Despite growing awareness and the existence of guidelines, undertreatment of cancer pain remains a persistent dilemma in the oncology community. Researchers from The University of Texas MD Anderson Cancer Center found that more than 33% of patients suffering from invasive cancer do not receive sufficient pain management, with minorities twice as likely to have inadequate pain care. The investigators stated that to improve symptom control, physicians needed to be open-minded, appropriately gauging the pain-relief requirements of their patients.

But busy oncologists also need readily available management guides, and there is none better than the third edition of A Physician’s Guide to Pain Symptom Management in Cancer Patients by Janet L. Abrahm, MD, Professor of Medicine at Harvard Medical School and a member of the Department of Psychosocial Oncology and Palliative Care at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital.

Symptom-Oriented, Person-Focused Treatment

Although there are a number of oncology texts that focus on disease-oriented treatment, A Physician’s Guide to Pain Symptom Management in Cancer Patients complements such books, concentrating on suffering in patients with cancer and offering symptom-oriented, person-focused treatment. And in that regard, this book is useful to clinicians who wish to enhance their relationships with patients and their families and expand the focus of their care.

Dr. Abrahm organized her book in two parts titled “Hidden Concerns, Unasked Questions” and “Pain Control, Symptom Management, and Palliative Care.” Part 1 addresses the unique concerns of cancer patients and their families and offers ways of dealing with the unasked questions. This section may be especially helpful for clinicians who are just starting to take responsibility for telling patients bad news, initiating advance care planning, and discussing prognosis limited to a few more months of life.

Dr. Abrahm includes a number of sample dialogues that demonstrate what she has learned about how to communicate concern, elicit useful responses from patients and their families, and satisfy their needs. “Mr. Ashton, whom I had been treating for metastatic lung cancer, asked me for pills so he could commit suicide ‘when the time is right.’” As we discussed his request further, it appeared he was not concerned for himself, but for his elderly wife: He feared she might ruin her health caring for him…but as I explained to him about how hospice and his friends and family would work together, he became reassured and he no longer requested aid in dying.”

Section 1 also deals with other difficult end-of-life issues, such as helping patients accept opioid medications. She explains that unless a number of barriers are overcome, many patients will not take their medications, which results in unnecessary suffering. Although much of this content has been published before, Dr. Abrahm’s book stands out for its readability and structure. She skillfully uses shaded call-out boxes with bulleted lists to highlight salient sections of each chapter. For instance, in Practice Points: Breaking Bad News, she advises clinicians to:

• Make yourself, the patient, and the family comfortable.
• Find out what they know.
• Tell them in words they can understand and in small chunks.
• Appreciate the role of silence…etc.

Would-be authors should take notes: Dr. Abrahm makes putting together a book like this easy, and it surely is not. Every page deals with the most difficult clinical issues facing today’s oncologists, and the advice she gives is spot-on.

One of the best chapters in section 1 deals with how uninformed staff can contribute to patient distress. She describes a patient of hers named Mr. Hines with extensive multiple myeloma. He was admitted in severe pain, and during his workup, he revealed that he had a long history of alcohol abuse and his son had been a heroin addict. To achieve pain control, he needed 90 mg of sustained-release morphine three times per day.

Dr. Abrahm writes, “When I visited him after he was settled in, he was very angry and depressed, saying that he would never take morphine again. When I asked him what had happened, he said that the intern told him that she’d never seen anyone take so much morphine and asked him if he really needed it. He heard her saying the same thing to nurses outside his door. In one short conversation, the intern had unwittingly undone everything I’d worked so hard to achieve with Mr. Hines.”

What Dr. Abrahm described happens each day, in one form or another, across our cancer-care system. This is another reason this book should be in every hospital and practicing oncologist’s office.

State-of-the-Art Pain Management

Section 2 is full of value-added information about proper state-of-the-art pain management. This section is complicated science, and this book drills down to the basics of assessing and treating pain. However, while Dr. Abrahm’s book is a perfect guide for busy community doctors treating common pain problems, they will need to reach out to specialists like Dr. Abrahm for more complicated pain issues.

Evaluating pain is also an art, and the section on assessing the patient in pain is peerless in its thoroughness and accessibility. All the major pain scales are evaluated along with delirium and depression scales. Dr. Abrahm includes highly perceptive family questionnaires and guidelines that can be reproduced for use in community practices.

Along with pharmacologic strategies to relieve pain, Dr. Abrahm includes insightful management techniques for other distressing problems, such as dysphagia, nausea, vomiting, and pruritus, among others. She also should be commended for her careful and delicate treatment on issues surrounding intimacy and sexuality in very sick cancer patients.

Dr. Abrahm makes a valuable point near the end of her very fine and invaluable book. “A survey of oncologists reported that they felt their institutions could do more to support them…. They wanted training on how to cope with their own losses, not just how to help patients and families. As oncology clinicians learn ways to care for themselves, they will be more helpful to the bereaved families they want to comfort,” writes Dr. Abrahm.

A Physician’s Guide to Pain Symptom Management in Cancer Patients is a useful tool that will help busy oncologists give better care to their patients. It hits all the marks and is highly recommended for The ASCO Post readers. ■