Cancer causes pain as it invades bone, compresses nerves, produces obstructive symptoms in the pulmonary, gastrointestinal, and genitourinary systems, and distends involved visceral organs. This manuscript reviews progress in cancer pain management during the past 2 decades. Since the 1980s, we have seen (1) genuine advances in research on the biology of pain, (2) new approaches to the treatment of cancer pain, and (3) important changes in the health-care system to ensure that pain is appropriately assessed and managed. Currently, clinicians have the appropriate diagnostic and therapeutic tools to ensure that the vast majority of patients with cancer pain can be comfortable during their illness. Nevertheless, too many patients with terminal malignancies continue to die in pain in nations around the globe. An effective strategy to make alleviating pain a major health-care priority remains the primary challenge to effectively palliating patients with cancer pain.
The article, "Cancer Pain Management in the 21st Century," by Grossman, Dunbar, and Nesbit, provides a concise overview of the past 20 years' research advances and new pharmacologic, surgical, and radiotherapeutic approaches to relieve the pain of patients with cancer. The article also includes a description of both the "carrots" (the National Comprehensive Cancer Network [NCCN] and American Pain Society [APS] guidelines) and the "sticks" (the Joint Commission on Accreditation of Healthcare Organizations [JCAHO] mandates) that should have led to marked improvements in the control of pain, but have not.
Barriers to Pain Management
The authors' Table 3, "Barriers to Cancer Pain Management," lists a number of factors that contribute to this failure, including "reluctance to report pain," "inadequate knowledge of pain and its treatment," "myths and misconceptions about opioids," and "inaccurate opioid conversions." Indeed, patients are often reluctant to tell us they have pain: (a) they don't want to be "complainers" and waste their 15 minutes with us talking about their pain; (b) they and their families worry that increasing pain means advancing disease; and (c) they resist taking stronger opioids because they'll "use them up, too" and have nothing left when the pain gets "really bad."
But when we know that 70% of our cancer patients will have pain, how can it be that we still have "inadequate knowledge of pain and its treatment"? At least part of the problem is inadequate training in pain assessment and management during nursing education and in medical school, residency, and oncology fellowship, despite the available consensus guidelines that, if followed, result in acceptable relief of pain in > 90% of cancer patients. These and other print resources "contain virtually all that is needed for a house staff, primary care physician, or specialists to make informed decisions regarding the evaluation and management of cancer pain." In addition, the Oncology Nursing Society offers pain management resources, and the American Society of Clinical Oncology offers oncology clinicians written curricula on pain and symptom management.
Treatment of pain is not simply a matter of choosing the right analgesic drugs or interventional techniques. Pain is exacerbated by anxiety and feelings of powerless, uselessness, and even hopelessness as patients become less and less able to fulfill their roles in the workplace, the community, and the family. Existential angst or rage at God, and the guilt and loneliness stemming from that rage, feel terrible. We must therefore assess and address the psychological, social, and spiritual causes of suffering that patients report as "pain," be expert communicators, and understand what it would take to make each person whole.
To acquire these new skills, clinicians need to do more than read: They need experiential training with experts, such as is offered in the communication training initiative entitled Oncotalk for oncology fellows, in the Education in Palliative and End-of-Life-Care-Oncology (EPEC-O) project for oncologists, and in educational materials from the End-of-Life Nursing Education Consortium (ELNEC) for oncology nurses. In addition, psychotherapists, chaplains, and social workers are superb resources, and palliative care consultants can provide hands-on training. While palliative care consultants have not been widely available either in the academic or community setting, fellowships are growing exponentially and palliative medicine is likely to be approved as a subspecialty this year by the American Board of Medical Specialties.
Palliative care specialists alone are insufficient to effect the needed culture change that can reverse the undertreatment of pain in cancer patients. Oncology clinicians will need to advocate for structural changes in our hospitals. Currently, hospital safety concerns focus on clinicians who overdose patients (usually opioid-naive postoperative patients). A root-cause analysis is done to uncover and correct systemic problems that contributed to the event. But no such attention is paid to the equally serious errors made by clinicians who underdose our oncology patients.
Underdosing often arises from inaccurate calculations. Rescue opioid doses are frequently underestimated: They should be ~10% of the total daily opioid dose. The oral equivalents of intravenous opioid doses are similarly underestimated, "teaching" patients that only parenteral opioids work. Because of first-pass metabolism by the liver, it takes 30 mg of oral morphine to equal a 10-mg intravenous or subcutaneous dose, and 7.5 mg of oral hydromorphone to equal a 1.5-mg intravenous or subcutaneous dose. The same computer resources that now calculate our patients' chemotherapy doses (taking into account their body mass and renal function) can be used to eliminate these calculation errors in opioid rescue doses and conversions.
Underdosing also occurs when patients who were previously taking chronic oral sustained-release opioids become unable to take medication by mouth. These patients need a basal opioid continuous infusion to provide a systemic level of opioids that is equivalent to the oral medication they were taking. Often, however, they are given only intermittent opioid bolus doses. Rather than focusing solely on overdosing problems, hospital and health system leaders must prioritize resources to discover the root causes involved in underdosing and provide corrective feedback to clinicians who chronically make these errors.
Increased clinician skills in comprehensive assessments of persons in pain, collaboration with pain and palliative care consultants, use of existing computer resources, individual accountability, and systemic monitoring can improve pain assessment and help eliminate the persistent undertreatment of pain that plagues our patients and their families. It is only by making the commitment to provide our patients with as much expertise in their pain assessment and management as we do in assessing and managing their cancers that we can hope to improve the quality of their lives as we enter the 21st century.
-Janet L. Abrahm, MD, FACP, FAAHPM
1. Grossman SE, Dunbar EM, Nesbit SA: Cancer pain management in the 21st century. Oncology (Williston Park) 23:1333-1340, 2006.
2. Abrahm JL: A Physician's Guide to Pain and Symptom Management in Cancer Patients. 2nd ed. Baltimore, Johns Hopkins University Press, 2005.
3. Cassell EJ: The Nature of Suffering and the Goals of Medicine, 2nd ed. New York, Oxford University Press, 2004.
4. Back AL, Arnold RM, Tulsky JA, et al: Teaching communication skills to medical oncology fellows. J Clin Oncol 21:2433-2436, 2003.