Thursday, April 30, 2015

Patient Education, Coaching, and Self-Management for Cancer Pain

  1. Patricia M. Davidson
+Author Affiliations
  1. Melanie R. Lovell and Meera Agar, HammondCare; Melanie R. Lovell and Frances M. Boyle, University of Sydney; Melanie R. Lovell, Tim Luckett, Jane Phillips, Meera Agar, and Patricia M. Davidson, ImPaCCT (New South Wales Palliative Care Trials Group); Tim Luckett and Patricia M. Davidson, University of Technology Sydney; Jane Phillips, University of Notre Dame; and Meera Agar, University of New South Wales, Sydney, New South Wales, Australia.
  1. Corresponding author: Melanie R. Lovell, MBBS, PhD, FRACP, FAChPM, 97-115 River Rd, Greenwich NSW 2065, Australia; e-mail:


Purpose Multiple systematic reviews and meta-analyses have identified the effectiveness of patient education in improving cancer pain management. However, the mechanisms by which patient education improves pain outcomes are uncertain, as are the optimal delivery, content, timing, frequency, and duration. This review provides best-bet recommendations based on available evidence to guide service managers and clinicians in developing a patient education program.
Methods We used patient-centered care, self-management, coaching, and a behavior change wheel as lenses through which to consider the evidence for elements of patient education most likely to be effective within the context of other strategies for overcoming barriers to cancer pain assessment and management.
Results The evidence suggests that optimal strategies include those that are patient-centered and tailored to individual needs, are embedded within health professional–patient communication and therapeutic relationships, empower patients to self-manage and coordinate their care, and are routinely integrated into standard cancercare. An approach that integrates patient education with processes and systems to ensure implementation of key standards for pain assessment and management and education of health professionals has been shown to be most effective.
Conclusion Patient education is effective in reducing cancer pain and should be standard practice in all settings. For optimal results, patient education should be integrated with other strategies for implementing evidence-based, person-centered care and overcoming barriers at the levels of patient, provider, and health system.

Under- or Overtreatment of Pain in the Patient With Cancer: How to Achieve Proper Balance

  1. Jamie H. Von Roenn
+Author Affiliations
  1. All authors: Feinberg School of Medicine, Northwestern University, Chicago, IL.
  1. Corresponding author: Jamie H. Von Roenn, MD, Hematology-Oncology Division, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair St, Suite 850, Chicago, IL 60611; e-mail:


Achieving balance in the appropriate use of opioids for the treatment of cancer painis complex. The definition of “balance” is continually being modified. Palliative care professionals, pain specialists, and oncologists have long been advocating for the aggressive management of pain for patients with advanced cancer. Some progress has been made in this arena but barriers persist. Fear of addiction by patients, family members, and oncology professionals presents a serious obstacle to the provision of adequate pain control. This is further complicated by societal factors that receive extensive media coverage, such as diversion of prescribed opioids for recreational use and increasing deaths as a result of this inappropriate use of prescription opioids. This growing concern has led to more opioid regulation, which increases obstacles to painmanagement in this population. Another evolving concern is whether the long-term use of opioids is safe and effective. Data from the chronic nonmalignant painliterature suggest that toxicities may result and misuse has been underestimated, yet little information is available in the cancer population. These issues lead to serious questions regarding how balance might be successfully achieved for patients in an oncology setting. Can pain relief be provided while reducing negative consequences of treatment? Which patient should be prescribed what medications, in what situations, for what kind of pain, and who should be managing the pain?

Quality of Cancer Pain Management: An Update of a Systematic Review of Undertreatment of Patients With Cancer

  1. Giovanni Apolone
+Author Affiliations
  1. Maria Teresa Greco, University of Milan; Maria Teresa Greco, Anna Roberto, and Oscar Corli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Istituto di Ricerche Farmacologiche “Mario Negri,” Milan; Silvia Deandrea, European Commission, Joint Research Centre, Ispra; Elena Bandieri, Azienda Unita Sanitaria Locale di Modena, Modena; and Silvio Cavuto and Giovanni Apolone, IRCCS, Arcispedale “S. Maria Nuova,” Reggio Emilia, Italy.
  1. Corresponding author: Maria Teresa Greco, MD, University of Milan, Department of Clinical Sciences and Community, “GA Maccacaro” Section Medical Statistics and Biometry, Via Vanzetti 5, 20133 Milano, Italy;


Purpose Pain is a frequent symptom in patients with cancer, with substantial impact. Despite the availability of opioids and updated guidelines from reliable leading societies, undertreatment is still frequent.
Methods We updated a systematic review published in 2008, which showed that according to the Pain Management Index (PMI), 43.4% of patients with cancer were undertreated. This review included observational and experimental studies reporting negative PMI scores for adults with cancer and pain published from 2007 to 2013 and retrieved through MEDLINE, Embase, and Google Scholar. To detect any temporal trend and identify potential determinants of undertreatment, we compared articles published before and after 2007 with univariable, multivariable, and sensitivity analyses.
Results In the new set of 20 articles published from 2007 to 2013, there was a decrease in undertreatment of approximately 25% (from 43.4 to 31.8%). In the whole sample, the proportion of undertreated patients fell from 2007 to 2013, and an association was confirmed between negative PMI score, economic level, and nonspecific setting for cancer pain. Sensitivity analysis confirmed the robustness of results.
Conclusion Analysis of 46 articles published from 1994 to 2013 using the PMI to assess the adequacy of analgesic therapy suggests the quality of pharmacologic painmanagement has improved. However, approximately one third of patients still do not receive pain medication proportional to their pain intensity.

Nonopioid Drugs in the Treatment of Cancer Pain

  1. Meera Agar
+Author Affiliations
  1. Janette Vardy, Sydney Medical School, University of Sydney, Sydney, and Concord Cancer Centre, Concord; Meera Agar, Braeside Hospital, Hammond Care, Prairiewood, and South West Sydney Clinical School, University of New South Wales, Liverpool, New South Wales, Australia.
  1. Corresponding author: Janette Vardy, MD, Concord Cancer Centre, Concord Repatriation General Hospital, Hospital Rd, Concord, New South Wales, 2137, Australia; e-mail:


The WHO analgesic ladder for the treatment of cancer pain provides a three-step sequential approach for analgesic administration based on pain severity that has global applicability. Nonopioids were recommended for mild pain, with the addition of mild opioids for moderate pain and strong opioids for severe pain. Here, we review the evidence for the use of nonopioid analgesic agents in patients with cancer and describe the mode of action of the main drug classes. Evidence supports the use of anti-inflammatory drugs such as acetaminophen/paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) for mild cancer pain. Adding an NSAID to an opioid for stronger cancer pain is efficacious, but the risk of long-term adverse effects has not been quantified. There is limited evidence to support using acetaminophen with stronger opioids. Corticosteroids have a specific role in spinal cord compression and brain metastases, where improved analgesia is a secondary benefit. There is limited evidence for adding corticosteroids to stronger opioids when pain control is the primary objective. Systematic reviews suggest a role for antidepressant and anticonvulsant medications for neuropathic pain, but there are methodologic issues with the available studies. Bisphosphonates improve pain in patients with bony metastases in some tumor types.
 Denosumab may delay worsening of pain compared with bisphosphonates. Larger studies of longer duration are required to address outstanding questions concerning the use of nonopioid analgesia for strongercancer pain.

Overcoming Barriers in Cancer PainManagement

  1. Jung Hye Kwon
+Author Affiliations
  1. From Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea.
  1. Corresponding author: Jung Hye Kwon, MD, PhD, Division of Hematology-Oncology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, 150, Sungan-ro, Gangdong-gu, Seoul, 134-701, Republic of Korea;


Pain is a devastating symptom of cancer that affects the quality of life of patients, families, and caregivers. It is a multidimensional symptom that includes physical, psychosocial, emotional, and spiritual components. Despite the development of novel analgesics and updated pain guidelines, cancer pain remains undermanaged, and some patients with moderate to severe pain do not receive adequate pain treatment. Inadequate pain management can be attributed to barriers related to health care professionals, patients, and the health care system. Common professional-related barriers include poor pain assessment, lack of knowledge and skill, and the reluctance of physicians to prescribe opioids. Patient-related barriers include cognitive factors, affective factors, and adherence to analgesic regimens. System-related barriers such as limits on access to opioids and the availability of pain and palliative care specialists present additional challenges, particularly in resource-poor regions. Given the multidimensional nature of cancer pain and the multifaceted barriers involved, effective pain control mandates multidisciplinary interventions from interprofessional teams. Educational interventions for patients and health care professionals may improve the success of pain management.

Psychological and Behavioral Approaches toCancer Pain Management

  1. Francis J. Keefe
+Author Affiliations
  1. Karen L. Syrjala and Jean C. Yi, Fred Hutchinson Cancer Research Center; Karen L. Syrjala, Mark P. Jensen, and M. Elena Mendoza, University of Washington, Seattle, WA; and Hannah M. Fisher and Francis J. Keefe, Duke University, Durham, NC.
  1. Corresponding author: Karen L. Syrjala, PhD, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, D5-220, Seattle, WA 98109-1024;


This review examines evidence for psychological factors that affect pain across thecancer continuum from diagnosis through treatment and long-term survivorship or end of life. Evidence is convincing that emotional distress, depression, anxiety, uncertainty, and hopelessness interact with pain. Unrelieved pain can increase a desire for hastened death. Patients with cancer use many strategies to managepain, with catastrophizing associated with increased pain and self-efficacy associated with lower pain reports. A variety of psychological and cognitive behavioral treatments can reduce pain severity and interference with function, as indicated in multiple meta-analyses and high-quality randomized controlled trials. Effective methods include education (with coping skills training), hypnosis, cognitive behavioral approaches, and relaxation with imagery. Exercise has been tested extensively in patients with cancer and long-term survivors, but few exercise studies have evaluatedpain outcomes. In survivors post-treatment, yoga and hypnosis as well as exercise show promise for controlling pain. Although some of these treatments effectively reduce pain for patients with advanced disease, few have been tested in patients at the end of life. Given the clear indicators that psychological factors affect cancerpain and that psychological and behavioral treatments are effective in reducing varying types of pain for patients with active disease, these methods need further testing in cancer survivors post-treatment and in patients with end-stage disease. Multidisciplinary teams are essential in oncology settings to integrate analgesic care and expertise in psychological and behavioral interventions in standard care for symptom management, including pain.