CHICAGO--Over the last decade, increasing attention has been paid
to the palliative care of patients whose colon cancer has not
responded to curative treatment so that they may achieve the best
possible quality of life.
For one aspect of palliative care--pain management--there is still
widespread undertreatment, however, Richard Payne, MD, said at
the National Conference on Colorectal Cancer, sponsored by the
American Cancer Society. More than 1.3 million copies of clinical
practice guidelines on pain management were distributed by the
Agency for Health Care Policy and Research in 1994 (see box on
page 28). Yet, far too many cancer patients are still not achieving
adequate pain relief.
A 1995 study from the University of Wisconsin that surveyed more
than 1,300 patients with advanced or metastatic cancer found that
67% of patients had pain and took analgesics on a daily basis.
A third of these patients had pain severe enough to impair function,
and 46% had negative pain management index scores, meaning they
did not receive an analgesic regimen in keeping with the severity
of their pain, said Dr. Payne, associate professor of medicine,
M.D. Anderson Cancer Center.
Of the survey patients with GI tumors, including colorectal, gastric,
and pancreatic tumors, 61% reported pain primarily due to encroachment
of tumors on pain-sensitive structures or bowel obstruction; 58%
classified their pain as 5 or worse on a 0 to 10 scale, and 41%
had a negative pain management index.
A 1993 study of colon cancer patients showed that among those
with moderate pain, activity was impaired in 47%, ability to walk
in 32%, ability to work in 55%, ability to sleep in 55%, and mood
and enjoyment of life in 55%. Yet, Dr. Payne said, use of the
three-step analgesic ladder can successfully manage pain in 75%
to 90% of cancer patients.
The three-step analgesic ladder stratifies pain as mild, moderate,
or severe, and assigns an analgesic regimen appropriate for the
pain intensity. The regimen for mild pain includes nonopioid,
nonsteroidal anti-inflammatory agents or tricyclic antidepressants,
particularly for neuropathic pain. Moderate pain is managed with
weak opioids, such as codeine, and severe pain is treated with