POST-MASTECTOMY PAIN SYNDROME ASSESSMENT AND MANAGEMENT BY HOUSESTAFF

Abstract

S316 INTRODUCTION: Post-mastectomy pain syndrome (PMPS) is a known complication of the surgical treatment of breast cancer. PMPS may persist for months or years resulting in impaired quality of life for cancer survivors. Lack of expertise by housestaff in assessing and managing cancer pain has been cited as an important cause of poor pain control. [1] This study was designed to use performance-based testing to evaluate the skills of resident physicians in assessing and managing the severe pain of a patient with PMPS. METHODS: 35 resident physicians (PGY1-6) within a single training program (University of Kentucky) were presented with the same standardized patient with PMPS as part of a yearly objective structured clinical examination (OSCE). In the first segment of the OSCE (Part A), each physician was asked to complete a detailed pain assessment of a 64-year-old woman with a history of PMPS. During the pain assessment (7 minutes), a faculty proctor checked off indicated items believed to be necessary in obtaining a complete post-surgical pain assessment. In the second segment (Part B), the residents were given 7 minutes to answer pain management questions about the patient seen in Part A. The residents' answers in Part B were evaluated by faculty members using a pre-defined check list. RESULTS: In the pain assessment, residents did well in assessing pain onset (86%), pain description (80%), and pain-relieving factors (80%). However, only 26% and 31% of physicians adequately assessed pain intensity and previous pain history, respectively. Ninety percent of the residents were judged to be competent in this clinical pain assessment. In Part B, opioid analgesics therapy was prescribed by 63% of residents, and 63% used the oral route. However, only 6% of prescriptions were for regular use. NSAIDs were prescribed by 63% of physicians with 54% of prescriptions for regular use. No physician provided a PRN analgesic for breakthrough pain. Co-analgesics were prescribed by only one physician. Constipation as a side-effect of therapy was inappropriately managed with decreased opioid dose by 71% of physicians. Persisting severe pain was treated by 54% of residents with opioids. Only 31% of residents would add a co-analgesic such as an antidepressant. CONCLUSIONS: 1) Most graduated physicians were judged to be competent in the assessment of severe PMPS of a standardized cancer patient. 2) Opioids and NSAIDs were the analgesics of choice; however, most were prescribed on a PRN basis only. 3) Few physicians managed severe PMPS according to WHO guidelines. 4) Co-analgesics were rarely prescribed for PMPS.