Cancer patients contending with breakthrough pain face an array of confusing questions: If they complain to their healthcare providers about their pain, will it impede their cancer care? What if they become addicted to their pain-relieving medication? What if health insurance won't cover the cost of that medication? Finally, what if their healthcare provider doesn't ask about their pain issues on a routine basis—are they still allowed to bring it up?
PAMELA BENNETT, BSN
Addressing breakthrough pain related to cancer "fits into a larger construct about the problem with pain in general," said Pamela Bennett, BSN. "Pain is a major public health problem. It affects at least 53 million Americans; that is more than the number of people with diabetes, cancer, and coronary heart disease combined. Pain that is not treated can slow recovery from disease or injury and can weaken the immune system."
Oncology News International spoke with a trio of experts on some of the prevailing attitudes about managing breakthrough cancer pain. In the end, they all agreed that pain can't be treated as an afterthought either by healthcare professionals or patients. The panelists were:
| • | Ms. Bennett, executive director of healthcare alliance development at Purdue Pharma in Stamford, Conn. |
| • | David S. Craig, PharmD, BCPS, a clinical pharmacist specialist and residency director in the psychosocial, palliative care, and integrative medicine department at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla. |
| • | Robert Kronenberg, PharmD, director of pharmacy at HealthSouth/Valley of the Sun Rehabilitation Hospital in Glendale, Az., and president of the Arizona Pain Initiative board of directors. |
ROBERT KRONENBERG, MD
ONI: What do you think is the most common misconception among healthcare professionals about breakthrough cancer pain?
Dr. Craig: I think [healthcare] professionals underestimate the extent of impact that breakthrough pain episodes can have on patients. A recent American Pain Foundation (APF) survey noted that effectively treating breakthrough pain episodes was often more important to cancer patients than treating their cancer diagnosis (see Related Reading). Furthermore, many oncology professionals still don't know what breakthrough cancer pain is or how to effectively screen, assess, and treat it (see Table 1).
Dr. Kronenberg: Sudden breakthrough pain is extremely debilitating and it's difficult to deal with because it comes on without notice and it lasts a short period of time, maybe five or 10 minutes. We know that oral [pain] medications take about 20 minutes to work. Why don't we manage pain better? We have communication problems. During a fairly short scheduled visit, the patient and physician may assume that, of course there is going to be pain.
| • | Incident pain occurs with or following physical activity. |
| • | End-of-dose failure occurs in the time between doses of medication. |
| • | Spontaneous breakthrough pain occurs without predictable cause or frequency. |
| Cancer-specific pain: | |
| • | Acute pain occurs because of the tumor (injury) but the pain subsides with healing. |
| • | Chronic pain occurs when the pain remains even though the injury has healed. |
Ms. Bennett: Patients don't necessarily understand that they have a right to an appropriate assessment and treatment for pain. And they don't always have healthcare providers who are trained to adequately assess pain. Unfortunately, this is particularly true in oncology.
The American Cancer Society did a call center survey to better understand the impact of pain on patient's lives. Sixty-five percent of the callers said they were experiencing cancer-related pain at that time with 76% rating it as moderate to severe. But only 58% said they were asked about their pain at their clinical visit (CA: Cancer J Clin 59:285-289, 2009).
