Pain remains one of the most prevalent and feared consequences of cancer. Establishing good pain control is an important priority for patients and clinicians and relies heavily on pharmacological management using effective analgesic medicines alongside cancer treatments, such as chemotherapy and radiotherapy. However, epidemiological studies of cancer pain suggest that pain remains common, severe and undertreated for many patients. This evidence highlights problems with the implementation of analgesic medicine in practice and therefore, demonstrates an educational gap between evidence and practice.
This review examines educational interventions directed at patients and professionals to bridge this gap. In this context, ‘education’ is defined as an intervention that results in improved knowledge, attitudes or both, which in turn alters the behaviour of the patient or professional and results in better pain outcomes.
Epidemiology of cancer pain management
Systematic reviews show that cancer pain affects around 48% of patients with early stage cancer, and rises to between 64 and 75% of patients with advanced disease [1,2]. Pain is often of moderate-to-severe intensity for many patients. Studies from secondary care settings suggest that average pain intensity is 3.7 on a 0–10 rating scale, and that 66% of patients rate their pain as greater than five out of 10 on this scale [3,4]. In community settings, average pain is reported to be 6.4 and 90% of patients rate their pain as greater than five out of 10 .
Deandrea et al. reviewed 26 studies, which examined analgesic prescribing for cancer patients and found that the prevalence of under treatment ranged from 8–82%, with a weighted mean of 43%. They concluded that nearly half of cancer patients received inadequate analgesia for their pain. A community-based study by Borgsteede et al. showed that many patients with cancer only received strong opioids in the last weeks of life when they may have been able to benefit from them earlier.
The WHO analgesic ladder has been shown to control pain in around 75% of patients with cancer when used in specialized units . Despite this apparently effective intervention, current evidence suggests that it may be poorly implemented in practice. This fact may be explained by the existence of barriers within patients and professionals relating to attitudes or knowledge towards cancer pain and analgesia that have been identified (Table 1). Educational interventions that are designed to overcome these barriers and alter subsequent behaviour may therefore be particularly useful in improving cancer pain control.
Education directed at patients
The effects of patient-based education on cancer pain management are positive, as shown by a recent systematic review and meta-analysis [9•] and some subsequent studies. Education is a complex intervention, requiring consideration of content, format, timing, duration, follow-up and the interaction of these factors, amongst other things. Nevertheless, some aspects of effective patient education are becoming clearer.
Meta-analysis of earlier evidence
Twenty-one trials were included in the meta-analysis [9•], and the benefits of education on both knowledge and pain scores were clearly demonstrated. Compared with usual care or control, educational interventions improved patients' knowledge and attitudes by half a point on a 0–5 rating scale; reduced average pain intensity by over one point on a 0–10 rating scale; and reduced the worst pain intensity by just under one point. It is, unfortunately, difficult to unravel precisely which aspects of the education – the who, how, what, when and where of its delivery – are the most important. The picture is clearly a complex one, and the studies included varied widely in terms of trial design and type of educational intervention. Common elements of the interventions included screening for misunderstandings about pain and analgesia when commencing analgesic therapy and addressing these aspects through clear advice and information, delivered by staff and/or by written or audio-visual material to take away.
Variations included those in sample size, which ranged from 30 to 1256 and although most studies allocated patients to one of two arms, one study randomized into three arms and yet another to four arms. Some trials used placebo as their control arm, whereas others used usual care, and follow-up differed, ranging from 1 to 26 weeks. In addition, there were many types of educational intervention. The majority included a face-to-face coaching session lasting 15–60 min, supplemented by an information booklet for participants to take away. Some studies used just one exposure to the intervention; some used a single intervention with telephone follow-up; and others used multiple interventions. In some cases the intervention was delivered by a nurse, whereas in others it was a researcher or not made clear who was involved. Clearly the numerous factors involved require consideration, but in many papers there was information missing which would have aided interpretation of the findings. This problem has been considered in detail and recommendations made for greater detail and consistency in the reporting of methods and results of such studies .
Recently, there have been more studies which support the role of patient education in the management of cancer pain. A video and a booklet together reduced average and worst pain scores by more than one point on a 0–10 scale and the combination was significantly better than either video or booklet alone [11•]. Interestingly, the effect of the intervention was significantly improved with the presence of a partner. Another study also showed significant benefit from a combination of a booklet and slide programme . Both these studies [11•,12] found improvement in average or present pain intensity between 1 and 2 points on a 0–10 rating scale, consistent with the earlier meta-analysis [9•]. A feasibility study showed that even in frail-ill patients, a 6-min digital video disc format was acceptable and has the potential to improve pain outcomes within a few weeks . Other educational interventions, which have focused on communication skills have successfully increased patients' ability to talk about their cancer pain concerns, although effects on pain scores were not assessed [14,15].
Some novel approaches, such as telecare, have also been tried [16••]. This intervention comprised a specialist nurse–physician team linked to home-based symptom monitoring via the internet or voice recording. This produced a reduction in 0–10 pain scores of over one point at 3 months post intervention. Not all such trials have produced a reduction in pain scores. One, which tailored education according to attitudinal barriers towards reporting pain and analgesic use, found no differences in pain outcomes . However, the majority has shown a positive effect, and a repeat of the meta-analysis may produce more robust results once sufficient additional trial data have been generated.
Taken together, the meta-analysis and other recent studies [11•,12–15,16••,17–19] suggest that ‘prescribing’ an educational intervention may be highly effective. For a cancer patient already taking opioid analgesics, education may be more effective than the addition of coanalgesic therapies such as gabapentin and paracetamol, i.e. a reduction of about one point on a 0–10 scale [20,21]. This may be a significant improvement for many patients, and merits further research to identify which patients may benefit most. Consideration of other factors may also be needed, such as the expertise of healthcare professionals, their empathy with patients and the patients' learning styles. These and other factors may affect the outcomes, but their precise influence is not yet known.
Meantime, the importance of education in the clinical care of this group needs greater recognition. A recent analysis of major evidence-based guidelines for practice in the management of cancer-related pain emphasized the role of patient education . Three specific areas were identified: dispelling misconceptions about pain and pain management, promoting user involvement through the provision of education about pain and its management, and the use of appropriate teaching materials especially where literacy is an issue. Further research is needed to unpack the complexities of such educational interventions, generating more evidence to underpin guidelines for practice.
Education directed at professionals
Barriers within healthcare professionals that appear to reduce optimal pain control in patients have been identified by Jacobsen et al. (Table 1). These barriers can be summarized as inadequate knowledge, poor pain assessment, inadequate opioid prescription (including a belief that opioids are addictive, using ‘as needed’ rather than regular dosing, lack of adjuvant analgesia, and failing to titrate if dose is ineffective) and finally, poor management of opioid side effects. The important research question is whether education directed at professionals and which addresses these barriers results in a change of behaviour, which actually improves the experience of pain from patients' perspectives.
Interventions that address professional's knowledge
Healthcare professionals value education in pain management. When asked about priorities for education in palliative care, healthcare professionals in central Europe ranked pain management of prime importance, closely followed by symptom control . A reasonable volume of evidence exists which demonstrates that educating healthcare professionals improves their own knowledge and attitudes towards cancer pain management, but it is much less clear the impact this approach has on improving patients' experiences of pain.
A review of studies of educational interventions to improve cancer pain control provides a comprehensive overview of the literature in the area up to the start of the last decade . The review included 33 papers, of which 25 focused on healthcare professionals published from 1982–1999. The included papers used a diverse set of research methods of varying quality to evaluate a wide variety of educational interventions. Because of this diversity, no attempts were made to pool results within the review.
Role-model training programmes of varying content and duration were evaluated in seven papers. The aim of these programmes was to enable doctors, nurses or pharmacists to become leaders in cancer pain management either as individuals or within their teams. The length of the programmes varied from 1-day to 2-week courses. Role-model training appeared to be effective in enabling healthcare professionals to become strong advocates of cancer pain control in their own clinical setting. Its impact on patients' pain management and relief was less apparent, as only one study included this as an outcome, with no significant improvement in patients' reported pain .
Lessons from interventions designed to change behaviour
Behaviours of professionals that are associated with patient satisfaction include the physician stating the importance of pain control, receiving instructions to manage pain at home, managing side effects, and allaying fears about addiction [27,28].
Comprehensive programmes, which evaluated multifaceted approaches to improving cancer pain management at an organisational level, were evaluated in five papers within the review  and supported by a more recent study . These interventions included: systematic use of pain management tools and the clarification of responsibilities between nurses and physicians; providing oncologists with algorithms designed to optimize cancer pain management. Some improvement in cancer pain management resulted which was measured in terms of adherence to prescribing guidelines, admissions for uncontrolled pain and patient satisfaction, and this approach. Patients' pain ratings and pain relief were only measured in one paper, however . Despite nurses having a significant improvement in knowledge and attitudes and increased adherence to daily assessment of pain, patients' average pain intensity did not decrease in this study, although they were more satisfied with their pain control.
One explanation for this is that pain assessment alone is not sufficient to improve a patient's pain. Systematically assessing pain but not ensuring these data were seen by clinicians did not result in patient benefit in one randomized controlled trial (RCT) . In contrast, another RCT compared pain assessment alone with consistent review of pain data by clinicians . Patients in the intervention arm experienced better prescribing and a reduced proportion were in pain compared with the control group at the end of study.
Educational interventions directed at clinicians that result in behavioural change with respect to better prescribing, are effective. Du Pen et al. demonstrated that restricting analgesic prescribing to clinicians who followed an agreed algorithm was superior to usual care in terms of increased medication adherence, increased patient satisfaction, and reduced pain intensity. However, the intervention arm also included home visits by nurses to check adherence and manage side effects so it is not clear whether better outcomes were the result of the physician or nurse behaviour, or some combination of both.
A cluster RCT by Cleeland et al. compared intervention sites, which used an oral analgesic protocol supported by an educational leaflet for patients, with usual care. There were significantly more patients treated at the intervention sites with either no pain or mild pain at the end of study, compared with control sites.
Summary of current research
To date, studies of educational interventions directed at patients suggest that improving knowledge and reducing fears is likely to lead to clinical benefits. In this context, changes in knowledge appear to bring about beneficial changes in behaviour though the mechanisms of action are not yet clear. Potential mechanisms include reduced anxiety, improved communication, increased medication adherence, and better management of adverse effects. Attention from healthcare practitioners delivering educational interventions (a context effect rather than a specific mechanism) is also likely to be important in achieving improvements in cancer pain management.
In contrast, educational interventions (i.e. classroom style learning) directed at professionals can improve knowledge and attitudes but these changes do not appear to translate into changes in behaviour, which benefit patients. However, changing professional's behaviour can be achieved with more targeted educational interventions within the clinical setting and which do result in improvements for patients. Clinical behaviours associated with improved pain control, improved patient satisfaction or both are as follows:
- Clinician stating importance of pain control.
- Clinician assessing pain and using these data when making prescribing decision.
- Clinician using a prescribing protocol and adhering to it.
- Screening for, and addressing misplaced fears in patients regarding pain and analgesia: a combination of leaflet and video/DVD which address these fears is effective.
- Explaining to patients (especially older people) how and when to take their drugs.
- Monitoring of adverse effects and dealing with them.
- Reassessing pain regularly.
The effect size of educational interventions directed at patients or professionals may appear to be modest (around one point reduction in average pain intensity on a 0–10 scale) but this is similar in magnitude to some pharmacological interventions and should be seen as comparable. In practice, optimal cancer pain management will be the result of good control of the cancer, skilful prescribing of analgesia, and improving the behaviours of patients and professionals through educational interventions.
The evidence to date is strong enough (i.e. consistent effects from several studies) to suggest that educational interventions should be part of daily clinical practice and that simple guidelines for good practice can be established (list above).
Most studies report average improvements in pain intensity. This outcome is helpful at a population level, but is not helpful for an individual patient . Future studies that report the number of responders to these interventions, and determine patient factors that predict response or nonresponse, will be more useful for clinicians in their daily practice. The recent review by Oldenmenger et al.[36••] suggests that while assessing patient's pain intensity is an important outcome measure, other outcomes may be equally important such as reduced interference from pain in daily activity, or increased satisfaction with pain management.
Future research studies are needed to understand how to deliver these educational interventions effectively in daily practice, particularly combining several components at the same time. Recent reviews on this topic clearly identify the need for well designed studies that identify a generalizable and multidisciplinary intervention [36••,37••,38]. This would focus on a multilevel approach which modifies the behaviour of both professionals (nurses and physicians), as well as patients, and perhaps carers too [11•,39].
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 66–67).
1 Hearn J, Higginson IJ. Cancer pain
epidemiology: a systematic review. In: Bruera ED, Portenoy RK, editors. Cancer Pain
: Assessment and Management. USA, London: Cambridge University Press; 2003. pp. 19–37.
2 van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al
. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol 2007; 18:1437–1449.
3 Klepstad P, Loge JH, Borchgrevink PC, et al
. The Norwegian brief pain inventory questionnaire: translation and validation in cancer pain
patients. J Pain Symptom Manage 2002; 24:517–525.
4 Yates PM, Edwards HE, Nash RE, et al
. Barriers to effective cancer pain
management: a survey of hospitalized cancer patients in Australia. J Pain Symptom Manage 2002; 23:393–405.
5 Breivik H, Cherny N, Collett B, et al
. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Ann Oncol 2009; 20:1420–1433.
6 Deandrea S, Montanari M, Moja L, Apolone G. Prevalence of undertreatment in cancer pain
. A review of published literature. Ann Oncol 2008; 19:1985–1991.
7 Borgsteede SD, Deliens L, Zuurmond WW, et al
. Prescribing of pain medication in palliative care. A survey in general practice. Pharmacoepidemiol Drug Saf 2009; 18:16–23.
8 Bennett MI. What evidence do we have that the WHO analgesic ladder is effective in cancer pain
? In: McQuay HJ, Moore R, Kalso E, editors. Systematic reviews in pain research; methodology refined. Seattle: IASP Press; 2008.
9• Bennett MI, Bagnall A-M, Closs SJ. How effective are patient-based educational interventions in the management of cancer pain
? Systematic review and meta-analysis. Pain 2009; 143:192–199. Review of 21 studies examining educational interventions directed at patients.
10 Stiles C, Biondo PD, Cummings G, Hagen NA. Clinical trials focusing on cancer pain
educational interventions: core components to include during planning and reporting. J Pain Symptom Manage 2010; 40:301–308.
11• Lovell MR, Stockler MR, Briganti EM, et al
. A randomized controlled trial of a standardized educational intervention
for patients with cancer pain
. J Pain Symptom Manage 2010; 40:49–59. Recent RCT confirming that combined approach of video and booklet superior to either alone.
12 Yildirim YK, Cicek F, Uyar M. Effects of pain education program on pain intensity, pain treatment satisfaction, and barriers in Turkish cancer patients. Pain Manag Nurs 2009; 10:220–228.
13 Capewell CMR, Gregory W, Closs SJ, Bennett MI. Brief DVD-based educational intervention
for patients with cancer pain
: feasibility study. Palliat Med 2010; 24:616–622.
14 Street RL, Slee C, Kalauokalani DK, et al
. Improving physician-patient communication about cancer pain
with a tailored education-coaching intervention. Patient Educ Couns 2009; 80:42–47.
15 Wilkie D, Berry D, Cain K, et al
. Effects of coaching patients with lung cancer to report cancer pain
. West J Nurs Res 2010; 32:23–46.
16•• Kroenke K, Theobald D, Wu J, et al
. Effect of telecare management on pain and depression in patients with cancer: a randomized trial. JAMA 2010; 304:163–171. Large RCT examining effect of combining symptom monitoring with nurse–physician educational interventions.
17 Ward SE, Wang KK, Serlin R, et al
. A randomized controlled trial of a tailored barriers intervention for Cancer Information Service (CIS) callers in pain. Pain 2010; 144:49–56.
18 Syrjala KL, Abrams JR, Polissar NL, et al
. Patient training in cancer pain
management using integrated print and video materials: a multisite randomized controlled trial. Pain 2008; 135(1–2):175–186.
19 van der Peet EH, van den Beuken-van Everdingen MH, Patijn J, et al
. Randomized clinical trial of an intensive nursing-based pain education program for cancer outpatients suffering from pain. Support Care Cancer 2009; 17:1089–1099.
20 Caraceni A, Zecca E, Bonezzi C, et al
. Gabapentin for neuropathic cancer pain
: a randomized controlled trial from the gabapentin cancer pain
study group. J Clin Oncol 2004; 14:2909–2917.
21 Stockler M, Vardy J, Pillai A, Warr D. Acetaminophen (paracetamol) improves pain and well being in people with advanced cancer already receiving a strong opioid regimen: a randomized, double-blind, placebo-controlled cross-over trial. J Clin Oncol 2004; 22:3389–3394.
22 Green E, Zwaal C, Beals C, et al
. Cancer-related pain management: a report of evidence-based recommendations to guide practice. Clin J Pain 2010; 26:449–462.
23 Jacobsen R, Sjøgren P, Møldrup C, Christrup L. Physician-related barriers to cancer pain
management with opioid analgesics: a systematic review. J Opioid Manag 2007; 3:207–214.
24 Becker G, Momm F, Deibert P, et al
. Planning training seminars in palliative care: a cross sectional survey on the preferences of general practitioners and nurses in Austria. BMC Med Educ 2010; 10:43.
25 Allard P, Maunsell E, Labbé J, et al
. Educational interventions to improve cancer pain
control: a systematic review. J Palliat Med 2001; 4:191–203.
26 Elliot TE, Murray DM, Oken MM, et al
. Improving cancer pain
management in communities: main results from a randomised controlled trial. J Pain Symptom Manage 2007; 11:81–87.
27 Dawson R, Spross JA, Jablonski ES, et al
. Probing the paradox of patients' satisfaction with inadequate pain management. J Pain Symptom Manage 2002; 23:211–220.
28 Reid CM, Gooberman-Hill R, Hanks GW. Opioid analgesics for cancer pain
: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol 2008; 19:44–48.
29 Vallerand AH, Riley-Doucet C, Hasenau SM, et al
. Improving cancer pain
management by home care nurses. Oncol Nurs Forum 2004; 31:809–816.
30 Bookbinder M, Coyle N, Kiss M, et al
. Implementing national standards for cancer pain
management: program model and evaluation. J Pain Symptom Manage 1996; 12:334–347.
31 Kravitz RL, Delafield JP, Hays RD, et al
. Bedside charting of pain levels in hospitalized patients with cancer: a randomized controlled trial. J Pain Symptom Manage 1996; 11:81–87.
32 Trowbridge R, Dugan W, Jay SJ, et al
. Determining the effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer. Acad Med 1997; 72:798–800.
33 Du Pen SL, Du Pen AR, Polissar N, et al
. Implementing guidelines for cancer pain
management: results of a randomized controlled clinical trial. J Clin Oncol 1999; 17:361–370.
34 Cleeland CS, Portenoy RK, Rue M, et al
. Does an oral analgesic protocol improve pain control for patients with cancer? An intergroup study coordinated by the Eastern Cooperative Oncology Group. Ann Oncol 2005; 16:972–980.
35 Moore RA, Eccleston C, Derry S, et al
. ‘Evidence’ in chronic pain: establishing best practice in the reporting of systematic reviews. Pain 2010; 150:386–389.
36•• Oldenmenger WH, Sillevis Smitt PAE, van Dooren S, et al
. A systematic review on barriers hindering adequate cancer pain
management and interventions to reduce them: a critical appraisal. Eur J Cancer 2009; 45:1370–1380. Excellent review of barriers within professionals and cancer patients.
37•• Goldberg GR, Morrison RS. Pain management in hospitalized cancer patients: a systematic review. J Clin Oncol 2007; 25:1792–1798. Excellent review of educational interventions for hospital-based cancer patients.
38 Sun VC, Borneman T, Ferrell B, et al
. Overcoming barriers to cancer pain
management: an institutional change model. J Pain Symptom Manage 2007; 34:359–369.
39 Ward SE, Serlin RC, Donovan HS, et al
. A randomized trial of a representational intervention for cancer pain
: does targeting the dyad make a difference? Health Psychol 2009; 28:588–597.