WASHINGTONPain in cancer patients is woefully undermanaged
because of multiple barriers from patients, physicians, and the
nations health care system, several speakers said at a
The bottom line is that we have the drugs and the mechanisms to
effectively treat the vast majority of pain. In fact, the World
Health Organization says that about 95% of pain can be treated with
existing modalities. The truth, however, is that about 70% of cancer
patients have pain that is moderate to severe and is not treated
adequately, said Betty Ferrell, RN, PhD, a nurse research
scientist at the City of Hope Cancer Center.
Bills Related to Cancer Pain
Dr. Ferrell spoke at a briefing arranged by the National Coalition
for Cancer Research (NCCR) and the Oncology Nursing Society (ONS). A
number of bills related to cancer pain have been introduced in the
House and Senate, and Capital Hill staff dealing with health issues
requested the briefing to better acquaint themselves with the issue.
According to NCCR, 89% of children with cancer suffer pain, but a
recent study found that only 27% of them get treatment that
alleviates their suffering.
Rep. Deborah Pryce (R-Ohio) emphasized the latter point in describing
the death of her 9-year-old daughter last year from neuroblastoma.
Much of her pain, if not all, was unnecessary, Rep. Pryce
said. As a parent watching my child suffer, I could not
understand why more could not be done at the end of her life.
Pain may occur before, and often leads to, the diagnosis of cancer,
said Robert L. DeWitty, Jr., MD, associate professor of surgery,
Howard University. It accompanies treatment, but once the
treatment is over, the pain tends to go way.
Some patients treated effectively for their cancer develop such
severe pain that it keeps them from functioning, but we can
alleviate that pain, put them back to work and play, and put them
back in balance, he said. Finally, he said, terminal patients
may suffer extraordinary pain.
Three Types of Barriers
Dr. Ferrell served as a member of a federal committee that in
19921994 drafted cancer pain management guidelines. Even
then we asked, if we know so much about controlling cancer pain, why
are we doing so badly at it? she said. The reasons are many,
she added, but they fit into three categories:
Patients: Patients themselves are very reluctant
to report their pain, Dr. Ferrell said. Everyday, I see
patients who are experiencing pain, but they dont want to admit
Their reasons are numerous, she said. They may not want to distract
their physicians attention from their underlying disease; they
may fear that if their pain is worsening, their disease must be
worsening; or they may have concerns about not being a
Many patients are unwilling to take pain mediations for a variety of
At City of Hope and elsewhere, researchers have documented that
even when patients have severe pain and have medicine available,
generally they are taking only about 50% of the medicine currently
prescribed for them, Dr. Ferrell said.
Many patients are fearful of side effects, of developing tolerance or
becoming addicted to the drugs, or of being thought of as an addict.
Patients and families are uniformly terrified by what will
happen if the pain gets worse, Dr. Ferrell added.
Some patients will refuse pain medication for such reasons as fear of
needles, Dr. DeWitty noted. We have lots of routes and
modalities to give pain medications, all goodtwice a day pills,
dermal patches, and, of course, the morphine pump, he said.
Health care professionals: Only two medical schools in
the United States have structured their programs to teach students
about pain. And in a review of the 50 leading nursing textbooks, Dr.
Ferrell and several of her colleagues found that only 2% of the
45,000 pages focused on any kind of end-of-life topic, including
Woman Sees 20 Physicians
Dr. Ferrell described the case of a woman who saw 20 physicians
before one of them took her complaints of pain seriously and
diagnosed her cancer. The reason pain is so poorly treated is
that there is a huge barrier of professional knowledge, she said.
According to a report by the Agency for Health Care Policy and
Research, now known as the Agency for Health-care Research and
Quality (AHRQ), Dr. Ferrell said, this knowledge gap results in poor
assessment of pain by doctors and nurses.
Such lack of knowledge may also lead health care professionals to
have unfounded concerns about running afoul of regulations governing
controlled substances. Uninformed health care professionals may avoid
prescribing appropriate opiate doses for fear of creating patient
tolerance and addiction.
Addiction Concerns Unwarranted
Concerns about addicting patients while treating cancer are
unwarranted, Dr. DeWitty said. If the cancer can be cured, the
treatment for pain is temporary, he said. For patients
who are terminal, you should never think about addiction but about
getting them the type of relief they need.
The system: Again citing the AHRQ, Dr. Ferrell said
that the nations system of delivering health care, as it has
evolved since the late 1980s, itself poses a barrier to controlling pain.
Often, Dr. Ferrell said, cancer pain treatment is given a low
priority; reimbursement is inadequate; regulation of controlled
substances is restrictive; and there may be problems with the
availability of pain treatment or the patients access to it.
I have talked to patients around the country who tell me:
In my managed care system, I have 10 minutes with the doctor,
and in that 10 minutes, I have to cover everything. So pain
often shifts to a lower priority, she commented.
Dr. DeWitty noted another problemthe inability of some patients
to obtain a prescribed pain medication because the pharmacy
doesnt keep it in stock.
Personal finances may also influence the use of analgesics. Some
of these medications can be expensive, Dr. DeWitty said.
If you have to prioritize how you spend your money, sometimes
you many not consider the prescription that you need to relieve your
symptoms as important as other things.