Data indicate that for more than 2 decades, cancer pain has been undertreated in the United States. The paradox of this stubborn clinical problem is that oncology has the ability to manage the great majority of cancer pain.
To clarify this issue, The ASCO Post recently spoke with nationally regarded palliative care specialist, Russell K. Portenoy, MD. Dr. Portenoy is Chairman of the Department of Pain Medicine and Palliative Care and Gerald J. Friedman Chair in Pain Medicine and Palliative Care at Beth Israel Medical Center, New York, Chief Medical Officer of MJHS Hospice and Palliative Care, and Professor of Neurology and Anesthesiology, Albert Einstein College of Medicine, Bronx, New York.
Cancer Pain Survey
You were one of the authors of a cancer pain survey published in the Journal of Clinical Oncology in 2011. Please explain the intent and results of the survey.
My colleague Brenda Breuer, PhD, was lead author on an anonymous survey that we mailed to 2,000 medical oncologists (overall response rate, 32%) who were randomly selected from the AMA’s Physician Masterfile. We formatted the survey to be precise but without being an untoward time burden on busy oncologists. The full 46-item survey took 10 to 11 minutes to complete. Two shortened versions had 25 and 27 items, respectively, and took 6 to 7 minutes to complete.
We created two vignettes involving challenging pain circumstances and asked oncologists to specifically recommend a course of action for each. We found that most of the oncologists did not respond correctly. In fact, 60% and 87% gave answers to the two vignettes, respectively, that were inconsistent with best practice. After publishing the results in JCO,1 letters to the editor commented that the results of our study were very similar to a pain survey of 20 years ago.2 This, of course, is a good metric to tell us that the problem, although identified, persists within the oncology community.
What message do you think the survey gives to the oncology community?
Statistical limitations notwithstanding, the results from the vignettes raise a concern that the oncology community needs to further highlight the problem of pain. The community needs to shine a spotlight on the issue and begin to focus on cancer pain management as a best practice that needs periodic updating in terms of education and commitment. The science behind pain medicine has evolved. We need to make sure that medical oncologists are knowledgeable about these advances and that they are using them to manage different challenges in pain.
Why Undertreatment Persists
Why is the problem of undertreated pain still a major issue in cancer care?
For one, undertreatment is hard to define. To achieve an accurate definition, you first need to know what the best practice is and what the expected response to that best practice should be. Then you need to determine whether best practice was applied and if the response was optimal, based on the literature. So defining undertreatment is more complex than simply using a pain scale.
We would expect the vast majority of our patients to have well-controlled pain if simple guidelines for opioid-based therapy were applied in a sophisticated manner. However, data indicate that there is a high prevalence of inappropriate use of opioid therapy among oncologists, both in the community setting and in academic medicine. The data also show that when asked how to solve a challenging pain problem, most oncologists get the answers wrong. The documented knowledge deficit and the failure to adhere to best practices is a significant reason that undertreatment of cancer pain is still a problem in the oncology community.
Continuum of Challenges
What is the most significant clinical challenge in managing cancer pain?
I view the treatment of cancer pain as a continuum of challenges with varying degrees of difficulty. A large majority of our patients with cancer can have their pain adequately controlled with relatively simple techniques that focus on the appropriate choice and use of drugs. It’s important to note that these pain management techniques are within the purview of all practicing oncologists. However, these fairly easy-to-employ pain strategies—which should be in the armamentarium of every oncologist—are not being evenly applied for the patient populations that need them.
Another more challenging category involves pain patients whose treatment requires a specialized set of skills that the general community oncologist probably won’t have—for instance, in the management of neuropathic pain or bone pain. It would be understandable if the community doctor recognized his or her limitations and partnered with a specialist, but we found in our survey that it is a very rare event when an oncologist refers a patient to a cancer pain specialist. Frequent referrals to pain or palliative care specialists were reported by only 14% and 16%, respectively.
‘80/20 Rule’
Do we know why this clinical partnership between the oncology generalist and the pain specialist is not being utilized?
It’s another systemic issue with several causes. We have pain specialists who are not oncologists but who might have the requisite skills in cancer pain management. For whatever reason, they are not getting referrals. And the palliative care community is getting the patients when end-of-life control is needed instead of bringing us into the clinical care of the patient early on, so that the symptoms related to cancer can be addressed as part of the continuum of care.
The undertreatment dilemma could be considered a variation of the 80/20 rule—the principle that for many events, 80% of the effects come from 20% of the causes. In this case, 80% of patients whose pain could be managed with straightforward tactics well within the skill sets of the general oncologist are being undertreated. Then the 20% whose cancer pain needs more advanced techniques are not being referred to specialists.
There is no single reason for this culture of undertreated cancer pain. However, our survey suggests that education of oncologists could be part of a strategy to improve the status quo.
Closing Thoughts
Any last thoughts on this important issue?
We need to think of pain within a model of unmet palliative care needs, including the treatment of other symptoms and other quality-of-life concerns. The palliative care community is very intent on shifting palliative care forward, as a construct that begins upstream in illness. It’s not end-of-life care—it is care that should be initiated at the time of diagnosis.
Generalist-level palliative care should be offered to every patient with cancer as a best practice. Why shouldn’t a patient whose oncologist is working hard to keep him or her alive expect that same oncologist to evaluate and treat their symptoms of discomfort or pain? That’s one gap in care we need to fill. ■
Disclosure: Dr. Portenoy reported no potential conflicts of interest.
References
1. Breuer B, et al: Medical oncologists’ attitudes and practice in cancer pain management. J Clin Oncol 29:4769-4775, 2011.
2. Von Roenn JH, et al: Physician attitudes and practice in cancer pain management. Ann Intern Med 119:121-126, 1993.
