© 2004 by Oxford University Press
2004 © Oxford University Press
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Abstract: Assessment of Pain in Cancer
Charles S. Cleeland, PhD, M. D. Anderson Cancer Center, University of Texas, Houston, TX 77030
Numerous studies document that pain caused by cancer is inadequately managed and that existing effective therapies for pain are not used to maximize pain relief. The result is a high level of unnecessary distress for patients and families, a significant impairment in quality of life, and an increased use of health care systems to treat poorly managed pain on an emergent basis. Factors that lead to poor pain treatment have been well studied. Patients, for a variety of reasons, are often reticent to report pain or the lack of effective treatment. The most significant practice error that health care professionals make in pain management is inadequate assessment. When patients are reluctant to report pain, inadequate assessment becomes even more of a problem for adequate pain control. Studies of oncology professionals in several countries demonstrate that these persons are very aware that poor assessment is the greatest barrier to cancer pain management. Studies of patients document that one of the strongest predictors of poor pain management is the discrepancy of pain estimate between treating doctors and the pain report of patients.
Barriers to pain assessment are many and include a lack of time for assessment in the clinical encounter, a low priority assigned to pain management, poor training of health care professionals in pain management, and a lack of negative sanctions for ineffective provision of pain control. Clinics rarely provide a protocol for either pain assessment or management or have care plans in place for titration of analgesics and adjuvant drugs. Systematic follow-up is rare and a special problem when the majority of patients has developed more severe pain over time due to the progressive nature of their disease. Minority patients are at greater risk for having their pain underestimated and their pain inadequately treated.
It can be argued that if pain control were taken seriously as an element of good cancer care, practice could be improved for the benefit of patients. Current control methods in place for the management of infection could provide a model. Infection is monitored by vital signs, such as fever. If infection is present, protocols are implemented to deal with it. If monitoring indicates that the infection is not controlled, the protocol is modified, or new protocols are put in place. When infection is not controlled, the health care system treats the situation as very serious, and there are negative consequences for those who practice. Pain and symptom management could be viewed in the same way. Pain needs to become a vital sign, protocols to treat pain need to be in place, and the effectiveness of pain management needs to be monitored and, if deficient, corrected. The potential effectiveness of this type of practice change in pain and symptom assessment needs to be studied.
The evolution of the scientific basis for pain assessment has helped advance treatment decision making. This presentation will present an overview of this progress and the type of clinical research. New methods for simultaneously monitoring pain together with other symptoms, such as computer-based telephone queries to patients at home, can greatly enhance follow-up and better long-term symptom control. Better longitudinal data on the time course and severity of symptoms over time may yield information about potential mechanisms responsible for these symptoms.
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Reprinted from the program book of the National Institutes of Health State-of-the-Science Conference on Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002 (http://consensus.nih.gov/ta/022/programabstractbook.pdf)
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