Abstract:
Background: Pain management is critical in the everyday job of healthcare professionals who encounter patients who are in pain on a regular basis. To provide efficient pain treatment, these healthcare professionals must acquire extensive training and have a solid grasp of cancer-related pain. Regrettably, adherence to the World Health Organization's (WHO) treatment recommendations is frequently poor. Our research aims to analyze cancer patients' pain management understanding and practices, as well as medical oncologists' attitudes, knowledge, and practices in the context of pain treatment.
Methodology:
The study involved the distribution of pain management tool questionnaires to oncologists (Consultant Oncologists, senior registrars) during their outpatient department (OPD) visits. The questionnaire comprised a total of 27 questions, which were a mix of multiple-choice and short-answer format.
Results:
Despite the fact that many oncologists are acquainted with the WHO pain ladder and grading system, barely half of them use it on a regular basis. Only a few oncologists are knowledgeable with opioid dose, maximum dosage, and conversion formulas, while the others are only vaguely acquainted. In terms of hospital resources, the majority of oncologists have access to a pain management team; however, only a few of them engage with this team on a regular basis, and the vast majority never involve the pain management team in patient care choices.
Conclusion:
Our findings indicate a lack of both knowledge and training in pain treatment. Because good pain management is a vital component of successful cancer therapy, we believe that pain management training should be prioritized within the oncology curriculum.
Introduction:
The International Association for the Study of Pain (IASP) defines pain as an unwelcome experience that encompasses both sensory and emotional elements, linked to actual or potential harm to bodily tissues or expressed in connection with such harm. Individuals dealing with cancer often face multiple sources of discomfort in various areas. According to several surveys, as many as thirty-three percent of patients experience more than one type of pain, and eighty-one percent report two or more distinct instances of pain, with thirty-four percent dealing with multiple types.
Numerous studies have demonstrated the occurrence, intensity, pain relief extent, and impact on the quality of life among patients with various cancer types, including lung, colon, and ovarian cancers. Effectively addressing the needs of cancer patients relies on a multidisciplinary approach involving diverse healthcare professionals. The American Society of Clinical Oncology now recognizes pain control and palliative care as essential components of holistic cancer care for all patients with advanced solid malignancies.
Research suggests that early introduction of palliative care, along with effective pain control and comprehensive cancer management, can prolong patient survival and improve quality of life. Effective pain management plays a critical role in comprehensive cancer care to achieve the best outcomes for patients. The World Health Organization (WHO) has issued global recommendations for the relief of cancer-related pain and supportive care.
However, it has been noted that these guidelines are not adequately followed. According to results from the WHO and several domestic and international studies, 33% of cancer patients receiving active oncological treatment report experiencing moderate to severe pain, compared to 60% to 90% of patients with the disease in its advanced stages. In India, an estimated 1 million cancer cases are diagnosed each year, and during the following 20 years, the cancer burden is predicted to nearly treble.
Similar to the scenario globally, 60% to 80% of patients in India who are now receiving diagnoses are found to be at an advanced stage, with 70% to 80% reporting pain. Numerous people across the country continue to experience needless suffering as a result of poor pain management techniques, despite years of efforts by a small palliative care community to address the availability of pain-relieving drugs.
Less than 3% of Indian cancer patients were thought to have access to appropriate pain treatment over two decades ago. The goals of pain management encompass pain relief, physical activities, potential side effects, appropriate drug usage, and emotional impact. Every healthcare provider should be familiar with terms such as opioid-naive, opioid-tolerant patients, pain intensity scale, maximum recommended opioid dosages, adverse effects, and supplementary pain management approaches.
Evaluating pain should be a routine part of regular assessments, focusing on factors like pain location, duration, severity, characteristics, factors that worsen or alleviate it, and how it affects daily activities. Given the noticeable gap in adherence to pain management guidelines established by the World Health Organization (WHO), it is imperative to consistently implement interventions such as training and assessments that focus on cancer pain control protocols for physicians.
It has been observed that a physician's familiarity with cancer pain management guidelines is associated with improvement in pain management practices. The purpose of this survey was to evaluate the level of understanding among oncologists regarding cancer pain control guidelines, their adherence to these guidelines, the challenges encountered in Cancer Pain Management (CPM), their grasp of opioid analgesics' pharmacology, engagement with pain management teams, and their familiarity with alternative therapies for cancer pain.
The main goal of this research was to assess the attitudes, knowledge, and practices of oncologists concerning the management of cancer-related pain.
Materials and Methods:
This observational study was conducted within tertiary healthcare centers in New Delhi that house oncology departments. Its objective was to assess the comprehension of pain management techniques for cancer patients among medical, surgical, and radiation oncologists. A customized questionnaire focusing on pain management tools was created and completed by the participating oncologists. The questions were derived from a selection of previous studies and surveys.
The administration of the questionnaire occurred during Outpatient Department (OPD) visits. For individuals unable to complete the questionnaire during OPD visits, the questionnaires were emailed to their addresses. The questionnaire contained a total of 27 questions in the format of multiple-choice or short-answer queries. These questions addressed various specific aspects of pain management, including:
- Opioid dosages, toxicity, and addiction;
- Transitioning from parenteral morphine to oral administration;
- Adherence to the World Health Organization (WHO) pain ladder;
- Evaluation of pain;
- Perceived barriers to prescribing opioid analgesics;
- Utilization of alternative modalities.
The design of the questionnaire aimed to ensure completion within approximately 15 minutes. This time frame was chosen to align with the optimal range of web survey filling time (10 to 20 minutes). Providing responses to all questions was mandatory for successful submission.
After collecting the data, it was processed and analyzed using SPSS-20. Descriptive statistics were utilized to interpret the test statistics. Quantitative data was presented as the mean and standard deviation from the mean. Additionally, accuracy, sensitivity, positive predictive value, and negative predictive value were calculated using standard formulas based on a contingency table.
This observational research study was conducted within tertiary care centers, specifically within the departments of medical, surgical, and radiation oncology, located in New Delhi.
The primary participants in this study consisted of consultant oncologists, senior registrars who had recently completed oncology training, and third-year residents/oncology trainees (across medical, surgical, and radiation oncology), distribution showed in Figure 1a. This study primarily encompassed medical oncologists, surgical oncologists, radiation oncologists, senior registrars (specializing in oncology), and third-year oncology trainees.
Individuals who declined to participate, oncologists in administrative and research roles, oncology trainees in their first and second years, and pediatric oncologists were excluded from the study. As this study was designed as a pilot investigation and drew on response rates from previous studies, a total of 100 oncologists were engaged in the evaluation. The study spanned a period of two years, commencing from July 2018 and concluding in June 2020 with no specific interventions or treatments.
A questionnaire focusing on pain management was developed and administered to the participating oncologists. The questionnaire was accessible in offline and online formats, allowing participants to choose their preferred mode of completion. All pertinent information was gathered according to the content of the prepared questionnaire. For data analysis, descriptive statistics were employed. In addition, the appropriate method, either Pearson chi-square test or Fisher’s Exact Test, was applied to explore associations between categorical variables.
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Results
In our study, a total of 103 oncologists responded to the questionnaire. Among the respondents, the majority were medical oncologists (69.9%), and a significant portion was resident doctors (65.04%). Answers recorded are tabulated in Table 1 and 2. While a substantial portion of oncologists (85.4%) are aware of the WHO pain ladder, only 53.4% consistently utilize it, with 39.8% employing it periodically.
Table 1
| Sr No | Questions | Answer | Total Responses | Correct Response | Incorrect Response | No Response |
|---|---|---|---|---|---|---|
| 1 | Any patient who is given opioids for pain relief is at a 25% or more risk for addiction? | FALSE | 103 | 68 | 23 | 12 |
| 2 | When opioids are taken on a regular basis, respiratory depression is rare? | TRUE | 103 | 71 | 22 | 10 |
| 3 | Doses of opioid for breakthrough pain should be 10% of the total daily dose (every 1 hour to 2 hours as needed)? | TRUE | 103 | 78 | 19 | 6 |
| 4 | Physical dependence while on opioid is a sign of addiction? | FALSE | 103 | 75 | 21 | 7 |
| 5 | Patient who complain of pain out of proportion to its cause are usually substance abusers? | FALSE | 103 | 73 | 20 | 10 |
| 6 | Increasing request for analgesics usually indicates unrelieved pain? | TRUE | 103 | 79 | 18 | 6 |
| 7 | Morphine for cancer pain shortens life but makes people more comfortable? | FALSE | 103 | 40 | 61 | 2 |
Table 1b
| St No | Questions | Answer | Total Responses | Correct Response | Wrong Response |
|---|---|---|---|---|---|
| 1 | 100 MG morphine is equivalent to ... MCG of fentanyl patch 50 | 103 | 39 | 64 | |
| 2 | 300 MG Tramadol is equivalent to ... MG of morphine 30 | 103 | 43 | 60 | |
| 3 | Maximum dose of Tramadol ....... MG | 400 | 103 | 86 | 17 |
| 4 | Maximum dose of morphine ...... | No maximum dose | 103 | 47 | 56 |
Table 2
| Sr No | Questions | Total Responses | YES | NO | Others |
|---|---|---|---|---|---|
| 1 | Are you well versed with the WHO ladder of pain management? | 103 | 88 | 15 | Not Applicable |
| 2 | Do you know the ceiling dose of opioid? | 103 | 33 | 15 | 55 (Not of all drugs) |
| 3 | Are you aware of the maximum tolerating doses of neuropathic drugs like Pregabalin? | 103 | 69 | 6 | 28 (Somewhat) |
| 4 | Do you have pain management team in your hospital? | 103 | 78 | 25 | Not Applicable |
| 5 | Do you frequently refer to them? | 103 | 31 | 44 | 29 (Sometimes) |
Table 2b
| Sr No | Questions | Total Responses | Always | Sometimes | Never |
|---|---|---|---|---|---|
| 1 | How frequently do you use WHO ladder for pain management? | 103 | 55 | 7 | 41 |
| 2 | How often do you use pain gradation score to decide pain management? | 103 | 52 | 2 | 49 |
Table 2c
| Sr No | Questions | Total Responses | 12 Hour | 24 Hour | Not Daily |
|---|---|---|---|---|---|
| 1 | How frequently you assess to see pain control? | 103 | 22 | 66 | 15 |
Table 2d
| Sr No | Questions | Confident | Somewhat | Don't Know |
|---|---|---|---|---|
| 1 | Are you confident of conversion doses of oral opioids to another or weak opioids to strong opioids? | 43 | 19 | 41 |
Concerning pain gradation scores, 50.5% of oncologists consistently use them, while 47.6% do so intermittently. Regarding the knowledge of opioid dosing, only 32% of oncologists are aware of the ceiling doses, and 53.4% acknowledge partial familiarity with them. This study also shows that confidence levels vary, with only 41.7% feeling assured about various conversion doses and formulas, while 39.8% are uncertain about the conversion process. In terms of specific conversions, merely 37.9% of oncologists accurately converted oral morphine doses to fentanyl patches, and 41.7% correctly converted IV tramadol to oral morphine equivalents. Understanding maximum tolerated doses is varied, with 83.5% correctly recognizing tramadol's limits, while just 45.6% accurately noted that there is no maximal dose for morphine.
Many true/false questions were correctly answered by a majority of oncologists. Regarding hospital infrastructure, 75.7% of oncologists have access to a pain management team. However, only 29.4% frequently engage this team, while nearly 42.2% never involve the pain management team in patient care decisions.
4. Discussion
This study aims to evaluate oncologists' current practices, attitudes, and knowledge regarding cancer pain management. This assessment serves as an initial step in developing educational initiatives for better pain relief in cancer patients. It is the first survey exploring oncologists in the Delhi-National Capital Region, encompassing medical, radiation, and surgical specialties, with a focus on their familiarity, attitudes, and challenges in prescribing opioid analgesics.
Out of a total of 395 oncologists, only 103 participated in the survey by responding to the questionnaire, yielding a response rate of 26.07%. Compared with response rates from other studies, such as 10.4% by Shalini Singh et al. [33], 33% for Brenda Breuer et al.'s study [29], 57% by LP Ger et al. [27], 90.9% for Zhang Q et al. [28], and 74.5% for Rama Sapir et al.'s study [32], the variance in response rates is attributed to differences in the studied populations.
Within the medical oncology category, respondents included 8 senior consultants, 15 senior registrars, and 49 trainees. In radiation oncology, there were 2 senior consultants, 4 senior registrars, and 7 junior oncology trainees. Surgical oncology had 2 senior consultants, 5 senior registrars, and 11 trainees. Notably, a majority of the respondents were oncology trainees specializing in medical oncology.
Our investigation demonstrates that a significant portion (85.4%) of oncologists possess awareness and a strong understanding of the World Health Organization (WHO) pain management ladder. In contrast, a study by S. Singh et al. [33] reveals that only 54.9% of physicians are acquainted with the WHO ladder. This discrepancy is attributed to our study focusing exclusively on oncologists, while Singh's study included physicians from all fields. In China, a study by Zhang Q et al. [28] reported that 72% of physicians were familiar with the WHO Ladder. However, despite the majority of oncologists being cognizant of the WHO ladder, only 53.4% consistently employ it, and 39.8% use it intermittently.
Within our study, 50.5% of oncologists consistently use a pain gradation score, while 47.6% do so occasionally. In contrast, Zhang Q et al.'s [28] study reveals that 95% of physicians employ a pain gradation score. It is essential for every oncologist to be familiar with pain gradation scores, as pain management strategies vary accordingly. A score of 0 to 3 signifies mild pain and aligns with WHO pain ladder 1, using NSAIDs. Scores of 4 to 6 indicate moderate pain, requiring WHO ladder 2 (NSAIDs and mild opioids), while scores of 7 to 10 denote severe pain, necessitating WHO ladder 3, involving strong opioids.
Only 32% of oncologists have knowledge of opioid ceiling doses, while 53.4% acknowledge partial knowledge. It's crucial for all oncologists to be well-versed in maximum allowable opioid doses, as concerns over side effects, tolerance, addiction, and availability often lead to suboptimal dosing.
In a comprehensive survey conducted across multiple Indian tertiary cancer hospitals involving 1600 patients, it was noted that 67% of patients reported inadequate pain management [25]. Correspondingly, a study by LP Ger [27] et al found that 66% of patients receive insufficient treatment, and an RTOG study led by Cleeland CS [37] et al revealed that 83% of oncologists believed that a majority of cancer patients with pain were not receiving adequate medication.
In our investigation, a notable 64.1% of oncologists engage in daily pain assessment, a pattern congruent with the findings of Zhang Q (28) et al. Moreover, only 41.7% of oncologists exhibit confidence in various conversion doses and formulas, encompassing the transition from weak to potent opioids, short-acting to long-acting opioids, and parenteral to oral opioids. Conversely, 39.8% of oncologists lack knowledge of the conversion formulas. Within our study, a mere 37.9% of oncologists accurately converted oral morphine doses to fentanyl patch equivalents, while 41.7% successfully converted IV tramadol to its oral morphine equivalent. This aspect of opioid conversion is crucial, particularly given that IV morphine is recommended for severe pain due to its rapid onset within 15 minutes. However, many healthcare professionals struggle with the conversion of IV morphine to the oral form.
Our study indicates that a substantial 83.5% of oncologists possess awareness of the maximum tolerated doses for tramadol, whereas a mere 45.6% provided the accurate response regarding morphine, recognizing that there exists no maximum dose for it. Additionally, 67% of oncologists are familiar with the maximum tolerable doses of neuropathic medications like pregabalin. While these antiepileptic and antidepressant drugs aren't first-line treatments and function as adjuvant pain management options, it remains crucial for every physician to understand their potential side effects, maximum dosage thresholds, and contraindications.
Patients often avoid morphine fearing addiction, leading doctors to under-dose opioids or choose milder options. This stems from misconceptions. Our study, with seven true/false questions, addresses these myths. Notably, 10-15% of patients prescribed opioids face addiction risk. In our study, 66% of oncologists correctly answered that opioid use doesn't pose a 25% or higher addiction risk, while 22.3% provided incorrect responses.
When prescribing opioids, a comprehensive pain assessment should be conducted. This involves evaluating the patient's prior history of substance abuse and performing a psychosocial assessment. Certain patient profiles, such as those who are young, possess prior psychiatric conditions, have a history of alcohol dependence, or were previous substance abusers, are more susceptible to addiction [39]. Within our survey, 68.9% of oncologists concurred that regular use of opioids seldom leads to respiratory depression. This finding aligns with the observations made in the study conducted by R Gallagher [34] et al, where 79.5% of physicians shared the sentiment that respiratory depression is infrequent among patients who use opioids regularly. In routine clinical practice, there is also a tendency to under-dose drugs like morphine due to concerns surrounding respiratory depression.
The occurrence of physical dependence during opioid use does not necessarily indicate addiction. This fact was accurately recognized by 72.8% of oncologists in our study, a response consistent with the findings of the research conducted by R Gallagher [34] et al. Moreover, the understanding that opioids can be safely prescribed to individuals experiencing chronic cancer pain along with a coexisting substance use disorder was linked to having knowledge about the nature of addiction [33].
As per the NCCN guidelines, Breakthrough pain refers to episodic pain that remains unmanaged by current pain treatment regimens. This category of pain encompasses incident pain and spontaneous breakthrough pain [40]. In a survey involving 1000 oncology patients, 44% of the respondents reported experiencing incident pain, 41.5% indicated experiencing spontaneous pain, while the remaining participants reported both types of pain. In our study, 75.7% of oncologists provided accurate responses concerning breakthrough pain. This contrasts with the findings from the research conducted by R Gallagher [34] et al, where only 55% of physicians correctly answered questions related to breakthrough pain.
In our survey, a significant majority of oncologists, accounting for 70.9%, hold the viewpoint that patients who express pain disproportionate to its cause are not necessarily substance abusers. Additionally, a substantial proportion, 76.7%, of oncologists agrees that an increased request for analgesics typically indicates unresolved pain. Furthermore, 59.2% of oncologists concur that the utilization of Morphine for cancer pain not only brings comfort but also enhances the quality of life, contrary to the misconception that it shortens life.
Pain management constitutes an essential aspect of palliative care and is even considered the fifth vital sign [23]. Among the various interventional strategies, options like nerve blocks, regional infusions via intrathecal administration, deep brain stimulation, epidural approaches, and surgical procedures such as percutaneous vertebroplasty and regional plexus are employed. These interventions become necessary when pain remains uncontrolled despite opioid usage. Hence, the establishment of a pain management team within each hospital catering to cancer patients is paramount.
Our study indicates that 75.7% of oncologists have a pain management team present in their respective hospitals. However, only 29.4% of them frequently refer to this team, while 42.2% never involve the pain management team in patient care decisions. Consultation for interventional strategies becomes pertinent in cases where medical treatment fails to provide adequate analgesia and when nerve blocks can yield effective pain relief, such as employing a celiac plexus block for pancreatic cancers.
5. Conclusion
Our study identifies knowledge and training gaps in pain management among oncologists. Despite their involvement in cancer pain management, there's limited mastery of appropriate opioid use, adherence to WHO guidelines, and familiarity with conversion formulas. These findings highlight the urgent need for comprehensive pain management training in oncology education in India. Promoting a positive attitude among oncologists towards cancer pain management is crucial. Encouraging multidisciplinary collaboration with other specialists can enhance patient care. In the context of the COVID era, pain management conferences, Continuing Medical Education (CME) sessions, seminars, workshops, and webinars can bridge knowledge gaps and provide a holistic understanding of cancer management. Given that effective pain management is a significant outcome of successful cancer therapy, we advocate for increased pain management training within the oncology curriculum.
6. Acknowledgement
We want to extend our heartfelt thanks to everyone who played a role in making this research paper possible. First and foremost, we are deeply grateful to Miss. Jacinthlyn Sylvia for her invaluable assistance in the preparation and writing of this manuscript. We are deeply appreciative of her unwavering support throughout this process. Additionally, our sincere appreciation goes out to all the study participants for generously dedicating their time and sharing their experiences. Their contributions have proven indispensable in enhancing our understanding of the subject matter and deriving meaningful conclusions.
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