Unrelieved cancer pain can render a patient bedbound, leading to depression, fear, and suicidal ideation. Along with physical distress, severe pain is associated with existential suffering, a complex tormentor of patients with cancer and their families.
Studies show that most patients with advanced cancer in the United States suffer significant pain, and a majority of patients with any stage of disease report undertreated pain. Since we have the clinical tools to relieve cancer-related pain in most cases, it begs the question: Why does this problem persist on such a large scale?
Standardized Procedures
The U.S. health-care system is vast and highly fractionated, making uniform adoption of pain guidelines a steep uphill battle. Diane E. Meier, MD, FACP, Director, Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, suggests that we implement standard operating procedures. “There are hospital discharge procedures, such as administration of pneumonia vaccine, that are done routinely for all patients,” said Dr. Meier. “Pain control procedures need to be standardized as well.”
Dr. Meier acknowledged that hospital and office practice doctors are stretched thin, but treating pain should be an established priority. “If a patient has severe pain, there should be a mandatory protocol that assures that someone on the staff—a nurse practitioner or physician assistant—with pain expertise begin a pain regimen while simultaneously reaching out to the attending physician. Untreated pain should be a never-event,” stressed Dr. Meier.
Infrastructure Needed
“We currently lack sufficient motivation to implement standards of operational pain control by empowering all health professionals to perform at their highest level of training,” said Dr. Meier. “We need an infrastructure to help hospitals apply their existing professional resources, such as well-trained nursing staff, to the relief of physical and other forms of suffering,” said Dr. Meier.
A step in that direction is the accreditation initiative by the American College of Surgeons Commission on Cancer. Moving forward, to receive the Commission on Cancer’s accreditation, community cancer centers will need to demonstrate that they offer palliative care services to their patients. “There are several ways for centers to approach this, but the important thing is that offering palliative care services to patients with cancer under active treatment will no longer be optional,” concluded Dr. Meier.
Redirection of Priorities
Russell K. Portenoy, MD, Chairman, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, told The ASCO Post that a recent survey he and his colleagues conducted, found that pain management education and training in medical schools and residency was rated as very poor.
A nationally regarded expert in palliative medicine, Dr. Portenoy opined, “We accept that good pain management is a best practice and that oncologists are committed to it. So we have to ask the broader question: Why isn’t pain management given priority in educational programming?”
He offered a partial explanation: “Since the 1980s, the pace of advances in oncology has been extremely rapid, and the challenge of keeping up with advances in disease management has taken priority over pain and symptom control.”
There are a host of comorbid issues that complicate pain management. For instance, treating patients with cancer who have a history of substance abuse presents special challenges. Again, Dr. Portenoy stressed education. “Basic knowledge of ‘Universal Precautions’ [in pain medicine], empowers oncologists to treat patients who have substance abuse disorders. But most oncologists have never been taught the principles of risk management, and the result may be undertreated pain,” Dr. Portenoy said.
According to Dr. Portenoy, a simple national mandate would be the best step forward in addressing undertreated cancer pain. “In the United States, we need to refocus our attention on pain management as a best practice in oncology, which would be associated with skills-building in opioid-based pharmacotherapy directed at both optimizing analgesic outcomes and minimizing risk.”
Ethical Barriers
In some cases, pain is not relieved because of ethical concerns. This may happen, for example, near the end of life, when opioid use is accompanied by the specter of unintentionally hastened death. When pain is refractory to routine strategies, the ethically challenging approach of palliative sedation may be considered. Palliative sedation is an accepted therapy, but misperceptions arise when clinicians do not understand its ethical framework or standards of care, and mistakenly perceive the approach as “slow euthanasia.”
Dr. Portenoy explained that oncologists who offer sedation must appreciate both the medical and ethical implications of this intervention. “The key principle is the ‘double effect.’ Although sedation carries a risk of an earlier death, there is a clear line between sedation and physician-hastened death. The intent is to relieve suffering, and the doses of medication are appropriate for achieving that outcome,” said Dr. Portenoy, adding that the imperative to relieve symptoms when other medical strategies fail justifies the approach at the end of life.
The Patient Perception Barrier
Speaking with The ASCO Post, palliative care expert Kathleen M. Foley, MD, Memorial Sloan-Kettering Cancer Center, said that patient perception about cancer pain creates its own barrier to care. “An ongoing obstacle we’re seeing more of is the belief by patients with cancer that pain is an unavoidable part of their disease. They’re tied into the treatment/cure paradigm and don’t seek out separate therapy for pain.”
Dr. Foley said that reporting in the lay media about widespread abuse of opioids further exacerbates the patient perception barrier. “Patients with cancer, many of whom are older, read stories about overdose and addiction, and it scares them. It becomes one more reason for patients to shy away from proper pain control.”
Tools Help
Dr. Foley said that a way to help busy community doctors manage pain is by giving them tools such as patient-reported outcomes or enlisting physician extenders. She noted a study done in the 1990s, looking at how oncologists gauged their patients’ pain level. “The investigators found that if evaluation triggers and a nurse expert were put into the scenario, pain management scores improved markedly. That was because the oncologists were getting better quality information from their patients about their pain. It allowed them to personalize the pain management according to patient-specific needs,” said Dr. Foley.
Barriers to proper cancer pain control are multileveled, a phenomenon that is heavily influenced by the larger sociocultural perspective. “Over the past decade, we’ve embraced an idea that everyone is at risk for abuse, in some cases swinging the care pendulum in favor of caution over aggressive pain control. This is a big change in how we think about caring for pain in the cancer population,” stressed Dr. Foley.
Breakthrough Pain
Breakthrough pain, a spike in otherwise well-controlled persistent pain, presents a tricky clinical challenge for doctors treating patients with cancer living at home. Sloan Karver, MD, palliative care physician at the Moffitt Cancer Center, South Florida, said that many community oncologists are hesitant about prescribing the increasingly higher doses of potentially lethal drugs necessary to control pain in advanced disease, “whereas palliative care specialists are comfortable prescribing higher doses of opioids,” said Dr. Karver.
“The goal for patients is not to “chase” the pain but to keep ahead of the pain curve. Patients need to have a better understanding of their pain-control needs, not look at the clock and wait for a special time frame before taking their pain meds,” said Dr. Karver.
As Dr. Karver pointed out, breakthrough pain remains undertreated due to a number of doctor/patient-driven factors. “By providing education to health-care providers, patients, and family caregivers, steps can be taken to ensure that persistent cancer pain and cancer breakthrough pain are properly treated,” said Dr. Karver.
Conclusion
The oncology community has identified undertreated cancer pain as an endemic problem. We have the pharmacotherapy tools to manage cancer pain; now we need consensus on how to best address this problem on a national scale. ■
Financial Disclosures: Dr. Foley, Dr. Meier, Dr. Portenoy, and Dr. Karver reported no potential conflicts of interest.
