Pattern and quality of care of cancer pain management. Results from the Cancer Pain Outcome Research Study Group

G Apolone, O Corli, A Caraceni, E Negri, S Deandrea, M Montanari, M T Greco, Cancer Pain Outcome Research Study Group (CPOR SG) Investigators, Giovanni Apolone, Oscar Bertetto, Augusto Caraceni, Oscar Corli, Franco De Conno, Roberto Labianca, Marco Maltoni, Maria Flavia Nicora, Valter Torri, Furio Zucco, V Adamo, M Airoldi, M Allegri, G Altavilla, G Azzarello, E Bandieri, M L Barzelloni, F Bassan, G Belfiore, G Bernardo, G Bersano, R Bertè, O Bertetto, C Bianchessi, A Bologna, S Bravi, A Buono, F Buzzi, C Cacioppo, J Capuccini, C Caroti, G Castagnini, M Ceste, S Chisari, B Chiurazzi, A Comandone, E Cortesi, C Crispino, A Cuomo, A De Martino, A De Matteis, A De Salve, S Del Prete, F Della Rovere, C Dello Ioio, S Derni, L Di Alesio, F Di Costanzo, C Di Fonzo, R Di Gregorio, M Di Lanno, M Di Seri, M Di Stefano, D Dini, D Dini, M Duro, G Facchini, A Farris, C Ferrara, P Ferrari, M Frascaroli, D Furiosi, F Fusco, V Gebbia, M G Ghi, D Giannunzio, C Giuffrè, C Guarino, F Henriquet, L Isa, P La Ciura, F La Rocca, R Labianca, C Longhi, G Lupo, S Mameli, A Manni, L Manzione, C Martini, A Martoni, N Marzano, S Masseroni, V Mattioli, P Maurizi, D Miotti, L Montanari, L Moscetti, V Murgia, L F Nardi, F Narducci, F Negri, C Orlandini, D Ottaviani, G Pancera, F Paoletti, A Pappalardo, M K Paris, C Pittureri, L Piva, L Ponchio, C Reale, A Rinaldi, E Romagnoli, A Russo, C Sandomenico, A Sbanotto, F Scanzi, I Schiavetto, L Trentin, M Tucci, G Vaccaro, D Valenti, V M Valori, G Vasini, E Veltri, V Zagonel, E Zecca, G Zeppetella, M Ziliotti, F Zucco, G Apolone, O Corli, A Caraceni, E Negri, S Deandrea, M Montanari, M T Greco, Cancer Pain Outcome Research Study Group (CPOR SG) Investigators, Giovanni Apolone, Oscar Bertetto, Augusto Caraceni, Oscar Corli, Franco De Conno, Roberto Labianca, Marco Maltoni, Maria Flavia Nicora, Valter Torri, Furio Zucco, V Adamo, M Airoldi, M Allegri, G Altavilla, G Azzarello, E Bandieri, M L Barzelloni, F Bassan, G Belfiore, G Bernardo, G Bersano, R Bertè, O Bertetto, C Bianchessi, A Bologna, S Bravi, A Buono, F Buzzi, C Cacioppo, J Capuccini, C Caroti, G Castagnini, M Ceste, S Chisari, B Chiurazzi, A Comandone, E Cortesi, C Crispino, A Cuomo, A De Martino, A De Matteis, A De Salve, S Del Prete, F Della Rovere, C Dello Ioio, S Derni, L Di Alesio, F Di Costanzo, C Di Fonzo, R Di Gregorio, M Di Lanno, M Di Seri, M Di Stefano, D Dini, D Dini, M Duro, G Facchini, A Farris, C Ferrara, P Ferrari, M Frascaroli, D Furiosi, F Fusco, V Gebbia, M G Ghi, D Giannunzio, C Giuffrè, C Guarino, F Henriquet, L Isa, P La Ciura, F La Rocca, R Labianca, C Longhi, G Lupo, S Mameli, A Manni, L Manzione, C Martini, A Martoni, N Marzano, S Masseroni, V Mattioli, P Maurizi, D Miotti, L Montanari, L Moscetti, V Murgia, L F Nardi, F Narducci, F Negri, C Orlandini, D Ottaviani, G Pancera, F Paoletti, A Pappalardo, M K Paris, C Pittureri, L Piva, L Ponchio, C Reale, A Rinaldi, E Romagnoli, A Russo, C Sandomenico, A Sbanotto, F Scanzi, I Schiavetto, L Trentin, M Tucci, G Vaccaro, D Valenti, V M Valori, G Vasini, E Veltri, V Zagonel, E Zecca, G Zeppetella, M Ziliotti, F Zucco

Abstract

Most patients with advanced or metastatic cancer experience pain and despite several guidelines, undertreatment is well documented. A multicenter, open-label, prospective, non-randomised study was launched in Italy in 2006 to evaluate the epidemiology, patterns and quality of pain care of cancer patients. To assess the adequacy of analgesic care, we used a standardised measure, the pain management index (PMI), that compares the most potent analgesic prescribed for a patient with the reported level of the worst pain of that patient together with a selected list of clinical indicators. A total of 110 centres recruited 1801 valid cases. 61% of cases were received a WHO-level III opioid; 25.3% were classified as potentially undertreated, with wide variation (9.8-55.3%) according to the variables describing patients, centres and pattern of care. After adjustment with a multivariable logistic regression model, type of recruiting centre, receiving adjuvant therapy or not and type of patient recruited (new or already on follow-up) had a significant association with undertreatment. Non-compliance with the predefined set of clinical indicators was generally high, ranging from 41 to 76%. Despite intrinsic limitations of the PMI that may be considered as an indicator of the poor quality of cancer pain care, results suggest that the recourse to WHO third-level drugs still seems delayed in a substantial percentage of patients. This delay is probably related to several factors affecting practice in participating centres and suggests that the quality of cancer pain management in Italy deserves specific attention and interventions aimed at improving patients' outcomes.

Figures

Figure 1
Figure 1
Pain management index.
Figure 2
Figure 2
Synopsis of the stages of the study.
Figure 3
Figure 3
Percentages (95% confidence interval) of patients with negative PMI in all the combinations among levels of recruiting centres, adjuvant therapy and time of recruiting.

References

    1. Apolone G, Bertetto O, Caraceni A, Corli O, De Conno F, Labianca R, Maltoni M, Nicora M, Zucco F, Cancer Pain Outcome Research Study Group (2006a) Pain in cancer. An outcome research project to evaluate the epidemiology, the quality and the effects of pain treatment in cancer patients. Health Qual Life Outcomes 14: 4–7
    1. Apolone G, Mangano S, Compagnoni A, Negri E, Mosconi P, Mannino S, Villa M, Zuccaro P, Cancer Pain Outcome Research Study Group (CPOR SG) (2006b) A Multidisciplinary Project to improve the quality of cancer pain management in Italy. Background, methods, and preliminary results. J Ambul Care Manage 29: 332–341
    1. Apolone G, Mosconi P, Colombo P, Tamburini M (2004) Il dolore nel paziente con cancro: un progetto di ricerca. Ricerca Pratica 20: 137–143
    1. Apolone G, Corli O, Greco MT, Zagonel V (2008) Factors influencing the decision to take or reject opioids for cancer pain: are we on target? Ann Oncol 19(5): 1021–1022
    1. Brink-Huis A, van Achterberg T, Schoonhoven L (2008) Pain management: a review of organisation models with integrated processes for the management of pain in adult cancer patients. J Clin Nurs 17: 1986–2000
    1. Caraceni A, Mendoza T, Mencaglia E, Baratella C, Edwards K, Forjaz MJ, Martini C, Serlin RC, de Conno F, Cleeland CS (1996) A validation study of the Italian version of the Brief Pain Inventory (Breve Questionario per la Valutazione del Dolore). Pain 65: 87–92
    1. CEVEAS: Centro per la valutazione della efficacia della assistenza sanitaria (2004) Morfina orale e altri oppioidi nel dolore oncologico. Aggiornamento sui farmaci no. 9, October,
    1. Cleeland CS, Gonin R, Hatfiled AK, Edmonson JH, Blum RH, Stewart JA, Pandya KJ (1994) Pain and its treatments in outpatients with metastatic cancer. N Engl J Med 330: 592–596
    1. Clivio L, Tinazzi A, Mangano S, Santoro E (2006) The contribution of information technology: towards a better clinical data management. Drug Dev Res 67: 245–250
    1. Cohen MZ, Easley MK, Ellis C, Hughes B, Ownby K, Rashad BG, Rude M, Taft E, Westbrooks JB, for the JCAHO (2003) Cancer pain management and the JCAHO's Pain Standards. An institutional challenge. J Pain Symptom Manage 25: 519–527
    1. De Conno F, Ripamonti C, Brunelli C (2005) Opiods purchase and expenditures in nine western European countries: are we killing off morphines? Palliat Med 19: 179–184
    1. de Wit R, van Dam F, Abu-Saad HH, Loonstra S, Zandbelt L, van Buuren A, van der Heijden K, Leenhouts G (1999) Empirical comparison of commonly used measures to evaluate pain treatment in cancer patients with chronic pain. J Clin Oncol 17: 1280–1287
    1. Deandrea S, Montanari M, Moja L, Apolone G (2008) Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol 19: 1985–1991
    1. Di Maio M, Gridelli C, Gallo C, Manzione L, Brancaccio L, Barbera S, Robbiati SF, Ianniello GP, Ferraù F, Piazza E, Frontini L, Rosetti F, Carrozza F, Bearz A, Spatafora M, Adamo V, Isa L, Iaffaioli RV, Di Salvo E, Perrone F (2004) Prevalence and management of pain in Italian patients with advanced non-small-cell lung cancer. Br J Cancer 90: 2288–2296
    1. Du Pen SL, Du Pen AR, Polissar N, Hansberry J, Kraybill BM, Stillman M, Panke J, Everly R, Syrjala K (1999) Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial. J Clin Oncol 17: 361–370
    1. Goldberg GR, Morrison RS (2007) Pain management in hospitalized cancer patients: a systematic review. J Clin Oncol 25: 1792–1801
    1. Grond S, Zech D, Diefenbach C, Radbruch L, Lehman KA (1996) Assessment of cancer pain: a prospective evaluation in 2266 cancer patients referred to a pain service. Pain 64: 107–114
    1. Hanks G, De Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, Mercadante S, Meynadier J, Poulain P, Ripamonti C, Radbruch L, Casas JR, Sawe J, Twycross RG, Ventafridda V, Expert Working Group of the Research Network of the European Association for Palliative Care (2001) Morphine and alternative opioids in cancer pain the EAPC recommendations. Br J Cancer 84: 587–593
    1. Harrington SB, Smith TJ (2008) The role of chemotherapy at the end of life: ‘When is enough, enough?’. JAMA 299: 2667–2678
    1. Hearn J, Higginson IJ (2003) Cancer pain epidemiology: a systematic review. In Cancer Pain, Assessment and Management Bruera ED, Portenoy RK (eds) Cambridge University Press: Cambridge
    1. Jacox A, Carr DB, Payne R (1994) New clinical-practice guidelines for the management of pain in patients with cancer. N Engl J Med 330: 651–655
    1. Mercadante S (1999) Pain treatment and outcomes for patients with advanced cancer who receive follow-up care at home. Cancer 85: 1849–1858
    1. Maltoni M (2008) Opioids, pain, and fear. Ann Oncol 19: 5–7
    1. Meyers FJ, Linder J, Beckett L, Christensen S, Blais J, Gandara DR (2004) Simultaneous care: a model approach to the perceived conflict between investigational therapy and palliative care. J Pain Symptom Manage 28: 548–556
    1. Osservatorio Nazionale sull’impiego dei farmaci (2007) Rapporto nazionale gennaio-settembre 2007. L’uso dei farmaci in Italia,
    1. Reid CM, Gooberman-Hill R, Hanks GW (2008) Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol 19: 44–48
    1. Russell PB, Aveyard SC, Oxenham DR (2006) An assessment of methods used to evaluate the adequacy of cancer pain management. J Pain Symptom Manage 32: 581–588
    1. Scottish Intercollegiate Guidelines Network (2008) Control of pain in adult patients with cancer. A national clinical guidelines accessed on 03.03.2009
    1. van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, Schouten HC, van Kleef M, Patijn J (2007) Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol 18: 1437–1449
    1. Ventafridda V, Tamburini M, Caraceni A, DeConno F, Naldi F (1987) A validation study of the WHO method for cancer pain relief. Cancer 59: 851–856
    1. Ventafridda V, Caraceni A, Gamba A (1990) Field-testing of the WHO guidelines for cancer pain relief, in Advances in Pain Research and Therapy, vol. 16, In 2nd International Congress on Cancer Pain. Foley KM, Ventafridda V, Bonica JJ (eds), pp 451–464. Raven Press: New York
    1. Wong RKS, Wiffen PJ (2002) Bisphosphonates for the relief of pain secondary to bone metastases. Cochrane Database of Systematic Reviews, (Issue 2): Art. No. CD002068. DOI 10.1002/14651858.Cd002068
    1. World Health Organization (1996) Cancer Pain Relief, 2nd edn World Health Organization: Geneva

Source: PubMed

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