Cancer Pain Guidelines Research Articles

Screening and Audit as Service-Level Strategies to Support Implementation of Australian Guidelines for Cancer Pain Management in Adults: A Feasibility Study

Background: Pain in people with cancer is common but often under-recognized and under-treated. Guidelines can improve the quality of pain care, but need targeted strategies to support implementation. Aim: To test the feasibility of two service-level strategies for supporting guideline implementation: a screening system and medical record audit. Design: Multimethods. Setting: One oncology outpatient service, and one palliative care outpatient and inpatient service. Participants: Patients with advanced cancer. Methods: Patients were screened in the waiting room with a modified version of the Edmonton Symptom Assessment System-revised either electronically or in paper-based format. Feasibility indicated the percentage of patients successfully screened from the total number attending the services. An audit assessed adherence to key indicators of pain assessment and management. Feasibility thresholds were set at 75% incidence for screening and a median of 30 minutes per patient for audit. Results: Of 452 patient visits, 95% (n = 429) were successfully screened, 34% (n = 155) electronically and 61% (n = 274) paper-based. Electronic pain screening was technically challenging and time-intensive for nurses. Thirty-one patients consented to have their records audited. The median audit time was 37.5 minutes (range 10-120 minutes). Variability arose from the number and type of record (outpatient or inpatient). Adherence to indicators varied from 63% (pain assessment at first presentation) to 94% (regular pain assessment and medication prescribed at regular intervals). Conclusions: This study confirmed the need to implement evidence-based guidelines for cancer pain and generated useful insights into the feasibility of pain screening and audit.

Medical Treatment of Cancer Pain: Drug Therapy according to Guidelines Will Improve the Quality of Life of Cancer Patients

Cancer pain is the most common and troublesome symptom for cancer patients. The more the cancer patient gets to the end of the life, the worse the pain. There are many clinical practice guidelines for cancer pain, and most pain can be controlled with appropriate medication by guideline. We would like to summarize various domestic and foreign clinical practice guidelines relatively simply. According to the clinical practice guidelines, medical treatment including opioids will greatly improve the quality of life of cancer patients. (Korean J Med 2018;93:260-265)

Effectiveness of acupuncture for cancer pain: protocol for an umbrella review and meta-analyses of controlled trials

IntroductionThe National Comprehensive Cancer Network guidelines for adult cancer pain indicate that acupuncture and related therapies may be valuable additions to pharmacological interventions for pain management. Of the systematic reviews...

Using a framework for resource stratification to adapt palliative care guidelines to Sub-Saharan Africa.

145 Background: The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance of 27 leading cancer centers in the United States (US), but the NCCN’s mission to improve cancer care extends world-wide. Nearly half of the registered users of the NCCN Guidelines are based outside the US, and the NCCN has developed a process for adapting its Guidelines to lower-resourced settings. The cancer burden in Sub-Saharan Africa (SSA) is significant – by 2030, annual cancer deaths in the region are projected to reach 1,000,000 people – and most cancers diagnosed in SSA are late-stage. Methods: The NCCN Framework outlines a rational approach for constructing cancer management systems to provide the highest achievable care. Each of the 4 NCCN Framework levels builds on the one before it, so care can evolve as resources grow: “Basic Resources” are essential for care; “Core Resources” add services improving disease outcomes; and “Enhanced Resources” include more cost-prohibitive services. The Guidelines themselves are the final level: evidence-based, consensus-driven recommendations from each NCCN Panel. Resource-stratification begins with modification of the Guidelines by a NCCN Framework Committee within each Panel. Results: In the case of SSA, organizers from the NCCN, American Cancer Society, Clinton Health Access Initiative, and IBM arranged 3 consensus meetings in which resource-stratified drafts of the Guidelines for Palliative Care and Cancer Pain will be refined by a committee of NCCN representatives, oncologists, and palliative care providers from Burundi, Ethiopia, Ghana, Kenya, Nigeria, Uganda, and the US. Important themes emerging from the first meeting included early screening for palliative care needs, even before tissue diagnosis, in areas with limited availability of anti-cancer therapy. In addition, cultural differences on the topic of “Physician-Aid-in-Dying” led to its replacement with guidance on caring for patients expressing a wish to die. Conclusions: Collaboration with colleagues in SSA, and other areas around the globe, to resource-stratify NCCN Guidelines will allow more systematic use of the guidelines and improve the quality, effectiveness, and efficiency of cancer care.

Oncologist's knowledge and implementation of guidelines for breakthrough cancer pain in Spain: CONOCE study.

Breakthrough cancer pain (BTcP) has been shown to be a prevalent and poor prognostic factor for oncologic patients, which remain under diagnosed and undertreated. In 2012, the Spanish Society of Medical Oncology (SEOM) published a clinical practice guideline (CPG) for the treatment of cancer pain which specifically addressed the management of BTcP. Fundación ECO designed a qualitative study using an Internet-based survey to investigate the attitudes toward, compliance with, and use of SEOM Guideline. A total of 83 oncologists with a mean experience of 13years responded. Overall, 82% were aware of different guidelines to manage BTcP. Notably, attitudes toward guidelines were highly positive and there was nearly unanimous agreement that CPG provided the best scientific evidence available (99%), on the minimum information to be gathered for the medical history (100%), on the need for a specific treatment for BTcP (100%), and fentanyl as the first-choice drug (99%). Interestingly, there were discrepancies between what oncologists agreed with and what they do in clinical practice. In fact, 87.6% declare full compliance with SEOM guideline, although adherence to registration of BTcP data in medical records ranged from 30.1 to 91.6% (mean 64.5%); therapeutic management compliance was higher ranging from 75.9 to 91.6%. Main barriers identified were time pressure together with vague statements and limited dissemination of the guidelines. Despite oncologist's clinical practice is increasingly guided by GPC, it suffers from limited compliance, at least in part due to suboptimal statements. Improved dissemination and education are needed to enhance guideline implementation.

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Study on compliance with breakthrough cancer pain guidelines by medical oncologists in Spain.

e18260 Background: Breakthrough cancer pain (BTcP) has been shown to be a prevalent and poor prognostic factor for cancer patients, which remains undertreated and underdiagnosed. The Spanish Society for Medical Oncology (SEOM) developed a clinical practice guideline (CPG) for the treatment of cancer pain which specifically addressed the management of BTcP. Methods: With the objective of evaluate compliance with SEOM’ guideline, Fundación ECO designed a survey to identify awareness, perceptions, implementation and gaps, among Spanish medical oncologists. Results: A total of 83 oncologists with a median experience of 13 years responded. Although 87% of oncologists considered their clinical practice complied with SEOM recommendations, there were discrepancies between what oncologists agreed to do versus how they do in clinical practice, as shown in the table. Main barriers identified in our study were time pressure together with vague statements in some recommendations, and the need to regularly update to reflect the most recent knowledge on therapeutic management. Conclusions: Nonetheless, this nationwide survey reflects that oncologist’s clinical practice is increasingly guided by GPC, and thus, the evaluation process is necessary, both to gauge the true application of the GPC by the professionals and to evaluate their impact on health care. [Table: see text]

Can A Complex Online Intervention Improve Cancer Nurses’ Pain Screening and Assessment Practices? Results from a Multicenter, Pre-post Test Pilot Study

Unrelieved cancer pain has an adverse impact on quality of life. While routine screening and assessment forms the basis of effective cancer pain management, it is often poorly done, thus contributing to the burden of unrelieved cancer pain. The aim of this study was to test the impact of an online, complex, evidence-based educational intervention on cancer nurses' pain assessment capabilities and adherence to cancer pain screening and assessment guidelines. Specialist inpatient cancer nurses in five Australian acute care settings participated in an intervention combining an online spaced learning cancer pain assessment module with audit and feedback of pain assessment practices. Participants' self-perceived pain assessment competencies were measured at three time points. Prospective, consecutive chart audits were undertaken to appraise nurses' adherence with pain screening and assessment guidelines. The differences in documented pre-post pain assessment practices were benchmarked and fed back to all sites post intervention. Data were analyzed using inferential statistics. Participants who completed the intervention (n = 44) increased their pain assessment knowledge, assessment tool knowledge, and confidence undertaking a pain assessment (p < .001). The positive changes in nurses' pain assessment capabilities translated into a significant increasing linear trend in the proportion of documented pain assessments in patients’ charts at the three time points (χ2 trend = 18.28, df = 1, p < .001). There is evidence that learning content delivered using a spaced learning format, augmented with pain assessment audit and feedback data, improves inpatient cancer nurses' self-perceived pain screening and assessment capabilities and strengthens cancer pain guideline adherence.

Interdisciplinary Pain Education: Moving From Discipline-Specific to Collaborative Practice.

Pain is a common symptom reported by hospitalized patients with cancer. Cancer pain management requires an interdisciplinary approach for quality patient care. Although the literature suggests that most cancer pain can be managed with available treatments, many patients continue to experience pain even with opioid prescriptions. Implementation of evidence-based guidelines, such as the National Comprehensive Cancer Network's guidelines for adult cancer pain, promotes collaboration across disciplines and enhances patient care. This article reports the development, implementation, and evaluation of an interdisciplinary pain education program, Oncology Provider Pain Training (OPPT), to improve clinician knowledge and promote collaborative practice. The Kirkpatrick Model was used to design the OPPT program. A multifaceted training approach was used to accommodate the various needs of potential participants. Interdisciplinary educational sessions were held during a one-month period. Knowledge gained, learner reaction, and satisfaction were evaluated using predetermined benchmarks one month following program completion. Satisfaction benchmarks for content, teaching materials, and presenter were met. Although the knowledge gained benchmark was not met, substantial progress toward achievement was made. Additional modifications include increasing discipline-specific content and focus on pain pathophysiology and addressing time constraints. Inconsistent technology adoption across disciplines may have a negative effect on interdisciplinary educational efforts.

Acute pain management in radiation oncology: Quality of care and the impact of an integrated palliative oncology service.

195 Background: Radiotherapy (RT) effectively palliates bone metastases, but relief may take weeks, frequently necessitating acute pain management (APM). NCCN Guidelines for Adult Cancer Pain (V2.2015) recommend initiation/titration of analgesics for patients with pain scale value (PSV) ≥ 4. We sought to evaluate how often symptomatic patients have analgesic regimens assessed and intervened upon at radiation oncology (RO) consult for bone metastases, and the impact of a dedicated palliative RO service on APM. Methods: We reviewed consult notes for 217 bone metastases patients treated with RT at Dana Farber Cancer Institute/Brigham &amp; Women’s Hospital (DFCI/BWH) and University of California, San Francisco (UCSF) during June-July 2008, Jan-Feb 2010, Jan-Feb 2013, and June-July 2014, time periods before and after implementation in 2011 of a dedicated palliative RO service at DFCI/BWH. For symptomatic patients, rate of assessment of analgesic regimen was recorded. Among patients with PSV ≥ 4, rate of pain intervention was recorded. The impact of a palliative RO service on these rates was evaluated. Results: Median age was 63 and median KPS was 70. Median PSV for painful bone metastases was 5 (IQR 2-7); 51% had PSV ≥ 4. Among symptomatic patients, analgesic regimen was assessed for 44.5% (51.7% at DFCI/BWH and 28.1% at UCSF). Among patients with PSV ≥ 4, pain intervention occurred for 17.2% (20.5% for DFCI/BWH, 0% for UCSF). At DFCI/BWH, consultation by a dedicated palliative RO provider was associated with higher rate of assessment of analgesic regimen (82.4% vs 47.7%, p = 0.007). At DFCI/BWH, consultation by a palliative RO provider was associated with higher rate of pain intervention (31.2% vs 7.9%, p = 0.012). There was no difference in analgesic regimen assessment or intervention between non-dedicated palliative RO providers at DFCI/BWH and UCSF (p = 0.07 and 0.09, respectively). Conclusions: At two cancer centers, half of bone metastases patients seen for RT have PSV ≥ 4, yet a minority have analgesic assessment and intervention, indicating need for APM quality improvement in RO. An integrated palliative RO service was associated with improved assessment and management of acute pain per NCCN guidelines.

Management of Chronic Pain in Survivors of Adult Cancers: ASCO Clinical Practice Guideline Summary

As a result of extraordinary advancements in diagnosis and treatment, approximately 14million individuals are living in the United States with a history of cancer (excluding nonmelanomatous skin cancers). Two thirds of these individuals are surviving 5 or more years after diagnosis. Unfortunately, these impressive outcomes in survival often come with physical, psychosocial, and financial burdens as a result of the tumor, exposure to cancer treatment, or other medical comorbidities. Chronic pain can be a serious, negative consequence of surviving cancer. Although estimates vary, the prevalence of pain in cancer survivors has been reported to be as high as 40%. Predictors include the type and invasiveness of the tumor, the treatment regimen used, time since cancer treatment, and the efficacy of initial pain therapy. Significant pain is associated with impaired quality of life in this population. Many guidelines and recommendations have been advanced to support the management of cancer pain, yet the focus of these documents has been primarily on relieving acute pain or pain associatedwith advanced disease. Few evidence-based cancer pain guidelines address the more nuanced care required when pain persists formonths or years. This situation is in part a result of the relative absenceof studies exploring the experiences of chronic pain in cancer survivors or the long-term safety and effectiveness of analgesic interventions. Whereas opioid-based pharmacotherapy is widely accepted as the foundation of care for acute pain or pain associated with advanced cancer, the management of patients who are free of cancer after treatment or are living with cancer as a chronic illness is not grounded in broad consensus. The management of these populations with chronic cancer pain requires greater consideration of a multimodality plan of care that balances pharmacologic and nonpharmacologic techniques and may necessitate the involvement of an interdisciplinary team. The goals of treatment in these populations should focus on improving function and limiting longterm adverse effects of pain and its treatment as much as or more than they do on improving comfort. As the population of cancer survivors expands, all clinicians who interact with these individuals, including oncologists, advanced practice providers, and primary care physicians, will require the knowledge and skills to implement best practices in the management of chronic pain. When analgesic drugs are used, the imperative to prescribe safely must expand beyond immediate adverse effects, such as respiratory depression or constipation associated with opioids, to incorporate awareness and mitigation of long-term consequences of these and other analgesic agents. The purpose of this guideline summary is to provide guidance to

Application effects of the pain nursing operation flowchart in standardized wards of cancer pain

Objective To investigate application effects of the pain nursing operation flowchart in the management of cancer pain patients. Methods Eighty-two patients were divided into the control group (40 patients) and the study group (42 patients) according to the admission time using the convenience sampling method. The patients in the control group received routine nursing. In the study group the pain nursing operation flowchart was designed based on the adult cancer pain guideline and the establishment standard of cancer pain standardized treatment example wards. The nursing form was designed corresponding to the flowchart. The standardized training was carried out in all nurses in the department for the improvement of their operation standardization. The comprehensiveness and the dynamics of the pain assessment, the timeliness of communicating with doctors, the comprehensiveness of pain propaganda and education, the timeliness of the management of adverse reactions and the satisfaction degree of discharged patients in the two treatment groups were evaluated. Results For the quality inspection of pain nursing of the patients in the study group, after using the flowchart, the qualified rates of the comprehensiveness and the dynamics of the pain assessment, the timeliness of communicating with doctors, the comprehensiveness of pain propaganda and education, the timeliness of the management of adverse reactions were 100.0%, 100.0%, 95.2%, 100.0%, 97.6%, respectively; the satisfaction degree of discharged patients was 97.6%, all of which were significantly higher than those in the control group (χ2= 9.31, 6.80, 4.44, 8.04, 7.74, 4.18; P<0.05). Conclusions The application of the pain nursing operation flowchart in standardized wards of cancer pain can significantly improve the quality of pain management, which achieves good social benefits and worthy of promotion. Key words: Pain management; Standardized wards of cancer pain; Nursing operation flowchart; Quality control

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Dutch Pain Specialists' Adherence to the Multidisciplinary Guideline on Treating Pain in Patients with Cancer: A Case Vignette Study.

Many patients with cancer suffer from pain, which is often not optimally treated. In 2008, the evidence-based, multidisciplinary Dutch guideline on the diagnosis and treatment of pain in this patient group was published. We assessed knowledge about and adherence to the guideline by pain specialists. A cross-sectional case vignette survey describing a palliative patient with intractable pancreatic cancer and pain was sent to all 350 Dutch anesthesiologists registered as pain specialists at the Netherlands Association of Anesthesiology. Descriptive statistics were conducted. Ninety-three pain specialists completed the questionnaire (27%). The majority appeared to follow the guideline recommendations on pharmacological (99%) and invasive treatment (95%) in the diverse stages of the disease. However, the recommendation to use a one-dimensional pain scale to evaluate the effect of pain treatment and the recommendation to perform a multidimensional pain assessment if the patient in pain is in a deteriorating stage were only followed by a minority of the respondents (23% and 15%, respectively). Regarding most recommendations, Dutch pain specialists know and intend to follow the national multidisciplinary cancer pain guideline. Yet, only a minority of them perform structural pain assessment of the patient with cancer pain. However, as the response rate was low (27%), the results should be interpreted with caution and cannot be generalized to the entire population of pain specialists in the Netherlands. We recommend that, in the guideline update and implementation programs, more attention be given to thorough assessment of the patient with pain and cancer.

Adaptation of international guidelines on assessment and management of cancer pain for the Australian context.

To develop clinical practice guidelines for screening, assessing and managing cancer pain in Australian adults. This three-phase project utilized the ADAPTE approach to adapt international cancer pain guidelines for the Australian setting. A Working Party was established to define scope, screen guidelines for adaptation and develop recommendations to support better cancer pain control through screening, assessment, pharmacological and non-pharmacological management, and patient education. Recommendations with limited evidence were referred to Expert Panels for advice before the draft guidelines were opened for public consultation via the Cancer Council Australia Cancer Guidelines Wiki platform in late 2012. All comments were reviewed by the Working Party and the guidelines were revised accordingly. Screening resulted in six international guidelines being included for adaptation - those developed by the Scottish Intercollegiate Guidelines Network (2008), National Health Service Quality Improvement Scotland (2009), National Comprehensive Cancer Network (2012), European Society of Medical Oncology (2011), European Association for Palliative Care (2011, 2012) and National Institute of Clinical Excellence (2012). Guideline adaptation resulted in 55 final recommendations. The guidelines were officially launched in November 2013. International guidelines can be efficiently reconfigured for local contexts using the ADAPTE approach. Availability of the guidelines via the Cancer Council Australia Wiki is intended to promote uptake and enable recommendations to be kept up to date. Resources to support implementation will also be made available via the Wiki if found to be effective by a randomized controlled trial commencing in 2015.

South African guidelines for the treatment of cancer pain: South African Cancer Pain Guidelines Working Group

The production of these guidelines, written by South African medical practitioners, is a most welcome and important step in the treatment of cancer pain in this country. The overall prevalence of pain in cancer patients is estimated to be 53%, and 64% in patients with advanced and metastatic disease. 1 Too often, the only guidelines available to us are those written by practitioners in other countries which may be inappropriate for implementation here owing to the differing availability of drugs or disease profile.

Adaptation of an evidence-based clinical practice guideline in cancer pain management by medical oncologists: a case vignette study.

Pain is a major problem in all cancer stages. Cancer pain guidelines are developed to improve management of pain. It is unclear whether these recommendations are applied in daily practice. Therefore, the objective of this study was to assess medical oncologists' adherence to an evidence-based clinical practice guideline in cancer pain management and their confidence in treatment choices. A cross-sectional case vignette survey describing a patient with intractable pancreatic cancer and pain was sent to all 268 medical oncologists registered at the Netherlands Association of Internal Medicine. Descriptive statistics were conducted. Sixty-three of 268 medical oncologists (24 %) completed the survey. Adherence to the different recommendations of the guideline ranged from 18 to 100 %. Confidence for treatment choice ranged from 5.6 to 9.5 on a Numeric Rating Scale (0-10). Most of the responding oncologists (94 %) adhered to prescribing paracetamol as first-line pain treatment, and all prescribed a laxative in combination with opioids to prevent constipation. However, only 24 % of the respondents adhered to the guideline when first-line treatment had insufficient effect. Additionally, only 35 % adhered to the recommendation for insomnia treatment providing psychosocial support or using a multidimensional pain questionnaire besides pharmacological treatment. Finally, only 18 % adhered to the recommendation to perform a multidimensional pain assessment when disease worsens and pain increases. The recommendations of the guideline have been partly adopted in cancer pain practice by medical oncologists. Particularly, pain assessment is not applied in the recommended manner. Therefore, implementation strategies should focus on adequate pain assessment in patients with cancer.

European Oncology Nursing Society breakthrough cancer pain guidelines

PurposeThe overall aim of the project was to update and inform nurses of current best practice based on previously published literature to enable nurses to assess and manage breakthrough cancer pain (BTCP) and thereby to provide optimal management of BTCP. MethodsThe EONS started a project in 2010 by recruiting a working group and a multidisciplinary advisory board to develop guidelines with the purpose of helping oncology nurses understand and recognise BTCP. ResultsThis paper presents and overview of the guideline. Key recommendations include; using an algorithm for assessment of BTCP, individualise treatment interventions, optimization of analgesia and reassessment of outcomes of interventions. ConclusionsBy implementing the EONS guidelines nurses will utilise the latest available knowledge in clinical practice and the understanding and management of BTCP will improve assessment and overall management of breakthrough pain in cancer patients.

Australian survey of current practice and guideline use in adult cancer pain assessment and management: The community nurse perspective

Cancer pain remains a major public health concern. Despite effective treatments being available to manage the majority of cancer pain, this debilitating symptom is frequently under treated. As cancer has becomes a chronic disease a range of health professionals, including community nurses in Australia are increasingly caring for people living with cancer related pain. Yet, little is known about community nurses capacity to assess and manage cancer pain in accordance with best available evidence. This study aimed to: identify the barriers and facilitators to adult cancer pain assessment and management as perceived by Australian health professionals; identify if cancer pain guidelines are currently used; identify barriers and facilitators to guideline use; and establish the need for Australian cancer pain guidelines. This article reports on community nurses' perceptions of managing cancer pain in the community setting. A cross-sectional survey was administered online. Invitations were circulated via peak bodies and clinical leaders seeking the views and experiences of health professionals involved in caring for people living with cancer pain. Descriptive statistics were used to summarise the quantitative data, and thematic content analysis were used to describe the qualitative data. Sixty-two community nurses responded to the survey, representing 29% of the total sample. These participants reported high levels of adherence to accepted cancer pain management practices in their workplace, with 71% nominating the Palliative Care Therapeutic Guideline V.3 as being most frequently used to manage community patients' cancer related pain. Key barriers to effective cancer pain management in the community were: difficulties accessing non-pharmacological interventions (89%), lack of coordination by multiple providers (89%), and impact of distance on ability to access pain-related services for patients (86%). A range of system, health professional and consumer barriers limit access to best available treatment in the community setting for people with cancer pain. A clinical pathway that gives step-by-step guidance on evidence-based practice along with an evaluation framework may be the best way of enabling community nurses to ensure their patients with cancer related pain have access to best available care.

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