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Assessment, management tool alleviates cancer-related pain

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April 30, 2018

A pain-assessment tool with built-in treatment guidance reduced cancer-related pain outcomes, according to study data.

The test also improved prescribing practices but did not influence opioid-related adverse effects.

“Despite the availability of pain management guidelines, poor outcomes are common,”
Marie Fallon, MD, of the institute of genetics and molecular medicine at Edinburgh Cancer Research, and colleagues wrote. “Common shortcomings in pain management include unstructured assessment, use of treatment guidelines that lack explicit algorithms and do not address clinicians’ concerns about prescribing opioids, and lack of systematic monitoring of outcomes, including adverse effects. Admission to a cancer center provides an important opportunity to improve pain outcomes.”

Fallon and colleagues developed the Edinburgh pain assessment and management tool, or EPAT, to systematically assess cancer-related pain, guide treatment and determine efficacy of treatment.

Researchers randomly assigned 19 cancer centers in the U.K. to implement EPAT in addition to usual care (n = 10) or to usual care alone (n = 9).

Change in percentage of participants at each center with clinically significant improvement in worst pain from admission to 3 to 5 days after admission served as the primary endpoint. Secondary outcomes included quality of analgesic prescribing and opioid-related adverse effects.

Outcome data were available for 1,795 patients (mean age, 60 years; 49% women) with various cancer types, including genitourinary (14.2%), gastrointestinal (13.5%), breast (12%) and lung (11.5%).

Among centers randomly assigned to use EPAT, the proportion of patients with a clinically significant improvement in worst pain increased from 47.7% before using the tool to 54.1% after the tool, for an absolute increase of 6.4 percentage points. For centers not assigned the tool, the proportion of patients with a clinically significant improvement in pain decreased from 50.6% before assignment to 46.4% after assignment, for an absolute decrease of 4.2 percentage points.

These differences equated to an absolute difference of 10.7 percentage points (95% CI, 0.2-21.1) between the two groups. When two centers who failed to implement EPAT were excluded, the absolute difference increased to 15.4 percentage points (95% CI, 5.8-25).

Centers assigned EPAT showed greater improvements of good practice prescribing and greater changes in the mean worst pain item and in mean pain subscale scores than centers assigned usual care.

Researchers did not observe differences in pain or distress outcomes and opioid adverse effects between the two groups.

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“Inspection of the results by cancer center revealed that the difference in the primary outcome between centers delivering EPAT and centers continuing usual care reflected not only an improvement in pain management with EPAT (except in the two centers that failed to implement EPAT), but also a deterioration in pain management in most of the centers that continued usual care,” Fallon and colleagues wrote.

The limitations of the study included conducting the study in one health care system and lack of long-term outcome data.

The test’s brevity, imbedded treatment-guiding algorithms and integration into a patient’s bedside chart all facilitate implementation of the tool into clinical practice, Paul B. Jacobson, PhD, associate director of the NCI Healthcare Delivery Research Program, and Claire F. Snyder, PhD, professor of medicine at Johns Hopkins School of Medicine and program director of the Building Lifestyle, Outcomes, and Care Services Research in Cancer at the Sidney Kimmel Comprehensive Cancer Center, wrote in an accompanying editorial.

“Similar studies need to be conducted in other cancer care delivery settings and for other common symptoms experienced by patients with cancer,” the wrote. “In addition to the direct benefits observed in the participating institutions and patients, these studies yield valuable how-to methods that can be used in many other practice settings. They also yield important real-world evidence that can inform development of new polices and standards for the assessment and management of cancer-related symptoms that could have far-reaching impact.” – by Cassie Homer

Disclosures: Fallon reports institutional research funding from Pfizer. The other authors report no relevant financial disclosures. Snyder reports stock ownership in Immunomedics, royalties as a section author from UpToDate, honoraria/funding from CARET and Optum, and institutional research funding from Genentech. Jacobson reports no relevant financial disclosures.

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