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Treatment outcome in a multidisciplinary cancer pain clinic
Pain, 47 (1991) 129-134 ~ 1991 Elsevier Science Publishers B.V. AII rights reserved 0304-3959/91/$03.50
129
PAIN 01857
Clinical Section Treatment outcome in a multidisciplinary cancer pain clinic A. Banning, P. Sj0gren and H. Henriksen Pain Clinic, Department of Anaesthesia, Finsen Institute, Rigshospitalet, DK-2100 Copenhagen (Denmark) (Received 9 August 1989, revision received 20 February 1991, accepted 1 March 1991)
Summary The early and long-term effect of multimodal pain management was studied in 200 cancer patients referred consecutively to a multidisciplinary cancer pain clinic from the departments of medical and surgical oncology. At the initial contact 186 patients presented with a pain problem. Of these, 172 patients had pain in motion, 144 had pain at rest and 124 had pain that interrupted sleep. After 1-2 weeks of treatment the early effect could be evaluated in 131 patients: pain at rest, 108 before and 35 after; pain in motion, 123 before and 83 after; pain interrupting sleep, 92 before and 20 after. The over-all pain relief reported by 131 patients was: none 14; slight 17; moderate 25; considerable 65; complete 10. During this period the modalities of pain management were medical: analgesic tailoring, non-neurolytic blockades, epidural opioid therapy and combinations of these. The long-term effect of multidisciplinary pain treatment was evaluated by questionnaires 4-29 weeks after referral. The pain relief reported by 65 patients was: none 7; slight 8; moderate 13; considerable 31; complete 6. In 55 patients pain relief had remained stable or had changed only one step. These patients had continued medical pain treatment supplemented by psychological intervention and social worker assistance for selected cases. Key words: Cancer pain; Pain clinic; Pain treatment
Introduction
In the last 2 decades much progress has been made within the field of oncology. Many patients with cancer receive repeated series of antineoplastic treatment, often administered on an outpatient basis. During treatment many patients are able to live an active life, but the quality of life depends on the possibilities of relieving pain and other distressing symptoms associated with disease or treatment. In the majority of patients pain due to cancer can be controlled fairly easily. However conventional analgesic therapy fails to provide acceptable pain relief in a significant minority of patients with cancer [6]. Clinical experience and a few studies suggest that cancer patients with severe pain benefit from a multidisciplinary approach that includes analgesic tailoring, anaesthetic procedures, psychological intervention and supportive care [3-5].
Correspondence to: A. Banning, Moseg~_rdsvej 158, DK-2820 Gentofte, Denmark.
The pain clinic at the Finsen Institute in Copenhagen, a university oncology centre, was founded in order to provide treatment facilities for cancer patients who do not obtain satisfactory pain relief from conventional analgesic therapy. During the study period the pain clinic was staffed with one senior and two junior anaesthesiologists, a nurse, a psychologist and a social worker. Pain management was based on the principles of continuing care. Pain treatment was given in close cooperation with the patient and often relatives attended consultations. The frequency of appointments was adjusted according to the needs of the patients and they could contact the pain clinic whenever they wanted to. The pain clinic had no over-night beds, but patients could be admitted to one of the oncology wards when necessary. Treatment was individualized and different treatment modalities were often used simultaneously. Choice of treatment was based on a detailed analysis of the patient's pain condition taking into consideration the pain type and aetioiogy, the stage of the cancer disease as well as the prognosis and psychosocial circumstances.
13~ When the pain clinic had been operating for 18 months, a prospective study was initiated in order t~ evaluate the effect of multimodal pain management.
ment" a n d / o l 'pain unrelated to eal~cer disease/ ((~7 cases). In 2~ palicnts pah~ ~,as not caused by turnout
growth. Wc fltund that 37 patients prcs~:ntcd ~ilh onc pain cause, 57 patients with two, 44 patients with Ihrec and 48 patients with four or more pail1 causcs [2j.
Material and method
We studied 200 patients with cancer consecutively referred to the pain clinic. Patients were referred from departments of medical and surgical oncology during a period of 10 months. Registration was completed 1 month after entry of the last patient. Prior to referral the patients had received antineoplastic treatment (radiation therapy, chemotherapy and surgery) and conventional analgesic therapy with insufficient pain relief. After referral the patients continued treatment and follow-up at the oncology department.
Personal demographics Of the total sample 122 patients were women and 78 were men. Median age at referral was 58 years (range: 17-85 years). Fifteen months after study initiation 132 patients had died. The median survival of this group was 10 weeks (range: 0.5-58 weeks). Cancer related demographics The cancer diagnoses were: breast 55, lung 42; male urogenital 22; female urogenital 20; gastrointestinal 19; head and neck 13; hematological 11; sarcoma 8; other 10. Cancer disease was disseminated in 172 patients. At the initial contact to the pain clinic 139 patients were receiving antineoplastic therapy; in 39 patients it had been discontinued because of lack of response. Twenty-two patients were in partial or complete remission following antineoplastic therapy. Performance status was recorded according to Karnofsky's classification [1]. The 3 main categories were used. Nineteen patients were classified in group A: 'Able to carry on normal activity and to work. No special care is needed.'; 121 in group B: 'Unable to work. Able to live at home, care for most personal needs. Varying degree of assistance needed.'; and 42 in group C: 'Unable to care for self. Requires equivalent of institutional or hospital care. Disease may be progressing rapidly.' Eighteen patients were not classified. Pain related demographics In 186 patients pain was the reason for referral, while 14 patients were referred solely for psychological problems. At the first contact with the pain clinic, pain causes were classified as (a) 'due to tumour growth,' (b) 'secondary to cancer disease or treatment' and (c) 'unrelated to cancer disease.' Within each main category pain causes were subclassified. 158 patients had 'pain due to tumour growth, alone (61 cases) or combined with 'pain secondary to cancer disease or treat-
Pain manageme,t The average treatment time was 78 days (range: 1-333 days). Sixty-six percent of the cont;.|c|s wcrc ()n outpatient basis and 34% of the contacts were wittl hospitalized patients. All patients except those referred for psychological assistance only, were first seen by one of the doctors. At daily staff meetings the patients were presented and it was dccidcd which patients should also bc seen by other members of the team. The specific nursing interventions offered to 103 patients concerned (a) information about drug cffects and drug administration, (b) coordination of examination and treatment programmcs and (c) psychological support. The social worker had contact with 28 patients dealing with (a) application for anti coordination of social services and (b) psychological support. Thirty patients wcrc seen by the psychologist for (a) psychotherapy or (b) relaxation therapy. The modalitics of medical pain management were chosen for the individual patient on the basis of the nature, quality and location of pain, but there was no protocol specifying choice of treatment. Pharmacological therapy was used in 179 patients, oral opioids in 167 patients, analgesics with peripheral action in 147. antidepressants in 46. anticonvulsants in 16 and benzodiazepines in 75 patients. Epidural catheters wcrc inserted in 37 patients for home-based long-term cpidural opioid therapy: 110 patients received non-ncurolytic nerve blocks, epidural blocks or trigger-point injections and 24 patients reccivcd TNS. t:t'aluation Et'ahtation 1 (before treatment). At the initial contact, pain status was registered. The patients answered the following 3 questions (yes/no): Do you have pain at rest? Do you have pain in motion? Is your sleep interrupted by pain? E~,aluation I1 (early treatment outcome). Evaluation of pain status was repeated 1-2 weeks after referral and patients were asked to indicate pain relief according to a 5-point verbal rating scale (none, slight, moderate, considerable, complete). Et'aluation IH (long-term treatment outcome). When patients had been treated at the pain clinic for at least 1 month, a questionnaire concerning pain relief and treatment effect was mailed to the patients who were asked to return it anonymously. Questionnaires were not sent to terminal patients as we found it unethical to burden these severely ill patients with answering questionnaires.
131 sions rather than monitoring daily fluctuations in pain severity. The early effect of treatment at the pain clinic was evaluated 1-2 weeks after referral because, in our experience, stable pain relief is normally achieved after this period. Also at this time alterations in pain intensity due to progression of disease are not prominent and an initial placebo effect has decreased. This early evaluation measured only the effect of medical treatment and nursing care since psychological and social interventions were postponed until the most severe pain had been controlled. The evaluation of long-term effect performed more than 1 month after referral measured also the effect of the multidisciplinary effort. In patients with metastatic disease, pain is frequently aggravated by physical activity. Uninterrupted sleep during the night is crucial for the patients' ability to cope with their disease. Therefore, freedom of pain during the night, at rest and in motion were identified as separate goals of treatment [11]. We chose to have the patients answer y e s / n o to the questions of pain related to the three different levels of activity. This
Again the degree of pain relief was recorded according to the 5-point scale and the patients were asked if treatment at the pain clinic had influenced (a) their mood or (b) their daily life in a positive or negative way. The questionnaires were coded enabling comparison with prior scorings. For statistical analyses the chi-square test was used, the level of significance being P < 0.05. The present study was performed in order to evaluate the total effect of treatment of patients with severe pain at a specialized cancer pain clinic and it was not attempted to describe the effects or side effects of specific treatment modalities. From a methodological point of view a study design including a control group is generally to be preferred. However, for the purpose of the present study, we found this approach ethically unacceptable and practically unfeasible. Optimal timing of pain evaluation is difficult to define in patients with pain due to cancer [7]. An important goal when treating pain in patients with cancer is to establish continuous pain control. Therefore, we have chosen to evaluate pain status and treatment effect on two occa-
Pain at r e s t ? N =131 Pain relief
4
Yes (108)
(11)
1 None 2 Slight 8-14days I
No (73)
3 Moderate 4 Considerable
Yes (2)
1.Evaluation Fig. 1. Pain status a t
rest
2.Evaluation
for 131 patients at evaluations I and II. For the patients who did not become pain free at rest, the degree of pain relief is shown.
132 Pain in motion ? N=131
S l e e p i n t e r r u p t e d by pain? No=131 Pain relief Pain relief
None (12)
Yes
Slight (15) Yes (83) Yes (123)
Mode rate (20)
2 4"
(20)
1 2 3 4
Yes (921 No (72)
Con
side rable (36)
(2)
i'" None Slight Moderate Considerable
8-14days] 8-14daysl No (40)
Yes (2)
Yes (1)
NzrN 1.Evaluation 2.Evaluation Fig. 2. Pain status in motion for 131 patients at evaluations 1 and 11. For the patients who did not become pain free in motion, the degree of pain relief is shown. ungraded evaluation underestimates the total treatment effect as patients may well experience some degree of pain relief although they do not b e c o m e free of pain (Figs. 1-3). Therefore, the over-all effect was m e a s u r e d using a 5-point pain relief scale.
Results
Pain status was evaluated in 184 patients (14 patients did not present a pain problem and 2 patients were not evaluated by mistake). Before treatment 144 patients had pain at rest, 172 patients had pain in motion and in 124 patients had pain interrupted sleep. After 1 - 2 weeks of treatment 131 patients could be re-evaluated. Pain status at evaluations I and II for the 131 patients is shown in Figs. 1-3. The over-all pain relief reported by the 131 patients is shown in Table I. Reasons for dropping out were: 34 patients had been transferred to other institutions for palliative care, 7 patients had died, 6 patients failed to a p p e a r for appointments and 6 b e c a m e inevaluable because of acute complications. Between evaluations I and II the 131 patients had received the following treatment: oral opioids (111 patients), epidural opioids (17 patients), analgesics with peripheral action (100 patients), antide-
1.Evaluation 2.Evaluation l~ig. 3. Pain status during sleep for 131 patients at evaluations I and II. For the patients who did not achieve uninterrupted sleep, the degree of pain relief is shown.
pressants (24 patients), benzodiazepines (40 patients), anticonvulsants (6 patients), non-neurolytic nerve blocks or trigger-point injections (66 patients). During this early period the patients had a median of 4 contacts with the pain clinic (range: 1-11 contacts). The pain relief obtained in patients with the most frequently occurring pain causes (bone metastases, visceral involvement and n e r v e / p l e x u s pressure or infiltration) was analysed separately. E a c h of these 3 groups were c o m p a r e d to the c o m p l e m e n t a r y population, the latter defined as the total population excluding the selected group (Table II). T h e bone metastases group
TABLE I THE OVERALL PAIN RELIEF REPORTED BY 131 PATIENTS AT EVALUATION ]I AND BY 65 PATIENTS AT EVALUATION II1 Pain relief
Evaluation II (N = 131)
Evaluation II1 (N = 65)
None Slight Moderate Considerable Complete
14 17 25 65 1(/
7 8 13 31 6
133 TABLE ll PAIN STATUS IN MOTION, AT REST AND DURING SLEEP BEFORE AND AFTER TREATMENT In the total population and in 3 groups of patients with pain caused by (a) bone metastases, (b) visceral involvement and (c) nerve/plexus pressure or infiltration. Each complementary population (see text) is titled 'other'. X / Y means that out of Y patients who had pain at evaluation I, X were free of pain at evaluation II. The percentages are given in parenthesis.
Total Bone metastases Other Visceral Other Nerve/plexus Other
Pain free in motion
Pain free at rest
Pain does not interrupt sleep
40/123 "1/18 39/105 *'8/14 32/109 10/25 30/98
73/108 11/15 62/93 9/11 66/97 16/23 57/85
72/92 (78%) 12/15 (80%) 60/77 (78%) 9/10 (90%) 63/82 (77%) 13/18(72%) 59/74(76%)
(33%) (6%) (37%) (57%) (30%) (40%) (31%)
(68%) (73%) (67%) (82%) (66%) (70%) (67%)
* = different from complementary population, P = 0.008. * * = different from complementary population, P = 0.04.
(n = 19) consisted of patients having bone metastases as the only 'pain caused by tumour growth.' In the visceral group (n = 15) were patients having visceral pain as the only 'pain caused by tumour growth.' In both groups the patients could also have 'pain secondary to cancer disease or treatment' or 'pain unrelated to cancer.' In the material only 4 patients had pain caused by nerve or plexus pressure or infiltration as the sole 'pain caused by tumour growth.' This number is too small to allow any comparison with the other groups; therefore, we chose to include in the nerve/ plexus group (n = 26) patients with pain caused by nerve or plexus pressure or infiltration, irrespective of other simultaneously occurring pain causes. When performing the registration of pain causes, the graded influence of each pain cause as a contributor to the total pain condition was not evaluated. The results are given in detail in Table II. Testing for differences between the selected groups and the complementary population we found that significantly more patients in the visceral pain group ( P = 0.04) and significantly fewer patients in the bone metastases group ( P = 0.008) became free of pain in motion compared to the complementary populations. No differences were found between the groups regarding freedom of pain at rest. Questionnaires for evaluation of long-term treatment effect were mailed to 90 patients and were completed by 71 (65 of the patients had been referred for pain treatment and 6 patients for psychological therapy) after a median of 12 weeks of treatment (range: 4-29 weeks). During the period from referral to evaluation III the 65 patients had received the following treatment: pharmacological therapy (65 patients), nerve blocks or trigger-point injections (44 patients), epidural opioid therapy (14 patients), nursing care (44 patients), social worker assistance (18 patients) and psychological therapy (17 patients). The pain relief reported by the 65 patients referred for pain treatment is shown in Table I. Pain relief compared to the early treatment
outcome had remained stable or had changed only 1 step on the 5-point rating scale in 55 patients, while 10 patients had changed 2 or more steps. Of the 71 patients who returned the questionnaire, 50 patients reported that treatment at the pain clinic had improved their mood, and 1 patient reported that treatment had affected mood adversely. Fifty-nine patients indicated that their daily life was improved after contact with the pain clinic, and 12 reported no effect on daily life.
Discussion Many difficulties are met when performing longitudinal studies of pain in severely ill cancer patients [7]. Pain does not remain constant but tends to increase with progressing disease or is alleviated by successful antineoplastic treatment. Pain in cancer frequently involves many sites, is multifactorial [2,9,10], and acute pain is often superimposed on an underlying chronic pain [8]. Patients with advanced stages of cancer are in existential crisis and psychological factors may greatly influence pain experience. A large number of drop-outs is to be expected since life expectancy is short and many patients may lose contact with a centralized hospital unit when being referred to other institutions for palliative care. Patients may fail to appear for appointments either because their problems are rapidly solved or because they feel that the pain clinic cannot help them. Therefore the patients who are evaluated at any time during the study period represent subpopulations selected on criteria that may well make them different from the basic population. Recommendations on pain treatment and palliative care are many, but studies on treatment outcome are few. Differences in patient populations, study design and evaluation tools make comparison to other studies difficult. In a study of 109 patients referred to a cancer
13,1 pain center, C o h e n ct al. [5] reported i m p r o v e m e n t ol pain VAS, mood VAS, and activity levcl for the majority of patients at 1-6 follow-up visits. These in\,cstigators also had problems with a large n u m b e r of dropouts. In our series the large majority of patients obtained some degree of pain relief although tc~ became entirely free of pain. However freedom of pain at rest and during sleep was o b t a i n e d by most paticnls, bul physical activity was still associated with pain in many patients. F r e e d o m of pain in motion was particularly difficult to achieve in patients with bone metastases. More surprising were the findings that. in the Msceral ~4roup, more patients became free of pain in motion c o m p a r e d to the c o m p l e m e n t a r y population, and thai freedom of pain at rest was achieved with cqual frequencies in the n e r r e / i ) l e r u s and the hone metastases ,t~rolqz~. A d j u s t m e n t of analgesic therapy was p e r f o r m e d in close c o o p e r a t i o n with the patient, and often the patients gave f r e e d o m from sedation and the m a i n t e n a n c e of n o r m a l physical and psychosocial activity higher priority than complete pain control. ]'he introduction of epidural opioid therapy and differentiated oral analgesic t r e a t m e n t has n a r r o w e d the indications for n c u r o a b l a t i v e p r o c e d u r e s and in the present study neuroablative pain t r e a t m e n t was not used. It is possible that neurolytic blocks or n e u r o a b l a t i v e p r o c e d u r e s could have improved pain relief in some of the patients. However in an Italian study V e n t a f r i d d a et al. [12] showed that, even if patients who received neurolytic pain t r e a t m e n t in addition to pharmacological therapy achieved faster pain relief than patients receiving only pharmacological therapy, the long-term results evaluated after 6 weeks were similar in the 2 groups. Although a control group was n o t included in our study, we find that our data show that t r e a t m e n t at the pain clinic improved pain relief in our patients. The long-term effect of t r e a t m e n t as evaluated from the q u e s t i o n n a i r e s showed that the initial pain relief could be m a i n t a i n e d for longer periods of time. We believe
lhat lhe tavourablc results arc duc Io lhc rcgutar contact between patient and the pain clinic and to the c o m b i n e d use of analgesic and psychosociat i n t c r \ c n tions, c o n t i n u o u s l y adjusted to the changing needs of the patient.
Acknowledgement The present study was s u p p o r t e d by the Danish C a n c e r Society.
References 1 Aaronsen, N.K. and Beckman, J., The Oualily of t,ifc in (':moor Patients, Vol. 17, Raven Press, New York, 1087, pp. 41 fll 2 Banning, A.. Sjogren, P. and tlenriksem It., Pain causes m patients with cancer referred to a specialized cancer pain clinic, Pain, 45 11991)45-48, 3 Bonica, J.J., Importance of the Problem. Adwmces in Pare Rc search and Therapy, Vol. 2, Raven Press, New York, 1979, pp. I 12. 4 Bonica, J.J., The management of cancer pain. Acta Anacsthesiol. Scand., 74 (1982) 75 82. 5 Cohen, R.S., Ferrer-Brechner, J., Pavlov, A. and Reading. A.E. Prospective evaluation of treatment outcome in patients rclerrcd to a cancer pain center, ('lin, J. Pain, 2 (1985) 105-109. (~ Daut, R.L. and Clecland. C.S., The prevalence and severity of pain in cancer. Cancer. 51111982) 1913-1918. 7 Dcschamps, M., Band, P.R. and Coldman, AJ.. Assessment of adult cancer pain: shortcomings of current methods, Pain. 32 11988) 133 t39. S Foley. K.M., Clinical assessment of cancer pain. Acla Anaesthesiol. Stand., 74 11982) 91 96. q Foley, K.M., Pain Syndromes in Patients with Cancer. Advances in Pain Research and Therapy, Vol. 2. Raven Press. New York. 1979. pp. 59 75. 10 Twycross, R.G. and Fairfield, S., Pain in far-advanced cancer, Pain, 14 11982) 303-310. I I Vcntafridda, V., Continuing care: a major issue in cancer pain management, Pain, 36 (1989) 137- 143. 12 Vcntafridda, V., Tamburini. M. and De Conno, F., Comprehensive Treatment in Cancer Pain. Advances in Pain Research and Therapy. Vol. 9, Raven Press. New York, 1985, pp. 617-628.
129
PAIN 01857
Clinical Section Treatment outcome in a multidisciplinary cancer pain clinic A. Banning, P. Sj0gren and H. Henriksen Pain Clinic, Department of Anaesthesia, Finsen Institute, Rigshospitalet, DK-2100 Copenhagen (Denmark) (Received 9 August 1989, revision received 20 February 1991, accepted 1 March 1991)
Summary The early and long-term effect of multimodal pain management was studied in 200 cancer patients referred consecutively to a multidisciplinary cancer pain clinic from the departments of medical and surgical oncology. At the initial contact 186 patients presented with a pain problem. Of these, 172 patients had pain in motion, 144 had pain at rest and 124 had pain that interrupted sleep. After 1-2 weeks of treatment the early effect could be evaluated in 131 patients: pain at rest, 108 before and 35 after; pain in motion, 123 before and 83 after; pain interrupting sleep, 92 before and 20 after. The over-all pain relief reported by 131 patients was: none 14; slight 17; moderate 25; considerable 65; complete 10. During this period the modalities of pain management were medical: analgesic tailoring, non-neurolytic blockades, epidural opioid therapy and combinations of these. The long-term effect of multidisciplinary pain treatment was evaluated by questionnaires 4-29 weeks after referral. The pain relief reported by 65 patients was: none 7; slight 8; moderate 13; considerable 31; complete 6. In 55 patients pain relief had remained stable or had changed only one step. These patients had continued medical pain treatment supplemented by psychological intervention and social worker assistance for selected cases. Key words: Cancer pain; Pain clinic; Pain treatment
Introduction
In the last 2 decades much progress has been made within the field of oncology. Many patients with cancer receive repeated series of antineoplastic treatment, often administered on an outpatient basis. During treatment many patients are able to live an active life, but the quality of life depends on the possibilities of relieving pain and other distressing symptoms associated with disease or treatment. In the majority of patients pain due to cancer can be controlled fairly easily. However conventional analgesic therapy fails to provide acceptable pain relief in a significant minority of patients with cancer [6]. Clinical experience and a few studies suggest that cancer patients with severe pain benefit from a multidisciplinary approach that includes analgesic tailoring, anaesthetic procedures, psychological intervention and supportive care [3-5].
Correspondence to: A. Banning, Moseg~_rdsvej 158, DK-2820 Gentofte, Denmark.
The pain clinic at the Finsen Institute in Copenhagen, a university oncology centre, was founded in order to provide treatment facilities for cancer patients who do not obtain satisfactory pain relief from conventional analgesic therapy. During the study period the pain clinic was staffed with one senior and two junior anaesthesiologists, a nurse, a psychologist and a social worker. Pain management was based on the principles of continuing care. Pain treatment was given in close cooperation with the patient and often relatives attended consultations. The frequency of appointments was adjusted according to the needs of the patients and they could contact the pain clinic whenever they wanted to. The pain clinic had no over-night beds, but patients could be admitted to one of the oncology wards when necessary. Treatment was individualized and different treatment modalities were often used simultaneously. Choice of treatment was based on a detailed analysis of the patient's pain condition taking into consideration the pain type and aetioiogy, the stage of the cancer disease as well as the prognosis and psychosocial circumstances.
13~ When the pain clinic had been operating for 18 months, a prospective study was initiated in order t~ evaluate the effect of multimodal pain management.
ment" a n d / o l 'pain unrelated to eal~cer disease/ ((~7 cases). In 2~ palicnts pah~ ~,as not caused by turnout
growth. Wc fltund that 37 patients prcs~:ntcd ~ilh onc pain cause, 57 patients with two, 44 patients with Ihrec and 48 patients with four or more pail1 causcs [2j.
Material and method
We studied 200 patients with cancer consecutively referred to the pain clinic. Patients were referred from departments of medical and surgical oncology during a period of 10 months. Registration was completed 1 month after entry of the last patient. Prior to referral the patients had received antineoplastic treatment (radiation therapy, chemotherapy and surgery) and conventional analgesic therapy with insufficient pain relief. After referral the patients continued treatment and follow-up at the oncology department.
Personal demographics Of the total sample 122 patients were women and 78 were men. Median age at referral was 58 years (range: 17-85 years). Fifteen months after study initiation 132 patients had died. The median survival of this group was 10 weeks (range: 0.5-58 weeks). Cancer related demographics The cancer diagnoses were: breast 55, lung 42; male urogenital 22; female urogenital 20; gastrointestinal 19; head and neck 13; hematological 11; sarcoma 8; other 10. Cancer disease was disseminated in 172 patients. At the initial contact to the pain clinic 139 patients were receiving antineoplastic therapy; in 39 patients it had been discontinued because of lack of response. Twenty-two patients were in partial or complete remission following antineoplastic therapy. Performance status was recorded according to Karnofsky's classification [1]. The 3 main categories were used. Nineteen patients were classified in group A: 'Able to carry on normal activity and to work. No special care is needed.'; 121 in group B: 'Unable to work. Able to live at home, care for most personal needs. Varying degree of assistance needed.'; and 42 in group C: 'Unable to care for self. Requires equivalent of institutional or hospital care. Disease may be progressing rapidly.' Eighteen patients were not classified. Pain related demographics In 186 patients pain was the reason for referral, while 14 patients were referred solely for psychological problems. At the first contact with the pain clinic, pain causes were classified as (a) 'due to tumour growth,' (b) 'secondary to cancer disease or treatment' and (c) 'unrelated to cancer disease.' Within each main category pain causes were subclassified. 158 patients had 'pain due to tumour growth, alone (61 cases) or combined with 'pain secondary to cancer disease or treat-
Pain manageme,t The average treatment time was 78 days (range: 1-333 days). Sixty-six percent of the cont;.|c|s wcrc ()n outpatient basis and 34% of the contacts were wittl hospitalized patients. All patients except those referred for psychological assistance only, were first seen by one of the doctors. At daily staff meetings the patients were presented and it was dccidcd which patients should also bc seen by other members of the team. The specific nursing interventions offered to 103 patients concerned (a) information about drug cffects and drug administration, (b) coordination of examination and treatment programmcs and (c) psychological support. The social worker had contact with 28 patients dealing with (a) application for anti coordination of social services and (b) psychological support. Thirty patients wcrc seen by the psychologist for (a) psychotherapy or (b) relaxation therapy. The modalitics of medical pain management were chosen for the individual patient on the basis of the nature, quality and location of pain, but there was no protocol specifying choice of treatment. Pharmacological therapy was used in 179 patients, oral opioids in 167 patients, analgesics with peripheral action in 147. antidepressants in 46. anticonvulsants in 16 and benzodiazepines in 75 patients. Epidural catheters wcrc inserted in 37 patients for home-based long-term cpidural opioid therapy: 110 patients received non-ncurolytic nerve blocks, epidural blocks or trigger-point injections and 24 patients reccivcd TNS. t:t'aluation Et'ahtation 1 (before treatment). At the initial contact, pain status was registered. The patients answered the following 3 questions (yes/no): Do you have pain at rest? Do you have pain in motion? Is your sleep interrupted by pain? E~,aluation I1 (early treatment outcome). Evaluation of pain status was repeated 1-2 weeks after referral and patients were asked to indicate pain relief according to a 5-point verbal rating scale (none, slight, moderate, considerable, complete). Et'aluation IH (long-term treatment outcome). When patients had been treated at the pain clinic for at least 1 month, a questionnaire concerning pain relief and treatment effect was mailed to the patients who were asked to return it anonymously. Questionnaires were not sent to terminal patients as we found it unethical to burden these severely ill patients with answering questionnaires.
131 sions rather than monitoring daily fluctuations in pain severity. The early effect of treatment at the pain clinic was evaluated 1-2 weeks after referral because, in our experience, stable pain relief is normally achieved after this period. Also at this time alterations in pain intensity due to progression of disease are not prominent and an initial placebo effect has decreased. This early evaluation measured only the effect of medical treatment and nursing care since psychological and social interventions were postponed until the most severe pain had been controlled. The evaluation of long-term effect performed more than 1 month after referral measured also the effect of the multidisciplinary effort. In patients with metastatic disease, pain is frequently aggravated by physical activity. Uninterrupted sleep during the night is crucial for the patients' ability to cope with their disease. Therefore, freedom of pain during the night, at rest and in motion were identified as separate goals of treatment [11]. We chose to have the patients answer y e s / n o to the questions of pain related to the three different levels of activity. This
Again the degree of pain relief was recorded according to the 5-point scale and the patients were asked if treatment at the pain clinic had influenced (a) their mood or (b) their daily life in a positive or negative way. The questionnaires were coded enabling comparison with prior scorings. For statistical analyses the chi-square test was used, the level of significance being P < 0.05. The present study was performed in order to evaluate the total effect of treatment of patients with severe pain at a specialized cancer pain clinic and it was not attempted to describe the effects or side effects of specific treatment modalities. From a methodological point of view a study design including a control group is generally to be preferred. However, for the purpose of the present study, we found this approach ethically unacceptable and practically unfeasible. Optimal timing of pain evaluation is difficult to define in patients with pain due to cancer [7]. An important goal when treating pain in patients with cancer is to establish continuous pain control. Therefore, we have chosen to evaluate pain status and treatment effect on two occa-
Pain at r e s t ? N =131 Pain relief
4
Yes (108)
(11)
1 None 2 Slight 8-14days I
No (73)
3 Moderate 4 Considerable
Yes (2)
1.Evaluation Fig. 1. Pain status a t
rest
2.Evaluation
for 131 patients at evaluations I and II. For the patients who did not become pain free at rest, the degree of pain relief is shown.
132 Pain in motion ? N=131
S l e e p i n t e r r u p t e d by pain? No=131 Pain relief Pain relief
None (12)
Yes
Slight (15) Yes (83) Yes (123)
Mode rate (20)
2 4"
(20)
1 2 3 4
Yes (921 No (72)
Con
side rable (36)
(2)
i'" None Slight Moderate Considerable
8-14days] 8-14daysl No (40)
Yes (2)
Yes (1)
NzrN 1.Evaluation 2.Evaluation Fig. 2. Pain status in motion for 131 patients at evaluations 1 and 11. For the patients who did not become pain free in motion, the degree of pain relief is shown. ungraded evaluation underestimates the total treatment effect as patients may well experience some degree of pain relief although they do not b e c o m e free of pain (Figs. 1-3). Therefore, the over-all effect was m e a s u r e d using a 5-point pain relief scale.
Results
Pain status was evaluated in 184 patients (14 patients did not present a pain problem and 2 patients were not evaluated by mistake). Before treatment 144 patients had pain at rest, 172 patients had pain in motion and in 124 patients had pain interrupted sleep. After 1 - 2 weeks of treatment 131 patients could be re-evaluated. Pain status at evaluations I and II for the 131 patients is shown in Figs. 1-3. The over-all pain relief reported by the 131 patients is shown in Table I. Reasons for dropping out were: 34 patients had been transferred to other institutions for palliative care, 7 patients had died, 6 patients failed to a p p e a r for appointments and 6 b e c a m e inevaluable because of acute complications. Between evaluations I and II the 131 patients had received the following treatment: oral opioids (111 patients), epidural opioids (17 patients), analgesics with peripheral action (100 patients), antide-
1.Evaluation 2.Evaluation l~ig. 3. Pain status during sleep for 131 patients at evaluations I and II. For the patients who did not achieve uninterrupted sleep, the degree of pain relief is shown.
pressants (24 patients), benzodiazepines (40 patients), anticonvulsants (6 patients), non-neurolytic nerve blocks or trigger-point injections (66 patients). During this early period the patients had a median of 4 contacts with the pain clinic (range: 1-11 contacts). The pain relief obtained in patients with the most frequently occurring pain causes (bone metastases, visceral involvement and n e r v e / p l e x u s pressure or infiltration) was analysed separately. E a c h of these 3 groups were c o m p a r e d to the c o m p l e m e n t a r y population, the latter defined as the total population excluding the selected group (Table II). T h e bone metastases group
TABLE I THE OVERALL PAIN RELIEF REPORTED BY 131 PATIENTS AT EVALUATION ]I AND BY 65 PATIENTS AT EVALUATION II1 Pain relief
Evaluation II (N = 131)
Evaluation II1 (N = 65)
None Slight Moderate Considerable Complete
14 17 25 65 1(/
7 8 13 31 6
133 TABLE ll PAIN STATUS IN MOTION, AT REST AND DURING SLEEP BEFORE AND AFTER TREATMENT In the total population and in 3 groups of patients with pain caused by (a) bone metastases, (b) visceral involvement and (c) nerve/plexus pressure or infiltration. Each complementary population (see text) is titled 'other'. X / Y means that out of Y patients who had pain at evaluation I, X were free of pain at evaluation II. The percentages are given in parenthesis.
Total Bone metastases Other Visceral Other Nerve/plexus Other
Pain free in motion
Pain free at rest
Pain does not interrupt sleep
40/123 "1/18 39/105 *'8/14 32/109 10/25 30/98
73/108 11/15 62/93 9/11 66/97 16/23 57/85
72/92 (78%) 12/15 (80%) 60/77 (78%) 9/10 (90%) 63/82 (77%) 13/18(72%) 59/74(76%)
(33%) (6%) (37%) (57%) (30%) (40%) (31%)
(68%) (73%) (67%) (82%) (66%) (70%) (67%)
* = different from complementary population, P = 0.008. * * = different from complementary population, P = 0.04.
(n = 19) consisted of patients having bone metastases as the only 'pain caused by tumour growth.' In the visceral group (n = 15) were patients having visceral pain as the only 'pain caused by tumour growth.' In both groups the patients could also have 'pain secondary to cancer disease or treatment' or 'pain unrelated to cancer.' In the material only 4 patients had pain caused by nerve or plexus pressure or infiltration as the sole 'pain caused by tumour growth.' This number is too small to allow any comparison with the other groups; therefore, we chose to include in the nerve/ plexus group (n = 26) patients with pain caused by nerve or plexus pressure or infiltration, irrespective of other simultaneously occurring pain causes. When performing the registration of pain causes, the graded influence of each pain cause as a contributor to the total pain condition was not evaluated. The results are given in detail in Table II. Testing for differences between the selected groups and the complementary population we found that significantly more patients in the visceral pain group ( P = 0.04) and significantly fewer patients in the bone metastases group ( P = 0.008) became free of pain in motion compared to the complementary populations. No differences were found between the groups regarding freedom of pain at rest. Questionnaires for evaluation of long-term treatment effect were mailed to 90 patients and were completed by 71 (65 of the patients had been referred for pain treatment and 6 patients for psychological therapy) after a median of 12 weeks of treatment (range: 4-29 weeks). During the period from referral to evaluation III the 65 patients had received the following treatment: pharmacological therapy (65 patients), nerve blocks or trigger-point injections (44 patients), epidural opioid therapy (14 patients), nursing care (44 patients), social worker assistance (18 patients) and psychological therapy (17 patients). The pain relief reported by the 65 patients referred for pain treatment is shown in Table I. Pain relief compared to the early treatment
outcome had remained stable or had changed only 1 step on the 5-point rating scale in 55 patients, while 10 patients had changed 2 or more steps. Of the 71 patients who returned the questionnaire, 50 patients reported that treatment at the pain clinic had improved their mood, and 1 patient reported that treatment had affected mood adversely. Fifty-nine patients indicated that their daily life was improved after contact with the pain clinic, and 12 reported no effect on daily life.
Discussion Many difficulties are met when performing longitudinal studies of pain in severely ill cancer patients [7]. Pain does not remain constant but tends to increase with progressing disease or is alleviated by successful antineoplastic treatment. Pain in cancer frequently involves many sites, is multifactorial [2,9,10], and acute pain is often superimposed on an underlying chronic pain [8]. Patients with advanced stages of cancer are in existential crisis and psychological factors may greatly influence pain experience. A large number of drop-outs is to be expected since life expectancy is short and many patients may lose contact with a centralized hospital unit when being referred to other institutions for palliative care. Patients may fail to appear for appointments either because their problems are rapidly solved or because they feel that the pain clinic cannot help them. Therefore the patients who are evaluated at any time during the study period represent subpopulations selected on criteria that may well make them different from the basic population. Recommendations on pain treatment and palliative care are many, but studies on treatment outcome are few. Differences in patient populations, study design and evaluation tools make comparison to other studies difficult. In a study of 109 patients referred to a cancer
13,1 pain center, C o h e n ct al. [5] reported i m p r o v e m e n t ol pain VAS, mood VAS, and activity levcl for the majority of patients at 1-6 follow-up visits. These in\,cstigators also had problems with a large n u m b e r of dropouts. In our series the large majority of patients obtained some degree of pain relief although tc~ became entirely free of pain. However freedom of pain at rest and during sleep was o b t a i n e d by most paticnls, bul physical activity was still associated with pain in many patients. F r e e d o m of pain in motion was particularly difficult to achieve in patients with bone metastases. More surprising were the findings that. in the Msceral ~4roup, more patients became free of pain in motion c o m p a r e d to the c o m p l e m e n t a r y population, and thai freedom of pain at rest was achieved with cqual frequencies in the n e r r e / i ) l e r u s and the hone metastases ,t~rolqz~. A d j u s t m e n t of analgesic therapy was p e r f o r m e d in close c o o p e r a t i o n with the patient, and often the patients gave f r e e d o m from sedation and the m a i n t e n a n c e of n o r m a l physical and psychosocial activity higher priority than complete pain control. ]'he introduction of epidural opioid therapy and differentiated oral analgesic t r e a t m e n t has n a r r o w e d the indications for n c u r o a b l a t i v e p r o c e d u r e s and in the present study neuroablative pain t r e a t m e n t was not used. It is possible that neurolytic blocks or n e u r o a b l a t i v e p r o c e d u r e s could have improved pain relief in some of the patients. However in an Italian study V e n t a f r i d d a et al. [12] showed that, even if patients who received neurolytic pain t r e a t m e n t in addition to pharmacological therapy achieved faster pain relief than patients receiving only pharmacological therapy, the long-term results evaluated after 6 weeks were similar in the 2 groups. Although a control group was n o t included in our study, we find that our data show that t r e a t m e n t at the pain clinic improved pain relief in our patients. The long-term effect of t r e a t m e n t as evaluated from the q u e s t i o n n a i r e s showed that the initial pain relief could be m a i n t a i n e d for longer periods of time. We believe
lhat lhe tavourablc results arc duc Io lhc rcgutar contact between patient and the pain clinic and to the c o m b i n e d use of analgesic and psychosociat i n t c r \ c n tions, c o n t i n u o u s l y adjusted to the changing needs of the patient.
Acknowledgement The present study was s u p p o r t e d by the Danish C a n c e r Society.
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