Cancer Doctors Still Not Great With Patients' Pain
THURSDAY Nov. 17, 2011 -- Oncologists think they are good at managing cancer patients' pain, but a new survey shows otherwise.
In response to two hypothetical vignettes describing a cancer patient who was suffering from pain, the majority of oncologists offered up a treatment plan that pain specialists would consider "unacceptable."
"There are serious deficiencies in oncologists' knowledge of cancer pain management," said study author Brenda Breuer, director of epidemiologic research in the department of pain medicine and palliative care at Beth Israel Medical Center in New York City.
The study appears in the Nov. 14 issue of the Journal of Clinical Oncology.
Depending on the type of cancer and how advanced it is, anywhere from 14 percent to 100 percent of cancer patients experience pain, according to background information in the study.
In recent years, there's been a growing understanding among cancer experts about the importance of both properly assessing and treating pain, and better techniques for doing so, said Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society.
Despite talk about a greater understanding of the importance of treating pain, oncologists' attitudes toward pain management have "demonstrated disturbingly little progress" since 1990, when a similar survey was conducted, according to an accompanying journal editorial.
"The entire issue of pain management for patients with cancer has been a priority concern for many experts and organizations, particularly over the past several years," Lichtenfeld said. "We have begun to recognize that we are not managing pain adequately and this report and editorial go directly to the heart of the matter. Doctors think they are managing pain properly, but the results of the report suggest otherwise."
Under-treating pain can occur for multiple reasons, experts said. Some patients are reluctant to complain too much, Breuer said. "They don't want to be 'bad' patients, or they just think pain goes with the territory and don't realize there may be help for them," she said.
Others put their trust in their oncologist and don't realize he or she may not know all there is to know about treating pain, Breuer said.
In some cases, oncologists may be focused on treating the disease and not ask enough questions about a patient's pain, Lichtenfeld said.
In the study, researchers surveyed more than 600 U.S. oncologists about their knowledge, attitudes and practices related to pain management. Oncologists tended to rate themselves as less conservative than their peers in administering pain medications.
According to the oncologists, barriers to proper pain management include patient reluctance to report pain; patient reluctance to take opioids because of addiction fears or fears of adverse reactions; excessive regulation of opioids; inadequate assessment of patients' pain by doctors and nurses and patient inability to pay for services or pain medications.
In one hypothetical scenario, oncologists were asked whether it was a good idea to increase the dosage of morphine for a man with lung cancer who was experiencing pain despite already being on a relatively high dose of morphine.
The correct answer is "no," because the increase in dosage suggested was unnecessarily high. Even so, 31 percent of oncologists thought it would be a good idea. While the rest knew it wasn't a good idea, only 13 percent chose both the right answer and the right reason for avoiding such a large increase, which was the risk of side effects such as excessive sleepiness and "mental clouding."
Wrong reasons cited for not giving the higher dose included causing a dangerous decrease in respiration; because the higher dose could lead to increasing tolerance and the medication to become less effective over time; and because of a "regulatory climate that puts doctors under scrutiny if relatively high doses are prescribed."
The study also found that few oncologists (16 percent) said they frequently made referrals to pain or palliative medicine care specialists, who specialize in treating people at the end of life, Breuer said.
"Patients need to know that there is such a thing as pain medicine and palliative care specialists. These are recognized specialities that you get board certification in. Patients can ask for consults. That is the best advice I can give them," she said.
The American Cancer Society has more on pain control for cancer patients.
Posted: November 2011
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