Does an oral analgesic protocol improve pain control for patients with cancer? An intergroup study coordinated by the Eastern Cooperative Oncology Group

BACKGROUND: Cancer pain is highly prevalent and commonly undertreated. This study was designed to determine whether dissemination of a clinical protocol for pain management would improve outcomes in community oncology practices. PATIENTS AND METHODS: A pain management protocol was developed based on accepted guidelines. After baseline assessment, oncology practices were randomly assigned to 'analgesic protocol' (AP) sites, where oncologists implemented the guidelines in a group of lung or prostate cancer patients, or to 'physician discretion' (PD) sites, where customary treatment was continued. Patients treated on protocol and a comparison group of patients with pain due to breast cancer or myeloma were monitored for change in pain using the Brief Pain Inventory, and for change in other symptoms or mood. RESULTS: The protocol terminated early because of poor accrual. We compared groups using proportions of patients who had no or mild pain at follow-up. Although measures of protocol adherence did not suggest the occurrence of major practice change, the proportion of lung or prostate cancer patients with no or mild pain increased significantly from baseline for those treated at AP sites compared with those treated at PD sites. There was no significant difference between the breast and myeloma patients treated at AP sites versus those treated at PD sites. CONCLUSION: A protocol for cancer pain management can improve pain control. Diffusion of these benefits to other patients was not confirmed. Given the small sample size, these findings require confirmation in a larger trial.     

Optimal pain management for patients with cancer in the modern era

Pain is a common symptom among patients with cancer. Adequate pain assessment and management are critical to improve the quality of life and health outcomes in this population. In this review, the authors provide a framework for safely and effectively managing cancer‐related pain by summarizing the evidence for the importance of controlling pain, the barriers to adequate pain management, strategies to assess and manage cancer‐related pain, how to manage pain in patients at risk of substance use disorder, and considerations when managing pain in a survivorship population. CA Cancer J Clin 2018;68:182–196 . © 2018 American Cancer Society .     

Progress of cancer pain management in Korea

Cancer pain management had received relatively little attention until the late 1990s, when approximately 100,000 new cancer cases and 60,000 cancer deaths occurred each year in Korea. In 2001, a Cancer Pain Management Guideline was prepared for the first time by the Korean Society of Hospice and Palliative Care. This guideline facilitated cancer pain management by health professionals since then. In addition, cancer pain management has been included in the regular curriculum of all medical schools in Korea. The Korean Cancer Pain Assessment Tool, which was developed in 2003, has been accepted as a reliable and valid instrument for assessing cancer pain in Korea. The Korean version of quality of life assessment tools has also been accepted as a useful method. Oral short-acting opioids became available, along with other effective and convenient opioid drugs. The Korean government first published the Cancer Pain Management Guideline for health care professionals in 2004 and expanded the medical reimbursement criteria for cancer pain management, which reflect the government's support and interest in cancer pain care. The cancer pain surveys conducted in 2001 and 2006 demonstrated a significantly increased patient satisfaction on pain control (37% in 2001, n = 3,006 vs. 42% in 2006, n = 3,737, p = 0.003). Therefore, cancer pain management has been systematically approached both by health professionals as well as the government and resulted in a vast improvement in cancer pain control.     

Standards for palliative care delivery in oncology settings

This review aims to describe available standards for delivery of palliative and supportive care for cancer patients and discuss to what extent these guidelines have been evaluated and disseminated into standard care. Ovid searches were conducted to identify relevant guidelines, randomized studies comparing guideline-based care to usual care, and articles describing the use of guidelines in the usual care setting. Published guidelines address specific issues related to symptom management. Broader consensus statements have presented a framework for the delivery of palliative care for cancer patients. Dissemination of guidelines into standard care has been limited. Limited data suggest that implementation of palliative and supportive care guidelines can improve patient outcomes. Clinical trial publications rarely address supportive care in detail. Guideline efficacy has not been evaluated, and their dissemination into standard care has been poor. A conceptual framework for better implementation of existing guidelines might improve usage and outcomes.     

Impact of yoga on functional outcomes in breast cancer survivors with aromatase inhibitor-associated arthralgias

Arthralgia affects postmenopausal breast cancer survivors (BCSs) receiving aromatase inhibitors (AIs). This study aims to establish the feasibility of studying the impact of yoga on objective functional outcomes, pain, and health-related quality of life (HR-QOL) for AI-associated arthralgia (AIAA). Postmenopausal women with stage I to III breast cancer who reported AIAA were enrolled in a single-arm pilot trial. A yoga program was provided twice a week for 8 weeks. The Functional Reach (FR) and Sit and Reach (SR) were evaluated as primary outcomes. Pain, as measured by the Brief Pain Inventory (BPI), self-reported Patient Specific Functional Scale (PSFS), and Functional Assessment of Cancer Therapy-Breast (FACT-B) were secondary outcomes. Paired t tests were used for analysis, and 90% provided data for assessment at the end of the intervention. Participants experienced significant improvement in balance, as measured by FR, and flexibility, as measured by SR. The PSFS improved from 4.55 to 7.21, and HR-QOL measured by FACT-B also improved; both P < .05. The score for the Pain Severity subscale of the BPI reduced. No adverse events nor development or worsening of lymphedema was observed. In all, 80% of participants adhered to the home program. Preliminary data suggest that yoga may reduce pain and improve balance and flexibility in BCSs with AIAA. A randomized controlled trial is needed to establish the definitive efficacy of yoga for objective functional improvement in BCSs related to AIAA.     

Effects of symptom clusters and depression on the quality of life in patients with advanced lung cancer

People with advanced lung cancer experience later symptoms after treatment that is related to poorer psychosocial and quality of life (QOL) outcomes. The purpose of this study was to identify the effect of symptom clusters and depression on the QOL of patients with advanced lung cancer. A sample of 178 patients with advanced lung cancer at the National Cancer Center in Korea completed a demographic questionnaire, the M.D. Anderson Symptom Inventory–Lung Cancer, the Center for Epidemiological Studies Depression Scale, and the Functional Assessment of Cancer Therapy–General scale. The most frequently experienced symptom was fatigue, anguish was the most severe symptom‐associated distress, and 28.9% of participants were clinically depressed. Factor analysis was used to identify symptom clusters based on the severity of patients' symptom experiences. Three symptom clusters were identified: treatment‐associated, lung cancer and psychological symptom clusters. The regression model found a significant negative impact on QOL for depression and lung cancer symptom cluster. Age as the control variable was found to be significant impact on QOL. Therefore, psychological screening and appropriate intervention is an essential part of advanced cancer care. Both pharmacological and non‐pharmacological approaches for alleviating depression may help to improve the QOL of lung cancer patients.     

Validation of the Edmonton Symptom Assessment Scale

BACKGROUND: The Edmonton Symptom Assessment Scale (ESAS) is a nine-item patient-rated symptom visual analogue scale developed for use in assessing the symptoms of patients receiving palliative care. The purpose of this study was to validate the ESAS in a different population of patients. METHODS: In this prospective study, 240 patients with a diagnosis of cancer completed the ESAS, the Memorial Symptom Assessment Scale (MSAS), and the Functional Assessment Cancer Therapy (FACT) survey, and also had their Karnofsky performance status (KPS) assessed. An additional 42 patients participated in a test-retest study. RESULTS: The ESAS "distress" score correlated most closely with physical symptom subscales in the FACT and the MSAS and with KPS. The ESAS individual item and summary scores showed good internal consistency and correlated appropriately with corresponding measures from the FACT and MSAS instruments. Individual items between the instruments correlated well. Pain ratings in the ESAS, MSAS, and FACT correlated best with the "worst-pain" item of the Brief Pain Inventory (BPI). Test-retest evaluation showed very good correlation at 2 days and a somewhat smaller but significant correlation at 1 week. A 30-mm visual analogue scale cutoff point did not uniformly distinguish severity of symptoms for different symptoms. CONCLUSIONS: For this population, the ESAS was a valid instrument; test-retest validity was better at 2 days than at 1 week. The ESAS "distress" score tends to reflect physical well-being. The use of a 30-mm cutoff point on visual analogue scales to identify severe symptoms may not always apply to symptoms other than pain.     

Barriers to pain assessment and management in cancer survivorship

Introduction Healthcare providers frequently lack the knowledge and skills to provide optimal pain management for cancer survivors. Scientific evidence and clinical guidelines are lacking in the management of chronic, persistent pain in survivors. The purpose of this article is to describe pain-related issues of cancer survivors using case presentations of selected patients enrolled in a randomized trial to eliminate barriers to pain management. Materials and methods Case presentations were selected from a National Cancer Institute-funded study that utilizes patient and professional educational content derived from the clinical guidelines of the National Comprehensive Cancer Network. Case presentation criteria included a pain rating of ≥6 and diagnosis of Stage I, II, or III of the following cancers: breast, colon, lung, or prostate cancer. Cases are presented based on the study’s framework of patient, professional, and system-related barriers to optimal pain relief. Results Across all three case presentations, barriers such as fear of side effects from pain medications, fear of addiction, lack of professional knowledge of the basic principles of pain management, and lack of timely access to pain medications due to reimbursement issues are prevalent in cancer survivorship. Conclusions Chronic pain syndromes related to cancer treatments are common in cancer survivors. Patient, professional, and system-related barriers that are seen during active treatment continue to hinder optimal pain relief during survivorship. Implications for cancer survivors Healthcare providers must acknowledge the impact of chronic, persistent pain on the quality of cancer survivorship. Clinical as well as scientific efforts to increase knowledge in chronic pain management will improve the symptom management of cancer survivors. Supported by a grant from the National Cancer Institute R-01 CA115323.     

Adequacy of cancer pain management in a Japanese Cancer Hospital

BACKGROUND: Pain is one of the most frequent and deleterious symptoms in cancer patients. This study was carried out to investigate the adequacy of pain management at the National Cancer Center Hospital East, Japan. METHODS: The available data were obtained from 138 ambulatory cancer patients with pain. The data included pain severity, which patients reported using the Japanese version of the M. D. Anderson Symptom Inventory, along with such medical information as cancer and treatment information and currently prescribed analgesics. Adequacy of pain management was assessed using the Pain Management Index, which revealed whether prescribed analgesic drugs were congruent with pain severity. RESULTS: Physicians undertreated pain in 70% of patients. Patients with non-advanced cancer (local cancer or no evidence of any recurrent cancer) were more likely to receive inadequate treatment than those with advanced cancer [P = 0.009, odds ratio = 0.18, Exp (95% CI) lower = 0.05, higher = 0.64] in the exploratory logistic regression analysis. Additionally, we found significant differences among physicians in ability to manage cancer pain, unrelated to a physician's years of experience as an oncologist. CONCLUSIONS: This study suggests that cancer pain management is insufficient at the investigated institute. Remedial action should be taken, including increasing awareness of symptom management in medical staff and incorporating existing knowledge into routine clinical practice.     

Pain Syndromes in the Cancer Patient

Effective management of cancer patients with pain requires a thorough assessment of the nature of the pain. Recognizing and treating the cause of pain should be the first-line approach to this common symptom. A series of common pain syndromes are unique to cancer and its treatment. Pain may result from direct infiltration of tumor or from treatment of lumor by surgery, chermotherapy, or radiation. Cancer patients often have multiple causes of pain, and each cause needs careful evaluation and treatment.     

Zoledronic acid significantly improves pain scores and quality of life in breast cancer patients with bone metastases: a randomised, crossover study of community vs hospital bisphosphonate administration

Patients with bone metastases from breast cancer often experience substantial skeletal complications -- including debilitating bone pain -- which negatively affect quality of life. Zoledronic acid (4 mg) has been demonstrated to reduce significantly the risk of skeletal complications in these patients and is administered via a short, 15-min infusion every 3 weeks, allowing the possibility for home administration. This study compared the efficacy and safety of zoledronic acid administered in the community setting vs the hospital setting in breast cancer patients with > or =1 bone metastasis receiving hormonal therapy. After a lead-in phase of three infusions of 4 mg zoledronic acid in the hospital setting, 101 patients were randomized to receive three open-label infusions in the community or hospital setting, followed by three infusions in the opposite venue (a total of nine infusions). The Brief Pain Inventory (BPI) and the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire 30 (EORTC QLQ-C30) were used to assess potential benefits of zoledronic acid therapy. At study end, analysis of the BPI showed significant reductions in worst pain (P=0.008) and average pain in the last 7 days (P=0.039), and interference with general activity (P=0.012). In each case, there were significantly greater improvements in pain scores after treatment in the community setting compared with the hospital crossover setting for worst pain (P=0.021), average pain (P=0.003), and interference with general activity (P=0.001). Overall global health status showed a significant median improvement of 8.3% (P=0.013) at study end. Physical, emotional, and social functioning also showed significant overall improvement (P=0.013, 0.005, and 0.043, respectively). Furthermore, physical, role, and social functioning showed significantly greater improvements after treatment in the community setting compared with the hospital crossover setting (P=0.018, 0.001, and 0.026, respectively). There was no difference between hospital and community administration in renal or other toxicity, with zoledronic acid being well tolerated in both treatment settings. These data confirm the safety and quality-of-life benefits of zoledronic acid in breast cancer patients with bone metastases, particularly when administered in the community setting.     

Unequal quality of cancer pain management: disparity in perceived control and proposed solutions

Purpose/Objectives: To examine poverty-related and racial and ethnic disparity in cancer pain management. Data Sources: Published articles, conference proceedings, testimony, and clinical case studies. Data Synthesis: Disparity in the quality of cancer pain management exists resulting from interactions among patient, provider, and environmental factors. Irrespective of etiology, disparity results in inadequate management of cancer pain for vulnerable populations (poor patients, ethnic and racial group members, older adults) and is unacceptable in cancer care. Inadequate symptom management affects cancer treatment tolerance, exacerbating disparity in treatment outcomes and affecting end-of-life care. Conclusions: Evidence-based solutions include a systems approach, quality-improvement and quality-assurance processes that expose disparities and enforce evidence-based treatment per national guidelines, and statewide comprehensive cancer planning to target pain management outcomes. Implications for Nursing: Oncology nurses and interdisciplinary teams must be aware of disparities in cancer pain management for vulnerable groups, intervene to empower patients through customized educational approaches, and simultaneously implement systemwide strategies to ensure effective pain management and targeted monitoring for high-risk patients.     

Symptom and quality of life survey of medical oncology patients at a veterans affairs medical center: a role for symptom assessment

BACKGROUND: The current study was conducted to assess symptom prevalence and symptom intensity and their relation to quality of life in medical oncology patients at a Veterans Affairs medical center. METHODS: Consecutive inpatients and outpatients were asked to complete the Functional Assessment Cancer Therapy (FACT-G), Memorial Symptom Assessment Scale (MSAS), and the Brief Pain Inventory. Symptoms then were analyzed by their relation to Karnofsky performance status (KPS) and quality of life. RESULTS: Two hundred forty patients participated. The median number of symptoms was 8 per patient (range, 0-30 symptoms). The 5 most prevalent symptoms were lack of energy (62%), pain (59%), dry mouth (54%), shortness of breath (50%), and difficulty sleeping (45%). Patients with moderate intensity pain had a median number of 11 symptoms and patients with moderate intensity lack of energy had a median number of 13 symptoms. The number of intense symptoms increased as the KPS decreased (P < 0.001). Patients with moderately intense pain or fatigue also were more likely to experience nausea, dyspnea, and lack of appetite. The number of symptoms rated as present on the MSAS was found to correlate significantly with the FACT-G Sum Quality of Life score. CONCLUSIONS: Intense symptoms were highly prevalent in this population. The presence of pain, lack of energy, or poor performance status should lead to comprehensive symptom assessment. Patients free of disease nevertheless still may experience intense symptoms. The number of symptoms present may be a helpful guide to quality of life. Routine comprehensive symptom assessment may identify a significant fraction of patients who urgently require intensive symptom palliation.     

Pain experienced by lung cancer patients: a review of prevalence, causes and pathophysiology

BACKGROUND: Lung cancer is one of the commonest cancers to cause pain, but little is known regarding the extent of this complex problem in these patients. METHODS: Medline (1966-June 2002) and Cancerlit (1975-May 2002) were searched to identify studies of lung cancer patients' experience of pain, its prevalence, causes and underlying pathophysiology. RESULTS: Thirty-two studies were identified. Patients were recruited from diverse populations, and the prevalence varied according to study setting. Pain affected 27% of outpatients (range 8-85%), and 76% of patients cared for by palliative care services (range 63-88%). Pain was caused by cancer in 73% (range 44-87%), and cancer treatment in 11% (range 5-17%). Nociceptive pain was the major pathophysiological subtype in lung cancer pain, but neuropathic pain accounted for 30% (range 25-32%) of cases. CONCLUSIONS: The overall weighted mean pain prevalence of pain was 47% (range 6-100%). Cancer patients should be asked about pain at all stages of management. Those with pain should be investigated for disease progression and considered for referral for specialist management.     

Patient and Clinical Variables Account for Changes in HealthrelatedQuality of Life and Symptom Burden as TreatmentOutcomes in Colorectal Cancer: A Longitudinal Study

Objective: The aim of the current study was to evaluate changes in treatment outcomes in terms of healthrelatedquality of life (HRQoL) and symptom burden at zero, one, three, and six months after an initial diagnosisof colorectal cancer. The demographic and clinical characteristics that account for outcome changes in patientswere investigated using a repeated measures framework. Methods and Materials: A cohort study was performedof 134 colorectal cancer patients followed from diagnosis to 6 months post-treatment in Central Taiwan. HRQoLand symptoms were assessed at diagnosis and one, three, and six months thereafter. The Functional Assessmentof Cancer Therapy-Colon (FACT-C) questionnaire, VAS pain, and the Memorial Symptom Assessment Scale(MSAS) were used for data collection. A generalized estimating equation (GEE) was applied for statisticalanalysis. Results: The majority of the patients were male (55%) and married (91.5%). The mean age was 60.4years (SD = 11.71). Most were diagnosed stage III and IV colorectal cancer (54.5%). All underwent surgery;some also received chemotherapy (CT) or concurrent chemoradiation therapy (CCRT). The results of the GEEshowed that overall, the HRQoL, pain, and symptoms of the patients significantly improved over the treatmentperiod. Patients with stage IV disease who had received surgery and CCRT showed the worst HRQoL. Females,patients with comorbidity, and stage IV patients had higher pain scores over time. Female and stage IV patientshad more severe physical symptoms, whereas stage II and IV patients had worse psychological symptoms overtime. Conclusion: The patients’ HRQoL, pain, and symptoms significantly improved over the 6-month treatmentperiod. Certain patient and clinical variables accounted for changes in treatment outcomes regarding HRQoLand symptom burden in colorectal cancer patients.     

Development and validation of the Functional Assessment of Cancer Therapy-Kidney Symptom Index (FKSI)

The Functional Assessment of Cancer Therapy (FACT)-Kidney Symptom Index (FKSI) was developed and validated to enhance treatment decision-making, practice guidelines, symptom management, and treatment efficacy for kidney cancer patients. Thirty-four symptoms related to the disease were identified and tested. An equal weighting of patient and clinician ratings of the relative importance of each of these items led to production of a 15-item index (FKSI-15) and a 10-item abbreviated option (FKSI-10). To assess psychometric properties, patients completed the FKSI, Functional Assessment of Cancer Therapy-General (FACT-G), Eastern Cooperative Oncology Group-Performance Status Rating (ECOG-PSR), and a Global Rating of Change Scale (GRCS). Patient responses to the FKSI were analyzed for internal consistency, test-retest reliability, convergent and discriminant validity, and responsiveness to change in clinical status. The FKSI-10 showed high internal consistency; correlations between both FKSI-10 and the physical and functional well being domains of the FACT-G were high. The FKSI-10 differentiated patients grouped by ECOG-PSR (all P < 0.001) and discriminated patients based on their GRCS rating. The minimally important difference (MID) range estimate for the FKSI-10 was 2-4 points; the psychometric properties of the FKSI-15 were very similar (MID range, 3-5 points).Thus, the FKSI-15 and FKSI-10 are reliable and valid symptom indices for evaluating kidney cancer patients.     

Symptom burden in cancer survivors 1 year after diagnosis: a report from the American Cancer Society's Studies of Cancer Survivors

BACKGROUND:

Few studies have examined risk for severe symptoms during early cancer survivorship. By using baseline data from the American Cancer Society's Study of Cancer Survivors‐I, the authors examined cancer survivors with high symptom burden, identified risk factors associated with high symptom burden, and evaluated the impact of high symptom burden on health‐related quality of life (HRQoL) 1 year postdiagnosis.

METHODS:

Participants were enrolled from 11 state cancer registries approximately 1 year after diagnosis and were surveyed by telephone or mail. The outcomes measures used were the Modified Rotterdam Symptom Checklist and the Profile of Mood States‐37 (to assess symptom burden) and the Satisfaction with Life Domains Scale‐Cancer (to assess HRQoL).

RESULTS:

Of 4903 survivors, 4512 (92%) reported symptoms related to their cancer and/or its treatment. Two‐step clustering yielded 2 subgroups, 1 with low symptom burden (n = 3113) and 1 with high symptom burden (n = 1399). Variables that were associated with high symptom burden included lung cancer (odds ratio [OR], 2.27), metastatic cancer (OR, 2.05), the number of comorbid conditions (OR, 1.76), remaining on active chemotherapy (OR, 1.93), younger age (OR, 2.31), lacking insurance/being underinsured (OR, 1.57), having lower income (OR, 1.61), being unemployed (OR, 1.27), and being less educated (OR, 1.29). Depression, fatigue, and pain had the greatest impact on HRQoL in survivors with high symptom burden, who also had lower HRQoL (P < .0001).

CONCLUSIONS:

More than 1 in 4 cancer survivors had high symptom burden 1 year postdiagnosis, even after treatment termination. These results indicate a need for continued symptom monitoring and management in early post‐treatment survivorship, especially for the underserved. Cancer 2011;. © 2011 American Cancer Society.     

Feasibility of quantitative pain assessment in outpatient oncology practice.

PURPOSE: Although physicians view failure to assess pain systematically as the most important barrier to outpatient cancer pain management, little is known about pain assessment in this setting. We sought to determine whether pain is routinely assessed and whether routine quantitative pain assessment is feasible in a busy outpatient oncology practice. PATIENTS AND METHODS: We conducted a pre- and postintervention chart review of 520 randomly selected medical and radiation oncology patient visits at a community hospital-based private outpatient practice. The intervention consisted of training health assistants (HAs) to measure and document patient pain scores by using a visual analog scale. The main outcome measures included HA documentation of patient pain scores, quantitative and qualitative mention of pain in the physician note, and analgesic treatment before and after the intervention. RESULTS: After the intervention, HA documentation of pain scores increased from 1% to 75.6% (P < .0001). Physician documentation increased from 0% to 4.8% for quantitative documentation (P < .01), and from 60.0% to 68.3% for qualitative documentation (not significant). Of all the patients, 23.1% reported significant pain. Subgroups with greater pain included patients actively receiving radiation treatments and patients with lung cancer. Of patients with significant pain, 28.2% had no mention of pain in the physician note and 47.9% had no documented analgesic treatment. CONCLUSION: Quantitative pain assessment was virtually absent before our intervention but easily implemented and sustained in a busy outpatient oncology practice. Pain score collection identified a high prevalence of pain, patient subgroups at risk for pain, and a significant proportion of patients with pain that was neither evaluated nor treated by their oncologists.