Cancer Pain - Medscape report on new NCCN guidelines

[Guest guest]

http://bit.ly/fLeROu

Copying snips from sections of this important Medscape article provided by

Anjou:

The Latest Guidelines for Assessment

" For some people diagnosed with cancer, the fear of pain is greater than the

fear of death. I don't know if this is really true, but the prospect and

dread of pain surely add to the panoply of emotions experienced by the

patient with newly diagnosed cancer. Pain, in spite of being a markedly

subjective experience, is a common and inevitable feature of many cancers.

We have learned much about pain in the past few decades. We have more

pain-relief options than ever before, and roadmaps in the form of

evidence-based guidelines to help us use them appropriately. It is puzzling,

then, that cancer pain continues to be undertreated or poorly treated in so

many patients.[1] <javascript:newshowcontent('active','references');> These

variances imply that cancer pain treatment isn't simple or straightforward,

and many factors (opinions, beliefs, culture, and even genetics) influence

cancer pain management. "

Cultural Considerations

Studies of racial disparities in cancer pain treatment have also found that:

* Minority patients (primarily blacks and Hispanics) are more likely

to receive inadequate analgesia than are whites, regardless of setting[5]

<javascript:newshowcontent('active','references');> ;

* Physicians underestimate the pain severity of more minority patients

than nonminority patients[6]

<javascript:newshowcontent('active','references');> ; and

* Minority patients are more likely than whites not to receive any

analgesia at all.[7] <javascript:newshowcontent('active','references');>

Disparities can govern all components of cancer pain management, including

assessment, reassessment, treatment, and end-of-life care.[8]

<javascript:newshowcontent('active','references');> Assessment, however, is

the pivotal point in pain management because it determines how a patient's

pain will subsequently be managed.[8]

<javascript:newshowcontent('active','references');>

The Latest Guidelines for Assessment:

Severe, Uncontrolled Pain

Severe, uncontrolled cancer pain is recognized as a medical emergency, " just

as much as a drop in blood pressure or a pulmonary embolism, " reminds Paice.

The previous guidelines stated that severe, uncontrolled pain " should be

evaluated promptly " and in NCCN v.2010, the wording was altered to say

" should be responded to promptly " to reinforce the urgent nature of this

degree of pain.

Patient's Self Report of Pain

The self-report of pain is the cornerstone of pain assessment, and a

standard of care in adult cancer pain management.[2]

<javascript:newshowcontent('active','references');> When a patient is

unable to verbalize pain, alternative methods (such as a visual analog

scale) are used in lieu of the verbal report. The previous guidelines

recommended that an alternative method of pain rating and response be used,

" if the patient is unable to speak normally, " and in NCCN v.2010, this

sentence is changed to, " if the patient is unable to verbally report pain. "

This change reflects the understanding that pain can be indicated by

verbalizations other than speech, such as voicing " uh-huh " in response to

questions about pain.

Typical Expression of Pain

Hand-in-hand with the assessment of the patient's cultural beliefs about

pain is assessment of the patient's usual expression of pain. This construct

was added to the comprehensive assessment guidelines to prompt clinicians to

consider how the patient expresses pain, given his or her cultural beliefs.

Consequences of Pain

New in NCCN v.2010 is the recommendation, in addition to assessing the

meaning of pain, that healthcare professionals should " assess the

consequences of pain for the patient and family. " By adding this

recommendation, the panel of experts is hoping that clinicians will be more

attentive to the fact that family members can also suffer when a loved one

is in pain, and that this can play out in numerous ways. Family members are

often used as proxies when a patient is unable to report his or her level of

pain, but research indicates that the family's report of the patient's pain

intensity often exceeds the patient's own report -- this reflects the

meaning of pain to the family. When such a discrepancy exists, family

members might administer more (or less) pain medication than the patient

really needs.

Another common example of a consequence of pain, according to Paice, occurs

" when a patient becomes more withdrawn and less responsive at the end of

life. The family stops giving the pain medication because they believe that

the pain medication, rather than disease progression, is making their loved

one less responsive. It is often easier to blame the pain medication than to

acknowledge that the disease is taking over. "

Existential Suffering

More than the meaning of pain to many patients with cancer is the

existential suffering that accompanies pain, often when the patient realizes

that he or she has a life-limiting illness. " On top of organic, physiologic

pain, the expression of existential distress magnifies the patient's pain

experience. But, all the morphine in the world is not going to treat

existential suffering, " explains Paice. " It requires a different kind of

therapy. "

The question is: how can oncology professionals approach the existential

needs of patients? " The beauty of cancer pain management, " responds Paice,

" is that it's not something that a single person has to do. You can pull in

the team. If you suspect distress, you can pull in the social worker or the

chaplain or whatever resources you have to help with this kind of assessment

and management. "

Summary

The science of pain assessment is evolving, and we continue to learn about

the multidimensional meaning, experience, and expression of pain. Updates to

the NCCN guidelines for pain assessment distill those new findings into

practical, useful tools to help physicians and nurses caring for patients

with cancer to be as adept in the assessment of pain as they are in treating

it.

All the best,

~ Karl

Patients Against Lymphoma

Patients Helping Patients

Non-profit | Independent | Evidence-based

www.lymphomation.org | Current News: http://bit.ly/f2A0T

How to Help: www.lymphomation.org/how-to-help.htm