BeCOn OWN Educational Program
Modules
Module 2
Diagnosis 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 relief
of cancer pain and related outcomes
Early intervention and relief of cancer-related pain may reduce
the risk of central sensitisation or “windup,” which is associated
with 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
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
PMI, pain management index
Overall = 25.2%
0
10
20
30
40
50
% PMI-
Even at specialised centres, patients are classified as potentially undertreated
in 9.8–55.3% of cases
Apolone G, et al. Br J Cancer. 2009;100(10):1566-74.
60
70
Cancer pain is undertreated
European survey of 5,084 patients with various types of cancer
across 11 countries and Israel
80
70
69%
Patients (%)
60
50
56%
50%
44%
40
63%
30
20
10
0
Moderate to
severe pain
at least once
a month
Described
pain as
severe
Breivik H, et al. Ann Oncol. 2009;20(8):1420-33.
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
No. of
studies
Range of
negative
PMI (%)
1944-2000
12
27-79
2001-2007
14
8-82
United States
8
8-65
Europe
8
9-82
Asia
9
27-79
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
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
26
8-82
Characteristics
of studies
Year
Geographic
area
Economic level
Setting
Total
Deandrea S, et al. Ann Oncol. 2008;19(12):1985-91.
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
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
Cognitive
factors
Affective
factors
Poor pain
assessment
Patientrelated
barriers
Adherence to
analgesic regimens
HCPrelated
barriers
Fear of addiction,
tolerance, adverse
effects, respiratory
depression
Limits on
access to opioids
Healthcaresystem-related
barriers
Availability of pain
and palliative care
specialists
HCP – healthcare professional
Kwon JH. J Clin Oncol. 2014;32(16):1727-33.
Lack of
knowledge
and skill
Reluctance of
physicians to
prescribe opioids
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.
More effective management of pain requires
asking the right questions
Onset of pain?
Exacerbating factors?
Frequency of pain?
Relieving factors?
Site of pain?
Response to analgesics?
Radiation of pain
Response to other interventions?
Quality (character) of pain?
Associated symptoms?
Intensity (severity) of pain?
Interference with activities of daily
living?
Duration of pain?
Asking key questions can provide important insights into the patient’s pain
Davies A, et al. Eur J Pain. 2009;13(4):331-8.
LIDOCAINE: a mnemonic device to guide
the clinician in asking leading questions
Focus
L
I
D
O
C
A
I
N
E
Sample questions
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?
Pergolizzi JV, et al. Pain Pract. 2014 Dec 3. doi: 10.1111/papr.12253. [Epub ahead of print].
Pain management index (PMI)
WHO analgesic drug level
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
Pain Intensity
The PMI compares the most potent analgesic prescribed for a patient
with 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 scores
of 0 or higher are considered a conservative indicator of acceptable treatment
Cleeland CS, et al. N Engl J Med. 1994;330:592-596.
Guidelines on pain assessment
ESMO guidelines for adequate assessment
of pain at any stage of disease (i)
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
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 (ii)
2. Assess and re-assess the patient
Clinical 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 assessed
using (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 distress
should 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
Validated assessment tools for assessment of pain
Visual analogue scale VAS
10 cm
No
pain
Worst
pain
Verbal rating scale VRS
1
No
pain
2
Very
mild
3
4
Mild
5
Moderate
6
Severe
Very
severe
Numerical rating scale NRS
No
pain
0
1
2
3
4
5
Ripamonti CI, et al. Ann Oncol. 2012 Oct;23 Suppl 7:vii139-54.
6
7
8
9
10
Worst
pain
Wong-Baker FACES scale
Wong-Baker FACESTM Pain Rating Scale
0
2
4
6
8
10
No
hurt
Hurts
little bit
Hurts
little more
Hurts
even more
Hurts
whole lot
Hurts
worst
The Wong-Baker FACES scale is reliable and easy to administer
Bieri D, et al. Pain Manage Nurs. 1990;41:139-150.
Body pain diagram
Body 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 Tool
can be used in uncommunicative patients
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
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
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
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
Body movements
Compliance with the ventilator
(intubated patients)
OR
Vocalisation (extubated patients)
Total, range
0-8
Gélinas C, et al. J Adv Nurs. 2009;65(1):203-16.
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
Compared to usual care or control,
educational interventions:
Improved
knowledge
and attitudes
0.04 0.52
Reduced
average pain
intensity
-1.8
-1.1
-2.5
-2.0
-1.5
-1.0
Patient-based educational
interventions are probably
underused alongside more
traditional analgesic
approaches
-0.41
-1.21 -0.78
Reduced worst
pain intensity
1.0
-0.35
0.0
Bennett MI, et al. Pain. 2009;143(3):192-9.
0.5
1.0
Standardised educational interventions
can improve pain scores
-1.84
Booklet
versus SC
-0.89
0.06
P=0.07
-1.83
Video
versus SC
-0.86
0.11
P=0.08
-2.17
Booklet & Video
versus SC
-1.17
-0.17
P=0.02
-2.5
-2.0
-1.5
-1.0
-0.5
Favours
intervention
0.0
0.5
Favours
standard care (SC)
Lovell MR, et al. J Pain Symptom Manage. 2010;40(1):49-59.
Provision of a video and/or
booklet for people with
cancer pain is a feasible and
effective adjunct to
management of cancer pain
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 Pain
Questionnaire (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
DVD-based intervention is feasible and potentially effective
between 7–30 days follow up
Capewell C, et al. Palliat Med. 2010;24(6):616-22.
iPhone pain assessment application
for adolescents with cancer
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
Stinson JN, et al. J Med Internet Res. 2013;15(3):e51.
Medical oncologists’ attitudes and practice
in cancer pain management
Survey of 2000 oncologists (overall response rate 32%)
10
9
Median score
8
7
7
6
6
6
6
5
5
4
3
3
Rated peers as
more
conservative
prescribers
Quality of pain
management
training during
medical school
3
2
1
0
Rated their
specialty highly
for ability to
manage cancer
pain
Poor
assessment
Patient
reluctance to
take opioids
Patient
reluctance
report pain
Physician
reluctance to
prescribe
opioids
Barriers
Oncologists and other medical specialists who manage cancer pain have knowledge
deficiencies in cancer pain management
Breuer B, et al. J Clin Oncol. 2011;29(36):4769-75.
Steps for optimal cancer pain management
Patient misinterprets pain or
accepts pain as inevitable
Patient is uncertain how to
seek medical attention
Patient
experiences and
interprets pain
Patient
interacts with
HCP
Patient/HCP communication
about pain is suboptimal
Analgesia
commenced/
altered.
Anticancer & nonpharmacological
therapies
discussed
HCP fails to prescribe
adequate analgesic regimen
Intentional non-adherence
by patient (e.g. decision not
to mask pain, fear of side
effects or addiction)
Unintentional nonadherence by patient –
misunderstanding of dosing
regimen, forgetfulness
HCP fails to consider
adjuvant anticancer
therapies, or nonpharmacological therapies
Patient fails to report pain
Pain changes, e.g. due to
disease progression/
analgesic tolerance
Re-assessment
Pain is not re-assessed
Adam R, et al. Patient Educ Couns. 2015;98(3):269-82.
Pain assessment is
suboptimal
Patient education, coaching and self-management for
cancer pain
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
Lovell MR, et al. J Clin Oncol. 2014;32(16):1712-20.
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