Oncologists’ perceptions of cancer pain management in Spain: The real and the ideal

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Abstract
Methods Two-round Delphi survey of 24 medical oncologists from 22 large, geographically diverse hospitals in Spain. Physicians rated each of 150 statements on a Likert scale (1 = strongly disagree; 5 = strongly agree). The mean, standard deviation and frequency of replies in three agreement categories were calculated for each item. Statements allowing comparison of oncologists’ perceptions of how pain is managed in routine clinical practice with how it should be managed were grouped together and analyzed. Results The most notable discrepancies between the real and the ideal occurred in the failure to provide written information or to confirm that patients understand what they are told, the lack of comprehensive and systematic evaluation of pain, and the lack of use of non-pharmacological treatments (NPTs) for cancer pain. Conclusions Medical oncologists need to improve their communication skills, providing patients with both written and verbal information about their disease and the plan for pain management. Pain should be evaluated at each patient visit using validated scales, and greater attention should be paid to the possible use of NPTs. Keywords Pain control Pain assessment Physician preferences Delphi 1 Introduction Pain is one of the most frequently reported and feared symptoms in cancer patients. Estimates of the prevalence of pain from large, multicenter studies in different settings have varied from 57% of inpatients and outpatients ( Larue et al., 1995 ), to 67% of outpatients with metastatic cancer ( Cleeland et al., 1994 ), to over 70% of hospitalized patients with advanced cancer ( Yun et al., 2003 ). Despite the widespread availability of safe and effective analgesics ( Carr et al., 2004 ) and evidence-based guidelines for their use ( Carr, 2001 ), large variability in how physicians manage cancer pain has been documented ( Cleeland et al., 1994; Green et al., 2003; Von Roenn et al., 1993 ), and studies in many countries suggest that pain control is often inadequate ( Di Maio et al., 2004; Larue et al., 1995; Vainio, 1995; Von Roenn et al., 1993; Zenz et al., 1995 ). Although cancer pain can be alleviated in approximately 90% of cases ( Schug et al., 1990 ), it is estimated that about 20% of patients with cancer have uncontrolled pain ( Ahmedzai, 1997 ), rising to almost 70% of those in their last year of life ( Addington-Hall and McCarthy, 1995 ). Pain may be due to the location of the neoplasia, the effects of the treatment received, or other etiologies. Although the goal of therapy is to treat the source of pain, if this is not possible, the patient’s perception of pain can be altered in most cases using pharmacologic and non-pharmacologic approaches ( Levy, 1996 ). Although many studies have been carried out in different countries on the prevalence of cancer pain and physician attitudes regarding its treatment, little literature on this subject exists with respect to Spain. Such studies as do exist have documented the prevalence of acute and chronic pain in the general population ( Bassols et al., 1999; Catala et al., 2002 ) and in hospitalized patients ( Canellas et al., 1993; Valero et al., 1995 ), but not in oncology patients. Likewise, few studies have been published regarding physician attitudes about pain treatment in Spanish patients ( Farre et al., 1992; López de Maturana et al., 1993 ), and none of them have specifically explored medical oncologists’ attitudes and perceptions in this area. To fill this gap in knowledge, the ALGOS project was launched by a group of 58 medical oncologists from different centers in Spain in 1998. After holding a series of workshops to discuss the current situation of cancer pain management and to identify possible obstacles to adequate treatment, the ALGOS group designed a 3-phase study to produce relevant and scientifically valid knowledge on the problem of pain and its management by medical oncologists in Spain. The objectives of this project are to identify the perceptions, attitudes and experiences of medical oncology specialists with regard to pain in their patients (phase 1); to study the association between pain, its management and patient characteristics (phase 2); and to determine patient perceptions, attitudes and experiences with regard to pain (phase 3). The present study presents the partial results of the first phase of this project, comparing medical oncologists’ perceptions of how pain is managed in routine clinical practice (“the real”) and how it should be managed (“the ideal”). 2 Methods A 2-round Delphi survey of an expert panel of 24 medical oncologists in the ALGOS group was carried out between March and July 2004. The physicians included in the survey were from 22 mostly large teaching hospitals, representing 11 of Spain’s 17 Autonomous Communities, and were all chiefs of their respective Oncology Services or Units. Their mean age was 53 years (range 41–61). The survey instrument was a 150-item questionnaire developed by study investigators based on a literature review of the prevalence, evaluation and treatment of acute and chronic pain, clinical practice guidelines on pain management ( Benedetti et al., 2000; Jacox et al., 1994 ), other documents of the ALGOS group, and previous questionnaires used to evaluate perceptions and attitudes of patients, their family members and health professionals in regard to post-surgical pain. The items were divided into six thematic areas related with cancer pain: information, evaluation, management, and the attitudes of patients, medical oncologists and non-oncologist physicians. Each item consisted of a statement – for example, “Medical oncologists provide their patients with sufficient information regarding the possible side effects of pain medications” – to be rated on a 5-point Likert scale, where 1 = strongly disagree and 5 = strongly agree. New questionnaires were...