The Art and Science of Treating Cancer Pain: Challenges and Limitations
Cancer-related pain is a prevalent condition in the United States and across the globe. In 2018 it is estimated that 1,700,000 new cases of cancer will be diagnosed in the United States alone, with about 600,000 people will dying of the disease. It is estimated that in 2018 alone,1 about half of cancer survivors report moderate to severe pain even after their cancer has been in remission or cured.2 As the number of patients whose cancer has been cured continues to increase considerably, adequate control of their pain is imperative.
Historically, investigators have found that more than 50% of cancer patients have inadequate pain control.
In patients with malignant disease, pain severity may be associated with prognosis, survival, patient satisfaction, psychological distress, and decreased social activities.3 Up to 90% of patients with some types of cancer can achieve satisfactory pain relief.4 However, for many others, living with significant pain is the norm. Historically, investigators have found that more than 50% of cancer patients have inadequate pain control.5 Since 2013, increased awareness has resulted in a significant improvement in the treatment of cancer pain and in physician understanding of its importance.2 Yet, physicians often still report that they are ill equipped to manage cancer pain in their patients.
Challenges Related to Physicians
A majority of physicians report having significant difficulty in treating cancer pain secondary to complexity related to the cancer diagnosis and comorbid disorders that require highly specialized and comprehensive treatment. Indeed, several studies have demonstrated that physicians identify lack of support staff and time as potential barriers to providing care to patients suffering from cancer-related pain.4 Moreover, physician reluctance to prescribe opioids has led to ineffective and undertreatment of cancer pain.4 Often, physicians are resistant to the idea of prescribing opioids secondary to fears of potential patient addiction, uncontrolled side effects, and perceived regulatory constraints. A mere 19% of patients who could benefit from potent opioid therapy receive such treatment.4 Additionally, only about one-third of patients receive appropriate medications for breakthrough pain.4
Cancer pain often remains undertreated because of lack of clinician knowledge. One study’s results showed that when given clinical cases, up to 80% of oncologists did not manage cancer pain appropriately.6 Results from another study examining cancer pain knowledge among oncologists, palliative care physicians, and pain physicians showed that all three specialties performed poorly. Across disciplines, pain specialists scored the lowest and palliative care physicians scored the highest.6 More specifically, oncologists performed better than pain specialists with opioid dose titration and management and use of a co-analgesics to treat neuropathic pain.6 However, pain specialists performed better in the use of interventional procedures for cancer pain, selection of opioid and route, and management of opioid-related side effects.6
The lack of knowledge likely stems from the fact that medical training programs spend very little time teaching cancer pain management. Results from a survey of anesthesiologists as well as oncologists (medical, surgical, and radiation) in training showed that only 22% were satisfied with cancer pain management education in medical school.5 The rate climbed to 64% satisfaction with cancer pain education during residency but dropped again to 56% for education during fellowship.5 The deficit continues after training is completed, and the areas of greatest weakness are interventional pain procedures, palliative care interventions, and managing procedural and postoperative pain. In contrast, education related to the use of opioid analgesics for persistent pain and assessing pain etiology are the areas of greatest strength.5
Challenges Related to Patients
Patients’ attitudes and knowledge can significantly affect cancer pain treatment. Patients are often reluctant to report pain because they want to be a “good patient” and not bother providers or question their decisions.1 They are also sometimes reluctant to take opioids because of fear of addiction, tolerance, harm to their immune system, and potential side effects.1 Even when patients are prescribed opioids and are willing to take them, they may have significant nonadherence to prescribed medical therapy. Medication-related side effects or financial difficulties may hinder efforts at prescribed therapy adherence. Even with insurance coverage, the cost to patients for pain medications has increased 5%–9% per year in the since first looked into it in late 1990s.2
Challenges Related to the Health Care System
Collaboration in the health care system is essential for effective cancer pain management. Lack of coordination across multiple providers is often an issue. Oncologists commonly describe challenges related to accessing pain-related services and lack of pain management specialists.3 Surveys also reveal that physicians want more guidance on pain assessment, pain treatment, patient counseling, and safe opioid management practices for the oncologic patient.3 Challenges in the health care system also include ethnic and socioeconomic disparities. Minorities have higher rates of undertreated cancer pain, and patients from lower socioeconomic status are less likely to be prescribed opioids.3 This points to a systemic bias that needs to be overcome.
ASRA Cancer Pain and Palliative Care SIG
To address the challenges and overcome the barriers to treating cancer pain, ASRA members formed the Cancer Pain and Supportive Care Special Interest Group (SIG). The group’s inaugural meeting, with Magda Anitescu, MD, and Gina Votta-Velis, MD, as chair and vice chair, respectively, and Dalia Elmofty, MD, and Amitabh Gulati, MD, as newsletter and webcast liaisons, respectively, was held at the ASRA World Congress in New York City in April 2018. The ASRA Cancer Pain and Palliative Care SIG’s mission is to:
- Increase awareness in the medical community of the presence of undertreated cancer pain.
- Educate physicians on available treatments essential to effectively treat cancer pain.
- Improve outcomes, functional status, and quality of life in patients suffering from significant cancer pain.
- Promote collaborative efforts between subspecialties involved in cancer pain management.
- Advance translational research essential for the effective treatment of cancer pain.
To accomplish that mission, the leaders of the Cancer Pain and Supportive Care SIG developed the following goals:
- Increase awareness of available treatments for cancer pain.
- Educate members of the medical community about recognizing severe cancer pain and ways to involve available pain medicine options to treat cancer pain.
- Identify modalities to improve patient functional status through pain management techniques.
- Use patient-centered treatment modalities for severe and refractory cancer pain.
- Develop close collaboration, skills, and competencies to treat cancer pain through interventional and noninterventional modalities.
- Identify optimal palliative and curative techniques to treat severe cancer pain.
- Spread the knowledge base of cancer pain treatments through communications with practitioners, educators, and policymakers in a true multidisciplinary and comprehensive approach to treatment.
- Include teaching of interdisciplinary cancer pain management in all subspecialty fellowships involved (eg, chronic pain medicine, oncology and palliative care).
- Identify areas of research that can contribute to the effective treatment of cancer pain.
- Identify clinical and research collaboration across multiple disciplines to contribute to the identification and treatment of refractory cancer pain states.
- Identify and educate the medical community on palliative modalities to improve cancer pain and quality of life in patients at the end of life.
What’s Next for the SIG?
The Cancer Pain and Palliative Care SIG leadership has several goals and plans for the near future. Dr. Gulati, director of chronic pain at Memorial Sloan Kettering Cancer Center in New York, NY, said he wants the SIG to “continue to expand its membership and outreach with more thorough programming in this field, both at conferences and online” as well as to “provide a collaborate atmosphere with multiple organizations that provide cancer pain education to a variety of practitioners caring for cancer pain patients.”
Dr. Anitescu, section chief of the division of pain management at the University of Chicago Medical Center in Chicago, IL, agreed with the collaborative approach: “We will focus on increasing adherence to the SIG and creating connections with other specialties.”
The group plans to collaborate with sister cancer pain societies and other ASRA SIGs. Additionally, the leadership will prioritize sharing pain treatment protocols among cancer pain organizations, creating an education toolbox specifically tailored to cancer pain, and creating a mentorship database.
The Cancer Pain and Palliative Care SIG invites interested members to reach out to contribute ideas that could positively impact treating pain in patients with cancer.
- National Cancer Institute. Cancer statistics. April 27, 2018. From https://www.cancer.gov/about-cancer/understanding/statistics Accessed September 20, 2018.
- Pargeon K, Hailey BJ. Barriers to effective cancer pain management: a review of the literature. J Pain Symptom Manage. 1999;18:358–368.
- Scarborough B, Smith CB. Optimal pain management for patients with cancer in the modern era. CA Cancer J Clin. 2018;68:182–196. https://doi.org/10.3322/caac.21453
- Jacobsen R, Sjøgren P, Møldrup C, Christrup L. Physician-related barriers to cancer pain management with opioid analgesics: a systematic review. J Opioid Manag. 2007;3(4):207–214.
- Odonkor C, Osei-Bonsu E, Tetteh O, Haig A, Mayer RS, Smith TJ. Minding the gaps in cancer pain management education: a multicenter study of clinical residents and fellows in a low- versus high-resource setting. J Glob Oncol. 2016;6:387–396. https://doi.org/10.1200/JGO.2015.003004
- Breuer B, Chang VT, Von Roenn JH, et al. How well do medical oncologists manage chronic cancer pain? a national survey. 2015;20:202–209. https://doi.org/10.1634/theoncologist.2014-0276