What Can the Non-oncologist Physician Do to Facilitate Better Pain Care for Patients with Cancer?

Cancer pain is undertreated in the US, despite efforts to raise awareness of the widespread prevalence of pain in cancer patients, and of the need to prioritize effective assessment and treatment. One study presented at the 2011 American Society of Clinical Oncology (ASCO) annual meeting (http://bit.ly/qUuX0x) looked at analgesic prescribing and treatment adequacy in more than 3,000 patients with invasive cancer. The authors found that 67% of the patients “expressed pain or required analgesics;” one-third of those patients had “inadequate analgesic prescribing.”

The authors of a study published in the Annals of Oncology (http://bit.ly/qGERtu) conducted a literature search and reviewed 44 studies that measured undertreatment in cancer settings. Twenty-six of the studies assessed pain management using the Pain Management Index (PMI), described by the authors as “A well-validated method of assessing the adequacy of pain control” based on guidelines developed by the World Health Organization (WHO) and the Agency for Health Care Policy and Research (AHCPR). The authors noted that although the PMI “is not accurate for prescribing drugs for an individual and not appropriate to evaluate quality of care at an individual level,” it does provide “a rough estimate of how pain is treated in the population.” In the 26 studies that used PMI, 43% of patients had a negative score, indicating undertreatment of their pain (though with large variability in undertreatment prevalence across studies and settings). In studies that involved only cancer patients in the US, 39% of patients had a negative score.

Cancer Pain Resources for Primary Care

National Cancer Institute: Pain (PDQ)

This resource provides “comprehensive, peer-reviewed, evidence-based information about the pathophysiology and treatment of pain.”

http://bit.ly/qlj0sU

Breakthrough Cancer Pain: Mending the Break in the Continuum of Care

This report from the American Pain Foundation insists that “Responding to pain must be a standard of care and a best practice in oncology, and primary care providers need to be more involved in this arena.”

http://bit.ly/f4MEZV

In “The Management of Cancer Pain,” (http://bit.ly/nZJR62) published recently in CA: A Cancer Journal for Clinicians, the authors note that because unrelieved pain “impacts all dimensions of quality of life (QOL) and profoundly influences the patient’s ability to endure treatment and return to health as a cancer survivor,” it is imperative that patients receive “competent, compassionate, evidence-based” pain care. One in four newly diagnosed cancer patients reports experiencing pain, as do one in three patients undergoing active treatment, and three in four patients with advanced disease. Due to this high prevalence, “Cancer pain should be anticipated and responded to early in its course rather than only in crisis once it is severe.” And yet the authors report that “Despite the wealth of scientific evidence and efforts to synthesize and disseminate the evidence through clinician guidelines, suboptimal management of pain persists in clinical settings.”

Cancer patients’ primary care physicians, family physicians, and other non-oncologist physician members of the care team can play an important role in reversing this trend and promoting effective pain management. Francine Rainone, PhD, DO, addressed this in “Treating Adult Cancer Pain in Primary Care” (http://bit.ly/q67rPC), noting that primary care physicians are trained and experienced in a multidisciplinary approach to care, and their “role as patient advocates and educators” makes them particularly well suited to working with the patient and his or her oncologist to ensure adequate pain management. The authors of the article “Primary Care of the Patient with Cancer,” published in American Family Physician (http://bit.ly/qlj0sU), expanded on this further, outlining several specific examples of how the care of patients with cancer “can be enhanced by continued involvement of the primary care physician.”

Pain management is an essential part of comprehensive cancer care, and should be the responsibility of all members of the care team, including primary care physicians. As Portnoy, et al. noted, “Given that most recommended therapies for cancer pain are within the scope of both specialty and primary care medical practice, the treatment of cancer pain should be viewed as a best practice for all medical disciplines involved in the care of this population” (http://bit.ly/f4MEZV).