Article of the Month

Reviewed by Dr Carla Ripamonti (Italy), an IAHPC Board Member

Impact of setting of care on pain management in patients with cancer: a multicentre cross-sectional study

D. Sichetti 1 _ , E. Bandieri 2 _ , M. Romero 1 _ , K. Di Biagio 1 , M. Luppi 3 , M. Belfiglio 1 , G. Tognoni 1 & C. I. Ripamonti 4 for ECAD Working Group

1 Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, Santa Maria Imbaro (Chieti);
2 Palliative Care Unit, Ausl Modena, Modena;
3 Department of Oncology, Haematology and Respiratory Diseases, Azienda Ospedaliera Universitaria, University of Modena and Reggio Emilia, Modena and
4 Supportive Care in Cancer Unit, IRCCS Foundation, National Cancer Institute, Milano, Italy

Annals of Oncology on line 2010

Data in the literature indicate that:

• the prevalence of pain in patients with metastatic, advanced or terminal stages of the disease is 64%. It is 59% for patients who are on anticancer treatment and 33% for patients following curative treatment;
• there is no difference in pain prevalence between patients during anticancer treatment and those in advanced or terminal stages of the disease;
• the reported intensity of pain is moderate to severe in one-third of all patients;
• pain is undertreated in 56% to 82.3% of cancer patients;
• using the Pain Management Index (PMI), it was found that patients are under-treated in 25.3% of the cases (range from 9.8% to 55.3%). The studies consisted of inpatients and outpatients who had advanced/metastatic solid tumours that were cared for in centres that specialize in cancer and/or pain management (oncology/pain/palliative centres or hospice).

The ECAD-O group (Epidemiologia Clinico-Assistenziale del Dolore in Ospedale) was established to provide surveillance of pain management during routine care in a multicentre network of hospitals and in multidisciplinary working groups.

A multicentre cross-sectional study was conducted in 48 hospitals in 13 Italian regions. The aim was to determine if the location of care (an oncological service compared to non-oncological service such as general surgery, internal medicine or orthopaedics) has an impact on the effectiveness of pain treatment in cancer patients.

There were 164 clinical wards involved. All cancer patients treated with analgesic therapy were considered and sampled during six index days. The following information was gathered: demographic data, primary cancer and site of metastases, type of pain, and the intensity of pain was evaluated using a 4 level Verbal Rating Scale.

Patients were interviewed by a pharmacist concerning their perception of pain control and their pain intensity at the time of the interview and the worst intensity of pain during the previous 24 h.

Health care professionals were asked about their perception of the effectiveness of the analgesic treatment using the PMI and their thoughts were recorded as to why there might be an absence of response in some patients.

The results of the study show:

• There were differences in the frequency of use of the various classes of analgesic drugs administrated in the settings of care: 19.6% used non-opioids in the non-oncological setting vs 7% in the oncologic setting (p < 0.0001). Strong opioids were used more often in oncological units 69.5% vs 51.9% in the non-oncological setting.
• The number of patients receiving inadequate therapy (PMI <0) was 11.3% vs 18.8% (p=0.0024) in oncological vs non-oncological units respectively.
• Multiple logistic regression analysis showed that the admission to non-oncological setting and the absence of metastatic disease were independent factors associated with an increase risk of receiving an inadequate analgesic therapy.

Why I chose this article

To my knowledge this is one of the very few studies that compared the modalities of treatment of cancer-related pain in patients admitted to the different settings of care as defined above.

Educational programs on cancer pain management should be strongly considered for all physicians attending in the various clinical settings of care.

This study was summarized by Dr. Carla Ripamonti (Italy) who is also one of the authors. Dr. Ripamonti is a member of the Board of IAHPC; her bio may be viewed at: http://www.hospicecare.com/Bio/c_ripamonti.htm