mg morphine equivalent daily dose; 95% CI, −37.5 mg to −22.5 mg). The evidence grade was moderate because of the substantial heterogeneity among studies.

Conclusions and Relevance

This systematic review and meta-analysis found that acupuncture and/or acupressure was significantly associated with reduced cancer pain and decreased use of analgesics, although the evidence level was moderate. This finding suggests that more rigorous trials are needed to identify the association of acupuncture and acupressure with specific types of cancer pain and to integrate such evidence into clinical care to reduce opioid use.

Attitudes and appropriateness of pain management in cancer patients using pain management index

Objectives

Inadequate management of cancer pain (CP) remains a global medical problem. In this study, the aim was to assess attitudes of cancer patients towards their CP treatment and to evaluate effectiveness of pain management.

Methods

A sample of 300 adult cancer patients admitted to a single hospital were face-to-face interviewed in a cross-sectional study design using a structured questionnaire. The short form of the Brief Pain Inventory was used to collect data on pain, and Pain Management Index (PMI) was calculated to assess adequacy of pain management.

Key findings

Median age of patients was 53 years (interquartile range, 43–63). Half of patients (50.5%) believed their pain therapy needs improvement. Almost half patients had severe pain at interview (49.8%). Pain interfered most with patient enjoyment of life with a mean interference score 6.13 ± 2.37. Majority of cancer patients (84.3%) received a non-opioid analgesic while a minority (15.7%) received opioid analgesic in which morphine was the most common drug. The use of non-opioid adjuvants was minimal. Mean PMI for patients was −1.15 ± 0.75 (range −2 to +1), and most patients (80.3%) had inadequate pain treatment. Gender and smoking status of patients were significantly associated with adequacy of pain management (P = 0.009 and P = 0.004, respectively). There were no associations between patient age, educational level or tumour characteristics and adequacy of pain management.

Conclusions

Cancer patients in this study present with severe pain and the rates of undertreatment are high. There is an urgent need to improve management plans to assure appropriate use of therapeutic modalities for treatment of cancer-related pain.

Patient Trade-Offs Related to Analgesic Use for Cancer Pain: A MaxDiff Analysis Study

PURPOSE

Many patients with cancer pain deviate from prescribed analgesic regimens. Our aim was to elicit the trade-offs patients make based on their beliefs about analgesic use and rank utilities (importance scores) using maximum difference (MaxDiff) scaling. We also investigated if there were unique clusters of patients based on their analgesic beliefs.

METHODS

This was a secondary analysis of a three-month, prospective observational study. Patients (N = 207) were self-identified African Americans and Whites, >18 years, diagnosed with multiple myeloma or solid tumor, and were prescribed at least one around-the-clock analgesic for cancer pain. MaxDiff analysis allowed us to identify patients utilities. Second, a cluster analysis assisted in ranking how analgesic beliefs differed by groups. Third, clusters were described by comparing key sociodemographic and clinical variables.

RESULTS

Participants' beliefs were a significant factor in choices related to analgesic use (chi-square = 498.145, p < .0001). The belief, 'Pain meds keep you from knowing what is going on in your body', had the highest patient endorsement. Two distinct clusters of patients based on analgesic beliefs were identified; 'knowing body' was ranked as top priority for both clusters. The belief that cancer patients become addicted to analgesics was moderately important for both clusters. Severity of side effects was the only key variable significantly different between clusters (p = .043).

CONCLUSIONS

Our findings support tailored pain management interventions that attend to individual beliefs about cancer pain and analgesic use. Future research should explore the relationship between analgesic utilities, actual analgesic taking behaviors, and how they impact patients' cancer pain outcomes.

Priority Symptoms, Causes, and Self-Management Strategies Reported by AYAs With Cancer

CONTEXT

Cancer and symptom experiences of adolescents and young adults (AYAs) with cancer can be highly variable, creating challenges for clinicians and researchers who seek to optimize AYAs' health outcomes. Understanding the heuristics AYAs use to designate priority symptoms can provide insight into the meaning they assign to their symptoms and self-management behaviors.

OBJECTIVES

This study described the frequency and characteristics of priority symptoms. It qualitatively explored reasons for a symptom's designation as a priority symptom, perceived causes of priority symptoms, and strategies AYAs use to manage priority symptoms.

METHODS

Participants in this single-group, longitudinal study reported symptoms using a heuristics-based symptom reporting tool, the Computerized Symptom Capture Tool, at two scheduled visits for chemotherapy. AYAs designated priority symptoms and responded to three short answer questions: What makes this a priority symptom?, What do you think causes it?, and What do you do to make it better?

RESULTS

Eighty-six AYAs, 15-29 years of age (median 19 years), identified 189 priority symptoms. Priority symptoms were of greater severity (t = 3.43; P < 0.01) and distress (t = 4.02; P < 0.01) compared with nonpriority symptoms. Lack of energy, nausea, difficulty sleeping, and pain comprised 39% of priority symptoms. Reasons for priority designation included the impact of the symptom and the attributes of the symptom. Categories of self-management strategies included "Physical Care Strategies," "Things I take (or not)," and "Psychosocial Care Strategies."

CONCLUSION

Supporting AYAs to identify their priority symptoms may facilitate a more personalized approach to care. Seeking the patient's perspective regarding priority symptoms could enhance patient-clinician collaboration in symptom management.

Adequacy of Pain Control in Patients With Advanced Cancer in Pakistan

PURPOSE:

Pain is highly prevalent in advanced cancer and requires aggressive management. However, pain management in cancer is minimally investigated in Pakistan. This cross-sectional study explores the adequacy of pain management in patients with advanced stage cancer in Pakistan.

METHOD:

From January 2017 to May 2017, a cross-sectional study was conducted at Mayo Hospital, Lahore, Pakistan. A total of 218 patients with cancers were interviewed, and 136 patients with pain ≥5 on a Numerical Rating Scale for pain were included in the study. Demographic of patients and clinical characteristics of tumors were also evaluated.

RESULTS:

Only about one-third of the patients with advanced cancer reported adequate pain management. Chi-square test, χ² (1, n = 136) = 33.038, P < .05, indicated that pain scores were inversely associated with pain control; inadequate pain control was observed in patients with higher pain score and vice versa. Of the 55.88% of patients who were prescribed morphine, only 6 patients were compliant with treatment recommendations. Most patients were prescribed nonopioid medications and tramadol and codeine, which are weak opioid medications.

CONCLUSION:

The rate of undertreatment of cancer pain in Pakistan is alarming. Inadequate clinicians' training, patients' and caregivers' beliefs, lack of availability of opioid medications, and socioeconomic factors are some of the barriers to effective pain control. A multidisciplinary team approach is necessary to follow the World Health Organization pain ladder guidelines for the treatment of cancer pain.

Quality improvement activity for improving pain management in acute extremity injuries in the emergency department

Objective

Methods

Results

Conclusion

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.

Cancer pain: a review of epidemiology, clinical quality and value impact

Cancer-related pain, reported by more than 70% of patients, is one of the most common and troublesome symptoms affecting patients with cancer. Despite the availability of effective treatments, cancer-related pain may be inadequately controlled in up to 50% of patients. With the growing focus on ‘value’ (healthcare outcomes achieved per dollar spent) in healthcare, the management of cancer-related pain has assumed novel significance in recent years. Data from initiatives that assess the quality of pain management in clinical practice have shown that effective management of cancer-related pain improves patient-perceived value of cancer treatment. As a result, assessment and effective management of cancer-related pain are now recognized as important measures of value in cancer care.

A qualitative study of patient and provider perspectives on using web-based pain coping skills training to treat persistent cancer pain

OBJECTIVE

Persistent pain is common and inadequately treated in cancer patients. Behavioral pain interventions are a recommended part of multimodal pain treatments, but they are underused in clinical care due to barriers such as a lack of the resources needed to deliver them in person and difficulties coordinating their use with clinical care. Pain coping skills training (PCST) is an evidence-based behavioral pain intervention traditionally delivered in person. Delivering this training via the web would increase access to it by addressing barriers that currently limit its use. We conducted a patient pilot study of an 8-week web-based PCST program to determine the acceptability of this approach to patients and the program features needed to meet their needs. Focus groups with healthcare providers identified strategies for coordinating the use of web-based PCST in clinical care.

METHOD

Participants included 7 adults with bone pain due to multiple myeloma or metastasized breast or prostate cancer and 12 healthcare providers (4 physicians and 8 advanced practice providers) who treat cancer-related bone pain. Patients completed web-based PCST at home and then took part in an in-depth qualitative interview. Providers attended focus groups led by a trained moderator. Qualitative analyses identified themes in the patient and provider data.

RESULTS

Patients reported strongly favorable responses to web-based PCST and described emotional and physical benefits. They offered suggestions for adapting the approach to better fit their needs and to overcome barriers to completion. Focus groups indicated a need to familiarize healthcare providers with PCST and to address concerns about overburdening patients. Providers would recommend the program to patients they felt could benefit. They suggested applying a broad definition of cancer pain and having various types of providers help coordinate program its use with clinical care.

SIGNIFICANCE OF RESULTS

Web-based PCST was acceptable to patients and providers. Our findings suggest that patients could benefit from this approach, especially if patient and provider barriers are addressed.

Salient concerns in using analgesia for cancer pain among outpatients: A cluster analysis study

AIM

To identify unique clusters of patients based on their concerns in using analgesia for cancer pain and predictors of the cluster membership.

METHODS

This was a 3-mo prospective observational study (n = 207). Patients were included if they were adults (≥ 18 years), diagnosed with solid tumors or multiple myelomas, and had at least one prescription of around-the-clock pain medication for cancer or cancer-treatment-related pain. Patients were recruited from two outpatient medical oncology clinics within a large health system in Philadelphia. A choice-based conjoint (CBC) analysis experiment was used to elicit analgesic treatment preferences (utilities). Patients employed trade-offs based on five analgesic attributes (percent relief from analgesics, type of analgesic, type of side-effects, severity of side-effects, out of pocket cost). Patients were clustered based on CBC utilities using novel adaptive statistical methods. Multiple logistic regression was used to identify predictors of cluster membership.

RESULTS

The analyses found 4 unique clusters: Most patients made trade-offs based on the expectation of pain relief (cluster 1, 41%). For a subset, the main underlying concern was type of analgesic prescribed, i.e., opioid vs non-opioid (cluster 2, 11%) and type of analgesic side effects (cluster 4, 21%), respectively. About one in four made trade-offs based on multiple concerns simultaneously including pain relief, type of side effects, and severity of side effects (cluster 3, 28%). In multivariable analysis, to identify predictors of cluster membership, clinical and socioeconomic factors (education, health literacy, income, social support) rather than analgesic attitudes and beliefs were found important; only the belief, i.e., pain medications can mask changes in health or keep you from knowing what is going on in your body was found significant in predicting two of the four clusters [cluster 1 (-); cluster 4 (+)].

CONCLUSION

Most patients appear to be driven by a single salient concern in using analgesia for cancer pain. Addressing these concerns, perhaps through real time clinical assessments, may improve patients’ analgesic adherence patterns and cancer pain outcomes.

Influence of Social and Health Indicators on Pain Interference With Everyday Activities Among Older Black and White Cancer Patients

Objective: This prospective study aimed to determine the influence social and health factors have on pain interference with everyday activities among older patients receiving outpatient treatment services from a comprehensive cancer center. Method: Participants were surveyed on questions assessing pain interference, and social (communication), health (pain severity, comorbidities), behavioral (self-efficacy, affect), and demographic characteristics. Multivariate analyses were specified to examine determinants of pain interference, with items loading on separate cluster composites: physical interference and psychosocial interference. Results: Pain severity was a significant indicator for physical interference. Similarly, pain severity, education, self-efficacy, negative affect, and communication were predictors of psychosocial interference. Discussion: Factors defining the daily lived experiences of older adults are important in providing baseline information on functional status. This emphasizes the need to rigorously examine the association between pain, and clinical and psychosocial indicators, but more importantly indicators that contribute to the patient’s ability to perform normal everyday activities.

Assessment of Adequacy of Pain Management and Analgesic Use in Patients With Advanced Cancer Using the Brief Pain Inventory and Pain Management Index Calculation

Purpose

The objective of this cross-sectional, noninterventional, 6-month observational study was to assess the adequacy of pain management in patients with cancer admitted to the Oncology Department of Guru Gobind Singh Medical College in Faridkot, India.

Methods and Materials

A total of 348 patients with cancer were recruited for evaluation of the prevalence of inadequate cancer pain management using the Brief Pain Inventory Pain Management Index.

Results

The current study included 127 males (36.5%) and 221 females (63.5%). The most prevalent cancer type was genitourinary; 268 patients (77%) had inadequately managed pain. A significant correlation was observed between poorly managed pain and age groups, analgesic used, and body mass index.

Conclusion

Our observation of inadequate pain management among 77% of patients indicates that pain management was insufficient in three quarters of the patients in this study. Accumulating data regarding the inadequacy of cancer pain management is crucial to improve symptom management. Better management of pain not only alleviates pain symptoms but also increases the quality of life for patients with cancer.

Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis

CONTEXT

Cancer pain has a severe impact on quality of life and is associated with numerous psychosocial responses. Recent studies suggest that treatment of cancer pain has improved during the last decade.

OBJECTIVES

The aim of this review was to examine the present status of pain prevalence and pain severity in patients with cancer.

METHODS

A systematic search of the literature published between September 2005 and January 2014 was performed using the databases PubMed, Medline, Embase, CINAHL, and Cochrane. Articles in English or Dutch that reported on the prevalence of cancer pain in an adult population were included. Titles and abstracts were screened by two authors independently, after which full texts were evaluated and assessed on methodological quality. Study details and pain characteristics were extracted from the articles with adequate study quality. Prevalence rates were pooled with meta-analysis; meta-regression was performed to explore determinants of pain prevalence.

RESULTS

Of 4117 titles, 122 studies were selected for the meta-analyses on pain (117 studies, n = 63,533) and pain severity (52 studies, n = 32,261). Pain prevalence rates were 39.3% after curative treatment; 55.0% during anticancer treatment; and 66.4% in advanced, metastatic, or terminal disease. Moderate to severe pain (numerical rating scale score ≥5) was reported by 38.0% of all patients.

CONCLUSION

Despite increased attention on assessment and management, pain continues to be a prevalent symptom in patients with cancer. In the upcoming decade, we need to overcome barriers toward effective pain treatment and develop and implement interventions to optimally manage pain in patients with cancer.

Opioid risk assessment in palliative medicine

INTRODUCTION

Pain management with opioids is a fundamental element of palliative medicine. Since the risks of chronic opioid therapy have emerged, a reassessment of these risks in the setting of palliative care is warranted.

AREAS COVERED

This article presents information about opioid-related risks including i) sedation, cognitive impairment and falls; ii) constipation; iii) addiction to opioids and associated aberrant behavior; and iv) death due to respiratory depression. For this article, the medical literature was searched using PubMed and Web of Science for appropriate terms including 'palliative care' and 'opioid risk.' Medical subject headings were used to identify suitable articles including 'Analgesics, Opioid', 'Pain/drug therapy,' 'Palliative Care' and 'Hospice Care.' Further sources were identified by following cross-references within the literature and with the help of the University of Washington library staff.

EXPERT OPINION

Palliation of severe pain at the end of life is probably the most widely accepted indication for chronic opioid therapy. At increased doses, adverse effects of opioids may limit or interfere with the benefits of treatment. Careful screening and follow-up will allow risk factors to be recognized and addressed when possible. The use of adjunctive treatments for pain may reduce opioid requirements and yield better outcomes.

Cancer survivors' perspectives on delivery of survivorship care by primary care physicians: an internet-based survey

BACKGROUND

Helping cancer survivors to transition from active treatment to long-term survivorship requires coordinated efforts by both oncologists and primary care physicians (PCPs). This study aims to evaluate cancer survivors' perspectives on PCP-delivered survivorship care.

METHODS

We conducted an Internet-based cross-sectional survey of cancer survivors via www.OncoLink.org . Regression analyses were used to identify factors associated with perception of PCP-delivered survivorship care.

RESULTS

The 352 respondents rated overall PCP-delivered survivorship care as 60 out of 100 (SD = 23). The areas of care most strongly endorsed were general care (62 %), psychosocial support (65 %), and holistic care (68 %). Survivors were less likely to perceive their PCPs as knowledgeable about cancer follow-up (43 %), late or long-term effects of cancer therapy (45 %), and diagnosis and treatment of symptoms related to cancer or cancer therapy (42 %). While 72 % of survivors reported satisfaction with their PCP's care overall, only 41 % felt that their PCPs and oncologists communicated well with one another. In a multivariate regression analysis, higher trust in PCP (p < 0.001), non-white race (p = 0.001), living in the United States (p = 0.007), and visiting a PCP two or more times per year (p = 0.009) were significantly associated with higher ratings of PCP-delivered survivorship care.

CONCLUSIONS

While cancer survivors in general are satisfied with care delivery by PCPs, they perceived that their PCPs have limited abilities in performing cancer-specific follow-up and late effect monitoring and treatment. Better education of family physicians about survivorship issues and improved communication between PCPs and oncologists are needed to improve PCPs' delivery of survivorship care.

[Adolescents and young adults with cancer between adaptation and addiction: state of the question]

The purpose of this literature review is to make a point on the state of health of adolescents and young adults (15-25 years) suffering from cancer. The adaptation strategies and the impact of the announcement of cancer will be discussed. In addition, we are going to consider the characteristics of teenagers and young adults, given the fact that development is still in progress. This period is especially punctuated by various experiments and the emergence of some clinical signs. Also, we have identified various studies concerning the use of licit and illicit substances. Furthermore, we have taken interest in behavioral addictions, particularly cyber addiction. While trying to cross these variables with a population of teenagers and young adults in the context of somatic diseases, it occurred that this population was not well known and studied. The interest of this synthesis is to underline the importance to make future researches in these perspectives.

Current Clinical Opinions, Attitudes and Awareness of Interns Regarding Post-operative and Cancer Pain Management in A Tertiary Care Centre

Aim:

This prospective study was aimed to assess the opinion, awareness and attitude of interns regarding pain assessment, pain management and common barriers in effective pain therapy for patients experiencing pain.

Materials and Methods:

A questionnaire including demographic details, knowledge of the tools of pain assessment, choice of drugs used, side effects, lacunae in existing knowledge and barriers in pain management was designed. A total of 160 interns were approached, out of which 149 returned the completed questionnaire. Only a few of them had a chance exposure to cancer pain management but none of them had undergone any formal training, teaching or classes in this field.

Results:

Most respondents knew that the pain can be measured and the ways to do it. A significant number considered morphine as the preferred drug for managing cancer pain and thought morphine is responsible for addiction and respiratory depression. About 72% interns knew about transdermal preparation of fentanyl and its usage in malignancy but only a few were aware of buprenorphine transdermal patch. Though they were enthusiastic about relieving the cancer patients from suffering, they had limited knowledge of how to achieve this. The common barriers identified by them were lack of adequate knowledge and training and limited availability of opioids.

Conclusions:

The results of this study emphasize the need of special training programs pain management in order to change the current prevailing situation and improve the quality of analgesia provided to the patients.

Cancer pain and current theory for pain control

This article discusses current trends in managing cancer pain, with specific regard to opioid transmission, descending pathway inhabitation, and ways to facilitate the endogenous antinociceptive chemicals in the human body. Various techniques for opioid and nonopioid control of potential pain situations of patients with cancer are discussed. The benefits of using pharmacogenetics to assess the appropriate medications are addressed. Finally, specific treatment of abdominal cancer pain using radiofrequency lesioning is discussed.

Photodynamic therapy for lung cancer and malignant pleural mesothelioma

Photodynamic therapy (PDT) is a form of non-ionizing radiation therapy that uses a drug, called a photosensitizer, combined with light to produce singlet oxygen ((1)O2) that can exert anti-cancer activity through apoptotic, necrotic, or autophagic tumor cell death. PDT is increasingly being used to treat thoracic malignancies. For early-stage non-small cell lung cancer (NSCLC), PDT is primarily employed as an endobronchial therapy to definitively treat endobronchial or roentgenographically occult tumors. Similarly, patients with multiple primary lung cancers may be definitively treated with PDT. For advanced or metastatic NSCLC and small cell lung cancer (SCLC), PDT is primarily employed to palliate symptoms from obstructing endobronchial lesions causing airway compromise or hemoptysis. PDT can be used in advanced NSCLC to attempt to increase operability or to reduce the extent of operation intervention required, and selectively to treat pleural dissemination intraoperatively following macroscopically complete surgical resection. Intraoperative PDT can be safely combined with macroscopically complete surgical resection and other treatment modalities for malignant pleural mesothelioma (MPM) to improve local control and prolong survival. This report reviews the mechanism of and rationale for using PDT to treat thoracic malignancies, details prospective and major retrospectives studies of PDT to treat NSCLC, SCLC, and MPM, and describes improvements in and future roles and directions of PDT.

Definitive surgery and intraoperative photodynamic therapy: a prospective study of local control and survival for patients with pleural dissemination of non-small cell lung cancer

Patients with non-small cell lung cancer (NSCLC) with pleural dissemination have very limited survivals often of just 6-9 months. Prior reports of aggressive surgical resection of pleural metastases have shown no consistent improvements in overall survival and very high rates of local recurrences. Based on this and the generally very diffuse pleural dissemination seen in patients, chemotherapy and palliative interventions are standard of care. By attempting to sterile microscopic residual disease after surgical resection, intraoperative photodynamic therapy (PDT) could improve local pleural control and overall survival compared with surgery alone for patients with NSCLC with pleural metastasis. Prior attempts to demonstrate an improvement in clinical outcomes with PDT as an intraoperative adjuvant combined with definitive surgery to treat pleural malignancies have not been successful, perhaps due, in part, to limited ability to perform real-time dosimetry and ensure adequate and even light distribution throughout the chest cavity. A stratified phase II trial assessed the efficacy of definitive surgery and intraoperative PDT with real-time dosimetry in patients with NSCLC with pleural dissemination demonstrated prolonged local control and a higher than expected 21.7-month median survival from the time of surgery and PDT among 22 enrolled patients. This is the first ever report describing optimal methods, techniques, and dosimetry that could be used to safely and reproducibly deliver intraoperative PDT to the chest cavity as part of multimodality therapy for NSCLC with pleural metastasis.

Associations among pain, pain attitudes, and pain behaviors in patients with metastatic breast cancer

Metastatic breast cancer (MBC) patients often experience pain which can trigger pain behaviors, such as distorted ambulation. Psychological variables, such as individuals' attitudes toward pain, play a role in pain intervention. In this study, we used the cognitive-behavioral model of pain to examine the influence of patients' attitudes toward pain (as measured by the survey of pain attitudes or SOPA) on their pain behaviors (as measured by the pain behaviors checklist). Two hundred-one MBC patients completed surveys at treatment initiation and again 3 and 6 months later. Linear Mixed Model with repeated measures analyses showed that SOPA-solicitude, SOPA-emotions, SOPA-cure, SOPA-disability, and SOPA-medication pain attitudes were consistently significantly associated with pain behaviors at each assessment time point. Additionally, the belief that a medical cure for pain exists buffered the positive association between pain severity and pain behaviors. Our findings support and extend the cognitive-behavioral model of pain and suggest that it may be useful to target pain attitudes in pain management interventions for MBC patients.

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 pilot study to investigate adherence to long-acting opioids among patients with advanced lung cancer

BACKGROUND

Uncontrolled pain remains prevalent in patients with advanced cancer and has been associated with worse quality of life and greater health care utilization. Poor adherence to analgesics may represent a modifiable barrier to pain management.

OBJECTIVE

This pilot study aimed to establish feasibility/utility of evaluating self-reported adherence to long-acting (LA) opioids in patients with advanced lung cancer, and to explore rates and correlates of adherence.

METHODS

Consecutive patients attending an ambulatory thoracic oncology clinic with a diagnosis of advanced lung cancer and a current LA opioid regimen were approached to complete a brief questionnaire during their clinic visit. Participants reported LA opioid adherence during the past 4 weeks (0%-100%) and knowledge of their LA opioid regimen, and completed the Patient Health Questionnaire-2 (PHQ-2) depression screen. Demographic and clinical information were confirmed via electronic health record review.

RESULTS

Fifty-four eligible patients were approached to reach our target sample (n=50; enrollment=92.6%). Self-reported adherence to LA opioids was 85.4% (standard deviation [SD]=21.0). Twenty-eight percent reported a frequency of medication use that did not match the prescribed daily frequency. Lower adherence was associated with inaccurate frequency (p=0.004), positive depression screen (p=0.005), and older age (p=0.04).

CONCLUSIONS

Our results demonstrate the feasibility of integrating self-report assessments of LA opioid adherence into a thoracic oncology clinic. Patients reported high adherence, but more than one-quarter did not accurately report the prescribed frequency of daily doses. Understanding of LA opioid regimens may be a critical indicator of adherence in patients with advanced cancer.

Expectations of pain and accompanying symptoms during cancer treatment

Patients' experience of cancer pain varies throughout the course of the disease. It is important to recognize that patients may experience more than one type of pain, and pain often occurs in the presence of other symptoms. Controlling pain requires a multi-faceted approach to assessing and treating the underlying mechanisms. This article reviews the pain mechanisms responsible for pain during cancer treatment and how expectations of pain and associated symptoms contribute to the pain experience.

Management of pain with comorbid substance abuse

Substance use disorders are a large public health problem in the United States. Over the past decade, there has been a trend of increased prescription drug misuse, morbidity, and mortality related to prescription opioids. For providers who treat pain, this has led to clinical dilemmas as the newly appreciated risks must be balanced with the benefits of treatment, particularly in patients with known substance use disorders. Acute, chronic, and palliative each present distinct issues in pain treatment. A best practices model of pain treatment, including risk stratification and integrative treatment, may provide the best prospect for safe and effective treatment.