Palliative Medicine 2007; 21: 7 13
Prevalence of pain in hospitalised cancer patients in
Norway: a national survey
Anders Holtan Department of Anaesthesia and Post-operative Care, Ullevål University Hospital and Faculty of
Medicine, University of Oslo, Oslo, Nina Aass Palliative Care Research Unit, The Norwegian Radium Hospital,
Oslo, Tone Nordøy Department of Oncology, University Hospital of North Norway, Tromsø, Dagny Faksvåg
Haugen Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital,
Bergen, Stein Kaasa Palliative Medicine Unit, University Hospital of Trondheim, Trondheim, Wenche Mohr
Centre for Palliative Care, Ullevål University Hospital, Oslo and Ulf E Kongsgaard Department of Anaesthesia
and Intensive Care, The Norwegian Radium Hospital and Faculty of Medicine, University of Oslo, Oslo
Purpose: Pain severely impairs health-related quality of life and is a feared symptom
among cancer patients. Unfortunately, patients often do not receive optimal care.
We wanted to evaluate the quality of cancer pain treatment in Norwegian hospitals.
Patients and methods: A one-day prevalence study targeting hospitalised cancer
patients above 18 years of age was performed. A questionnaire based on the Brief Pain
Inventory was used, and additional information regarding sex, age, diagnosis, break
through pain (BTP), and treatment was included. Results: Fifty two percent of the
included patients stated having cancer related pain (n /453), and mean pain during the
previous 24 hours for these patients was NRS 3.99 (Numeric Rating scale 1 10).
Presence of metastasis, occurrence of BTP, and abnormal skin sensibility in the
area of pain were associated with higher pain scores. Forty two percent of all patients
used opioids. However, these patients still had higher pain scores, more episodes
of BTP, and more influence of the pain on daily life functions than average. Thirty
percent of patients with severe pain (NRS]/5) did not use opioids, and some
of these patients did not receive any analgesics at all. Conclusion: Although
most cancer patients receive an acceptable pain treatment in Norwegian hospitals,
there are patients who are not adequately managed. Lack of basic knowledge
and individual systematic symptom assessment may be reasons for the underuse
of analgesics and the resulting unnecessary suffering among the cancer patients.
Palliative Medicine 2007; 21: 7 13
Key words: cancer; pain; palliative care; prevalence; opioids; questionnaires
Introduction
Norway, with a total population of 4.5 million, has
21 000 new cancer cases discovered yearly (Cancer
Registry of Norway 2003). As a result, approximately
140 000 people living in Norway today have, or have had,
a cancer diagnosis (Minister of Health and Care Services
in Norway 2005). We have limited knowledge about the
incidence of cancer pain in Norway, but the improved
medical treatment and an increasingly aging population
are likely to result in even higher numbers of patients
living with cancer pain, making supportive cancer treatment a major challenge.
Studies have shown considerable variation in the
prevalence of pain among cancer patients.1,2 Different
Address for correspondence: Anders Holtan MD, Department
of Anaesthesia and Postoperative Care, Ullevål University
Hospital and Faculty of Medicine, University of Oslo, Oslo,
Norway. E-mail: anders.holtan@uus.no
# 2007 SAGE Publications
study populations and assessment tools may explain
some of the discrepancies, but it is generally agreed that
many patients still do not receive adequate pain relief.
This can partly be explained by health care personnel
having limited knowledge,3 or awareness of the need for
adequate symptom assessment and control,4,5 although
clinical guidelines recommend systematic pain assessment in individual patients in order to optimise pain
control.6 In addition, identification of parameters predicting a high probability of cancer related pain would be
helpful in daily clinical practice.
Surveys assessing pain in a large group of patients may
reveal important information about variations in and the
quality of the pain treatment offered. The results of a
national survey undertaken in Norwegian hospitals in
2004 are presented in this article. The aims of the study
were:
10.1177/0269216306073127
8
1)
2)
3)
A Holtan et al.
To assess pain treatment offered to hospitalised
cancer patients on a national basis.
To identify objective and reliable measures for
cancer related pain.
To identify possible factors associated with severe
cancer related pain.
Patients and methods
The target population was all cancer patients ]/18 years
of age, hospitalised due to their malignant disease, in any
somatic public hospital in the five health care regions in
Norway on the day of the study. All patients received oral
and written information prior to the study, and informed
consent was obtained.
Exclusion criteria were: (1) surgery B/24 hours prior to
the study; (2) cognitive impairment; (3) patient declining
participation; and (4) other reasons. All patients included
in the study were anonymous to the central data analysis.
Excluded patients, for whom administrative information
about age, diagnosis, and use of analgesics was registered,
were unidentifiable.
The survey was performed as a single day prevalence
study, between 08:00 and 12:00 hours in May 2004. All
participating hospitals, with the exception of three
hospitals in one single region, agreed to participate in
the survey on a given date. Due to limited personnel
resources, the remaining three hospitals performed the
survey on different days the following week.
The survey consisted of a questionnaire which was
filled in by both patients and investigators. The questionnaire was based on the Brief Pain Inventory (BPI),7
an evaluation tool for cancer related pain which has been
translated into Norwegian and validated in Norwegian
cancer patients.8 Pain is rated from 0 to 10 using a
numerical rating scale (NRS) (0 /no pain, 10/worst
possible pain). The experience of pain during the
previous 24 hours is assessed as ‘average pain’, ‘least
pain’ and ‘worst pain’. In addition, ‘pain right now’ is
assessed. Many investigators regard a NRS 5/3 as
acceptable and a NRS ]/5 as severe pain.9,10 These levels
were, therefore, used as cut-off points in the analysis. The
influence of pain on general activity, mood, walking
ability, working ability, relationship with other people,
sleep, and enjoyment of life were also examined. In
addition, the questionnaire covered information regarding sex, age, diagnosis, treatment modality, treatment
intention, occurrence of breakthrough pain (BTP), and
pain medication. Treatment intention was given as
curative, palliative, or unresolved. The questionnaire
also included a specific question (for the patient) regarding abnormal skin sensibility in the area of the pain.
Questions regarding BTP were: ‘Do you have short
episodes of intense pain when your pain treatment
otherwise has been generally effective?’, and ‘If yes;
how many episodes have you experienced each day
(24 hours) on the average?’ The term ‘pain medication’
included both classic analgesics, such as opioids, paracetamol and NSAIDs; and co-analgesics, such as steroids, tri-cyclic antidepressants and antiepileptics. The
cancer diagnoses were categorised according to the ICD10 system.11 Some patients had more than one cancer
diagnosis and, therefore, were omitted from sub-analyses
relating pain and other variables to specific diagnosis.
Data are also presented in relation to age and hospital
size. Older patients are defined as age 75 years and above
and younger as B/75 years. This project was supported by
an unrestricted grant from Mundipharma AS, Lysaker,
Norway and the Regional Committees for Medical
Research Ethics in Norway. The Norwegian Social
Science Data Services approved the study.
Statistical analyses
The statistical program SPSS, version 11.5, was used for
statistical analyses. Results in pain-scores are presented
as mean values. One-way variance analyses were used to
identify differences between groups, and t -tests were
thereafter applied to verify these differences. Although
the material did not always show a normal distribution,
parametric tests were applied due to the large size of the
groups. For smaller groups, KruskalWallis and Mann Whitney tests were applied. Categorical data was compared with Pearson’s x2-tests, Fisher’s exact test and
linear-by-linear x2-tests. Linear regression analyses were
used to determine predictors for higher pain scores/
intensity, and NRS scores were regarded as continual
variables in these analyses. A P valueB/0.05 was regarded
as statistically significant.
Results
Patient characteristics
A total of 1337 patients, with a mean age of 66 years,
from 57 hospitals in all five Norwegian health care
regions were accrued (Figure 1). Four small hospitals did
not take part in the study due to administrative problems.
A total of 872 patients were included and 465 excluded.
The reasons for exclusion were: patient refusal (n /158),
cognitive impairment (n/148), surgery B/24 hours prior
to the study (n/62), and other reasons (n/97). Detailed
patient characteristics are presented in Table 1. The most
prevalent diagnoses were gastrointestinal, gynaecological,
urological, pulmonary, and haematological malignancies.
Some 30% of the patients were age 75 or above, and this
group had a significant lower inclusion rate (56%) than
the younger patients (70%). Females, likewise, had a
significant lower inclusion rate compared to males (61.4
versus 70.1%). For other variables, no differences between the included and excluded patients were found.
Although the treatment intention was palliative for the
Cancer pain in Norwegian hospitals 9
Study target population
61 Norwegian public somatic hospitals
4 hospitals did
not participate
All patients
1337 patients, 57 Hospitals
Excluded patients
465 patients, 50 hospitals
Included patients
872 patients*, 55 hospitals
Included patients without cancer pain
404 patients*
Included patients with cancer pain
453 patients*
Figure 1 The term ‘‘all patients’’ is in this article defined as the total number of registered patients, both included patients,
who have accepted participating in the study; and the excluded patients. *There is missing information about presence of
cancer related pain in 15 included patients
Table 1 Descriptive data for the excluded patients, included patients without cancer related pain, and included patients with
cancer related pain. The figures show number of patients with percent on the basis of ‘‘all patients (n/1337)’’ in brackets:
No of patients*
Female
Male
Missing information regarding sex
Age (Mean years)
Missing information regarding age
Excluded patients
Included patients without
cancer related pain
Included patients with
cancer related pain
465
261
192
12
404
196
206
2
453
211
238
4
(100)
(56.1)
(41.3)
(2.6)
67.8 (n /459)
6 (1.3%)
(100)*
(48.5)
(51.0)
(0.5)
66.1 (n /404)
0
(100)*
(46.6)
(52.5)
(0.9)
63.4 (n /453)
0
Diagnosis**
GI cancer
Urological cancer
Haematological malignancies
Lung cancer
Gynaecological cancer
Breast cancer
Head and neck cancer
Other diagnoses
Missing information regarding diagnosis
122 (26.2)
77 (16.6)
54 (11.6)
52 (11.2)
32 (6.9)
37 (8.0)
20 (4.3)
82 (17.6)
n/1 (0.2)
99 (24.5)
67 (16.6)
70 (17.3)
48 (11.2)
46 (11.4)
27 (6.7)
14 (3.5)
49 (12.1)
n /0
113 (24.9)
71 (15.7)
64 (14.1)
57 (12.6)
50 (11.0)
37 (8.2)
20 (4.4)
54 (11.9)
n /1 (0.2)
Metastases-any localization
Bone metastases
Liver metastases
Lung metastases
Brain metastases
153
38
46
22
18
(32.9)
(8.2)
(9.9)
(4.7)
(3.8)
108
22
23
11
16
(26.7)
(5.4)
(5.7)
(2.7)
(4.0)
170
77
39
24
13
(37.5)
(17.0)
(8.6)
(5.3)
(2.9)
Treatment intention
Palliative
Curative
Unresolved
Missing information regarding treatment intentions
219
114
57
75
(47.1)
(24.5)
(12.2)
(16.1)
182
145
63
14
(45.0)
(35.9)
(15.6)
(3.5)
271
120
49
13
(59.8)
(26.5)
(10.8)
(2.9)
Treatment modality
Preceding surgery
Ongoing radiotherapy
Ongoing chemotherapy
Missing information regarding treatment modality
202
63
68
62
(43.4)
(13.5)
(14.6)
(13.3)
207
81
120
1
(51.2)
(20)
(29.7)
(0.3)
257
96
103
1
(56.7)
(21.2)
(22.7)
(0.2)
*There is missing information about presence of cancer related pain in 15 included patients.
**Diagnoses: GI-cancer includes oesophagus, ventricle, jejunum/ileum, colon, rectum, pancreas and liver cancer.
Gynaecological cancer includes ovarian, corpus uteri, cervix uteri, and vulva cancer. Urological cancer includes kidney, ureter,
bladder, urethra, penis, prostate, and testis cancer. Haematological malignancies include lymphoma, leukaemia, and multiple
myeloma. Some patients have more than one diagnosis.
10
A Holtan et al.
majority of patients in all hospitals, the relative proportion of this group was especially high in small local
hospitals.
Cancer related pain
A total of 52% of the included patients (n /453) reported
pain by answering ‘Yes’ to the opening question:
‘Throughout our lives, most of us have had pain from
time to time (such as minor headaches, sprains, and
toothaches). Have you had pain other than these everyday kinds of pain today?’.12 The prevalence of pain for
patients with advanced disease (metastases or palliative
treatment intention) was 61%. The mean scores, using the
NRS, for ‘average pain’ score during the last 24 hours for
patients who reported pain was 3.99 (SD 2.2), ‘worst
pain’ 5.10 (SD 2.6), ‘least pain’ 1.80 (SD 1.9), and ‘pain
right now’ 2.56 (SD 2.3). Some 80% of the patients with
cancer related pain had an ‘average pain’ scoreB/5
(Figure 2). There was no difference in pain scores
between the two age groups. Some 37% (n/322) of the
included patients reported having BTP, with a mean of
five episodes a day and a median of three. A total of 61
patients reported having six episodes or more of BTP
daily.
Compared to patients with scores5/3, patients who
reported average pain more than three times during the
previous 24 hours, more often had a palliative treatment
intention. They were also more likely to have episodes of
BTP, abnormal skin sensibility in the area of pain, or
used any form of opioid-analgesics. Increased pain,
measured as a continuous variable, correlated to high
scores with regard to the pain’s influence on general
activity, mood, walking ability, working ability, relationship to other people, sleep, and enjoyment of life. Patients
with BTP and abnormal skin sensibility in the area of
pain scored significantly higher on these functional
parameters than those without these symptoms.
Variables predicting severe cancer pain
Certain variables were tested to see whether they were
associated with higher pain intensity (Table 3). The
variables used in this analysis were partly selected from
relevant literature,13 16 and partly chosen from our own
clinical experience. The two variables found to be most
important in predicting pain, were ‘presence of BTP’ and
‘abnormal skin-sensibility in the area of pain’.
Use of analgesics
The use of analgesics was registered for both included
and excluded patients (Table 2). Of all patients, 28%
(n/374) used no analgesics, 4% (n /57) used only coanalgesics, while the rest used traditional analgesics that
could be related to steps on the WHO ladder.17 Excluded
patients used less analgesic than patients included in the
survey (Table 3).
The included patients were analysed in more detail:
75% used analgesics. Patients who reported pain used
more analgesics compared to patients without pain
(Table 2). Of the patients reporting pain, 62% used
opioids compared to 24% of the patients without pain.
One-third of the included patients who were using
weak opioids, corresponding to step 2 on the WHO
ladder, also used strong opioids belonging to step 3 on
the ladder. Looking at different routes of opioid
administration, the oral route was most common
(74%, n/284), followed by parenteral (29%, n /111),
and transdermal routes (27%, n /104). Of the included
patients, 10% (n /88) used both paracetamol and
NSAIDs. No difference related to age was found in
the use of opioids or NSAIDs. Patients who reported
BTP received significantly more analgesics and coanalgesics than patients without BTP. Of the patients
reporting pain, 37% did not receive any analgesic at all.
Of the patients with mean pain score]/5, 30% (n/54)
did not use opioids, and 7% (n/12) did not receive
any analgesics.
250
Discussion
200
150
100
50
9
8
7
6
5
4
3
2
1
0
10
M
is
si
ng
0
Figure 2 Dispersion of ‘average’ pain during the last 24
hours for the included patients (n /872), given as NRS
(X-axis) and number of patients (Y-axis)
This national survey was performed in 57 of 61 Norwegian public hospitals to evaluate the prevalence of pain in
hospitalised cancer patients. A total of 1337 cancer
patients were registered on the day of the study, of which
872 were included. Of the included patients, 52%
reported pain, with mean pain score (NRS 0 10)
‘average pain’ for the preceding 24 hours of 3.99. Of
the patients with pain, 20% reported ‘average pain’ as
severe ( ]/5). About 60% of the patients reporting pain
used strong opioids.
Our target population was all cancer patients hospitalised due to their malignant disease on the day of the
study. Four smaller hospitals did not take part in the
Cancer pain in Norwegian hospitals
11
Table 2 The table demonstrates the use of analgesics, given as the number of patients and columnar percentage. The
number of patients in each group that did not use any analgesics is also given:
Drug
All patients
n /1337
Excluded patients
n /465
All included patients
n /872
Included patients having no
cancer related pain
n /404
Included patients having
cancer related pain
n /453
Paracetamol
NSAIDs**
Weak opioids**
Strong opioids**
TCA & AE***
Steroids
No analgesics
617
191
186
559
117
274
374
190
58
46
177
36
87
157
427
133
140
382
81
187
217
150
42
42
97
16
78
44
272
89
94
281
63
108
167
(46.1)
(14.3)
(13.9)
(41.8)
(8.8)
(20.5)
(28.0)
(40.1)
(12.5)
(9.9)
(38.0)
(7.7)
(18.7)
(33.8)
(49.9)
(15.3)
(16.1)
(43.8)
(9.3)
(21.4)
(24.8)
(37.1)
(10.4)
(10.4)
(24.0)
(4.0)
(19.3)
(10.9)
(60.0)
(19.6)
(20.8)
(62.0)
(13.9)
(23.8)
(36.9)
*There is missing information about presence of cancer related pain in 15 included patients.
**NSAIDs include coxibs. Weak opioids include codeine, dextropropoxyphene, and tramadol. Strong opioids include morphine,
oxycodone, fentanyl, buprenorphine, and ketobemidone.
***TCA/tri-cyclic antidepressants, AE/antiepileptics.
study. There is, of course, a possibility that a few cancer
patients might have been missed in the 57 participating
hospitals. The percentage of females and old patients
was significantly lower among the included than the
excluded patients. More of the included patients used
analgesics compared to those not included in the survey.
Otherwise, there were no differences between the
included and excluded patients. Due to the high number
of included patients, we think the material is reliable
because of: (1) an overall inclusion rate of 66%; (2) a
normal distribution of gender and age; (3) few differences among the regions concerning included patients,
inclusion rates, diagnoses, and age; (4) and an overall
distribution of diagnoses reflecting the prevalence of the
different cancer types in Norway, as described by the
Norwegian Cancer Registry.18
To our knowledge a national sample, such as the
present series, has never been achieved before. Most
prevalence studies are smaller,20 have been performed in
smaller groups defined by diagnosis, limited geographical
areas, or hospitals.21 In this study, the prevalence of
cancer related pain in hospitalised patients was found to
be 52%. In a previous Norwegian regional survey, a
similar result of 51% was found.22 A review of other
studies gave a mean cancer pain prevalence of 40%
(range: 18 100%) for the group ‘general adult population’.23 Some of these studies also included outpatients,
which may be reflected in a lower prevalence of pain
Table 3 Regression analyses were used to identify variables associated with higher NRS. Pain scores were regarded as a
continual variable, and mean pain preceding 24 hours were chosen as the dependent variable:
Unstandardized Coefficients
B
(Constant)
Gender
Age]/75 orB/75 years
GI cancer
Urological cancer
Haematological malignancies
Other diagnoses
Lung cancer
Gynaecological cancer
Breast cancer
Head and neck cancer
Presence of metastases
Curative treatment intention
Palliative treatment intention
Treatment intention unresolved
Presence of Break Through Pain
Abnormal skin sensitivity*
Small Hospitals
Medium Hospitals
Large Hospitals
Dependent Variable: Mean pain 24 hours
3.649
/0.032
0.002
0.151
/5.096
/5.033
/5.179
/4.805
/5.150
/5.164
/4.395
0.133
0.040
0.440
0.555
1.849
1.023
/0.217
/0.028
/0.302
*Abnormal skin sensitivity in the area of pain.
Standardized Coefficients
Std. Error
Beta
t
Sig.
3.193
0.181
0.006
0.356
2.196
2.200
2.202
2.194
2.201
2.200
2.216
0.198
0.496
0.482
0.516
0.170
0.175
2.190
2.185
2.186
/0.007
0.012
0.026
/0.748
/0.704
/0.614
/0.645
/0.646
/0.974
/0.421
0.026
0.008
0.089
0.076
0.367
0.196
/0.033
/0.006
/0.061
1.143
/0.174
0.355
0.425
/2.320
/2.287
/2.352
/2.190
/2.340
/2.347
/1.984
0.672
0.081
0.913
1.075
10.878
5.855
/0.099
/0.013
/0.138
0.254
0.862
0.723
0.671
0.021
0.022
0.019
0.029
0.020
0.019
0.048
0.502
0.936
0.361
0.283
0.000
0.000
0.921
0.990
0.890
12
A Holtan et al.
compared to our findings. In the same review, the
prevalence of pain in patients with advanced cancer
was 74% (range: 53100%) compared to our findings of
61%.
When using the BPI, some patients may answer ‘Yes’ to
the opening question (‘Other than these everyday kinds
of pain, have you had pain today?’) on a different basis
than cancer related pain, ie, due to chronic nonmalignant conditions. However, this is probably relevant
for only a small number of patients. The instrument also
does not differentiate between disease related and treatment related pain. For some groups of patients, the pain
is mostly related to therapy, as in patients with head and
neck cancer receiving curative irradiation.19 Furthermore, a one-day prevalence study will not capture the
dynamic nature of pain. Our study, for example, did not
take into account the length of time the patient had been
admitted to the hospital.
Pain is one of the symptoms most feared by cancer
patients.24,25 In the present study, the ‘average pain’ score
for the last 24 hours was close to 4, and 20% of the
patients reported ‘average pain’ ]/5. It is also worth
mentioning that no differences in pain intensities related
to age are shown in this study (Table 3). Former studies
have both found,16 and not found,14 that increasing age
accompanies increased pain intensity. Even though many
patients were using strong opioids, there seems to be an
underuse of these drugs. As this was a survey in
hospitalised patients, it is not surprising that the parenteral route of opioid administration was often utilised.
Patients taking strong opioids had significantly higher
NRS scores than patients not using this type of analgesic.
Many of the patients on strong opioids also reported
having more than six episodes of breakthrough pain per
day, which might be a sign of under-dosage. It is,
therefore, reasonable to conclude that the use of neither
long-acting nor short-acting opioids seems to be optimal.
It could be argued that only those few patients who were
receiving opioids, but did not report having cancer
related pain, have received optimal treatment (n /97).
In relation to new knowledge regarding mechanisms in
cancer pain, it could also be argued that the use of coanalgesics in our patients group is too low (Table 2). This
is supported by our findings that altered skin sensibility
of pain (perhaps indicating a neuropathic component?)
was one of the variables for predicting severe cancer pain.
Thus, there is obviously a potential for improving cancer
pain management in Norway. Our findings indicate that
the principles of the WHO ladder,26 are not followed, and
that patients are suffering as a result. One example
illustrating this is that one out of three patients using
analgesics from step 2 (weak opioids, ie, codeine), also
use strong opioids belonging to step 3 of the ladder. This
is normally not regarded as state of the art pain therapy,
and this finding may suggest a need for better education
in palliative care. A mean NRS score for the previous
24 hours of close to 4 for ‘average pain’ is probably also
not satisfactory. On the other hand, the fact that 47% of
the included patients reported no pain may seem
acceptable. Comparison with other countries is not
possible, since no similar studies are known.
The prevalence of BTP is highly variable in different
study materials.27 In the present series, the prevalence of
BTP was 37%. Patients reporting BTP scored worse on
all pain and pain-related items. Our findings correspond
to results from previous studies, demonstrating that
patients with BTP assess their pain as worse than those
without BTP, and that they have a poorer quality of life,
and a more complex situation.27 The fact that patients
with BTP had a higher score on all pain related items,
may reflect that many patients did not have adequate fast
acting ‘on-demand’ analgesics, that they were on a too
low dosage of long-acting opioids, or that they have a
more complex pain syndrome with mixed pain or a
component of neuropathic pain. Several variables that
could predict severe cancer pain were found. Few studies
have searched for such positive and negative predictors,
and most deal with highly selected populations.13 16 The
two most prominent variables for predicting cancer
related pain were the existence of BTP and abnormal
skin sensibility in the area of pain. These results are
similar, in part, to other findings where researchers have
found, for example, bone metastases, BTP, and the
presence of metastases, associated with higher pain
intensity.13,14,16
Conclusion
In this study, 52% of the patients reported having cancer
related pain with a mean pain score (NRS) for ‘average
pain’ the previous 24 hours of 3.99. Patients with BTP,
and abnormal skin sensitivity in the area of pain were
found more likely to report more pain. Some 42% of all
patients used opioids, and these patients had higher pain
scores, more episodes of BTP, and had their daily life
functions more influenced by pain than those patients
not receiving opioids. Many patients reporting severe
pain did not use opioids, and some did not receive any
analgesics at all.
This survey reveals that many hospitalised cancer
patients in Norway do not receive adequate pain relief.
Health care personnel’s lack of basic knowledge in
treatment of pain, insufficient focus on the patients’
pain experience, and inadequate systematic symptom
assessment are probably some of the reasons for suboptimal treatment. This is a continuous challenge in basic
education and specialist training for all personnel groups
caring for cancer patients. New surveys should be
performed in order to monitor improvement.
Cancer pain in Norwegian hospitals
Acknowledgements
We have received statistical assistance from biostatistician
B Sandstad at The Norwegian Radium Hospital, Oslo,
Norway; and administrative assistance and technical
equipment offered by the Clinical Research Office, also
at The Norwegian Radium Hospital, Oslo, Norway. The
project was supported by an unrestricted grant from
Mundipharma AS, Lysaker, Norway.
9
10
11
Conflict of Interest Statement
Anders Holtan has received payment for his role as
lecturer from Mundipharma. All payments less than
$4000. Ulf E Kongsgaard has received payments for his
role as advisor, member of expert groups, and lecturer
from Mundipharma, Swedish Orphan and Pfizer. All
payments were lesss than $4000. He has also received
research funding from Mundipharma. Stein Kaasa has
received payments for his role as advisor and member of
expert groups from Janssen-Cilag, Mundipharma and
Nycomed. The other authors have no financial or other
relationships that might lead to conflict of interests.
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