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Breakthrough pain management in patients undergoing radiotherapy: a national survey on behalf of the Palliative and Supportive Care Study Group

Abstract

Aims

To assess the contribution of radiation oncologists in Italy in current management of breakthrough pain (BtP).

Methods

In 2012, the Palliative and Supportive Care Study Group of the Italian Association of Radiation Oncology (AIRO) proposed a survey. All Italian radiation oncologists were individually invited to complete an online questionnaire regarding their management of BtP in patients undergoing radiotherapy treatment.

Results

A total of 303 Italian radiation oncologists (of 330 who had access to the Web site) completed the questionnaire over an 8-month period. Some important differences were shown in pain intensity assessment by validated measurement scales, as well as in setting and prescribing analgesic therapy to prevent procedural pain. These differences were also reviewed and discussed related to international guidelines and data available from the literature.

Conclusions

Compared to other medical professionals, the involvement of radiation oncologists in cancer pain management remains marginal, at least in Italy. More than 70% of radiation oncologists directly optimized the analgesic therapy during the treatment course and more than 50% implemented specific treatment for BtP. However, the ability of the radiation oncologist to manage BtP could be improved. In order to increase the consciousness of systematic symptom measurement and to spread the knowledge of the best type of analgesic drugs to be used, training events promoted by national associations, such as AIRO, and a collaborative multidisciplinary approach of the management of cancer pain will be promoted.

Tumori 2015; 101(6): 603 - 608

Article Type: ORIGINAL RESEARCH ARTICLE

DOI:10.5301/tj.5000308

Authors

Luciana Caravatta, Sara Ramella, Antonella Melano, Fabio Trippa, Anna Santacaterina, Simonetta Bacchiddu, Giovanni Mandoliti, Giovanna Mantini

Article History

Disclosures

Financial support: None.
Conflict of interest: None.

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Introduction

Pain is the most frequent symptom in cancer patients and may be the first treatment demand in the patient with advanced stage disease (1). Despite advanced knowledge in the physio-pathologic mechanisms of cancer pain, the development of effective and less invasive interventional techniques, and therapeutic recommendations by the World Health ­Organization (WHO) (2), pain relief remains a primary challenge in the integral management of cancer patients.

Assessment of pain is a critical step to provide good pain management. Several tools for pain intensity measurement have been developed and validated (3-4-5-6). Thus, the use of validated scales, pain questionnaires, or other patient-related instruments for pain evaluation is suggested by international guidelines (2-3-4-5-6-7). In particular, since the 100-mm visual analogue scale (VAS) pain intensity scale proved to be easy to use and sufficiently sensitive to detect differences in pain rating (3), its utilization is currently recommended for pain assessment by Italian government laws (8), before and after each medical intervention, to better evaluate the drug efficacy and determine whether therapy modification is needed.

Breakthrough pain (BtP) is defined as transient pain exacerbation in patients with stable and controlled basal pain (9) and is recognized as an important and often problematic aspect of cancer pain. In fact, its incidence remains very high in patients with cancer (405-85%) (10). In addition, spontaneous or incidental BtP can be identified. Incidental BtP can be classified as volitional (caused by a voluntary act such as walking), nonvolitional (caused by an involuntary act such as sneezing or coughing), or procedural (caused by therapeutic interventions, for instance, the bandaging of a wound).

Procedural BtP could also occur during some procedures related to external beam radiotherapy or brachytherapy delivery. To our knowledge, data about the incidence and management of BtP in patients who undergo radiation treatment are not available. Therefore, based on these considerations, the Palliative and Supportive Care Study Group of the Italian Association of Radiation Oncology (AIRO) proposed a survey aimed to assess the current management of BtP in Italy, with particular attention to the evaluation of the contribution of radiation oncologists compared to other specialists involved in the management of cancer pain.

Methods

An online survey was produced via www.surveymonkey.com, and all medical members of AIRO were individually contacted by e-mail to request their contribution to the study. Full anonymity was guaranteed. The online questionnaire (supplementary material, available online at www.tumorijournal.com) was open for completion through March and November 2012. ­Fifteen questions were included in the survey, with between 3 and 9 multiple choice responses for each, besides the opportunity for free text comments.

Sections of the questionnaire are summarized as follows:

Demographics and personal data: 7 questions concerning region of practice, sex, employment (medical specialist or resident), workplace (treatment planning, linear accelerator [LINAC], brachytherapy, hospital ward, day hospital), occupational category (medical director, unit or department ­director), professional seniority, affiliation (public hospital, accredited private hospital, or university hospital).

Satisfaction and setting of the analgesia therapy: 2 questions regarding the number of patients coming to radiation oncologist observation with an appropriate therapy for analgesia in relation to the WHO therapeutic recommendation (2) and the specialist who had already set the analgesic therapy in these patients.

Pain assessment: 2 questions about the frequency ­(never, sometimes, often, always) of use of a validated measurement pain assessment scale during the first evaluation and during the radiation treatment, respectively.

Optimization of the analgesic therapy: 2 questions referring to the percentage of patients in whom the radiation oncologist directly establishes or optimizes the analgesic therapy and the kind of analgesic drug most frequently performed by patients = underwent radiation treatment (long-acting opioid, long-acting opioid + rescue, as-needed opioid).

Procedural pain treatment: 2 questions on the percentage of patients in whom the radiation oncologist directly implements the therapy for procedural pain and the kind of analgesic drug most frequently prescribed by the radiation oncologist for procedural pain related to the radiation treatment (oral or transdermal opioids, IV morphine, transmucosal opioids, nonsteroidal anti-inflammatory drugs [NSAID]).

Responses were tabulated, and the percentage values are reported. The comparison between relative variations was evaluated using the Student t distribution.

Results

A total of 330 Italian radiation oncologists had access to the Web site and 303 (91.8%) completed the questionnaire over an 8-month period.

Demographics and personal data

The geographic distribution of region of practice of responding radiation oncologists reflected the distribution of radiotherapy centers throughout the country (Tab. I).

Region of practice

No. %
Abruzzo 5 1.7
Basilicata 4 1.3
Calabria 8 2.6
Campania 17 5.6
Emilia Romagna 11 3.6
Friuli Venezia-Giulia 8 2.6
Lazio 38 12.5
Liguria 8 2.6
Lombardia 70 23.1
Marche 5 1.7
Molise 3 1.0
Piemonte 32 10.6
Puglia 13 4.3
Sardegna 16 5.3
Sicilia 20 6.6
Toscana 21 6.9
Trentino Alto Adige 4 1.3
Umbria 8 2.6
Valle d’Aosta 0 0.0
Veneto 12 4.0
Total 303 100

Demographics and personal data of all responding radiation oncologists are described in detail in Table II. Most of the radiation oncologists (148 [48.8%]) carried out their activities at the LINAC. Twenty-one (6.9%) and 4 (1.3%) radiation oncologists were involved in day hospital and hospital ward activity, whereas 57 (18.9%) and 54 (17.9%) were involved in different workplaces at the same time, excluding or including brachytherapy, respectively. A total of 172 (56.52%) of the respondents had more than 10 years of professional experience, and 60 (19.8%) had more than 30 years.

Personal data of all responding radiation oncologists

No. %
Sex
 Male 147 48.5
 Female 156 51.5
Employment
 Resident 24 7.9
 Medical specialist 279 92.1
Up to 1 year 15 5
1-5 years 54 18
6-10 years 51 16
11-20 years 61 20.1
21-30 years 42 14
More than 30 years 56 19
Occupational category
 Medical director 231 76.3
 Unit or department director 72 23.7
Affiliation
 Public hospital 204 67.4
 Accredited private hospital 57 19.0
 University hospital 42 13.6
Total 303 100

Satisfaction and setting of the analgesic therapy

Therapy for analgesia was considered satisfactory if appropriate in relation to the WHO therapeutic recommendation (2). Most of the respondents (137 [45.2%]) asserted that from 25% to 50% of all patients came to their observation with a satisfactory therapy for analgesia, whereas for 53 (17.5%), 89 (29.4%), and 24 (7.9%) radiation oncologists the therapy was considered adequate in less of 25%, 50% -75%, and more than 75% of patients, respectively.

The analgesic therapy in these patients was already set by the medical oncologist alone (34.9%) or in accordance with the pain or palliative care therapist (25.5%) and with the radiation oncologist (8.7%). Pain or palliative care therapist, general practitioner, or radiation oncologist was primarily involved for 16.5%, 10.5%, and 0.6% of the respondents, respectively (Tab. III).

Professional directly involved in the setting of the analgesic therapy

No. %
General practitioner 32 10.5
Pain or palliative care therapist 50 16.5
Pain or palliative care therapist + medical oncologist 77 25.5
Pain or palliative care therapist + radiation oncologist 3 0.9
Pain or palliative care therapist + medical oncologist + radiation oncologist 26 8.7
Medical oncologist 106 34.9
Medical oncologist + radiation oncologist 7 2.4
Radiation oncologist 2 0.6
Total 303 100

Pain assessment

The frequency of use of a validated measurement pain assessment scale is shown in detail considering regional variation for North, Central, and South Italy (Tab. IV) and the impact of seniority and years of practice (Tab. V). Only around 6% of all Italian radiation oncologists stated that they never used a validated pain assessment scale, while 41.3% and 32.7% always used that scale during the first evaluation and during the radiation treatment, respectively. No statistically significant difference was found among North, Central, and South Italy.

Frequency of pain intensity assessment by validated measurement scales reported by all Italian radiation oncologists and considering regional variation for North, Central, and South Italy

All Italian radiation oncologists North Italy Central Italy South Italy
No. % No. % No. % No. %
North Italy includes Emilia Romagna, Friuli Venezia Giulia, Liguria, Lombardia, Piemonte, Trentino Alto Adige, and Veneto; Central Italy includes Abruzzo, Lazio, Marche, Toscana, and Umbria; South Italy includes Basilicata, Calabria, Campania, Molise, Puglia, Sardegna, and Sicilia.
aThe highest percentage value.
During the first patient evaluation
 Never 17 5.6 5 3 6 8 6 7
 Sometimes 63 20.8 29 20 25 33 9 12
 Often 98 32.3 41 28 18 24 39 48a
 Always 125 41.3a 71 49a 27 35a 27 33
 Total 303 100 146 100 76 100 81 100
During the radiation treatment
 Never 19 6.3 7 5 7 9 5 6
 Sometimes 85 28.0 41 28 29 39a 15 18
 Often 100 33.0a 44 30 20 26 37 46a
 Always 99 32.7 54 37a 20 26 24 30
 Total 303 100 146 100 76 100 81 100

Frequency of pain intensity assessment by validated measurement scales related to seniority and years of practice

Resident Medical specialist
Up to 1 y 1-5 y 6-10 y 11-20 y 21-30 y >30 y
Values are n (%).
aThe highest percentage value.
During the first patient evaluation
 Never 0 (0) 0 (0) 2 (4) 3 (6) 4 (7) 3 (7) 5 (10)
 Sometimes 6 (25) 2 (13) 10 (18.5) 12 (23.5) 9 (15) 10 (24) 14 (25)
 Often 8 (33) 8 (54)a 22 (40.5)a 12 (23.5) 21 (35) 14 (33) 13 (23)
 Always 10 (42)a 5 (33) 20 (37) 24 (47)a 27 (42)a 15 (36)a 24 (42)a
 Total 24 (100) 15 (100) 54 (100) 51 (100) 61 (100) 42 (100) 56 (100)
During the radiation treatment
 Never 1 (4) 0 (0) 3 (6) 3 (6) 4 (7) 3 (7) 5 (10)
 Sometimes 5 (21) 3 (20) 14 (26) 13 (25) 17 (27) 16 (38)a 17 (30)a
 Often 10 (42)a 10 (67)a 19 (35)a 13 (25) 20 (33)a 11 (26) 17 (30)a
 Always 8 (33) 2 (13) 18 (33) 22 (44)a 20 (33)a 12 (29) 17 (30)a
 Total 24 (100) 15 (100) 54 (100) 51 (100) 61 (100) 42 (100) 56 (100)

Optimization of analgesic therapy

A total of 217 (72%) radiation oncologists directly optimized the analgesic therapy in 10%-50% of patients coming in to the radiation center (Fig. 1). The analgesic drugs most frequently already used by these patients were long-acting opioid plus a rescue medication, long-acting opioid, or as-needed opioid in 51.5%, 36%, and 12.5%, respectively.

Percentage of patients in whom radiation oncologists directly established or optimized the analgesic therapy.

Procedural pain treatment

A total of 157 (52%) radiation oncologists declared that they directly implement a specific treatment for procedural pain, regardless of the analgesic therapy in place, in <25% of patients (Fig. 2). The analgesic therapy usually prescribed to prevent specific procedural pain was NSAID, transmucosal opioids, oral or transdermal opioids, and IV morphine in 34.3%, 33.3%, 29%, and 3.4%, respectively.

Percentage of patients in whom radiation oncologists directly implemented a specific treatment for procedural pain.

Discussion

Cancer pain is the most frequent treatment demand in the patient with advanced disease. Improper pain management is a primary cause of patient discomfort and disability and a common cause of hospital admissions (9). Cancer pain represents a serious public health issue. Although radiotherapy offers an effective treatment for cancer pain, it also can act as a triggering event of procedural pain. The simulation and delivery practices related to external beam treatment, as well as the more invasive practices of brachytherapy, may represent a root cause of BtP. Hence, correct identification and management of BtP is increasingly becoming a highly relevant issue also for the radiation oncologist.

A primary aim of pharmacologic treatment of BtP is to ensure that baseline persistent pain is assessed at regular intervals and effectively treated with around-the-clock doses of an analgesic (2). Appropriate and efficacious analgesic treatment cannot be obtained without the use of validated tools for systematic and uniform pain detection and measurement.

This is the first nationwide study to evaluate practices relating to cancer pain and BtP management among radiation oncologists in Italy. In Italy, The 38 Law of 15 March 2010 aimed to improve pain management and include the end-of-life period in the care process, offering adequate pain treatment and quality of life to all citizens (8). To this end, the use of a simple tool for pain evaluation, such as VAS, was suggested and regulated for each involved health professional. To evaluate the routine use of VAS and the consequent correlation with BtP management, questions 10 and 11 were examined. Our analysis found that 41.3% and 32.7% of respondents always use the VAS during the first patient evaluation and radiation treatment, respectively (Tabs. IV and V), showing that, although the VAS is widely used, it is not constantly and regularly inserted in clinical practice. No statistically significant difference was found among North, Central, and South Italy. These data are relevant when compared with those reported in other studies showing an inadequacy by medical professionals in pain assessment (11). This aspect has been pointed out as an important barrier to cancer pain control and suggests that education of medical professionals is necessary to improve cancer pain management (11).

Moreover, our analysis showed that in patients = underwent radiation treatment, the analgesic therapy was already set by the medical oncologist alone (34.9%) or in accordance with the pain/palliative care therapist (25.5%) and with the radiation oncologist (8.7%). Therefore, compared to other medical professionals, the involvement of the radiation oncologist in cancer pain management remains marginal (Tab. III). Even though the therapy was judged to be satisfactory in 25%-50% of patients by 45% of respondents, a direct intervention for its optimization was implemented in half of patients (10%-50%) by the majority of radiation oncologists (72%). These aspects could highlight the need for recovery of the clinical role of the radiation oncologist as well as regular and durable transmission of clinical experience from seniors to young professionals. To support this hypothesis, 7.9% of responders were residents and 56.5% had more than 10 years of professional experience and 19.8% more than 30 years.

Finally, our analysis showed that the analgesic drugs most frequently already used by patients = underwent radiation treatment were long-acting opioid plus a rescue medication, long-acting opioid, or as-needed opioid in 51.5%, 36%, and 12.5%, respectively. A total of 157 radiation oncologists (52%) declared that they directly implement a specific treatment for procedural pain, regardless of the analgesic therapy in place, in <25% of patients (Fig. 2). The analgesic therapy usually prescribed to prevent specific procedural pain were NSAID, transmucosal opioid, oral or transdermal opioid, and IV morphine in 34.3%, 33.3%, 29%, and 3.4% of these patients, respectively. These data are not fully in agreement with those reported in the literature and suggested by the guidelines. In fact, after control of the baseline persistent pain has been achieved, the goal of pain management is to decrease the frequency and intensity of BtP. Many published and clinical experiences concerning BtP management involved opioids (12-13-14-15-16). Related to the short time from onset to peak pain intensity, the optimal opioid for BtP treatment should have a rapid onset of effective analgesia and an appropriate duration of action (12). For these reasons, oral immediate-release opioid may be appropriate in patients with predictable incident pain when given 30 to 45 minutes before the precipitating event (13). In addition, oral transmucosal opioids are well suited for absorption through the oral mucosa with minimal local irritation (14-15-16). The parenteral administration of opioids could be used as an alternative to the oral route, mainly in hospice settings and in inpatients experiencing multiple daily episodes of BtP poorly responding to oral opioids. Also, NSAID should be efficacious in treating BtP because of their nociceptive mechanisms. However, the use of these agents is complicated by dose-limiting toxicities and a long onset (half-hour or more) and duration of action (several hours). In addition, no published evidence exists to support their use in BtP.

This study has limitations. First, although we performed a multicenter study, the results may not be representative of other practices and knowledge of all radiation oncologists in Italy. Second, the obtained data may not be completely representative of other countries, also considering the national laws that regulate cancer pain and BtP management. However, our data are in agreement with those reported in the literature for other countries, showing that medical professionals’ inadequacy in pain assessment and management represents an important barrier to cancer pain control (11, 17, 18), suggesting that additional educational strategies to promote cancer pain management are needed in Italy, as well as in other countries. This is the first nationwide study to evaluate practices relating to cancer pain and BtP management among radiation oncologists in Italy. Compared to other medical professionals, direct involvement of the radiation oncologist in cancer pain management currently remains marginal, at least in Italy. Nevertheless, more than 70% of the radiation oncologists declared that they directly optimized the analgesic therapy during the treatment course and more than 50% implemented a specific treatment for BtP. Furthermore, the survey shows that, considering the high rate of inappropriate prescribing of pain medication, a recovery of the clinical role of the radiation oncologist is needed and the ability of pharmacologic management of BtP by the radiation oncologist could be improved.

In conclusion, based on these considerations, changes in educational strategy are required to increase the consciousness of systematic symptom measurement and to enhance clinical practice among health care professionals and radiation oncologists in relation to cancer pain management, ­especially regarding opioid administration or alternate therapies for pain control. In order to achieve these goals, training events promoted by national associations, such as AIRO, and a collaborative multidisciplinary approach of the management of cancer pain are recommended.

Acknowledgment

The authors thank the 303 radiation oncologists who took part in the survey and completed the questionnaire.

Disclosures

Financial support: None.
Conflict of interest: None.
References
  • 1. Hearn J Higginson I Cancer pain epidemiology: a systematic review. In: Bruera E, Portenoy R, eds. Cancer Pain Cambridge Cambridge University Press 2003:19-37. Google Scholar
  • 2. World Health Organization. Cancer Pain Relief: With a Guide to Opioid Availability, second edition. Geneva World Health Organization 1996. Google Scholar
  • 3. Ohnhaus EE Adler R Methodological problems in the measurement of pain: a comparison between the verbal rating scale and the visual analogue scale. Pain 1975 1 4 379 384 Google Scholar
  • 4. Melzack R The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975 1 3 277 299 Google Scholar
  • 5. Daut RL Cleeland CS Flanery RC Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain 1983 17 2 197 210 Google Scholar
  • 6. Hicks CL von Baeyer CL Spafford PA van Korlaar I Goodenough B The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain 2001 93 2 173 183 Google Scholar
  • 7. Gordon DB Dahl JL Miaskowski C et al. American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med 2005 165 14 1574 1580 Google Scholar
  • 8. Gazzetta Ufficiale della Repubblica Italiana. The 38 Law of Accessed 19 March 2010. Available at: www.gazzettaufficiale.it/gunewsletter/dettaglio.jsp?service=1&datagu=2010-03-19&task=dettaglio&numgu=65&redaz=010G0056&tmstp=1269600292070. Google Scholar
  • 9. Portenoy RK Hagen NA Breakthrough pain: definition, prevalence and characteristics. Pain 1990 41 3 273 281 Google Scholar
  • 10. Margarit C Juliá J López R et al. Breakthrough cancer pain: still a challenge. J Pain Res 2012 5 559 566 Google Scholar
  • 11. Breuer B Fleishman SB Cruciani RA Portenoy RK Medical oncologists’ attitudes and practice in cancer pain management: a national survey. J Clin Oncol 2011 29 36 4769 4775 Google Scholar
  • 12. Fortner BV Okon TA Portenoy RK A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain. J Pain 2002 3 1 38 44 Google Scholar
  • 13. Mercadante S Villari P Ferrera P Bianchi M Casuccio A Safety and effectiveness of intravenous morphine for episodic (breakthrough) pain using a fixed ratio with the oral daily morphine dose. J Pain Symptom Manage 2004 27 4 352 359 Google Scholar
  • 14. Farrar JT Cleary J Rauck R Busch M Nordbrock E Oral transmucosal fentanyl citrate: randomized, double-blinded, placebo-controlled trial for treatment of breakthrough pain in ­cancer patients. J Natl Cancer Inst 1998 90 8 611 616 Google Scholar
  • 15. Coluzzi PH Schwartzberg L Conroy JD Jr et al. Breakthrough cancer pain: a randomized trial comparing oral transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate release (MSIR). Pain 2001 91 1-2 123 130 Google Scholar
  • 16. Zeppetella G Ribeiro MD Pharmacotherapy of cancer-related episodic pain. Expert Opin Pharmacother 2003 4 4 493 502 Google Scholar
  • 17. Yanjun S Changli W Ling W et al. A survey on physician knowledge and attitudes towards clinical use of morphine for cancer pain treatment in China. Support Care Cancer 2010 18 11 1455 1460 Google Scholar
  • 18. Sapir R Catane R Strauss-Liviatan N Cherny NI Cancer pain: knowledge and attitudes of physicians in Israel. J Pain Symptom Manage 1999 17 4 266 276 Google Scholar

Authors

Affiliations

  • Radiation Oncology Department, “San Francesco” Hospital, Nuoro - Italy
  • Radiation Oncology, Campus Bio-Medico University, Rome - Italy
  • Radiotherapy Unit, “Santa Croce” Hospital, Cuneo - Italy
  • Radiation Oncology Centre, “S. Maria” Hospital, Terni - Italy
  • Operative Unit of Radiation Oncology, Azienda Ospedaliera Papardo-Piemonte, Messina - Italy
  • Service of Radiation Therapy, San Bortolo Hospital, Vicenza - Italy
  • Department of Radiation Oncology, Rovigo’s State Hospital, Rovigo - Italy
  • Department of Bioimaging and Radiological Sciences, Unit of Radiation Oncology, Catholic University of the Sacred Heart, Rome - Italy

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