BERKELEY, CA (UroToday.com) - What are the three main take-home messages from this article?
- Pain remains a paramount issue in outpatient cancer care, with two-thirds of the patients reporting pain or use of pain medications
- About one-third of patients with pain are undertreated for their pain. The pain management index was used as the criterion for adequacy of treatment.
- About one-third of the undertreated patients become adequately treated over one month of follow-up.
- There is significant disparity in pain treatment adequacy, with minority patients being twice as likely to be undertreated. These findings, related to racial disparity in this study of over 3000 patients, represent a critical observation. These data awaken us to a major opportunity in healthcare to work harder and smarter to improve cancer pain care for all patients and to resolve this striking disparity.
- The good news is that we did not see disparity related to age or gender. Age and gender disparity had been seen in a landmark study of pain management in oncology outpatients published almost 20 years ago in the New England Journal of Medicine. That previous study did not collect information on individual patients’ race/ethnicity.
Why are minorities undertreated?
- We do not know exactly why minorities are undertreated. Some possible reasons could be:
- Differences in the attitudes of minority patients about pain medicines, particularly narcotic pain relievers
- more concerns about opioid side effects, costs, addiction, drug diversion; different viewpoints about the meaning of pain
- Differences in the attitudes of doctors and nurses towards minority patients (in relation to the same issues as above)
- Differences in the patterns of communication between healthcare providers and patients. Communication is critical to pain assessment and fundamental to making treatment decisions and negotiating goals of care
- Differences in the responsiveness of minority patients to pain treatments and techniques (i.e. biological differences that are not yet understood)
- Differences in access to expert pain management and/or access to effective patient education information about pain management and the role of opioids
- Implicit stereotyping and bias among healthcare providers, even in the absence of the providers’ awareness or intention (www.ncbi.nlm.nih.gov/pubmed/22420815)
- Differences in the attitudes of minority patients about pain medicines, particularly narcotic pain relievers
Why is pain management such an important topic?
- Pain is one of the most feared symptoms of cancer and it has tremendous impact on the quality of life and function of patients with cancer. Pain issues also impact family members of cancer patients, and family narratives about the cancer experience.
In 2002, a National Institutes of Health State-of-the-Science Panel focusing on pain, fatigue, and depression noted that “Additional research is needed on the definition, occurrence, the treatment of pain, depression, and fatigue, alone and in combination, in adequately funded prospective studies.” This State-of-the-Science meeting inspired the development of the SOAPP study by ECOG (the Eastern Cooperative Oncology Group, www.ecog.org/ , an NCI-funded clinical cooperative group now known as ECOG-ACRIN.
Whereas hospitalized patients with significant pain issues are often evaluated by pain specialists, outpatients with cancer and pain are nearly always managed by their treating cancer specialists alone. The goal of treating pain is to restore quality of life and function, reduce suffering, and control pain treatment side effects. There has always been public concern about the adequate treatment of cancer pain. Currently, there is also a lot of public concern about the prescription of opioid medications to outpatients and some of the problems with overdose, drug addiction, and drug diversion. It is not yet clear how this growing concern and new programs related to opioid prescribing will influence pain assessment and management in outpatient oncology, and whether there might be a differential impact on minority patients.
How can we access these data and more information about this study?
There is a study-specific website that you can access at: www.ecogsoapp.org
What else? What did you find out from this study about other symptoms and treatments?
There was an enormous amount of information collected in this study and there have been reports of these data at national meetings since 2009. This manuscript was one of 4 papers presented at the ASCO 2011 Annual Meeting. There are 9 further presentations that were made at national meetings in June 2012 (6 at the ASCO Annual Meeting, 3 at the MASCC Annual Meeting). See the www.ecogsoapp.org website for further details. Provocative data that have been analyzed thus far include the follow topics:
- fatigue
- depression and use of antidepressants
- drowsiness and disturbed sleep
- measuring symptoms and how they change over time
- predictors of employment and the ability to drive,
- symptom experiences in specific tumors (lung, breast, prostate, and colorectal),
- the influence of other conditions (comorbidities) on care,
- patterns of medication use
- further information about pain
Written by:
Michael Fisch, MD, MPH, FACP, FAAHPM as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Chair, Department of General Oncology
MD Anderson Cancer Center
Houston, TX USA
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