Support Care Cancer (2008) 16:1203–1211 DOI 10.1007/s00520-008-0456-7
SUPPORTIVE CARE INTERNATIONAL
Prevalence and treatment of cancer pain in Italian oncological wards centres: a cross-sectional survey Sebastiano Mercadante & Fausto Roila & Oscar Berretto & Roberto Labianca & Stefania Casilini & DOMAIN-AIOM study group
Received: 25 February 2008 / Accepted: 3 April 2008 / Published online: 14 May 2008 # Springer-Verlag 2008
Abstract Objective The aim of this national cross-sectional survey was to draw information on pain prevalence and intensity from a large sample of patients who were admitted to oncologic centres for different reasons and to evaluate the pain treatment and possible influencing factors. Materials and methods A total of 2,655 patients completed the study. Nine hundred and one patients (34%) reported pain. Results and discussions Higher pain levels were observed in inpatients, in the presence of bone metastases, and with low levels of Eastern Cooperative Oncology Group status.
Janssen Cilag had a role in sponsoring investigation meetings. Study design, collection, analysis and interpretation of data, writing of the manuscript, and the decision to submit the manuscript for publication were performed by the authors who lead the study. S. Mercadante (*) Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit,, La Maddalena Cancer Center, Via S.Lorenzo 312, 90145 Palermo, Italy e-mail:
[email protected] F. Roila Department of Oncology, Azienda Ospedaliera di Perugia, Perugia, Italy O. Berretto Department of Oncology, ASO San Giovanni Battista, Turin, Italy R. Labianca Department of Oncology, A.O. Ospedali Riuniti di Bergamo, Bergamo, Italy S. Casilini Medical Affairs, Janssen Cilag Spa, Cologno Monzese, Italy
The number of patients receiving strong opioids increased with the highest levels of pain. However, a significant part of patients with moderate–severe pain were not receiving appropriate medication, patients being predominantly administered non-opioid drugs. General practitioners’ attitudes did not negatively influence the opioid prescription. Conclusion The results of this survey indicate a need for continuing educational and informative program in pain management for oncologists and more generally for any physician dealing with cancer patients. Keywords Cancer pain . Epidemiology . Opioids
Introduction Pain is a common symptom experienced by cancer patients, with wide variations according to the primary diagnosis and disease stage, the prevalence of pain being more than 70% in advanced stages [3, 21]. Despite available treatments and the development of effective guidelines for the management of cancer pain, proven effective in the majority of subjects, a large proportion of cancer patients remain undertreated due to barriers related to health care resources, patient, and family. However, misconceptions about opioids, insufficient education of health care professionals and restrictive regulation in some countries for many years have been the main cause of the lack of application of simple guidelines of the World Health Organization (WHO) for cancer pain relief. Barriers to adequate cancer pain management include unnecessarily strict rules and regulations, lack of economic means and insufficient resources and patients’, relatives’ and medical professionals’ negative perceptions about controlled drugs limiting their rational use [18]. Lack of adherence with analgesic regimen is a further barrier to effective cancer pain management [20].
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However, misconceptions about opioids, insufficient education of healthcare professionals and restrictive regulation in some countries for many years have been the main cause of the lack of application of simple guidelines of the WHO for cancer pain relief. As the treatment should start at the step of the analgesic ladder appropriate for the severity of pain, all patients with moderate to severe pain should receive a trial of opioid analgesics, regardless of aetiology. Opioid consumption in Italy is ranked among the lowest in Europe, despite the fact that legislative impediments have been partly overcome [7, 14]. Differently from other countries, which often produced questionnaire-based data [13, 27, 29, 30, 32], clinical data regarding the prevalence of pain in a large sample of general Italian population with cancer and attitudes about opioid prescription by oncologists are lacking. A study performed in an institution with the longest tradition in cancer pain management in Italy underlined the need of educational and informative programs to reduce the frequency and severity of pain [24]. The knowledge of the prevalence of pain in a general population followed by cancer centers may help provide reasonable estimates of the major patients’ needs, planning organisation, or re-design therapeutic strategies. The aim of this national cross-sectional survey was to draw information on pain prevalence and intensity from a general population of patients who were admitted to oncologic centers for different reasons (primary outcome). The secondary outcome was to evaluate the pain treatment and possible influencing factors.
Support Care Cancer (2008) 16:1203–1211
The following data were collected: civil status, educational qualification, job, social condition, reason for visit or hospital admission, Eastern Cooperative Oncology Group (ECOG) performance status, clinical data regarding the disease (no evidence of disease, locally advanced, locoregional relapsed, metastatic disease and type of oncological treatment), the presence of pain and its intensity and/or a prescription of analgesics. In patients reporting pain or receiving analgesic drugs, the pain intensity reported in the last 24 h was evaluated by using a verbal scale (no pain, mild, moderate and severe). Pain duration (less than 1 week, 1 week to 1 month, 1 to 3 months and more than 3 months) was also recorded. Type of analgesics including non-opioids, opioids for moderate pain, known as weak opioids (WO) and strong opioids (SO), and physicians who prescribed these drugs were recorded. Patients who were prescribed were asked about possible difficulties in having the drugs prescribed by their general practitioner (GP) or delivering by pharmacies and their satisfaction with their analgesic treatment. Consumption of symptomatic drugs, including laxatives, anti-emetics or gastroprotectors was also recorded. Statistical analysis A descriptive analysis of the survey was performed. In addition to and in accordance with the design and purpose of the survey, conventional chi-square tests (with Yates correction if deemed appropriate) were employed, and Bowker test was performed for the comparison of data expressed on verbal scales.
Materials and methods This survey was planned in collaboration with AIOM, the Italian association of medical oncologists grouping the majority of Italian oncologists. For each region, a coordinator identified the oncological centres with adequate facilities, including out-patient clinic, day-hospital, and beds. One hundred and twenty-nine centres were selected for the study and received the material for administrative and ethical purposes and data collection materials to fill in. The survey was performed in the centres that agreed to participate and had the approval of administrative and ethical committees. The survey took place on an established day, 18th November 2004, according to a cross-sectional design. All patients attending the out-patient clinic, the day-hospital, or admitted to the oncological ward as inpatients in a planned day were surveyed. Inclusion criteria were age more than 18 years and diagnosis of cancer. Exclusion criteria were surgery in the previous 72 h, a level of cognitive failure impeding the interview or inability to complete the questionnaire and evaluation tools.
Results Of the selected centres, 102 of 129 (79%) centres participated in the study. Of the 102 centres that intended to participate in the study, 94 centres were involved in administrative-ethical issues, and eight were not considered for different reasons (relinquishment, no institution of ethical committee and other reasons). A total of 2,655 patients, aged 22–100 years, completed the study. The most frequent cancer diagnoses were in a rank order: breast, 695 (26.4%); colon-rectum, 539 (20.3%) and lung, 501 (18.8%). Characteristics of patients stratified for pain intensity are listed in Table 1. The most frequent reasons for hospital referral was chemotherapy (56%, p
