A comprehensive review of the literature yielded 22 outcome measures that assessed pain in adults with a diagnosis of cancer. Of these, 3 measures received the highest rating (4 = highly recommend) and 4 received the second highest rating (3 = recommend). Eleven measures are recommended as reasonable to use, but it is important to note that there are limited studies using these measures in the cancer population to support a higher recommendation. Three of the outcomes reviewed are not recommended because they have poor psychometric properties and/or poor clinical utility. The ratings of the 22 assessed outcome measures are presented in Table 4.
The purposes of this review were to systematically identify and analyze outcome measures for assessing pain in the adult cancer population and to recommend outcome measures with adequate psychometric properties and clinical usefulness. Two of the recommended measures are unidimensional in nature and typically investigate pain intensity or severity, whereas 5 are considered multidimensional and investigate additional characteristics such as pain quality and interference with daily activity. Three measures were highly recommended, and 4 additional measures were recommended. The clinical utility (Table 3) and psychometric properties (Table 4) of the highly recommended and recommended measures are discussed in the following text.
The MPQ-SF has been found to be sensitive to change in 3 groups of patients administered different types of analgesia—epidural anesthetic for labor pain, transcutaneous nerve stimulation for musculoskeletal pain, and analgesic drugs for postsurgical pain.11 There is no described MDC, but an MCID has been reported for a mean improvement in total scores of more than 5 on the 0 to 45 score for the 15 pain descriptors.9,18 The MPQ-SF has been administered in studies of a variety of cancer diagnoses including breast, colorectal, lymphoma, prostate, lung, gastrointestinal, genitourinary, gynecological, head and neck, kidney, and melanoma.15,19
Psychometrics for the NRS have been reported in a number of patient conditions, including a variety of cancers. In adults with a diagnosis of cancer, Jensen23 reported good stability for the NRS rating of worst pain (r = 0.93) and average pain (r = 0.78) but not for current pain (r = 0.59) during a 2-day period. In another study, the coefficient α for the NRS used for measuring present, average, worst, and least pain in a population with cancer was 0.81.24 Reproducibility was 0.86 (Cohen's K) when measuring pain exacerbations in a population of patients with advanced cancer with pain.25 Convergent validity of the NRS compared with the VAS is strong (r = 0.847, P = .001) in a population with cancer.26 The NRS has demonstrated good criterion validity through significant correlations with analgesic medication and other specific cancer-related symptoms.23 A reported 2-point change represents a clinically meaningful difference.27,28 Responses on the NRS were able to predict decreases in functioning in patients with various cancer diagnoses.29 For cancer pain, NRS scores can be categorized as mild (1-3), moderate (4-6), or severe (7-10).24,30 Scores that are greater than 5 may have an adverse effect on health-related quality of life.31
The NRS has been used extensively in both clinical and research settings, with numerous studies involving patients with the following cancer diagnoses: chronic cancer pain, breast cancer, neuropathic cancer pain, head and neck, palliative care, liver, pancreatic, gastric, colorectal, hematologic, lung, genitourinary, and multiple myeloma.23–26,29,30 The NRS has the disadvantages of many unidimensional measures in that it measures only one aspect of the pain experience (intensity) where the overall pain experience in adults with a diagnosis of cancer may require a more multidimensional measurement tool.32
Despite the strong reported psychometric properties for the VAS, there is evidence that this tool may be more difficult than other pain measures for patients to understand and complete.23 One study found that 16% of 101 palliative care patients were unable to complete the VAS even with assistance from a nurse, and this number increased to 84% as the disease progressed.37 Research has shown that administering the VAS to elderly patients is associated with a higher failure of completion rates than other unidimensional tools such as the NRS.38,39 In addition, many cancer survivors are prescribed opioids for pain from cancer and/or treatments; difficulty understanding the VAS has been found when patients are taking this type of medication.40
The PDI has been used in 3 cross-sectional studies in women with a diagnosis of breast cancer.79–82 Reliability of the PDI when administered to the general chronic pain population was 0.87 (Cronbach α).72 The PDI has been shown to have acceptable concurrent and construct validity in individuals with chronic pain.72 The PDI has a reported MCID of 6 points for individuals with low back pain.83 While the PDI was developed for patients with chronic pain from multiple causes, including cancer-related pain, published psychometrics for the PDI when administered to only a cancer population could not be found. The PDI has been used in individuals with breast and metastatic cancers. Since the measure has good psychometric properties in mixed chronic pain populations, it is therefore still a recommended measure.
There are a variety of factors that should be considered when interpreting the Task Force recommendations. An outcome measure may have been excluded in this review because of a lack of published data; the authors are aware that new studies may have been published after August 15, 2016. For measures not recommended at this time, additional information may become available that might elevate the Task Force recommendation in the future. The literature search was limited to English-language journals; therefore, journals in other languages were not reviewed and could limit the number of measures reviewed. Researchers and clinicians are encouraged to review the Task Force recommendations, as well as each specific outcome measure, for more extensive information. While this article can serve as a guide, ultimately, it is up to clinicians and researchers to identify the best available evidence in addition to patient values and expectations in order to appropriately administer the correct pain outcome measure in the cancer population.84
The authors thank Sarah Foley, SPT, Megan Hass, SPT, and librarian John Mitchell, for their assistance with the literature search and EDGE forms.
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