From “Breakthrough” to “Episodic” Cancer Pain? A European Association for Palliative Care Research Network Expert Delphi Survey Toward a Common Terminology and Classification of Transient Cancer Pain Exacerbations

Abstract

Context. Cancer pain can appear with spikes of higher intensity. Breakthrough cancer pain (BTCP) is the most common term for the transient exacerbations of pain, but the ability of the nomenclature to capture relevant pain variations and give treatment guidance is questionable.Objectives. To reach consensus on definitions, terminology, and sub classification of transient cancer pain exacerbations. Methods.The most frequent authors on BTCP literature were identified using the same search strategy as in a systematic review and invited to participate in a two-round Delphi survey. Topics with a low degree of consensus on BTCP classification were refined into twenty statements. The participants rated their degree of agreement with the statements on a numeric rating scale (NRS 0-10). Consensus was defined as a median NRS score of ≥ 7 and an interquartile range of ≤ 3.Results. Fifty-two authors had published three or more papers on BTCP over the past ten years. Twenty-seven responded in the first round and 24 in the second round. Consensus was reached for 13 of 20 statements. Transient cancer pain exacerbations can occur without background pain, when background pain is uncontrolled, and regardless of opioid treatment.

Breakthrough Cancer Pain: Preliminary Data of The Italian Oncologic Pain Multisetting Multicentric Survey (IOPS-MS)

“…Some patients, for example, avoid taking a medication because BTP intensity is not considered high enough. On the other hand, in a recent Delphi survey, experts in the field of BTP suggested that transient pain exacerbations can occur independently of background pain level and ongoing pain medication, and the phenomenon includes several subgroups of BTP types [8]. …”

“…Patient-reported satisfaction with pain treatment is an important outcome measure when assessing both background pain and BTP [8]. Of interest, the use of FPNS and IV-M, home care assessment, pain therapy setting, and the absence of anticancer treatment were associated with the highest level of satisfaction.…”

“…A standard algorithm to diagnose BTP was followed according to the following definition: BTP is a transitory exacerbation of pain of moderate to severe intensity that occurs spontaneously or predictably [8–11], and is well distinguished from background pain of mild intensity [6, 12]. Exclusion criteria were the absence of a cancer diagnosis, uncontrolled background pain (>4 on a numerical scale of 0 to 10), or no relevant increases in pain intensity (<5) which could be interpreted as BTP episodes.…”

“…Moreover, some attempts to better characterize this phenomenon according to a number of variables have been made. Recently, an expert consensus suggested that a BTP subclassification according to the characteristics of BTP may provide tailored treatment [8]. …”

Breakthrough cancer pain (BTcP) management: a review of international and national guidelines

“…Nonetheless, patients may have short-lived episodes of pain without the existence of background pain 45. Recently, it has been suggested that short-lived episodes of pain that do not fit the diagnostic criteria for BTcP should be called ‘episodic pain’,46 even though (paradoxically) episodic pain has been used as a substitute term for BTcP in the past 22 47…”