ReviewEducational interventions for cancer pain. A systematic review of systematic reviews with nested narrative review of randomized controlled trials
Introduction
Cancer incidence and prevalence rates are increasing in developed countries due to an aging population and improvements in screening and treatment [1]. Pain of moderate to severe intensity affects around 40% of cancer patients at diagnosis, rising to 70% or more at the end of life [2], [3]. Cancer pain is burdensome at an individual and health care level [4]. For example, in Scotland, over 30% of primary care out of hours contacts for cancer symptoms relate to pain and around 14% of these patients are managed with education and advice [5]. Several large studies of emergency department visits by oncology patients in the USA and Canada have shown that pain is the most frequent reason for attendance, [6], [7] and that around 30% could be avoided [8]. These figures suggest considerable and potentially preventable suffering and healthcare utilization due to poor cancer pain management despite effective treatments being available [9].
Suboptimal cancer pain management is likely to be a product of both patient and health care provider (HCP) behaviors. For example there is evidence that patients do not always report their pain to HCPs, [10] can have difficulty communicating with HCPs about cancer pain and associated symptoms [11], and intentionally or unintentionally fail to adhere to prescribed analgesic regimes [12]. Studies have identified various determinants of these behaviors: patients are less likely to report their pain to a HCP if they believe that cancer pain is inevitable and uncontrollable [13] and they may under-report pain to keep the clinician focused on other aspects of their condition during the clinical assessment [14]. Pain monitoring by patients can be problematic and subject to recall bias and under-estimation, for example current pain ratings taken at an appointment do not correlate well with self-reported measures in daily or hourly pain diaries [15]. Patients’ beliefs and attitudes about analgesic side effects, addiction, and tolerance are known to influence medication adherence and subsequent pain control [16]. Intentional analgesic non-adherence can also occur if patients believe that pain is a helpful and necessary symptom, for example as an indicator of disease progression [17].
HCP behaviors may also prevent effective cancer pain management. It is known that analgesic prescriptions for patients with cancer pain are frequently suboptimal. Common deficiencies in analgesic prescriptions include failure to prescribe “around the clock” long acting analgesics, insufficient dosing of breakthrough medication, and failure to utilize adjuvant agents [18], [19]. Determinants of these behaviors include inadequate knowledge about pain assessment and opioid prescribing [20], [21] and concerns about hastening death with strong opioids [20].
Patient and HCP knowledge and attitudes appear to combine to influence patient-provider interactions and pain management behaviors. Interventions which target these behavioral determinants may therefore improve pain management. Interventions which have tried to improve health care provider or patient/carer knowledge about cancer pain management and improve pain management behaviors have broadly been referred to in the literature as educational interventions. Guidelines on the anticipatory management of cancer pain stress the importance of cancer pain education [22], however there is no recognized gold standard for cancer pain education in clinical practice and, as explained previously, cancer pain management is often suboptimal in clinical practice [9]. In the last 30 years a substantial number of educational interventions aiming to improve the management of cancer pain have been subjected to clinical trials. This review aimed to synthesize this evidence and to explore whether educational interventions can improve pain outcomes. In addition this review aimed to describe the components of these interventions and the theoretical rationale for their mechanisms of action according to the original study authors. By summarizing what has been learned about cancer pain education and by identifying the key components of previous interventions, this review will inform the development of future educational interventions to tackle suboptimal cancer pain management behaviors.
Section snippets
Methods
A systematic review of systematic reviews was conducted with nested review of the randomized controlled trials (RCTs) contained within selected reviews. Systematic reviews of systematic reviews are known to be useful, particularly for aiding policy and clinical decisions in healthcare when there are multiple existing reviews of a healthcare intervention [23]. By systematically identifying all reviews of cancer pain education, quality appraising existing reviews, and comparing and contrasting
Results
A PRISMA diagram is shown in Fig. 1. 2066 titles were identified by searching four databases, hand-searching bibliographies of reviews and randomized controlled trials, and checking trial registries. 27 full text articles were assessed, of which eight reviews satisfied the inclusion and exclusion criteria and were included in the narrative synthesis [27], [28], [29], [30], [31], [32], [33], [34].
Discussion
Educational interventions to date have targeted different individuals, mostly patients, but also carers and HCPs. Reviews with strict inclusion criteria and rigorous methodology show a small but statistically significant benefit of patient educational interventions on knowledge, attitudes and pain intensity in patients with cancer. Bennett et al. [29] reported that the average benefit of education on pain intensity measures was one point out of ten on the Brief Pain Inventory (i.e. a 10%
Conclusion
Educational interventions targeted at people with cancer can improve their knowledge about cancer pain and achieve reductions in self-reported pain intensity measurements. The effect of HCP education on patients’ pain outcomes is less clear.
Practice implications
Clinicians should specifically ask about pain at clinical assessments and should be alert to recognized barriers to optimal pain management. Cancer pain is rarely a static condition, and many educational interventions have incorporated strategies to prompt timely pain reassessment.
Educational interventions, regardless of target group have common component parts which are interconnected. These elements cannot be considered in isolation, but should be considered systematically in the development
Contributions
Dr Rosalind Adam was involved in the conception of this review, study identification and selection, data abstraction, data analysis, and drafting the article.
Professor Christine Bond was involved in study selection, data analysis, and revising the article critically.
Dr Peter Murchie was involved in conception, devising database search strategies, and revising the article critically.
Funding
Dr Rosalind Adam completed this work during a clinical academic fellowship funded by NHS Education for Scotland (NES).
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