BeCOn OWN Educational Program

Modules

Module 2Diagnosis and assessment of cancer pain

Date of preparation: June 2015 HQ/EFF/15/0024a

Contents

Evaluation of pain and intervention

Guidelines on pain assessment

Assessment tools

Interventions to improve management of pain

Evaluation of pain and intervention

Evaluation is a vital first step in management of cancer pain

Assessment of cancer pain demands an understanding of not only the physical problem, but also the psychological, social and spiritual component’s of the patient’s suffering

It is best achieved by a team approach

The responsibility for evaluation lies primarily with the physician, but certain components may be undertaken by other healthcare workers

Syrjala KL, et al. J Clin Oncol. 2014;32(16):1703-11.

Early intervention is key in reliefof cancer pain and related outcomes

Early intervention and relief of cancer-related pain may reducethe risk of central sensitisation or “windup,” which is associatedwith the transition from acute to chronic pain

The early relief of cancer-related pain may reduce a number of physical and psychological burdens on the patient: anorexia, insomnia, reduced cognition,incapacity, fatigue, reduced quality of life, reduced social interaction,psychological and existential distress and impaired coping skills

Pergolizzi JV, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12253. [Epub ahead of print].

Nearly half of patients are undertreated

Apolone G, et al. Br J Cancer. 2009;100(10):1566-74.

Even at specialised centres, patients are classified as potentially undertreated in 9.8–55.3% of cases

Recruitment centre

Adjuvant therapy

Time of recruiting Lower % Upper

Hospice No New 11.6 30.4 49.2

Hospice No Old 4.7 17.1 29.6

Hospice Yes New 6.8 20.0 33.3

Hospice Yes Old 0.7 9.8 18.8

Pall+Pain No New 46.8 55.3 64.0

Pall+Pain No Old 20.5 30.5 40.5

Pall+Pain Yes New 26.7 35.3 44.0

Pall+Pain Yes Old 7.7 11.8 15.9

Oncology No New 27.1 39.3 51.6

Oncology No Old 26.4 31.2 36.0

Oncology Yes New 16.8 26.2 35.6

Oncology Yes Old 13.2 16.3 19.4

0 10 20 30 40 50 60 70

% PMI-

Overall = 25.2%

PMI, pain management index

Cancer pain is undertreated

Breivik H, et al. Ann Oncol. 2009;20(8):1420-33.

European survey of 5,084 patients with various types of cancer across 11 countries and Israel

Patie

nts

(%)

80

70

60

50

40

30

20

10

0 Moderate to severe pain

at least once a month

56%44%

69%

50%63%

Described pain as severe

Pain-related difficulties

with everyday activities

QoL was not considered a

priority by HCP

Reported BTcP

There is a large variability of undertreatment across studies and settings

A systematic review covering 26 studies from 1987 up to 2007 that adopted the Pain Management Index (PMI) to assess the rate of potentially undertreated patient showed a rate from 8% to 82% with a weighted mean of 43%

Despite the large variability in adequate treatment of pain, it remains undertreated

Deandrea S, et al. Ann Oncol. 2008;19(12):1985-91.

Characteristics of studies

No. of studies

Range of negativePMI (%)

Year 1944-2000 12 27-79

2001-2007 14 8-82

Geographic area

United States 8 8-65

Europe 8 9-82

Asia 9 27-79

Economic level

GNI per capita < $20,000 8 31-79

GNI per capita $20,000 - $40,000 7 13-82

GNI per capita ≥ $40,000 11 8-65

Setting Specific for cancer patients or hospice 15 8-79

Not specific 5 29-74

Mixed 5 9-82

Stage of disease

At least 68.8% metastatic 8 13-65

<68.8% metastatic 12 29-82

Mean age of the sample

≥58 years 11 27-79

<57 years 11 8-82

Total 26 8-82

Update of systematic review of undertreatment of patients with cancer

Updated systematic review included observational and experimental studies reporting negative PMI scores for adults with cancer and pain published from 2007 to 2013

In the new set of 20 articles, 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

The undertreatment of pain decreased, however, as approximately one third of patients still do not receive pain medication proportional to their pain intensity

Greco MT et al. J Clin Oncol. 2014;32:4149-54.

Inadequate pain assessment is a leading barrier to adequate pain management

Recognition of pain should begin at pre-diagnosis

Pain assessment should include detailed history, psychosocial evaluation and physical examination

Baseline pain assessment, reassessment and analgesia efficacy must be documented within the patient's record

– In one study, 27% of patients said their doctor does not always ask them about their pain

– In another, only 7.9% had documentation of their pain and evidence of reassessment

Schute C. Ulster Med J. 2013;82(1):40-2.De Conno F, et al. European pain in cancer (EPIC) survey: a report. London: Medical Imprint; 2007. Available online from: http://www.paineurope.com/ fileadmin/userupload/Issues/EPICSurvey/EPICReportFinal.pdf. Last accessed Nov 2012.Sun VC, et al. J Pain Symptom Manage. 2007;34(4):359–69.

Inadequate pain management can be attributed to several types of barriers

Patient-related barriers

HCP-related barriers

Healthcare-system-related

barriers

Lack of knowledge and skill

Affective factors

Availability of pain and palliative care

specialists

Limits on access to opioids

Poor pain assessmentCognitive

factors

HCP – healthcare professional

Reluctance of physicians to

prescribe opioids

Kwon JH. J Clin Oncol. 2014;32(16):1727-33.

Fear of addiction, tolerance, adverse effects, respiratory

depression

Adherence to analgesic regimens

The main steps in evaluation of cancer pain (i)

1. Believe the patient’s report of pain

2. Initiate discussions about pain

3. Evaluate the severity of pain

4. Take a detailed history of the pain

5. Evaluate the psychological state of the patient

Cancer Pain Relief. World Health Organization. Available at: http://whqlibdoc.who.int/publications/9241544821.pdf. Accessed 11 Mar 2015.

The main steps in evaluation of cancer pain (ii)

6. Perform a careful physical examination

7. Order and personally review any necessary investigations

8. Consider alternative methods of pain control

9. Monitor the results of treatment

Cancer Pain Relief. World Health Organization. Available at: http://whqlibdoc.who.int/publications/9241544821.pdf. Accessed 11 Mar 2015.

Asking key questions can provide important insights into the patient’s pain

Onset of pain?

Frequency of pain?

Site of pain?

Radiation of pain

Quality (character) of pain?

Intensity (severity) of pain?

Duration of pain?

Exacerbating factors?

Relieving factors?

Response to analgesics?

Response to other interventions?

Associated symptoms?

Interference with activities of daily living?

More effective management of pain requiresasking the right questions

Davies A, et al. Eur J Pain. 2009;13(4):331-8.

LIDOCAINE: a mnemonic device to guidethe clinician in asking leading questions

Pergolizzi JV, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12253. [Epub ahead of print].

Focus Sample questions

LIDOCAINE

Location Where is your pain? Where does it go?

Intensity How bad is the pain?

Directionality Where does the pain go? Does the pain travel? Does it jump around or switch sides?

Occurrence How long have you been experiencing this pain? Do you remember when it started?

Character What does the pain feel like?

Alleviating Does anything improve your pain? Does anything make the pain go away?

Inciting Does anything seem to make the pain worse?

Neutral factors Are there things that do not seem to affect the pain at all, one way or the other?

Effect on function Does this pain affect your sleep? Are you limited in some of your everyday activities? Have you given up doing some of the things you used to enjoy?

Pain management index (PMI)

Cleeland CS, et al. N Engl J Med. 1994;330:592-596.

The PMI compares the most potent analgesic prescribed for a patientwith the reported level of the worst pain of that patient

The PMI, computed by subtracting the pain level from the analgesic level,ranges from −3 (a patient with severe pain receiving no analgesic drugs) to +3(a patient receiving morphine or an equivalent and reporting no pain)

Negative scores are considered to indicate pain undertreatment, and scoresof 0 or higher are considered a conservative indicator of acceptable treatment

WHO analgesic drug level

Pain Intensity No drugs(0)

NSAID(I)

Weak opioids(II)

Strong opioids(III)

No pain 0 +1 +2 +3

Mild (1-3) -1 0 +1 +2

Moderate (4-7) -2 -1 0 +1

Severe (8-10) -3 -2 -1 0

Guidelines on pain assessment

ESMO guidelines for adequate assessment of pain at any stage of disease (i)

Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.

1. Assess and re-assess the pain

Causes, onset, type, site, absence/presence of radiating pain, duration, intensity,relief and temporal patterns of the pain, number of breakthrough pains,pain syndrome, inferred pathophysiology, pain at rest and/or moving

Presence of the trigger factors and the signs and symptoms associated with the pain

Presence of the relieving factors

Use of analgesics and their efficacy and tolerability

Require the description of the pain quality

ESMO guidelines for adequate assessment of pain at any stage of disease (ii)

2. Assess and re-assess the patientClinical situation by complete/specific physical examination and specific radiological and/or biochemical investigations

Presence of interference of pain with the patient’s daily activities, work, social life, sleep patterns, appetite, sexual functioning, mood, well-being, coping

Impact of pain, disease and therapy on physical, psychological and social conditions

Presence of a caregiver, psychological status, degree of awareness of disease, anxiety and depression and suicidal ideation, his/her social environment, quality of life, spiritual concerns/needs, problems in communication, personality disorders

Presence and intensity of signs, physical and/or emotional symptoms associated with cancer pain syndromes

Presence of comorbidities (i.e. diabetic, renal and/or hepatic failure etc.)

Functional status

Presence of opioidophobia or misconception related to pain treatment

Alcohol and/or substance abuse

Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.

ESMO guidelines for adequate assessment of pain at any stage of disease (iii)

3. Assess and re-assess your ability to inform and to communicate with the patient and the family

Take time to spend with the patient and family to understand their needs

Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.

ESMO recommendations on assessment of pain

1. The intensity of pain and the treatment outcomes should be regularly assessedusing (i) VAS, (ii) VRS or (iii) NRS

2. When cognitive deficits are severe, observation of pain-related behaviours and discomfort (i.e. facial expression, body movements, verbalisation or vocalisations, changes in interpersonal interactions, changes in routine activity) is an alternative strategy for assessing the presence of pain (but not intensity)

3. Observation of pain-related behaviours and discomfort is indicated in patients with cognitive impairment to assess the presence of pain (expert and panel consensus)

4. The assessment of all components of suffering such as psychosocial distressshould be considered and evaluated

Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.

Assessment tools

Validated and most frequently used pain assessment tools

Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.

Validated assessment tools for assessment of pain

Visual analogue scale VAS

Worstpain

Nopain

10 cm

Nopain1 Very

severeSevereModerateMildVerymild2 3 4 5 6

Verbal rating scale VRS

Numerical rating scale NRS

Worstpain

Nopain 0 101 2 3 4 5 6 7 8 9

Wong-Baker FACES scale

Bieri D, et al. Pain Manage Nurs. 1990;41:139-150.

Wong-Baker FACESTM Pain Rating Scale

2 4 6 8 100

Hurtsworst

Hurtswhole lot

Hurtslittle more

Hurtslittle bit

Nohurt

Hurtseven more

The Wong-Baker FACES scale is reliable and easy to administer

Body pain diagramBody pain diagrams can assist in assessment of pain

Visser EJ, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12263.

The Critical-Care Pain Observation Toolcan be used in uncommunicative patients

Gélinas C, et al. J Adv Nurs. 2009;65(1):203-16.

Indicator Description Score

Facial expression No muscular tension observed Relaxed, neutral 0

Presence of frowning, brow lowering, orbit tightening and levator contraction Tense 1

All of the above facial movements plus eyelid tightly closed Grimacing 2

Body movements Does not move at all (does not necessarily mean absence of pain) Absence of movements 0

Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements Protection 1

Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed Restlessness 2

Muscle tension No resistance to passive movements Relaxed 0

Evaluation by passive flexion and extension of upper extremities

Resistance to passive movements Tense, rigid 1

Strong resistance to passive movements, inability to complete them Very tense or rigid 2

Compliance with the ventilator (intubated patients)

Alarms not activated, easy ventilation Tolerating ventilator or movement 0

Alarms stop spontaneously Coughing but tolerating 1

Asynchrony: blocking ventilation, alarms frequently activated Fighting ventilator 2

OR

Vocalisation (extubated patients) Talking in normal tone or no sound Talking in normal tone or no sound 0

Sighing, moaning Sighing, moaning 1

Crying out, sobbing Crying out, sobbing 2

Total, range 0 - 8

The Brief Pain Inventory is widely used

The BPI allows patients to rate the severity of their pain and the degree to which their pain interferes with common dimensions of feeling and function

Cleeland CS, Ryan KM. Ann Acad Med Singapore. 1994;23(2):129-38.

Edmonton symptom assessment system (ESAS)as a screening tool for depression and anxiety

Anxiety or depression ESAS items score >3 can be applied as a useful, easy and rapid screening tool for assessing anxiety and depression in non-advanced patients with solid or haematological malignancies

Ripamonti CI, et al. Support Care Cancer. 2014;22(3):783-93. Bruera E, et al. J Palliat Care. 1991;7(2):6-9.

Assessment of neuropathic pain

Assessment tools

Neuropathic Pain Scale

Neuropathic Pain Symptom Inventory

Tools for assessment and screening

LANSS

Neuropathic Pain Questionnaire

DN4 Questionnaire

Neuropathic Pain Scale

Galer BS, Jensen MP. Neurology. 1997;48(2):332-8.

Neuropathic Pain Symptom Inventory

Bouhassira D, et al. Pain. 2004;108(3):248-57.

Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)

Bennett M. Pain. 2001;92(1-2):147-57.

Neuropathic Pain Questionnaire

Krause SJ. Clin J Pain. 2003;19(5):315-6.

DN4 Questionnaire

Bouhassira D, et al. Pain. 2005;114(1-2):29-36.

Interventions to improve management of pain

Patient-based education interventions can improve attitudes and reduce pain intensity

Bennett MI, et al. Pain. 2009;143(3):192-9.

Patient-based educational interventions are probably underused alongside more traditional analgesic approaches

Improved knowledge

and attitudes

Reduced average pain

intensity

Reduced worst pain intensity

-2.5 -2.0 -1.5 -1.0 0.5 1.0

0.04 0.52

-1.1-1.8 -0.41

-1.21 -0.78 -0.35

1.0

0.0

Compared to usual care or control, educational interventions:

Standardised educational interventionscan improve pain scores

Provision of a video and/or booklet for people with cancer pain is a feasible and effective adjunct to management of cancer pain

Lovell MR, et al. J Pain Symptom Manage. 2010;40(1):49-59.

Bookletversus SC

Videoversus SC

Booklet & Videoversus SC

-2.5 -2.0 -1.5 -1.0 -0.5 0.0 0.5

Favoursintervention

Favoursstandard care (SC)

-1.84 -0.89 0.06

-0.86-1.83 0.11

-2.17 -1.17 -0.17

P=0.07

P=0.08

P=0.02

DVD-based educational intervention

Participants were shown a DVD at baseline (V1) and at 1 week (V2)

Outcomes were assessed using Brief Pain Inventory (BPI) and Patient PainQuestionnaire (PPQ) before intervention, and at V2 and V3 (4 weeks later)

Between V1 and V2:

Total BPI improved by 9.6% (p=0.02)

PPQ scores improved by 17% (p=0.04)

There were no further improvements at V3

Capewell C, et al. Palliat Med. 2010;24(6):616-22.

DVD-based intervention is feasible and potentially effective between 7–30 days follow up

iPhone pain assessment applicationfor adolescents with cancer

Stinson JN, et al. J Med Internet Res. 2013;15(3):e51.

Compliance with the app, assessed during feasibility testing, was high and adolescents found the app likeable, easy to use and not bothersome to complete

A valid and reliable electronic diary with pain management capabilities has the capacity to result in improved pain management

Medical oncologists’ attitudes and practicein cancer pain management

Breuer B, et al. J Clin Oncol. 2011;29(36):4769-75.

Med

ian

scor

e

0

3

10

7

8

5

2

Rated their specialty highly

for ability to manage cancer

pain

Rated peers as more

conservative prescribers

Quality of pain management

training during medical school

Physician reluctance to

prescribe opioids

7

3 3

5

Poor assessment

6

Patient reluctance to take opioids

6

Survey of 2000 oncologists (overall response rate 32%)

9

6

4

1

Patient reluctance report pain

6

Barriers

Oncologists and other medical specialists who manage cancer pain have knowledge deficiencies in cancer pain management

Patient/HCP communication about pain is suboptimal

Pain assessment is suboptimal

HCP fails to prescribe adequate analgesic regimenIntentional non-adherence by patient (e.g. decision not to mask pain, fear of side effects or addiction)Unintentional non-adherence by patient – misunderstanding of dosing regimen, forgetfulnessHCP fails to consider adjuvant anticancer therapies, or non-pharmacological therapies

Patient misinterprets pain oraccepts pain as inevitable

Patient is uncertain how toseek medical attention

Patient fails to report pain

Pain changes, e.g. due todisease progression/analgesic tolerance

Pain is not re-assessed

Patientexperiences andinterprets pain

Patientinteracts with

HCP

Re-assessment

Analgesiacommenced/

altered.Anticancer & non-pharmacological

therapiesdiscussed

Steps for optimal cancer pain management

Adam R, et al. Patient Educ Couns. 2015;98(3):269-82.

Patient education, coaching and self-management for cancer pain

Lovell MR, et al. J Clin Oncol. 2014;32(16):1712-20.

The available evidence suggests that optimal strategies include those that are:

Patient-centred and tailored to individual needs

Embedded within health professional-patient communication and therapeutic relationships

Empower patients to self-manage and coordinate their care

Routinely integrated into standard cancer care

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 is most effective

Summary

Early intervention is key in achieving improved patient outcomes

There are many barriers to more effective intervention in cancer pain related to physicians, patients and healthcare systems

ESMO has issued guidelines on assessment and treatment of cancer pain

A variety of simple assessment tools for cancer pain are in common clinical use

Educational interventions, using both traditional and innovative communication tools, may be associated with improvements in pain scores