Each month, Professor Catherine Walshe, Editor-in-Chief of ‘Palliative Medicine’, chooses an article that readers may find particularly interesting or useful and invites the authors to draw out the key points on the EAPC blog. Focusing on research that is novel, a robust review, from a specific country or just slightly left of field, the ‘Editor’s Choice’ post aims to share experience and stimulate ideas. We hope you’ll read the longer article in Palliative Medicine or EAPC members can access a free copy from the EAPC website.
Dr Emma Chapman, Senior Research Fellow in the Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, UK, gives the background to her longer article selected as Editor’s Choice in the April issue of ‘Palliative Medicine’ – and the journal’s first ever practice review…
Pain is not well managed in more than half of patients with advanced cancer 1 and is one of the symptoms that patients fear. When pain is poorly controlled this has the potential to negatively impact on the experience of the patient, their families and friends and also the staff who care for them.
The St Gemma’s Academic Unit of Palliative Care at the University of Leeds, UK, aims to improve care of those nearing the end of life through integrated research, teaching and clinical practice. We lead the RESOLVE research programme: “Improving health status and symptom experience for people living with advanced cancer”. A key aim of the programme is to provide support to enable clinical teams to better manage and improve the management of challenging symptoms including pain. At the start of this four-year research programme, funded by the charity Yorkshire Cancer Research, we set out to understand what approaches were currently being used and where difficulties arose. We collected qualitative data from interviews and focus groups with more than 60 healthcare staff who care for patients with advanced cancer in the UK. Staff were asked about how they managed symptoms, including pain, and what they saw were the barriers and facilitators to effective symptom control (manuscript in preparation). We did a ’stock take’ on what approaches were recommended by current guidelines and considered the state of the science of the evidence base to support these recommendations. This review forms the basis of our recent article “Evidence based and effective management of pain in patients with advanced cancer” published in Palliative Medicine. A strength of this article was the multidisciplinary nature of our authorship team, which contained clinical academics, senior research fellows, a nurse consultant and researchers with physiotherapy and pharmacy backgrounds.
We used a scoping review methodology to examine international guidelines from the last five years that concerned management of pain in adults with advanced cancer. Based upon the weight of supporting evidence, ‘Do’ or ‘Do not’ recommendations were made for interventions commonly advocated by key guidelines. Approaches categorised as ‘Don’t Know’ were those where there was insufficient evidence to advocate their use in people with advanced cancer and further research is needed.
We concluded that an oral strong opioid remains the drug of choice for treating moderate or severe pain in patients with advanced cancer. Bisphosphonates and/or radiotherapy should also be used where needed for bone pain. Optimal management requires a tailored approach, support for self-management and regular review of treatment outcomes. Non-pharmacological approaches are likely to have a role. Despite its common use, oral paracetamol should not routinely be used for patients who are already taking a strong opioid for moderate to severe pain. Cannabis-based medicines are not recommended as there is evidence that they are not effective.
We intend that this practice review will provide a concise overview to enable evidence-based decision-making by clinicians. Perhaps it will prompt some reflection upon current, frequently used practices and the decision behind their choice. Indeed, preliminary findings from our qualitative study show that paracetamol is prescribed to patients already taking strong opioids due to patient preference and staff habit.
Further research is needed into whether non-steroidal anti-inflammatory drugs, anti-convulsants, anti-depressants, corticosteroids, some invasive anaesthetic techniques, acupuncture, massage and transcutaneous electrical nerve stimulation should be used. We have also highlighted that good quality research into non-pharmacological supportive treatments such as acupuncture, massage and music therapy is lacking, which is a barrier to their use. We suggest that research funders should support trials of these interventions, which are inexpensive, low risk and adaptable to many different care settings.
Some of the challenges of conducting and evaluating RCTs in palliative care such as heterogeneity in trial design and outcome measures may be best overcome by the development of large, collaborative, multi-centre trials. Although sufficient recruitment can be an issue, research suggests that many people with advanced cancer view taking part in a trial as a positive experience.2
Our practice review was confined to the management of pain in adults with advanced cancer. While we consider that much of the recommendations may be generalizable to pain in non-cancer conditions, we recognise there is also a need to appraise more specific evidence for treatment of non-cancer conditions in palliative care.
- Breivik H, Cherny N, Collett B, de Conno F, Filbet M, Foubert AJ, Cohen R, Dow L. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Ann Oncol. 2009 Aug; 20 (8): 1420-33
- Middlemiss T, Lloyd-Williams M, Laird BJ, Fallon MT. Symptom Control Trials in Patients With Advanced Cancer: A Qualitative Study. J Pain Symptom Manage. 2015 Nov; 50 (5): 642–649. e1.
Editor’s note: The EAPC would like to point out that multiple guidelines (including WHO, 2018) are described in the full-text article here.
DOWNLOAD FREE COPY OF THE FULL ARTICLE IN ‘PALLIATIVE MEDICINE’ – IT’S OPEN ACCESS
This post relates to the longer article,‘Practice review: Evidence-based and effective management of pain in patients with advanced cancer’ by Emma Chapman, Zoe Edwards, Jason W Boland, Matthew Maddocks, Lucy Fettes, Catherine Malia, Matthew R Mulvey and Michael I Bennett, published in Palliative Medicine 2020, 34 (4); pages: 444-453. Article first published online 24 January 2020: (https://doi.org/10.1177/0269216319896955) Issue published: 1 April 2020.
- Contact Dr Emma Chapman by email.
- Follow Emma on Twitter @DrEmmaChapman1
- Read earlier Palliative Medicine Editor’s Choice posts on the EAPC blog.
- Follow Palliative Medicine on Twitter @palliativemedj
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