Cancer care

Cancer pain management: Australian experience suggests it’s hard to shift the needle

Cancer pain guideline implementation strategies do not appear to improve pain-related outcomes for adults attending outpatient oncology and palliative care services, research at Australian cancer centres shows.

A cluster-randomised clinical trial compared pain scores, among patients with a score of 5 or more on the numeric rating scale (NRS) for worst pain at week 1, at centres providing usual care (controls) and those centres with a local clinical champion, adherence audits, as well as health professional and patient education.

The study, published in JAMA Network Open, found there was no significant difference between the control and intervention phases in the percentage of patients with a pain reduction of 30% from the initial NRS at week 1 (11.9% v 11.8%).

Similarly there were no differences between the controls and intervention sites in secondary outcomes such as worst and mean pain NRS and patient quality of life using the EORTC QLQ-C15-PAL at 1, 2 and 4 weeks follow-up.

The investigators, led by Sydney palliative medicine physician Associate Professor Melanie Lovell, said there were several potential explanations for the apparent lack of effect.

“Optimistically, it may be that improvements in the screening condition resulted from clinicians using the data during consultations without the need for prompting introduced during the Intervention phase,” the study said.

“However, previous randomised clinical trials of screening interventions vs no screening in outpatient services have rarely demonstrated improvements in pain scores, especially in palliative care.”

The study said fidelity to the intervention was lower than anticipated.

Most sites had only one cycle of audit, completion rates of health professional training ranged from 12% to 74%, and the proportion of patients receiving written information was not much higher in the intervention compared to control sites (30% v 22%).

They also noted a major barrier to optimal patient education was the lack of nurses in ambulatory care.

“Adequate staffing with nurses in ambulatory care would provide rapid, focused assessment of patients, develop long-term nurse, patient, and family relationships, and deliver patient education.”

“Oncology ambulatory care services require adequate resources to provide routine pain screening, patient and staff education, and quality improvement cycles,” they concluded.

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