Cancer pain: Are we making progress?
With Dr Judith Paice | 3 Dec 2015 | Print
An interview with Judith Paice, PhD, RN, FAAN, Director of the Cancer Pain Program, Division of Hematology-Oncology and Research Professor of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
For the over 1.5 million people diagnosed each year with cancer, the over 12 million cancer survivors, and the over 570,000 individuals who will die each year, pain relief remains the most critical need. So wrote Drs Judith Paice and Betty Ferrell in a review of the management of cancer pain published in 2011.1 PainFocus™ had the privilege of interviewing one of the authors of this review, Dr Judith Paice (Feinberg School of Medicine, Northwestern University, USA), to learn more about the goals and views of this highly regarded expert in cancer pain management. Aside from her prestigious academic posts, Dr Paice is also the current secretary of the International Association for the Study of Pain.
For the over 1.5 million people diagnosed each year with cancer, the over 12 million cancer survivors, and the over 570,000 individuals who will die each year, pain relief remains the most critical need
For 30 years, Dr Paice has focused on pain, working to relieve the suffering experienced by patients and studying methods to better relieve pain due to cancer. Her commitment to this area of medicine was forged during her first position as a staff nurse in an inpatient oncology unit. “Pain was a prominent issue – and we did not do an especially good job in managing this pain,” she recalled. “I have very strong memories of patients who suffered severe pain and I saw the effect on their quality of life, as well as that of their family and loved ones. Several patients who had severe pain committed suicide. Once I became aware that this [suffering] was unnecessary, I became committed to work to relieve pain.”
Overcoming the challenges
Like the many other healthcare professionals involved in caring for individuals experiencing cancer pain, Dr Paice hopes that the time will soon come when all patients will receive appropriate attention to their pain and suffering. However, a number of barriers still stand in the way of this goal.
One of the obstacles Dr Paice identified is a lack of knowledge among healthcare professionals. She has personally endeavored to address this through developing and delivering educational programs to healthcare professionals around the world. Despite her efforts and those of contemporaries who share her commitment, there remains a disturbing number of oncologists who are not employing optimal pain management practices. Dr Paice cited a recent survey conducted by Breuer and colleagues2 among medical oncologists in the United States, which demonstrated the oncologists’ lack of proficiency in developing a pain treatment regimen for hypothetical cancer patients.
System-related barriers also exist. “The [healthcare] system complicates management as time is limited, there are few experts in cancer pain, and cost and reimbursement issues are becoming increasingly difficult,” noted Dr Paice. She believes that multidisciplinary care is crucial for patients with cancer, but limited reimbursement for this type of care restricts its availability. “Our current healthcare system [in the United States] reimburses for interventions or procedures, but provides little support for counseling, physical and occupational therapy, and education needed to help patients understand how to better manage pain and medications, and prevent adverse effects associated with pharmacologic therapies.” On patient-related barriers to optimal pain management, Dr Paice commented, “Patients and families occasionally under-report pain as they are afraid they might not be eligible for additional cancer treatment, such as clinical trials”.
Treatment-related chronic pain: A new frontier
One of Dr Paice’s chief clinical and research interests is cancer treatment-related chronic pain syndromes, and she publishes and speaks widely on this topic to foster greater awareness and understanding of this critical clinical need. “Chronic or persistent pain syndromes present the ‘new frontier’ because we are seeing many people experiencing these syndromes, yet we have so little data about prevalence, risk factors, neurobiology, prevention and treatment. There is an explosion in the number of people experiencing these syndromes – including chemotherapy-induced peripheral neuropathy, radiation-induced persistent pain syndromes, pain due to graft-versus host disease after stem cell transplant, and arthralgias after aromatase inhibitors. In some cases, the pain is so severe that patients are stopping potentially curative anti-cancer therapy; so the need to manage this pain is imperative.”
Dr Paice believes that it is essential that the skilled clinician be able to identify these syndromes, differentiate them from pain due to cancer, which would require different management, and work to relieve such pain. Yet the current situation is far from optimal. Dr Paice suggested a number of initiatives that should be pursued to improve the quality of life of patients with these treatment-related pain syndromes.
In some cases, the pain is so severe that patients are stopping potentially curative anti-cancer therapy
“Although education is key, education alone is not enough. Standardized assessment is a start, as this will ensure that all clinicians are aware of the patient’s pain, and optimally, other symptoms. Protocols or algorithms are helpful and several organizations have produced these tools, notably the National Comprehensive Cancer Network. But we cannot stop there. Regulators have an important role. And third-party payers need to be responsive to the special needs of people with cancer, which might include [analgesic] doses that are higher than those required by others with pain, as well as the need for multidisciplinary care.”
Towards universal access to essential pain-relief medicines
In view of Dr Paice’s global travels, PainFocus™ asked about her impressions of cancer pain management in the Asian region. Although her most recent experiences have been in Africa, Eastern Europe, Russia and the Middle East, Dr Paice observed that there are several areas that complicate pain control throughout the world, including in Asia. In particular, opioid availability remains a challenge in developing countries. In an effort to steer improvement in pain control around the world, the International Association for Hospice and Palliative Care (IAHPC) with the World Health Organization developed a list of essential medicines for palliative care, which includes immediate-release morphine tablets and liquid for relief of pain and dyspnea. Dr Paice noted that despite this initiative, immediate-release morphine and other important analgesics are not available in some countries, which represents a major impediment to the provision of adequate pain relief.
“Equitable access to cancer pain care and availability of medications on the list of essential medications is crucial. These medications need to be available to those patients who are in the hospital, as well as those cared for at home, and they need to be accessible easily so that if family members need to access these drugs for the patient, they are able to do so,” she stressed. The Pain & Policy Studies Group (PPSG) at the University of Wisconsin-Madison developed the Guidelines for Achieving Balance in National Opioids Control Policy (www.painpolicy.wisc.edu/publicat/00whoabi/00whoabi.htm), which has been endorsed by the International Narcotics Control Board. “This is a guide for all Asian countries – really every country around the world – to ensure there is balance between opioid availability and prevention of misuse.” Dr Paice drew attention to data from the PPSG website on country-specific opioid consumption rates. “Comparative data for the WHO Western Pacific Region reveals significant morphine use in New Zealand and Australia, but every other country in this region is below the global per capita intake of morphine of 6.3811 mg.” This suggests there are pain patients, including cancer patients, in these countries who are being denied the proven benefits of opioid analgesics. “In some countries, this low consumption may be due to attitudes about opioids and addiction, although more information is needed before we fully understand the contributing factors,” she commented.
Thoughts on the future
Dr Paice believes that greater awareness of the need for impeccable cancer pain management will drive positive change. “In addition, contributions to the understanding of the neurobiology of cancer pain, now being studied by our basic science colleagues, will inform prevention and management strategies, and new therapies will be derived from this knowledge.” Certainly an encouraging forecast for physicians and patients alike.
1. Paice JA, Ferrell B. CA Cancer J Clin 2011;61:157-182.
2. Breuer B, Fleishman SB, Cruciani RA, Portenoy RK. J Clin Oncol 2011;29:4769-4775.
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