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Education in cancer pain management

Bennett, Michael Ia; Flemming, Kateb; Closs, S Joséc

Current Opinion in Supportive and Palliative Care: March 2011 - Volume 5 - Issue 1 - p 20–24
doi: 10.1097/SPC.0b013e328342c607
Pain: cancer: Edited by Anthony H. Dickenson and Paul W. Farquhar-Smith

Purpose of review To describe the current position of educational interventions within the context of cancer pain management.

Recent findings Barriers to good cancer pain control exist within patients and professionals and centre on lack of knowledge or poor attitudes towards pain and opioid analgesia. Education provided to healthcare professionals increases knowledge and improves attitudes but this does not necessarily translate into improvements in patient outcomes. However, targeted interventions that modify professional behaviour are effective. Educational interventions directed at patients result in improved patient outcomes, although the mechanisms by which these improvements occur are not yet clear.

Summary Overall, educational interventions directed at patients or professionals can result in significant but modest clinical benefit which is similar in magnitude to that achieved by some analgesics. Educational interventions should be part of routine clinical practice alongside optimal oncological and analgesic management. Further work is needed on how best to implement multicomponent interventions within clinical services, including the identification of which combinations are most cost effective.

aInternational Observatory on End of Life Care, School of Health and Medicine, Lancaster University, Lancaster, UK

bUniversity of York, York, UK

cSchool of Healthcare, University of Leeds, Leeds, UK

Correspondence to Michael I. Bennett, MD, FRCP, FFPMRCA, Professor of Palliative Medicine, International Observatory on End of Life Care, School of Health and Medicine, Bowland Tower East, Lancaster University, Lancaster LA1 4YT, UK E-mail:

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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.

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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 [5].

Deandrea et al.[6] 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.[7] 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 [8]. 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.

Table 1

Table 1

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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.

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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 [10].

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Recent developments

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 [12]. 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 [13]. 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 [17]. 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.

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Clinical implications

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 [22]. 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.

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Education directed at professionals

Barriers within healthcare professionals that appear to reduce optimal pain control in patients have been identified by Jacobsen et al.[23] (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.

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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 [24]. 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 [25]. 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 [26].

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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 [25] and supported by a more recent study [29]. 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 [30]. 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) [31]. In contrast, another RCT compared pain assessment alone with consistent review of pain data by clinicians [32]. 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.[33] 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.[34] 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.

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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:

  1. Clinician stating importance of pain control.
  2. Clinician assessing pain and using these data when making prescribing decision.
  3. Clinician using a prescribing protocol and adhering to it.
  4. 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.
  5. Explaining to patients (especially older people) how and when to take their drugs.
  6. Monitoring of adverse effects and dealing with them.
  7. 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.

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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 [35]. 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].

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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).

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behaviour; cancer pain; educational intervention

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