Pain has been inadequately addressed and managed for a variety of cultural, educational, political, religious, and logistical reasons.¹ Persisting pain has major physiologic, psychological, economic, and social ramifications for patients and their families, as well as for society. All of the developed and many developing countries have the ability to significantly improve the treatment of pain of all types; it is not just cancer pain management that is deficient. Furthermore, global disparities in incidence of certain preventable cancers (eg, cervical), as well as in survival from several that are treatable (eg, lymphoma, leukemia, testicular carcinoma), are a demonstration of a lack of equity in the provision of health care, apparently determined solely by the hazard of what country one resides in.²

Worldwide, a total of 10.9 million new cases of cancer were reported in 2002. In the same year, there were 6.7 million deaths ascribed to cancer and 24.6 million persons within 3 years of diagnosis alive with their cancers.² At least 70% of patients suffered from pain caused by their cancer or its treatment.¹ Approximately 25% of cancer patients die without adequate pain relief in spite of the availability of appropriate tools for adequate pain control.³, ⁴ Adequate pain treatment is more often found in patients on palliative anticancer treatment than those receiving curative anticancer treatment.⁵ It has also been shown that patients with better performance status⁶ or without metastases⁷ are likely to receive less-than-adequate pain treatment. Cancer patients are exposed to the well-known barriers that impede adequate pain relief, such as fear of opioid and other medications and the completely inappropriate fear of starting opioids too early so that pain relief will not be available because of tolerance when the disease enters its terminal phase.

It is unfortunately true that the majority of the world’s cancer patients do not present until their disease has reached advanced status. For such patients, the currently available treatment options consist of pain management and palliative care. However, the course of disease leads to varying levels of pain, both acute and chronic, yet some cancer patients need pain relief throughout the entire course of their illness. It has been suggested that pain occurs in approximately one third of patients who are receiving ongoing active anticancer treatment. Treatment of the cancer and pain relief efforts must both remain the focus of the clinician. A recent NIH Consensus Conference on symptom management in cancer estimated that 5-year survival will occur in at least 60% of patients.⁸ This will mean that the need to address the effect of symptoms of cancer and its treatments on individuals’ lives will become progressively more important in the effort to reduce the pain, suffering, and disability, as well as the health care costs, of cancer.

The methods of measuring the adequacy of pain management have been the subject of numerous studies. The Pain Management Index (PMI) is a validated method of assessing the adequacy of pain control based on several widely accepted guidelines.⁹ This instrument examines the congruence between the patient’s self-reported level of pain and the appropriateness of the analgesic therapy. The PMI is a composite measure that is computed by subtracting a patient’s worst pain intensity from the rating of the most potent analgesic prescribed. The PMI is a conservative estimate; it does not take into consideration the doses of the analgesics used or the schedule at which they are prescribed. Even when the PMI is utilized, one half of patients with cancer pain seem to be undertreated.¹⁰ We strongly recommend the use of this or another validated instrument to assess the adequacy of cancer pain treatment.

The causes of inadequate pain management are certainly multifactorial and, often, exceedingly complex. Some of the factors that contribute to under-treatment of pain are itemized in Table 13.1. The inadequate prescription of opioids is a major component of the undertreatment of cancer pain. There are also patient characteristics, such as age, minority status, or lower educational achievement, that have been associated with an increased likelihood of inadequate pain treatment.⁶,¹¹, ¹², ¹³ Gender also appears to play a role in the adequacy of cancer pain management; women were significantly less likely to have been prescribed high-potency opioids by their primary oncology team and significantly more likely to report inadequate pain management in a study of 131 cancer patients.¹⁴

More than 90% of oncology care occurs on an outpatient basis, and consists predominantly of prescriptions for medications. Clinicians should be aware of the factors that contribute to the likelihood that prescribed medications will be taken as ordered. Adherence to prescriptions implies the active, voluntary collaboration by the patient in a mutually acceptable course of behavior that leads to the desired preventive or therapeutic result.¹⁵ Undertreatment can result from failure to adhere to prescriptions. Adherence rates are difficult to determine because of differences in the parameters chosen for defining variability. For example, Du Pen et al.¹⁶ reported that 62% to 72% of oncology patients adhered to their prescribed opioid therapy. By contrast, Miaskowski et al.¹⁷ reported that overall adherence rates for PRN analgesics ranged from 22.2% to 26.6%. Enting et al.¹⁸ found that 65% of 915 cancer patients receiving outpatient care were undertreated, as indicated by a negative PMI. Both physicians and patients contributed to ineffective pain management, characterized both by poor analgesic prescriptions and by poor adherence to those prescriptions. Valeberg et al.¹⁹ reported that only 41% of oncology outpatients were adherent to their
analgesic regimen—women less so than men. Higher adherence scores occurred in patients with higher average pain intensity scores, higher pain relief scores, and with those receiving strong opioid analgesics.

The persistence of undermedication despite the availability in developed countries of opioids and other analgesics for the treatment of cancer pain points either to limitations in current pain management guidelines or failure of those caring for cancer patients to utilize the existing guidelines. Even with the implementation of routine documentation of pain intensity in the United States, the quality of pain management did not appear to improve significantly.²⁰ Some of the issues identified include the health care professionals’ knowledge and attitudes about opioid prescribing;²¹, ²² patient reluctance to use opioids for pain relief (including the family’s reaction to such treatment);²³ and practitioner concern about regulatory scrutiny.²⁴

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