Early Access to Palliative/Supportive Care vs Usual Care Improves Pain Management


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The most striking finding from our study is that the risk of severe pain is remarkably reduced when an integrated care model is used compared with a model of routine care based on primary specialist alone. However, it is clear that the control rate of cancer pain needs to be improved.

Many cancer patients remain undertreated for pain despite availability of guidelines and educational efforts to improve pain treatment. In a recent Annals of Oncology article, Bandieri and colleagues from the Italian Epidemiologia Clinico-Assistenziale del Dolore in Ospedale (ECAD-O) group report a significant improvement in pain treatment in patients given access to an early palliative/supportive intervention compared with patients receiving usual care from a primary specialist.1

Study Details

This ECAD-O survey was a cross-sectional observational study involving 1,450 cancer patients seen in 32 Italian hospitals from 2007 to 2010. Among these, 602 patients constituted a standard care group treated in accordance with standard clinical practice by primary specialists who oversaw primary disease assessment and treatment and supportive/palliative care needs. A total of 848 patients in the early palliative/supportive care group were seen at the Oncology and Palliative Care Unit of the Local Health Unit in Modena, where an integrative early palliative/supportive care approach been established.

Patients receiving early palliative/supportive care met a trained team including 2 physicians, 2 nurses, a psychologist, and volunteers soon after diagnosis of cancer and received supportive care from the team concurrently with primary oncology care provided by their oncologist. The team followed each patient on a regular basis (eg, at every scheduled visit or every 3 to 4 weeks) in conjunction with the primary oncologist, and the team and oncologists met weekly to discuss patient issues. 

Pain intensity during the previous 24 hours was assessed by a numeric scale during an interview with a pharmacist not directly involved with patients’ care. Data on type of analgesic drug prescribed and administered within the previous 24 hours for each patient was collected from medical records.

Patients in both groups had a median age of 65 years. More patients in the early palliative/supportive care group were male (59% vs 52%, P = .010) and had metastatic disease (89% vs 71%, P < .001). All patients in the early palliative/supportive care group were recruited from oncology wards, whereas 43% of patients in the standard care group were from nononcology (internal medicine) wards. More than 90% of all patients were receiving analgesic treatment around the clock, but the proportion of patients receiving analgesia on an as-needed basis was greater in the standard care group (4.0% vs 0.1%).

Opioid Use

Nonopioid use (9.5% vs 2.0%, P < .001) and weak opioid use (27.7% vs 18.4%, P < .001) were significantly more common in standard care patients, whereas strong opioid use (62.8% vs 79.6%, P < .001) was significantly less common. Among 378 standard care patients and 675 early palliative/supportive care patients receiving strong opioids, transdermal fentanyl (Duragesic) use was significantly more common in standard care patients (40.8% vs 6.7%, P < .001), whereas morphine use (25.1% vs 53.6%, P < .001) and oxycodone use (20.1% vs 34.2%, P < .001) were significantly less common. Use of ‘other’ strong opioids was more common in the standard care group (14.0% vs 5.5%, P < .001).

Pain Control

Assessment of pain intensity during the previous 24 hours showed that significantly more early palliative/supportive care patients reported no pain (27.1% vs 16.9%, P < .001) and mild pain (32.9% vs 23.7%, P < .001) and significantly fewer patients receiving early palliative/supportive care reported moderate pain (22.6% vs 27.9%, P = .022) and severe pain (17.3% vs 31.4%, P < .001). 

On univariate analysis, factors significantly associated with risk of severe pain were early palliative/supportive care (31% reduction in risk, relative risk [RR] = 0.69, P = .037, vs standard care), male gender (25% risk reduction, RR = 0.75, P = .002, vs female gender), and age (RR = 0.99, P = .016); factors not significantly associated with severe pain were hospital ward (oncology vs nononcology), metastatic disease, and type of analgesic therapy (weak or strong opioids vs nonopioids). On multivariate analysis, only early palliative/supportive care (31% risk reduction, RR = 0.69, P = .045) and male gender (24% risk reduction, RR = 0.76, P = .003) were independent predictors of reduced risk for severe pain after adjustment for the other variables. 

The authors note that their findings indicate that current recommendations regarding analgesia in cancer patients appear not to be rigorously followed in standard care. For moderate to severe pain, oral formulations, and particularly oral morphine, continue to be recommended. Nonopioids or weak opioids were more frequently used in standard care patients compared with early palliative/supportive care patients in this study, and the most frequently used strong opioid in standard care patients was transdermal fentanyl, a drug infrequently used in the early palliative/supportive care group.

Study Ramifications

The authors also note that palliative medicine has largely focused on end-of-life care, with few patients gaining early access to such care. In this regard, they point out that a recent randomized controlled trial showed that patients with advanced non–small cell lung cancer and access to a specialist palliative care team had reduced depression, improved quality of life, and improved survival compared with patients receiving usual care alone.2

The current observational study both confirms that an early palliative/supportive care approach can be integrated into hospital oncology practice and suggests that it can improve pain treatment. A randomized controlled trial is needed to confirm the findings regarding improved treatment of pain. 

The investigators concluded, “Clearly, the most striking finding from our study is that the risk of severe pain is remarkably reduced when an integrated care model is used compared with a model of routine care based on primary specialist alone. However, it is clear that the control rate of cancer pain needs to be improved: despite the integrated care model, an unacceptable high percentage (17%) of patients still [suffer] with severe intensity. Thus, both pharmacological (such as therapy for breakthrough cancer pain) and nonpharmacological (such as psychosocial and spiritual) interventions should be considered and become the object of extensive research in the near future….”  ■

Disclosure: The authors of this article published in Annals of Oncology reported no potential conflicts of interest.

References

1. Bandieri E, Sichetti D, Romero M, et al: Impact of early access to a palliative/supportive care intervention on pain management in patients with cancer. Ann Oncol. May 6, 2012 (early release online).

2. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010.



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