Pain Remains Prevalent and Often Inadequately Treated among Cancer Outpatients

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“Pain is as prevalent in ambulatory oncology patients with common solid tumors as it was more than 20 years ago, despite the fact that opioid prescribing in the United States has increased more than 10-fold since 1990,” according to results of a study among 3,023 ambulatory patients with cancer identified to be at risk for pain. The patients were being treated for invasive cancer of the breast (50%), colon/rectum (21%), prostate (10%), or lung (19%) and were enrolled onto the prospective study regardless of phase of care or stage of disease.

“This study is the largest prospective evaluation of pain and other symptoms in outpatient oncology in the United States,” the researchers reported. “The distribution of the four solid tumors is typical for outpatient cancer care, including the low relative proportion of patients with prostate cancer.”

Design and Results

Patients completed a 25-item measure of pain, functional interference, and other symptom at initial assessment and 4 to 5 weeks later. “Providers recorded analgesic prescribing. The pain management index was calculated to assess treatment adequacy,” the researchers noted.

Among the 2,026 (67%) reported having pain or requiring analgesics at initial assessment, “670 (33%) were receiving inadequate analgesic prescribing,” the researchers found. There was no difference in treatment adequacy between the initial and follow-up visits. Multivariable analysis revealed that the odds of a non-Hispanic white patient having inadequate pain treatment were approximately half those of a minority patient after adjusting for other explanatory variables.

“Other significant predictors of inadequate pain treatment were having a good performance status, being treated at a minority treatment site, and having nonadvanced disease without concurrent treatment,” the researchers wrote. “The present study corroborates others’ findings about the inequality of pain treatment adequacy between minority patients and non-Hispanic white patients and shows that these findings persist at short-term follow-up,” the authors noted.

Of the 584 patients with moderate or severe pain at initial assessment, 241 (41%) were not receiving an opioid. “Twenty percent of the patients in severe pain were not receiving any analgesic. The most commonly prescribed nonopioids were acetaminophen (35%) and nonsteroidal anti-inflammatory agents (19%),” the researchers reported.

Gap in Pain Treatment

“Patients with nonadvanced cancer who were not receiving cancer-directed treatment were especially likely to be undertreated for pain. This disparity may be explained in part by the fact that nearly 50% of these patients experienced symptoms that oncologists believed were not attributable to cancer or cancer therapy and thus were not treated aggressively. This potential gap in pain treatment could be bridged with improved coordination of care between oncologists and nononcology providers,” the authors wrote.

“Finally, the availability of effective pain medication that is not perceived to interfere with driving, work performance, social interactions, or bowel habits could improve adherence to pain treatment,” the authors suggested. ■

Fisch MJ, et al: J Clin Oncol, April 16, 2012 (early release online).