Professor Marie Fallon

Cancer centres that adopt routine use of a simple pain assessment tool can achieve substantial improvements in patient’s pain levels, a major UK study has shown.

The impact of the Edinburgh Pain Assessment Tool (EPAT) was assessed in a randomised controlled trial in 19 cancer centres in the UK, of which half adopted the EPAT and half continued with usual care.

In the study, which assessed cancer pain outcomes at 3-5 days after admission in 1921 patients with varying cancers, those patients in the centres that adopted EPAT had a 15.4% improvement in absolute scores of worst pain compared to patients in the centres providing usual care.

In EPAT centres, the proportion of patients with a clinically significant improvement in pain increased from 47.7% to 54.1% after admission. In usual care centres, the proportion decreased from 50.6% to 46.4%.

The absolute difference of 15.4% in pain outcomes in favour of EPAT was seen after excluding two centres that were unable to implement it due to leadership and organisational changes.

Writing in the Journal of Clinical Oncology, the UK researchers said the improvement in pain outcomes was achieved through more appropriate use of analgesics but without an increase in opioid doses. There was also no increase in opioid adverse effects seen among patients at the EPAT centres, suggesting that prescribing continued to be appropriate, they said.

“This absence of increased adverse effects despite better pain management may be because EPAT alerts clinicians to monitor adverse effects of pain treatment as well as efficacy,” wrote Professor Marie Fallon and colleagues from the Edinburgh Cancer Research Centre.

They said the EPAT was a simple tool that builds on the concept of pain as the fifth vital sign. It prompts clinicians to systematically assess pain using a brief set of questions and follow specific treatment algorithms linked to patient responses.

While the tool was known to be effective in improving pain outcomes from smaller studies, the challenge was to show that it could be implemented in real world settings, they said.

The trial confirmed that routine use of EPAT improved pain outcomes and prescribing practice, but the implementation problems seen in two cancer centres highlighted the crucial role of organisational and leadership factors as well as clinician education, the study authors emphasised.

“The findings of this trial add to the accumulating evidence for the efficacy of more integrated and systematic approaches to  symptom management in patients with cancer,” they concluded.