COLUMBUS, Ohio--The evaluation of a cancer patients complaint
of pain should include an assessment of a variety of characteristics,
including psychosocial and emotional factors, said Neil MacDonald,
MD, director of the Cancer Ethics Programme, Center for Bioethics,
Clinical Research Institute of Montreal.
To enhance diagnosis and pain management, a number of simple
techniques for classifying and recording pain have recently been
introduced into clinical practice, Dr. MacDonald, who is also
professor of oncology at McGill University, said at a conference on
the role of narcotics in the treatment of pain, sponsored by Ohio
"We are trained to react to empirical data," Dr. MacDonald
said. "Its important that we attempt to quantify cancer
pain, because if we do, we can open doors to address it."
He suggested several memory aids that a physician can use to elicit
as much information as possible while assessing a patients
pain. The first, PQRST, is a simple alphabetical reminder of five
physical aspects of pain. Another memory aid, PAIN, can help the
physician assess emotional and social factors contributing to pain.
PQRST: Questions to Ask Patients About the Physical Aspects of Pain
The PAIN Mnemonic for Assessing Emotional and Social Factors Related
To help patients quantify their symptoms, including depression and
anxiety, physicians can use simple assessment scales. Rating scales
should also be used at regular intervals after starting or changing
treatment, to determine the efficacy of pain relief.
Dr. MacDonald described the Edmon-ton Symptom Assessment System but
noted that other scales, including the Memorial Pain Assessment Card
and the Wisconsin Brief Pain Questionnaire, are also useful. [See
Bruera E et al: The Edmonton Symptom Assessment System (ESAS): A
simple method for the assessment of palliative care patients. J
Palliative Care 7(2):6-9, 1991.]
Patients can use these scales to indicate whether their medication is
allowing them to adequately control their pain while still permitting
normal function. Finding this balance requires skillful adjustment of
opioids, anticancer therapy, and adjuvant techniques.
Finally, a complete physical examination must also be part of the
pain diagnosis. Dr. MacDonald advised taking special note of the
patients response to pain, including changes in facial
expression, during the examination.
Unfortunately, the use of scales like the Edmonton Symptom Assessment
System remains "cocooned" within the palliative care
setting, Dr. MacDonald said. This is very unfortunate, he added,
since it is crucial to address pain from the onset of cancer. Pain
that is poorly controlled can actually lead to an increase in overall
pain. "Palliation and practice of palliative principles should
infuse throughout all medical practice," he said.
Assessment of pain is a "major problem," he said. Every
study undertaken to examine the issue has found unrelieved suffering.
Women, the elderly, and blacks recorded the highest levels of
unaddressed pain, in a study by Cleeland et al (N Engl J Med 330:595,
This undertreatment of pain begins with the training--or lack
thereof--that physicians receive, Dr. MacDonald said. His own 1997
study of Canadian doctors showed that 67% of respondents rated their
medical school or basic undergraduate education in pain management as
poor or fair (J Pain Symptom Manage 14(6), Dec. 6, 1997.)
Learn to Communicate Quickly
Pain diagnosis benefits from communication between doctor and
patient, yet there is a great deal of pressure on physicians to be
efficient, Dr. MacDonald said. For this reason, memory aids and
measurement scales can improve pain treatment by making assessment
simple and convenient. "The lesson is that well have to
communicate quickly," he noted. Adding pain assessment scales to
patient charts, as Sloan-Kettering has done, can also act as a
reminder to busy clinicians.
"There isnt a physicians code anywhere that
doesnt include relieving suffering," Dr. MacDonald said.
"Yet studies show were not achieving this."