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Action type: Study

Problem: Cancer pain remains a widespread symptom with high-impact on patients‘ quality of life. Nevertheless, studies on prevalence of cancer pain are extremely uneven in terms of population of interest (e.g., clarifying disease stage, pain causes, diagnosis) and study methodology.

Objective:  To estimate the prevalence of pain in cancer patients, by updating the 2016 review by van den Beuken-van Everdingen, focusing on pain in cancer survivors and recommend practical steps to improve pain assessment, and management in patients during treatment, palliative care and in cancer survivors having completed their treatment. The report defines strategies to improve the quality of cancer care by optimizing the use of healthcare resources and promoting realistic and evidence-based responses to existing needs.

Implementation status: Completed

Key Contextual Factors

  • Cancer related pain is still a significant clinical problem and its epidemiology not yet fully understood.
  • Pain is a priority in cancer care and a factor of continuity between cancer treatment, survivorship care and palliative care.
  • Pain and other symptom assessment is not yet implemented in routine cancer care, clinical records and cancer registries.

Key Components/Steps

  • The starting point for the review was to update the 2016 review by van den Beuken-van Everdingen.
  • The literature search was conducted on MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases covering the period 1 January 2014 to 31 October 2020 to ensure overlap with the 2016 van den Beuken-van Everdingen review.
  • 42 studies were included in the review. Inclusion criteria for relevant study selection were: to have been conducted in human, adult patients with cancer pain; to reported data on pain prevalence and/or pain intensity; to be written in the English language.
  • Data were described according to patient populations assessing pain during cancer treatment, in advanced cancer, and in cancer survivors, but no meta-analysis was performed.
  • An international workshop was held to discuss the review results with the participation of the European Association for Palliative Care Research Network (EAPC-RN), the International Association for the Study of Pain (IASP) , the Organization of European Cancer Institute (OECI) and the European Cancer Patients Coalition (ECPC).

Main Impacts / Added Value

  • The estimated prevalence of pain in patients with advanced cancers ranges from 60-70%, with 50% of all patients reporting at least moderate pain.
  • Prevalence data vary across disease and treatment stages, with 30% of patients with advanced pancreatic cancer having moderate pain and 30% of patients having severe pain.
  • Pain prevalence in (disease-free) cancer survivors ranges from 9-73%, with a point estimate of approximately 30%, but the causes, clinical characteristics and impact of pain are seldom reported.
  • The heterogeneity implied by the definition of “cancer survivors” necessitates that data on pain be qualified by identifying at minimum the (1) time since diagnosis, (2) disease and (3) treatment status. The lack of a well-defined population of interest has a strong impact on the clinical meaning of pain prevalence estimate in survivors.
  • Systematic capturing of PROMs in clinical records and cross-linking cancer registries and other databases proved efficacious to highlight pain clinical history in some cases (e.g., pancreatic cancer). The only example of prospective symptom screening using PROMs in a comprehensive cancer network is the Symptom Assessment Database of the province of Ontario in Canada.
  • Reviewing the available literature also showed that pain screening with PROMs administration is not sufficient without accurate clinical assessment of specific pain conditions associated with cancer and its treatment. A pain diagnosis is necessary to identify effective, innovative interventions or to guarantee equitable access to services.
  • Guidelines on the management of pain due to advanced cancer dates back to the World Health Organization (WHO) three-step pain analgesic ladder. This simple, straightforward treatment algorithm is still relevant, and its use has been shown to result in adequate pain relief in the majority of patients.
  • Different types of barriers are recognized: lack systematic pain assessment and diagnoses, enhancing the quality of pain management with improved guidelines.
  • At the 11th world research conference of the European Association for Palliative Care, iPAAC Work Package 8 sponsored the open workshop with EAPC, OECI, IASP and ECPC on “Pain Control and Palliative Care Integration”, where evidence and recommendations were presented by work package members on the use of PROMs and their implementation in cancer care, pain prevalence and priorities in advanced cancer and survivorship care.

Lessons Learned

  • Despite the progress in therapies and management, pain remains one of the most frequent complaints by cancer patients affecting between 30% and 70% of cases according to disease stage.
  • The prevalence of pain has not substantially changed in recent decades although the attention of clinicians and patients has definitely improved.
  • There is still a need for more efforts to improve the quality of research, guidelines for clinical pathways, and integration of clinical and public health outcomes assessments to clarify the impact of pain, its different causes and the associated clinical conditions for stage-specific cancer patients and cancer survivors.
  • A key priority is to adopt and implement systematic PROM assessment in clinical records.
  • It is necessary to improve and update guidelines for cancer pain management based on evidence and patient shared development.
  • It is important to distinguish individual cancer patients needs across supportive care, survivorship care and palliative care.

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  • Institution/organization: IRCCS Foundation, National Cancer Institute Milan, Italy, European Association for Palliative Care Research Network (EAPC-RN)
  • Department/lead: Palliative Care, Pain Therapy and Rehabilitation Unit
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