Saturday, April 21, 2012

Cancer Patients Still Undertreated for Pain

Cancer Pain Despite guidelines and mandates calling for more aggressive management of pain associated with cancer, millions of persons with the disease still suffer needlessly because practitioners fail to adequately treat their pain, according to a new study. And, this is just the latest report pointing to this as a disgraceful neglect of pain in America and worldwide.

The new study, led by researchers at the University of Texas M.D. Anderson Cancer Center and published online ahead of print in the Journal of Clinical Oncology, is the largest-ever assessment of pain treatment for cancer patients in an outpatient setting. For this investigation, Michael J. Fisch, MD, and his team prospectively enrolled a total of 3,123 ambulatory patients at 38 institutions across the United States [Fisch et al. 2012].

Participants had invasive cancer of the breast, prostate, colon/rectum, or lung, and were recruited regardless of phase of care or stage of disease. They included patients in active treatment and survivors seeing healthcare providers for follow-up appointments, and whether pain was caused by cancer, by the treatment for cancer, or by other illness patients experienced during their cancer care.

During an initial assessment and at 4-to-5 weeks later, patients completed a 25-item measure of pain, functional interference, and other symptoms. Healthcare providers recorded analgesic prescribing, and a pain management index was calculated to assess treatment adequacy.

At the initial assessment, Fisch et al. found that, of the roughly 3,000 patients identified to be at risk for pain, two-thirds (2,000, or 67%) reported still having pain or requiring analgesics. Of these 2,000 patients, about one-third (670, 33%) were receiving inadequate analgesic prescribing — 20% with severe pain were not receiving any pain medication, and 13% received ineffective analgesia. The investigators observed no differences in treatment adequacy between the initial and follow-up visits, and most were being treated by oncologists rather than pain specialists.

Furthermore, multivariate analysis revealed that the odds of a non-Hispanic white patient having inadequate pain treatment were approximately 50% less than for a minority patient, after adjusting for other explanatory variables (Odds Ratio, 0.51; 95% CI, 0.37 to 0.70; P = 0.002). Other significant predictors of inadequate pain treatment were having good physical performance status, being treated at a site primarily serving minorities, and having non-advanced disease without concurrent cancer treatment.

The researchers conclude that most outpatients with common solid tumors must confront issues related to inadequate pain management and use of analgesics. There is significant disparity in pain-treatment adequacy, with the likelihood of undertreatment being twice as high for black and Hispanic patients. These unfortunate findings endured during one month of follow-up, highlighting the persistence and complexity of these problems.

COMMENTARY: According to the American Cancer Society, more than 19 million Americans have cancer or are survivors of the disease, and more than one million new cases are diagnosed each year, so this is a sizeable and growing population. With better treatments, the chances of cancer survival have dramatically improved in many cases, but this does not eliminate the potential for associated chronic pain disorders. In some cases, the cancer treatments, themselves, may result in residual pain conditions.

The lack of adequate pain management in cancer patients and survivors is somewhat surprising. Unlike the management of chronic noncancer pain, best-practice guidelines, healthcare organizations, and government agencies all have seemed to advocate that cancer is somewhat sacrosanct when it comes restrictions on pain relief therapies; no holds barred, no egregious regulations, whatever works best should be encouraged. Apparently, this is not so.

Unfortunately, this latest study did not investigate why cancer patients' pain was not being adequately treated. In a news interview [Houston Chronicle, April 19, 2012], Fisch suggested that common reasons might include patients' fears of becoming addicted to strong analgesics and doctors' fears of scrutiny by state regulatory agencies that monitor prescribing of high-dose pain relievers. Furthermore, insurance reimbursement for pain medications sometimes is inadequate, he said, and some practitioners simply do not understand the extent of patients' pain.

As to why minorities would receive less adequate pain management than whites, Fisch said it is not completely understood. Often-cited reasons, he noted, include the costs of some of the medications, the stigma of certain side effects among minority groups, and the possibility of unconscious stereotyping by prescribers that minorities might not be good candidates for certain drugs.

It seems plausible to us that many of the current fears and controversies surrounding the use of strong analgesics for treating noncancer pain are affecting attitudes and practices in the cancer field. The study by Fisch et al. is not the first to observe a dire situation when it comes to cancer-pain management:

  • In a prior UPDATE [here], we discussed a small study from the University of Michigan, Ann Arbor, that found 43% of cancer survivors had experienced pain since their diagnosis and 20% continued to have chronic pain related to their conditions. Furthermore, the pain was worse for black cancer survivors and also for women, who experienced significantly more pain, more pain flare-ups, higher disability related to pain, and more depression.

  • A small, online survey found that a majority of respondents (67%) reported having pain, with 48% of those persons attributing pain to their cancer and 47% to their treatment for cancer [UPDATE here]. Similar to the report from Fisch et al., a quarter of persons with cancer pain were not taking analgesics at all and overall use of analgesics was significantly less in minorities and patients with lower education levels. Usage varied by cancer diagnosis and was higher among patients who received chemotherapy and radiation. Also similar to what Fisch noted, above, various factors contributing to insufficient pain relief included side effects of medications, fear of addiction, and inability to pay for analgesics.

  • A survey of cancer specialists, oncologists, found that many have relatively little training and knowledge when it comes to assessing and managing their patients’ pain. And, as Fisch et al. also found in their study, only a minority of oncologists refer these patients to pain specialists [UPDATE here].

Surely, these data do not bode well for patients with cancer-related pain, and this clearly contributes significantly to the crisis of pain in America and the rest of the world. As we’ve noted before in various UPDATES, there especially seems to be no excuse for patients with cancer pain to suffer without any analgesic medication at all, and reasons why specific groups, like minorities and the socioeconomically disadvantaged, do not have access to adequate pain relief should be a high-priority topic for national discussion and legislative inquiry. Finally, the lack of pain management skills reported among oncologists, and their lack of patient referrals to pain specialists, seems difficult to justify.

REFERENCE: Fisch MJ, Lee J-W, Weiss M, et al. Prospective, Observational Study of Pain and Analgesic Prescribing in Medical Oncology Outpatients With Breast, Colorectal, Lung, or Prostate Cancer. J Clin Oncol. 2012(Apr 16); online ahead of print [abstract here].

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