More than one third of patients with invasive cancer are undertreated for their pain

More than one third of patients with invasive cancer are undertreated for their pain, with minorities twice as likely to not receive analgesics, according to research from The University of Texas MD Anderson Cancer Center.

The study, published in Journal of Clinical Oncology, is the largest prospective evaluation of cancer pain and related symptoms ever conducted in an outpatient setting.

Almost 20 years ago, Charles Cleeland, Ph.D., professor and chair of the Department of Symptom Research at MD Anderson, published the first comprehensive study to look at the adequacy of pain management in cancer care.

"We've known for years that the undertreatment of pain is a significant public health problem in the cancer treatment process, and that minorities are at greatest risk for not receiving appropriate pain care," said Cleeland, the JCO's study's senior author. "This new research tells us that our progress has been limited, with only a 10 percent overall reduction in inadequacy of pain management from our findings almost two decades ago."

The MD Anderson-led study was conducted by the Eastern Cooperative Oncology Group; it enrolled patients with invasive breast, prostate, colon and lung cancers from 38 institutions across the country, at any point during their care. All were treated on an outpatient basis at either an academic medical center or community clinic. The outpatient setting represents a unique setting, explain the researchers. While those hospitalized with significant pain may be evaluated by pain specialists, those treated on an outpatient basis are typically managed by their treating oncologists.

Patients completed a questionnaire providing their demographic and clinical information. Using a symptom assessment tool developed by Cleeland, the patients' pain levels were assessed, as well the level of analgesic that had been prescribed, if any. Assessment was repeated approximately one month later. The study's primary objective was to assess the prevalence of pain medication in oncology outpatient practice.

The researchers indentified 3,023 patients at risk for pain, with 2,026 (67 percent), taking analgesics, or pain medications. Approximately one fourth of those analyzed were minority patients, including Hispanic (9 percent), black (12 percent), Asian (1 percent) and other (1 percent). Of the 2,026 patients at risk for pain, 1,356, or 67 percent, had adequate pain management. For example, 20 percent of the patients who reported feeling severe pain were not receiving any analgesics, and of the 406 patients that were undertreated at an initial assessment, 31 percent received appropriate treatment by the follow-up visit. The researchers found that the odds of a non-Hispanic white patient having inadequate treatment for their pain at both initial and follow-up assessments was approximately half that of a minority patient.

While no discrepancy for age or gender was noted, interestingly, cancer survivors with pain also were less likely to be treated adequately.

"Pain is one of the most feared symptoms of cancer and it has tremendous impact on the quality of life and function of our patients," said Michael Fisch, M.D., associate professor and chair of the Department of General Oncology at MD Anderson, and the study's lead author. "These findings represent a significant discrepancy in treatment adequacy, with minority patients being twice as likely to be undertreated. This critical observation awakens us to a major opportunity in healthcare - to work hard to resolve this striking disparity."

The researchers cite a number of possible reasons for the discrepancy in findings, including: cultural and communication barriers; access to care; concerns about addiction and reluctance to admit pain; expert symptom management and access to effective patient education.

Implicit stereotyping and bias among healthcare providers, even in the absence of the providers' awareness or intention, may also be a factor, says Fisch. However, Cleeland notes that at underserved clinics, both whites and minorities were inadequately treated for their pain, thereby suggesting an overall lack of resources.

The study is not without its limitations, including the few number of disease types included, as well as that the researchers did not collect data on patients' comorbidities or socio-economic status.

Both Fisch and Cleeland agree that better symptom control must begin with open-minded physicians, appropriately gauging the needs of their patients, as well as more engaged patients and caregivers willing to communicate their pain level and other symptoms. The researchers plan to follow up these findings by looking at additional symptoms of patients as well as their emotional distress and fatigue.