Friday, November 18, 2011

Can Cancer Specialists Treat Pain Effectively?

Cancer Pain A new survey of cancer specialists, or oncologists, found that many have relatively little training and knowledge when it comes to assessing and managing their patients’ pain. A number of other barriers also prevent adequate pain care in patients with cancer, and only a minority of oncologists refer these patients to pain specialists.

Investigators at Beth Israel Medical Center in New York City conduced a nationwide survey to evaluate the attitudes, knowledge, and practices of medical oncologists in the U.S. regarding the management of cancer pain [Breuer et al. 2011]. An anonymous questionnaire was mailed to a geographically representative sample of oncologists randomly selected from the American Medical Association's Physician Master File. Of 2,000 cancer specialists sampled, a total of 610 (31%) responded, who were demographically similar to the total population of oncologists nationwide.

Writing in an early online edition of the Journal of Clinical Oncology, results on various questions were reported as scores on a 0-to-10 numeric rating scale. Overall, the oncologists rated their specialty somewhat high in its ability to manage cancer pain (median, 7; IQR, 6-8), but they rated their peers much lower, and as being more conservative prescribers, than themselves (median, 3; IQR, 2-5).

[Note: The median is the middle score, separating the upper and lower half of all scores. The interquartile range, or IQR, is the middle half of all scores; that is, the range encompasses scores that were entered by participants from 25% to 75% of the time and suggests how widely scattered the scores were.]

Oncologist respondents rated the quality of their pain management training during medical school quite low (median, 3; IQR, 1-5), and only slightly better during residency ( median, 5; IQR, 3-7). They indicated that the most important barriers to pain management were poor assessment of pain (median, 6; IQR, 4-7), and the reluctance of patients to take opioids (median, 6; IQR, 5-7) or to report their pain (median, 6; IQR, 4-7). Other barriers, but scoring somewhat lower, included physician reluctance to prescribe opioids (median, 5; IQR, 3-7) and perceived excessive regulation of opioids (median, 4; IQR, 2-7).

Survey participants also responded to two vignettes — invented by the study authors, who are all pain specialists — describing a patient in considerable pain despite being on relatively high-dose opioid therapy. Although they had rated their ability to manage pain fairly high, only 40% of respondents answered correctly to a question on how the patient’s opioid regimen should be modified. On another question, requiring an understanding of why a large increase in opioid dose could be hazardous, only 13% responded correctly. Respondents did generally agree that opioids, including morphine and oxycodone, should be first-line therapy for chronic cancer pain and are best prescribed as scheduled doses rather than PRN (ie, as needed).

The researchers conclude that their survey suggests the community of oncology professionals has not adequately addressed barriers to effective pain management and the limitations in pain-related knowledge and practices among practitioners. Furthermore, in this survey, frequent referrals to pain specialists were reported by only 14% of respondents, and only 16% referred patients to palliative care specialists. Clearly, additional efforts are needed to achieve meaningful progress in the management of cancer-related pain.

COMMENTARY: Cancer is among the most feared medical conditions and the burden of pain suffered by patients with cancer is unacceptable. In an earlier UPDATE [here] we noted that 43% of cancer survivors had experienced pain since their diagnosis and 20% still had unrelieved chronic pain related to their conditions. Other studies have reported that 70% of persons with cancer experience significant pain and fewer than half receive adequate pain relief; along with that, opioid analgesics were inadequately or improperly prescribed in as many as 70% of cases [UPDATE here].

So, the results of this current survey by Breuer et al. are not entirely surprising, but are still disappointing. While there are considerable controversies surrounding the treatment of noncancer pain, particularly with opioid analgesics, it is often assumed that there are “no holds barred” when it comes to treating cancer-related pain. Apparently, this is not the case, and many of the oncologists reported both a reluctance to prescribe opioids and fears of regulatory sanctions if they do.

It also is of concern that some respondents appeared to blame patients — for their reluctance to report their pain and/or to take opioid analgesics. In a news interview [here], lead author, Brenda Breuer, MD, said patients should “speak up about their pain. I think that the takeaway message is to know that there are specialists in pain medicine and palliative care medicine. [Patients] should not be afraid to request consults for managing pain."

However, should the burden be on patients with cancer to demand better pain management, and to know of what other resources in their communities are available and accessible for this? Or, as Breuer also states, the survey findings “point to a need for medical schools and residency programs to do a better job of preparing future oncologists to manage pain.” At the same time, we might add, it seems that currently practicing cancer specialists have an obligation to learn more about effective pain management and, if necessary, to refer patients to other healthcare providers who might be more capable.

Finally, from an evidence standpoint, it is unfortunate that less than a third of oncologists surveyed responded, since it is uncertain whether a sample of only 610 respondents could or should be considered representative of all cancer specialists in the U.S. However, this is the nature of survey research, and the results need to be taken at face value until a more comprehensive study is conducted.

Note: Healthcare providers may be interested in resources on cancer-related pain at see the Pain Disorders section [here] and the Guidelines section [here].

REFERENCE: Breuer B, Fleishman SB, Cruciani RA, Portenoy RK. Medical Oncologists' Attitudes and Practice in Cancer Pain Management: A National Survey. J Clin Oncol (JCO). 2011(Nov 14); online ahead of print [abstract here].