Evidence-Based Standards for Cancer Pain Management

Abstract

High-quality management of cancer pain depends on evidence-based standards for screening, assessment, treatment, and follow-up for general cancer pain and specific pain syndromes. We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel. Providers should routinely screen for the presence or absence and intensity of pain and should perform descriptive pain assessment for patients with a positive screen, including assessment for likely etiology and functional impairment. For treatment, providers should provide pain education, offer breakthrough opioids in patients receiving long-acting formulations, offer bowel regimens in patients receiving opioids chronically, and ensure continuity of opioid doses across health care settings. Providers should also follow up on patients after treatment for pain. For metastatic bone pain, providers should offer single-fraction radiotherapy as an option when offering radiation, unless there is a contraindication. When spinal cord compression is suspected, providers should treat with corticosteroids and evaluate with whole-spine magnetic resonance imaging scan or myelography as soon as possible but within 24 hours. Providers should initiate definitive treatment (radiotherapy or surgical decompression) within 24 hours for diagnosed cord compression and should follow up on patients after treatment. These standards provide an initial framework for high-quality evidence-based management of general cancer pain and pain syndromes.

Do High Symptom Scores Trigger Clinical Actions? An Audit After Implementing Electronic Symptom Screening

“…1,9,34 Second, the rate of symptom screening has been adopted as an indicator of quality of care in some settings. 19,28,32,[35][36][37] However, because our results demonstrate that high screening rates do not necessarily translate into high rates of symptom-related actions being taken, our results also suggest caution in interpreting screening rates alone as indicators of high-quality care. 38 Our study adds to the literature on the implementation of patient-reported outcome assessment in clinical practice.…”

“…In other cases, effective identification and management of symptom issues might be cancer specific, which might explain why shortness of breath was more commonly documented and treated in patients with lung cancer patients. Also, despite established guidelines for pain [28][29][30] and dyspnea, [31][32][33] physicians may lack the knowledge or experience to manage worsening or complex symptomatology, particularly when patients report a zero score for the majority of symptoms. 17 The ease of treatment options (eg, prescriptions) might explain why pain-related actions occurred more commonly than actions for shortness of breath.…”

Symptom Management in Metastatic Breast Cancer

“…Pain in cancer may also be a symptom of an oncologic emergency such as pathologic bone fracture, brain or epidural metastasis, leptomeningeal metastasis, infection, or an obstructed or perforated viscus. Spinal cord compression occurs in 5%-20% of cancer patients at autopsy and is a medical emergency requiring prompt evaluation and treatment [15]. Patients should be evaluated for impending cord compression if there are complaints of back pain because bone metastases are present in 95% of cases.…”

“…When using opioids for the treatment of cancer pain, the use of short-acting breakthrough opioids along with longacting opioids is recommended as symptoms fluctuate or worsen with disease progression [15,22]. Table 4 summarizes opioid equivalences and the relative potencies of drugs as compared with morphine, and Table 5 shows conversions to transdermal fentanyl.…”

Radiotherapy in palliative treatment of painful bone metastases

“…With persistence or increase in pain when using non-opioid analgesics only, the treatment progresses to utilize weak opioides (the second step) changing to higher doses or more potent opioids (the third step), if the pain persists or becomes more severe. [17][18][19] These more potent opioids have significant side effects (constipation and lethargy are particularly common).…”