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• W2065167411 abstract "To the Editor: Pain continues to be inadequately treated despite the publication of pain management guidelines and remains a challenge to health care providers. From January 1999 to January 2002, a total of 534 patients with bone metastases were referred to the Rapid Response Radiotherapy Program at Toronto Sunnybrook Regional Cancer Center. They were asked to rate their pain intensity on a categorical scale of 0–10 (0 = absence of pain; 10 = worst pain possible). Patient demographics and information on disease extent were collected. Analgesic intake during the preceding 24 hours was recorded and converted into total daily dose of oral morphine equivalent. Pain intensity was classified as follows: none (0), mild (1–3), moderate (4–7) and severe (8–10). Analgesics were categorized as none, non-opioids, “weak” opioids (e.g., codeine) and “strong” opioids (e.g., morphine and hydromorphone). Sixteen patients were unable to provide their pain score and were excluded from further analysis. Patient characteristics for the remaining 518 patients are summarized in Table 1. The pain intensity and analgesic category of the 518 patients are listed in Table 2. The mean/median baseline pain score at the irradiated site was 5.8/6, respectively (standard deviation = 2.9). The mean/median daily oral morphine equivalent was 152/40 mg, respectively (range 0–18,000).Table 1Patient CharacteristicsGender Male280 (54%) Female238 (46%)Age at Radiation Median68 years Range(31, 93)Primary Sites Lung130 (25%) Breast127 (25%) Prostate117 (23%) Others71 (14%) Gastrointestinal39 (7%) Unknown34 (6%)Weight Loss ≥10% over the last 6 months180 (35%)Karnofsky Performance Score at First Visit Median60 Range(10, 100)Other Sites of Metastases Lymph Nodes143 (28%) Lung111 (21%) Soft Tissue101 (19%) Liver90 (17%) Brain17 (3%) Open table in a new tab Table 2Pain Intensity and Analgesic Intake at Initial Consultation for 518 PatientsPainNoneMildModerateSevereTotalNo analgesic1524231779 (15%)Non-opioids39151643 (8%)Weak opioids711273681 (16%)Strong opioids123998166315 (61%)37 (7%)83 (16%)163 (31%)235 (45%)Mean/median total oral morphine equivalent for weak opioids: 15/10mg and for strong opioids: 245/100 mg, respectively. Open table in a new tab Mean/median total oral morphine equivalent for weak opioids: 15/10mg and for strong opioids: 245/100 mg, respectively. Of 518 patients, 163 (31%) and 235 (45%) were in moderate and severe pain at initial consultation, respectively. However, 134 (34%) of the 398 patients who had moderate and severe pain were prescribed no analgesics, non-opioids or “weak” opioids. Barriers to treatment with stronger opioids may come from providers (misconceptions about medications and side effects, insufficient knowledge and training in pain management, and lack of formal assessment procedures)1.Elliott T.E Elliott B.A Physician attitudes and beliefs about use of morphine for cancer pain.J Pain Symptom Manage. 1992; 7: 141-148Abstract Full Text PDF PubMed Scopus (93) Google Scholar, 2.Elliott T.E Murray D.M Elliott B.A et al.Physician knowledge and attitudes about cancer pain management: a survey from the Minnesota Cancer Pain Project.J Pain Symptom Manage. 1995; 10: 494-504Abstract Full Text PDF PubMed Scopus (90) Google Scholar, 3.Oneschuk D Fainsinger R Hanson J Bruera E Assessment and knowledge in palliative care in second year family medicine residents.J Pain Symptom Manage. 1997; 14: 265-273Abstract Full Text PDF PubMed Scopus (51) Google Scholar, 4.Fife B.L Irick N Painter J.D A comparative study of the attitudes of physicians and nurses toward the management of cancer pain.J Pain Symptom Manage. 1993; 8: 132-139Abstract Full Text PDF PubMed Scopus (54) Google Scholar, 5.Vainio A Treatment of terminal cancer pain in France: a questionnaire study.Pain. 1995; 62: 155-162Abstract Full Text PDF PubMed Scopus (46) Google Scholar, 6.Rawal N Hylander J Arner S Management of terminal cancer pain in Sweden: a nationwide survey.Pain. 1993; 54: 169-179Abstract Full Text PDF PubMed Scopus (46) Google Scholar, 7.Warncke T Breivik H Vainio A Treatment of cancer pain in Norway: a questionnaire study.Pain. 1994; 57: 109-116Abstract Full Text PDF PubMed Scopus (40) Google Scholar, 8.Von Roenn J.H Cleeland C.S Gonin R Hatfield A.K Pandya K.J Physicians attitudes and practice in cancer pain management: a survey from the Eastern Cooperative Oncology Group.Ann Intern Med. 1993; 119: 121-126Crossref PubMed Scopus (721) Google Scholar, 9.Larue F Colleau S.M Fontaine A Brasseur L Oncologists and primary care physicians' attitudes towards pain control and morphine prescribing in France.Cancer. 1995; 76: 2375-2382Crossref PubMed Scopus (135) Google Scholar, 10.Brunelli C Costantini M DiGiulio P et al.Quality of life evaluation: when do terminal cancer patients and health care providers agree?.J Pain Symptom Manage. 1998; 15: 151-158Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 11.Cleeland C.S Gonin R Hatfield A.K et al.Pain and its treatment in out-patients with metastatic cancer.N Engl J Med. 1994; 330: 592-596Crossref PubMed Scopus (1755) Google Scholar and patient/primary caregiver concerns (about addiction to pain medication or side effects), poor communication with health care providers, wanting to be a ‘good’ patient, and misconception about inevitability of pain.12.Ward S.E Goldberg N Miller-McCauley V et al.Patient-related barriers to management of cancer pain.Pain. 1993; 52: 319-324Abstract Full Text PDF PubMed Scopus (601) Google Scholar, 13.Riddell A Fitch M.I Patients' knowledge of and attitudes toward the management of cancer pain.Oncol Nurs. 1997; 24: 1775-1784PubMed Google Scholar, 14.Elliott B.A Elliott T.E Murray D.M Braun B.L Johnson K.M Patients and family members: the role of knowledge and attitudes in cancer pain.J Pain Symptom Manage. 1996; 12: 209-220Abstract Full Text PDF PubMed Scopus (65) Google Scholar, 15.Berry P.E Ward S.E Barriers to pain management in hospice: a study of family caregivers.Hospice J. 1995; 10: 19-33Crossref PubMed Google Scholar Patients taking “strong” opioids but still complaining of moderate or severe pain should be considered for referral for palliative radiotherapy. However, about 20% of patients will derive no benefit from palliative radiotherapy for their symptomatic bone metastases.16.Tong C Gillick L Hendrickson F.R The palliation of symptomatic osseous metastases: final results of the study by the Radiation Therapy Oncology Group.Cancer. 1982; 50: 893-899Crossref PubMed Scopus (681) Google Scholar, 17.Nielsen O.S Bentzen S.M Sandberg E et al.Randomized trial of single dose versus fractionated palliative radiotherapy of bone metastases.Radiother Oncol. 1998; 47: 233-240Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar, 18.Bone Pain Trial Working Party 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: randomised comparison with a multifraction schedule over 12 months of patient follow-up.Radiother Oncol. 1999; 52: 111-121Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar, 19.Steenland E Leer J van Houwelingen H et al.The effect of single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study.Radiother Oncol. 1999; 52: 101-109Abstract Full Text Full Text PDF PubMed Scopus (557) Google Scholar While most patients do respond, the time to onset of response may vary from 1 to 4 weeks after initiating radiotherapy16.Tong C Gillick L Hendrickson F.R The palliation of symptomatic osseous metastases: final results of the study by the Radiation Therapy Oncology Group.Cancer. 1982; 50: 893-899Crossref PubMed Scopus (681) Google Scholar, 17.Nielsen O.S Bentzen S.M Sandberg E et al.Randomized trial of single dose versus fractionated palliative radiotherapy of bone metastases.Radiother Oncol. 1998; 47: 233-240Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar, 18.Bone Pain Trial Working Party 8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: randomised comparison with a multifraction schedule over 12 months of patient follow-up.Radiother Oncol. 1999; 52: 111-121Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar, 19.Steenland E Leer J van Houwelingen H et al.The effect of single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study.Radiother Oncol. 1999; 52: 101-109Abstract Full Text Full Text PDF PubMed Scopus (557) Google Scholar and some patients may experience a transient flare of pain. Analgesic titration, therefore, remains a prime priority for patients while receiving or immediately after palliative radiotherapy. Furthermore, radicular pain may be an important component for bone metastases involving the spine. Pain relief is probably more successful with steroids than with opioids in such patients. The use of co-analgesics and adjuvant pain medication, such as steroids and analgesic antidepressants, should be considered. Fifty-one patients appeared to be adequately palliated with “strong opioids,” with no or mild pain. In circumstances when patients suffer from opioid side effects, it is also reasonable to refer them for palliative radiotherapy to lower their analgesic requirement and hence the side effects. Often patients present with multiple sites of pain. Although they may get complete relief of pain at the irradiated site, they still need analgesics for other painful sites. Often other sites may be unmasked when the radiated painful site gets better. Of course, radiotherapy not only can palliate the pain, but can also improve the remineralization/healing of the irradiated lytic bone metastases.20.Koswig S Budach V Remineralization and pain relief in bone metastases after different radiotherapy fractions (10 times 3 Gy vs. 1 time 8 Gy). A prospective study.Strahlenther Onkol. 1999; 175 ([in German]): 500-508Crossref PubMed Scopus (233) Google Scholar We previously reported the prevalence of underdosage of analgesics in 105 patients with bone metastases.21.Chow E Connolly R Franssen E et al.Prevalence of underdosage of cancer bone pain in patients referred for palliative radiotherapy and its potential implications in radiotherapy trials.Annals of the The Royal College of Physicians and Surgeons of Canada. 2001; 34: 217-290Google Scholar Our current data indicate that the situation has not improved. One-third of the patients who complained of moderate and severe pain were prescribed no analgesics, non-opioids or “weak” opioids. The authors thank Ms. Danielle Nywening for secretarial support. This study was supported by the Toronto Sunnybrook Regional Cancer Center Radiation Program Fund." @default.
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• W2065167411 title "Pain management in cancer patients with bone metastases remains a challenge" @default.
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