Impact of Undertreatment of Cancer Pain With Analgesic Drugs on Patient Outcomes: A Nationwide Survey of Outpatient Cancer Patient Care in Taiwan

Shen, Wen; Chen, Jen Shi; Shao, Yu‐Yun; Lee, Kuan Der; Chiou, Tzeon Jye; Sung, Yung Chuan; Rau, Kun Ming; Yen, Chia Jui; Liao, Yu Min; Liu, Ta Chih; Wu, Ming-Fang; Lee, Ming Yang; Yu, Ming; Hwang, Wen Li; Lai, Pang Yu; Chang, Cheng; Chou, Wen Chi; Hsieh, Ruey Kuen

doi:10.1016/j.jpainsymman.2017.02.018

Cited by 29 publications

(39 citation statements)

References 30 publications

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“…Several authors have used PMI to assess the prevalence of undertreatment of pain, defined as a negative PMI (9,(19)(20)(21)(22). This approach has been criticized since the original purpose of PMI was to measue physicians' responses to patients` pain, not undertreatment (23).…”

Section: Introductionmentioning

confidence: 99%

Pain management index (PMI)—does it reflect cancer patients’ wish for focus on pain?

Thronæs

Balstad

Brunelli

et al. 2019

Support Care Cancer

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Background: The Pain Management Index (PMI) was developed to combine information about the prescribed analgesics and the self-reported pain intensity in order to assess physicians' response to patients` pain. However, PMI has been used to explore undertreatment of cancer pain. The present study explores prevalence of negative PMI and its associations to clinical variables, including the patient-perceived wish for more attention to pain. Methods: A single-centre, cross-sectional observational study of cancer patients was conducted. Data on demographics and clinical variables, as well as patient-perceived wish for more attention to pain, were registered. PMI was calculated. Negative PMI indicates that the analgesics prescribed might not be appropriate to the pain intensity reported by the patient and associations to negative PMI were explored by logistic regression models. Results: 187 patients were included, 53% had a negative PMI score. Negative PMI scores were more frequent among patients with breast cancer (OR=4.2, 95% CI 1.3, 13.5), in a follow-up setting (OR 12.1, 95% CI 1.4, 101.4), and was inversely associated to low performance status (OR 0.14, 95% CI 0.03, 0.65). Twenty-two percent of patients with negative PMI scores reported that they wanted more focus on pain management versus 13 % among patients with a non-negative PMI score; the difference was not statistically significant. Conclusion: A high prevalence of negative PMI was observed, but only 1/5 of patients with a negative PMI wanted more attention to pain by their physician. Our findings challenge the use of PMI as a measure of undertreatment of cancer pain. Methods Study design This is a secondary analysis of a cross-sectional study among cancer in-patients and outpatients conducted in Mid-Norway in 2013-14 (1). Patients included in the study were admitted to St. Olavs Hospital, Trondheim University Hospital, a 800-bed referral centre. In general, cancer patients are treated at the Departments of Oncology, Surgery, Internal Medicine, and Gynaecology. All eligible cancer in-patients admitted to these departments were included at predefined days in the autumn of 2013. Outpatients were included from the Department of Oncology at predefined days in January 2014. Patients Inclusion criteria for the cross-sectional study were: adult cancer patients (age ≤ 18 years), no cognitive impairment (judged by the physician), and able to understand Norwegian language. Patients who had undergone surgical procedures the last 24 hours were excluded to minimize registration of transient symptoms related to surgery and anaesthesia. In the present secondary analysis, only patients who reported pain and /or were using analgesics were eligible. Data collection and assessment Data on primary cancer disease, metastatic pattern, comorbidity, Karnofsky Performance Status (KPS) (25), and current pain medications were collected by health care providers. The patients completed a questionnaire with information on gender, age, marital status, education, symptoms, and wishes for fo...

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Section: Introductionmentioning

confidence: 99%

Pain management index (PMI)—does it reflect cancer patients’ wish for focus on pain?

Thronæs

Balstad

Brunelli

et al. 2019

Support Care Cancer

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“…Interestingly, our study showed that early initiation of chemotherapy for patients presenting with tumor pain at diagnosis provided a survival benefit over delayed treatment. Pain is one of the most prevalent distressing symptoms in cancer patients, especially for those with unresectable pancreatic cancer . Undertreatment of tumor pain had been reported as a negative predictor for quality of life and survival outcome in cancer patients.…”

Section: Discussionmentioning

confidence: 99%

“…Pain is one of the most prevalent distressing symptoms in cancer patients, especially for those with unresectable pancreatic cancer . Undertreatment of tumor pain had been reported as a negative predictor for quality of life and survival outcome in cancer patients. In lung cancer, patients receiving standard oncology care integrated with early palliative care for adequate symptom control resulted in a longer survival time and a better quality of life .…”

Section: Discussionmentioning

confidence: 99%

Association of time interval between cancer diagnosis and initiation of palliative chemotherapy with overall survival in patients with unresectable pancreatic cancer

et al. 2019

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Introduction Palliative chemotherapy is the standard treatment for patients with unresectable pancreatic cancer. Whether the early initiation of palliative chemotherapy is associated with a favorable survival outcome for these patients is not known. This study aimed to analyze the association of the time interval between cancer diagnosis and initiation of palliative chemotherapy with survival outcome in patients with pancreatic cancer. Method A total of 838 patients with unresectable pancreatic cancer who underwent palliative chemotherapy from 2010 to 2016 at 4 institutions in Taiwan were retrospectively enrolled. All patients were categorized according to time interval between cancer diagnosis and initiation of palliative chemotherapy for comparison of the survival outcome. Result The median time interval was 14 days (range, 0 to 163 days) in our patient cohort. Accordingly, 22%, 29%, and 49% of the patients underwent palliative chemotherapy within 1, 1 to 2, and >2 weeks after cancer diagnosis, respectively. The survival outcome had no statistical difference among these 3 patient groups. Subgroup analyses revealed that patients with the time interval ≤2 weeks exhibited poorer survival outcome than those with the time interval >2 weeks if they initially presented with jaundice (6.1 months vs 8.4 months, P = 0.029). In contrast, patients with the time interval ≤2 weeks revealed a better survival outcome than those with the time interval >2 weeks if they initially presented with pain (8.0 vs 6.3 months, P = 0.014). Conclusion In our study, time interval between cancer diagnosis and the initiation of palliative chemotherapy >2 weeks was not associated with a poorer survival outcome for patients with unresectable pancreatic cancer. Our result might help clinicians to clarify that early initiation of palliative chemotherapy might provide survival benefit for patients who present with tumor pain, but not for those who present with jaundice.

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“…Although international guidelines for cancer pain management have been established for decades, [4] , [5] , [6] inappropriate care for cancer pain remains common and is reported in approximately 40% of patients. [7] , [8] , [9] Inappropriate cancer pain management is multifactorial. 10 , 11 The average consumption of opioids is extremely low in Asia compared with Europe and North America because the availability of appropriate opioids has been limited by regulatory problems and import difficulties, which is a major barrier to adequate cancer pain management.…”

Section: Introductionmentioning

confidence: 99%

Impact of expanded strong opioid availability on opioid prescription patterns in patients with cancer: A population-wide cohort study in Taiwan

Wu¹,

Hsu²,

Sun³

et al. 2021

The Lancet Regional Health - Western Pacific

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Background One of the major barriers to adequate cancer pain management in Taiwan is the limited prescription options regarding strong opioids. Internationally recommended strong opioids, including oxycodone and hydromorphone, were not introduced in Taiwan until late 2014. We analysed the patterns in opioid prescription for cancer pain management, after the introduction of new opioid options. Methods All inpatient and outpatient clinical visits from January 1, 2012, to December 31, 2017, with the diagnosis of cancer and the analgesic prescriptions were collected from the database of National Health Insurance, Taiwan, and analysed. Opioids were grouped into strong opioids, weak opioids, and guideline non-recommended opioids. Findings A total of 1, 292, 905 patients with cancers were included. Approximately 50% of patients used analgesics, 50% of which were opioids; the proportions were stable during the study period. The annual cumulative opioid use per patient (defined daily dose, DDD) significantly decreased from 36•41±102•59 (Mean±SD) in 2012 to 32•42±100•99 in 2017 ( p < •001). The annual cumulative strong opioid use per patient increased significantly from 17•54±89•23 in 2012 to 19•28±94•97 in 2017 (+9•90%, p < •001). In parallel, the annual cumulative weak opioids use per patient decreased from 18•64±40•81 in 2012 to 13•04±26•79 in 2017 (−30•04%, p < •001). Among extended-release strong opioids, the use of transdermal fentanyl significantly decreased after oxycodone and hydromorphone were introduced ( p < •001). Interpretation Increased therapeutic options in strong opioid prescriptions led opioid prescription patterns to evolve towards international cancer pain management guidelines. In addition, increased accessibility to a wider range of different strong opioids may facilitate more efficient opioid titration and rotation - and thus decrease, not increase, the opioid usage. Funding This study was supported by Ministry of Science and Technology, Taiwan (MOST-106-2314-B-002-213 and MOST-108-2314-B-002-072-MY3), Ministry of Health and Welfare, Taiwan (MOHW109-TDU-B-211-114002), National Taiwan University Hospital, Taipei, Taiwan (NTUH-103-002314 and NTUH. 105‐S2954), and National Center of Excellence for Clinical Trial & Research, National Taiwan University Hospital, Taipei, Taiwan (NCTRC201208 and NCTRC201603).

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Impact of Undertreatment of Cancer Pain With Analgesic Drugs on Patient Outcomes: A Nationwide Survey of Outpatient Cancer Patient Care in Taiwan

Abstract: One-third of Taiwanese outpatients experienced pain because of undertreatment. Awareness of the prevalence of undertreatment of cancer pain and identification of the vulnerable subjects may assist in enhancing patient care and improving patient's QoL.

Cited by 29 publications

References 30 publications

Pain management index (PMI)—does it reflect cancer patients’ wish for focus on pain?

Pain management index (PMI)—does it reflect cancer patients’ wish for focus on pain?

Association of time interval between cancer diagnosis and initiation of palliative chemotherapy with overall survival in patients with unresectable pancreatic cancer

Impact of expanded strong opioid availability on opioid prescription patterns in patients with cancer: A population-wide cohort study in Taiwan

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