Knowledge Is Not Enough
Cancer causes pain as it invades bone, compresses nerves, produces obstructive symptoms in the pulmonary, gastrointestinal, and genitourinary systems, and distends involved visceral organs. This manuscript reviews progress in cancer pain management during the past 2 decades. Since the 1980s, we have seen (1) genuine advances in research on the biology of pain, (2) new approaches to the treatment of cancer pain, and (3) important changes in the health-care system to ensure that pain is appropriately assessed and managed. Currently, clinicians have the appropriate diagnostic and therapeutic tools to ensure that the vast majority of patients with cancer pain can be comfortable during their illness. Nevertheless, too many patients with terminal malignancies continue to die in pain in nations around the globe. An effective strategy to make alleviating pain a major health-care priority remains the primary challenge to effectively palliating patients with cancer pain.
Grossman, Dunbar, and Nesbit accurately describe the knowledge that has grown over the past 20 years to enable better medical management of pain. They also allude to the disturbing fact that, despite this knowledge, pain control remains poor in around 50% of cancer patients with pain.
How large a problem is that? About half of all patients with cancer have moderate to severe pain. In advanced stages, that increases to 80%. In the United States, there are about 2.5 million people living with cancer, and about 500,000 die of cancer each year. This means that there are about 1.25 million people with cancer and moderate to severe pain; 750,000 of those have inadequate control. Of the 400,000 with advanced cancer and severe pain, 200,000 a year have inadequate control. As Grossman and colleagues point out, in the developing world, where most patients present with advanced, incurable cancer, the situation is far worse.
Beyond Analgesics
Grossman et al don't mention that analgesics alone won't relieve cancer-related pain. Pain has physical, psychological, social, and spiritual dimensions. Getting the analgesics right is often the first step in relieving the suffering associated with cancer. This requires interdisciplinary care that, at a minimum, involves nursing, social work (or other mental health professionals), and chaplaincy in addition to the physician. Analgesics, along with team work, hope, open communication, coping skills, and meaning-making more fully create a healing context reflective of the patient, family, and health-care team experience.
How can the situation be improved? The solution must acknowledge two facts. First, knowledge alone does not lead to improved patient outcomes. We now know that giving cancer pain relief knowledge to oncologists will not lead their patients to report their pain is relieved.[1] Paradoxically, the acquisition of knowledge, without skill, can give the illusion of benefit when in fact it is a barrier to actually tackling the problem of relieving cancer pain. Oncologists, and other health professionals, will continue to manage pain poorly until their education includes the development of particular skills. That will require the health-care professional to practice prescribing at the bedside under the tutelage of someone else. Unfortunately, in oncology, if that someone else is an oncologist, he or she is also unlikely to know how to do it appropriately.
In a survey of members of the American Society of Clinical Oncology, including medical, surgical, radiation, and pediatric oncologists, the single most important source of information about pain and palliative care was trial and error (90%).[2] The second most important source of information was from a colleague (75%)-who also learned by trial and error! Few oncologists have expertise in symptom management beyond rudimentary pain management skills to begin with. It would be unrealistic to expect them to have mastered all the dramatic clinical advances, treatment options, new agents, and routes of administration described by Grossman et al.
System Change
Second, behavior change requires system change. Indeed, systems are being developed that don't require the doctor alone to think of the right thing to do. Examples are analgesic dosing services[3] and palliative care services.[4] In addition to assuring quality care, these services address the first issue described above-the most common way clinicians in practice learn new skills is through consultation on their own patients.
Comprehensive cancer programs are belatedly developing services that have already been developed in hospitals and health systems. Some of the country's leading facilities, such as Memorial Sloan-Kettering, M. D. Anderson, Cleveland Clinic, and other comprehensive cancer centers, have developed pain and palliative care programs that improve patient outcomes.[5] It should be clear from the article by Grossman and colleagues that the subject is now too important and complex for the oncologist to be the only person responsible for the management of cancer pain. To do so creates unrealistic expectations for all but a few oncologists while inadvertently increasing the possibility that awareness of pain and other noxious symptoms will be avoided by the rest.
At the UCSD John and Rebecca Moores Comprehensive Cancer Center, we have implemented the Doris A. Howell Service to see patients in the inpatient and outpatient settings for the management of pain and other palliative care issues. The service is named for an outstanding pediatric oncologist for two reasons: (1) She is known campus-wide for compassion and competence, and (2) the name "The Howell Service" permits easy access, so oncologists and patients won't be put off by calling in "the pain service" or "the palliative care service" with the limitations that sometimes brings.
The Howell Service has developed its own reputation based on the outcomes of the patients it treats. Half the consultations come from the inpatient blood and marrow transplant service. The service, staffed by a nurse practitioner, social worker, palliative medicine fellow, palliative medicine attending physician, and clinical coordinator, has led to dramatic improvements in pain control for cancer patients.
Conclusion
In summary, Grossman et al describe the first step toward improved symptom control-knowledge. However, the skills and behaviors associated with pain relief also require specialist consultation services (when initial approaches fail) and systems that don't require the doctor to initiate action. Fortunately, those models are beginning to be implemented in the nation's cancer centers.
-Charles F. von Gunten, MD, PhD-Matthew J. Loscalzo, MSW
References:
1. Ferris FD, von Gunten CF, Emanuel LL: Knowledge: Insufficient for change. J Palliat Med 4:145-147, 2001.
2. Emanuel LL, Von Roenn JH, von Gunten CF, et al: The Education on Palliative and End-of-Life Care curriculum for Oncologists (EPEC-O). Bethesda, Md; National Cancer Institute; 2005.
3. Lothian S, Fotis M, von Gunten C, et al: Cancer pain management through a pharmacist-based analgesic dosing service. Am J Health System Pharm 56:1119-1125, 1999.
4. von Gunten CF, Martinez J: A program of hospice and palliative care in a private, non-profit US teaching hospital. J Palliat Med 1:265-275, 1998.
5. Levy MH, Back A, Bazargan S, et al: Palliative care. JNCCN 4:776-818, 2006.
