1
|
Bulls HW, Hamm M, Wasilewski J, Olejniczak D, Bell SG, Liebschutz JM. "To prescribe or not to prescribe, that is the question": Perspectives on opioid prescribing for chronic, cancer-related pain from clinicians who treat pain in survivorship. Cancer 2024. [PMID: 38567685 DOI: 10.1002/cncr.35299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Opioid pain management in cancer survivorship is a complex and understudied topic. METHODS The authors conducted in-depth, qualitative interviews to understand clinician approaches to opioid pain management in chronic cancer pain and to generate ideas for improvement. They used a rigorous, inductive, qualitative, descriptive approach to examine clinician (n = 20) perspectives about opioid pain management in survivorship, including oncologists (n = 5), palliative care clinicians (n = 8), primary care clinicians (n = 5), and pain management specialists (n = 2). RESULTS The findings indicated that no consistent medical home exists for chronic pain management in cancer survivors and that there are fundamental differences in how each subspecialty approaches chronic pain management in survivorship (e.g., "Do we think of this as noncancer pain or cancer pain?… This is in this limbo zone-this gray zone-because it's cancer-related pain, right?"). Simultaneously, clinicians are influenced by their peers' perceptions of their opioid prescribing decisions, sparking intraprofessional tension when disagreement occurs. In these instances, clinicians described overthinking and doubting their clinical decision-making as well as a sense of judgment, pressure, and/or shame. Finally, clinicians acknowledged a fear of consequences for opioid prescribing decisions. Specifically, participants cited conflict with patients, sometimes escalating to aggression and threats of violence, as well as potential disciplinary actions and/or legal consequences. CONCLUSIONS Participants suggested that opportunities to improve chronic cancer pain care include developing clear, systematic guidance for chronic cancer pain management, facilitating clinician communication and consultation, creating tailored survivorship care plans in partnership with patients, and developing accessible, evidence-based, complementary pain treatments.
Collapse
Affiliation(s)
- Hailey W Bulls
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Challenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Megan Hamm
- Qualitative, Evaluation, and Stakeholder Engagement Services, Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julia Wasilewski
- Qualitative, Evaluation, and Stakeholder Engagement Services, Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Donna Olejniczak
- Division of General Internal Medicine, Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah G Bell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Department of Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
2
|
Roberson ML, Henricks A, Woods J, Glenn L, Maues J, James D, Reid S. Re-imagining metastatic breast cancer care delivery: a patient-partnered qualitative study. Support Care Cancer 2023; 31:735. [PMID: 38055111 PMCID: PMC10700428 DOI: 10.1007/s00520-023-08201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE While significant progress in metastatic breast cancer (MBC) treatment has prolonged survival and improved prognosis, there remain substantial gaps in providing patient-centered supportive care. The specific care delivery needs for metastatic cancer differ from that of early-stage cancer due to the incurable nature and lifelong duration of the condition. The objective of this study was to assess how patients living with MBC would re-imagine cancer care delivery. METHODS This qualitative study was conducted in partnership with patient-led organizations Guiding Researchers and Advocates to Scientific Partnerships (GRASP) and Project Life, a nonprofit, online wellness community founded by patients with MBC for patients living with MBC. Virtual semi-structured interviews (n = 36) were conducted with Project Life members purposively sampled from the groups' overall membership. The interview guide contained items surrounding patients' lived experiences of MBC, greatest unmet needs related to care, and perspectives on virtual wellness community involvement. Interviews were coded using two-stage deductive and inductive analysis. RESULTS Three major themes for re-imagining cancer care delivery were identified, including holistic care, information needs, and conceptual shifts. Within these several subthemes emerged with patients re-imagining referrals to non-oncological services, caregiver support, acceptance of integrative medicine, streamlined clinical trial enrollment, curated quality patient resources, MBC-specific terminology and approaches, long-term life and goal-of-care planning, and patient-centered voice throughout. CONCLUSION People living with metastatic cancers have specific supportive care needs. These findings highlight patient-driven areas for re-imagination that are most salient for individuals with MBC.
Collapse
Affiliation(s)
- Mya L Roberson
- Gillings School of Global Public Health, Department of Health Policy and Management, University of North Carolina at Chapel Hill, 1106B McGavran Greenberg Hall, 135 Dauer Drive, CB#7411, Chapel Hill, NC, 27599-7411, USA.
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA.
| | - Anna Henricks
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Joshua Woods
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Julia Maues
- Guiding Researchers and Advocates to Scientific Partnerships (GRASP), Baltimore, MD, USA
| | | | - Sonya Reid
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
| |
Collapse
|
3
|
Bao T, Zhi WI, Baser RE, Li QS, Weitzman M, Gillespie EF, Robson M, Mao JJ. Electro-acupuncture versus battle field auricular acupuncture in breast cancer survivors with chronic musculoskeletal pain: subgroup analysis of a randomized clinical trial. Breast Cancer Res Treat 2023; 202:287-295. [PMID: 37612534 PMCID: PMC11218664 DOI: 10.1007/s10549-023-07072-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/20/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE Chronic musculoskeletal pain is common and debilitating among breast cancer survivors. The PEACE trial demonstrated that electro-acupuncture (EA) and battle field auricular acupuncture (BFAA) both reduced pain more than usual care (UC) in cancer survivors. However, the comparative effectiveness between EA and BFAA among breast cancer survivors is unknown. METHODS EA and BFAA received ten weekly treatments. UC was offered ten EA treatments after week 12. The primary endpoint was change in mean Brief Pain Inventory (BPI) pain severity from baseline to week 12. We analyzed the subset of 165 (46%) trial participants with a breast cancer primary diagnosis. We conducted constrained linear mixed model analyses, which constrained all arms to a common pre-randomization baseline mean. Model-based mean estimates at weeks 12 and 24 were compared between arms using model contrasts. RESULTS Among 165 breast cancer survivors, common pre-randomization mean pain severity was 5.35 [95% Confidence Interval (CI) 5.04, 5.66]. At week 12, BPI pain severity score was 2.69 (2.26. 3.13) in EA, 3.60 (3.17, 4.02) in BFAA, and 5.06 (4.47, 5.65) in UC. EA reduced pain severity significantly more than BFAA at weeks 12 [- 0.90 (- 1.45, - 0.36), p = 0.001] and 24 [- 0.82, (- 1.38, - 0.27), p = 0.004]. EA and BFAA significantly improved both Patient-Reported Outcomes Measurement Information System (PROMIS) - Global Health physical health and mental health component scores at week 12 compared to UC. Mild toxicities were reported. CONCLUSION EA was more effective than BFAA at reducing pain severity, but both similarly improved physical and mental health scores. Breast cancer survivors with chronic musculoskeletal pain may consider EA before BFAA. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02979574. https://clinicaltrials.gov/ct2/show/NCT02979574.
Collapse
Affiliation(s)
- Ting Bao
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Breast Medicine Service, Solid Tumor Division, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 321 E. 61st Street, 4th Floor, New York, NY, 10065, USA.
| | - W Iris Zhi
- Breast Medicine Service, Solid Tumor Division, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raymond E Baser
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Q Susan Li
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew Weitzman
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Erin F Gillespie
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA
| | - Mark Robson
- Breast Medicine Service, Solid Tumor Division, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jun J Mao
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
4
|
Affiliation(s)
- Ana Maria Lopez
- Sidney Kimmel Medical College and Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
5
|
Desai N, Besaw RJ, Sedhom R, Qasim Hussaini SM, Blaes AH, Dusetzina SB, Gupta A. Estimated out-of-pocket costs for cancer-directed and supportive care medications for older adults with advanced pancreatic cancer. J Geriatr Oncol 2022; 13:754-757. [PMID: 35168921 DOI: 10.1016/j.jgo.2022.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/05/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Nidhi Desai
- Department of Internal Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Robert J Besaw
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Ramy Sedhom
- Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, United States of America; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA, United States of America
| | | | - Anne H Blaes
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN, United States of America
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States of America; Vanderbilt-Ingram Cancer Center, Nashville, TN, United States of America
| | - Arjun Gupta
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN, United States of America.
| |
Collapse
|
6
|
Kong YC, Kimman M, Subramaniam S, Yip CH, Jan S, Aung S, Khoa MT, Ngelangel CA, Nyein HL, Sangrajrang S, Tanabodee J, Bhoo-Pathy N. Out-of-pocket payments for complementary medicine following cancer and the effect on financial outcomes in middle-income countries in southeast Asia: a prospective cohort study. Lancet Glob Health 2022; 10:e416-e428. [PMID: 35180423 DOI: 10.1016/s2214-109x(21)00595-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 12/06/2021] [Accepted: 12/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Complementary medicine, which refers to therapies that are not part of conventional medicine, comprising both evidence-based and non-evidence-based interventions, is increasingly used following a diagnosis of cancer. We aimed to investigate out-of-pocket spending patterns on complementary medicine and its association with adverse financial outcomes following cancer in middle-income countries in southeast Asia. METHODS In this prospective cohort study, data on newly diagnosed patients with cancer were derived from the ASEAN Costs in Oncology (ACTION) cohort study, a prospective longitudinal study in 47 centres located in eight countries in southeast Asia. The ACTION study measured household expenditures on complementary medicine in the immediate year after cancer diagnosis. Participants were given cost diaries at baseline to record illness-related payments that were directly incurred and not reimbursed by insurance over the 12-month period after study recruitment. We assessed incidence of financial catastrophe (out-of-pocket cancer-related costs ≥30% of annual household income), medical impoverishment (reduction in annual household income to below poverty line following subtraction of out-of-pocket cancer-related costs), and economic hardship (inability to make necessary household payments) at 1 year. FINDINGS Between March, 2012, and September, 2013, 9513 participants were recruited into the ACTION cohort study, of whom 4754 (50·0%) participants were included in this analysis. Out-of-pocket expenditures on complementary medicine were reported by 1233 households. These payments constituted 8·6% of the annual total out-of-pocket health costs in lower-middle-income countries and 42·9% in upper-middle-income countries. Expenditures on complementary medicine significantly increased risks of financial catastrophe (adjusted odds ratio 1·52 [95% CI 1·23-1·88]) and medical impoverishment (1·75 [1·36-2·24]) at 12 months in upper-middle-income countries only. However, the risks were significantly higher for economically disadvantaged households, irrespective of country income group. INTERPRETATION Integration of evidence-supported complementary therapies into mainstream cancer care, along with interventions to address use of non-evidence-based complementary medicine, might help alleviate any associated adverse financial impacts. FUNDING None.
Collapse
Affiliation(s)
- Yek-Ching Kong
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Merel Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, Netherlands
| | - ShriDevi Subramaniam
- Centre for Clinical Epidemiology, Institute of Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | | | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Soe Aung
- Oncology Society, Myanmar Medical Association, Yangon, Myanmar
| | | | - Corazon A Ngelangel
- Section of Medical Oncology, University of the Philippines-College of Medicine, Philippine General Hospital, Manila, Philippines
| | - Htun Lwin Nyein
- Haematology Department, Yangon General Hospital, Yangon, Myanmar
| | | | | | - Nirmala Bhoo-Pathy
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| |
Collapse
|
7
|
Gupta A, Nshuti L, Grewal US, Sedhom R, Check DK, Parsons HM, Blaes AH, Virnig BA, Lustberg MB, Subbiah IM, Nipp RD, Dy SM, Dusetzina SB. Financial Burden of Drugs Prescribed for Cancer-Associated Symptoms. JCO Oncol Pract 2022; 18:140-147. [PMID: 34558297 PMCID: PMC9213200 DOI: 10.1200/op.21.00466] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/28/2021] [Accepted: 09/01/2021] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The financial toxicity of anticancer drugs is well-documented, but little is known about the costs of drugs used to manage cancer-associated symptoms. METHODS We reviewed relevant guidelines and compiled drugs used to manage seven cancer-associated symptoms (anorexia and cachexia, chemotherapy-induced peripheral neuropathy, constipation, diarrhea, exocrine pancreatic insufficiency, cancer-associated fatigue, and chemotherapy-induced nausea and vomiting). Using GoodRx website, we identified the retail price (cash price at retail pharmacies) and lowest price (discounted, best-case scenario of out-of-pocket costs) for patients without insurance for each drug or formulation for a typical fill. We describe lowest prices here. RESULTS For anorexia and cachexia, costs ranged from $5 US dollars (USD; generic olanzapine or mirtazapine tablets) to $1,156 USD (brand-name dronabinol solution) and varied widely by formulation of the same drug or dosage: for olanzapine 5 mg, $5 USD (generic tablet) to $239 USD (brand-name orally disintegrating tablet). For chemotherapy-induced peripheral neuropathy, costs of duloxetine varied from $12 USD (generic) to $529 USD (brand-name). For constipation, the cost of sennosides or polyethylene glycol was <$15 USD, whereas newer agents such as methylnaltrexone were expensive ($1,001 USD). For diarrhea, the cost of generic loperamide or diphenoxylate-atropine tablets was <$15 USD. For exocrine pancreatic insufficiency, only brand-name formulations were available, range of cost, $1,072 USD-$1,514 USD. For cancer-associated fatigue, the cost of generic dexamethasone or dexmethylphenidate was <$15 USD, whereas brand-name modafinil was more costly ($1,284 USD). For a 4-drug nausea and vomiting prophylaxis regimen, costs ranged from $181 USD to $1,430 USD. CONCLUSION We highlight the high costs of many symptom control drugs and the wide variation in the costs of these drugs. These findings can guide patient-clinician discussions about cost-effectively managing symptoms, while promoting the use of less expensive formulations when possible.
Collapse
Affiliation(s)
- Arjun Gupta
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | - Leonce Nshuti
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Udhayvir S. Grewal
- Department of Internal Medicine, Louisiana State University, Shreveport, LA
| | - Ramy Sedhom
- Division of Oncology, University of Pennsylvania, PA
| | - Devon K. Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Helen M. Parsons
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN
| | - Anne H. Blaes
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | - Beth A. Virnig
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN
| | | | - Ishwaria M. Subbiah
- Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ryan D. Nipp
- Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Sydney M. Dy
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| |
Collapse
|