Cancer: Pain Measurement in Ambulatory Patients Interview with:
Fengmin Zhao, MS,PhD Biostatistician
Department of Biostatistics & Computational Biology Dana-Farber Cancer Institute
Boston, MA 02215 What are the main findings of the study?

Dr. Zhao: We analyzed 2,761 patients in this study. We found that at initial assessment, 53.0% of patients had no pain, 23.5% had mild pain, 10.3% had moderate pain, and 13.2% had severe pain. Overall, one third of patients with initial pain had pain reduction within 1 month of follow-up, and one fifth had an increase. Inadequate pain management was significantly associated with pain deterioration in these patients, as were lower baseline pain level, younger age, and poor health status. Of the patients without pain at initial assessment, 28.4% reported pain at the follow-up assessment (8.9% of them were moderate to severe pain), and more than half of them received inadequate pain management. Were any of the findings unexpected?

Dr. Zhao: An unexpected finding of our study was that improvement in pain levels varied with baseline pain levels. Patients with lower baseline pain level were more likely to have pain deterioration.

It is now clear that baseline pain severity is an indicator of pain management complexity and an important element to consider when designing pain intervention clinical trials to improve the assay sensitivity of these trials. What should clinicians and patients take away from your report?

Dr. Zhao: The main message of the study is that pain remains a significant concern in ambulatory oncology. Pain is not only prevalent but also persistent and dynamic in cancer patients. Inadequate pain management is the main problem for effective pain control, partly due to the adverse effects of analgesics.

For clinicians, it is not enough to simply ask about pain at each visit.  There needs to be improvement in the way clinicians select and titrate analgesics, utilize expert consultants, and understand patient’s concerns about adverse effects of analgesics, There needs to be close monitoring patients for the analgesic’s pain control effect and its adverse effects that is also feasible in the modern clinical oncology setting. Such monitoring requires knowledge and skills at the individual level and also the system level.  Clearly, effective and culturally competent communication and patient education are needed. What recommendations do you have for future research as a result of this study?

Dr. Zhao: More studies are needed to better understand the reasons for inadequate pain management in ambulatory oncology and to explore new ways to deliver effective care and to monitor and continuously improve that aspect of the patient experience. In addition, studies about biological mechanisms of cancer-related pain are important to better understand pain and to guide targeted interventions.


Determinants of Pain Severity Changes in Ambulatory Patients With Cancer: An Analysis From Eastern Cooperative Oncology Group Trial E2Z02

Fengmin Zhao, Victor T. Chang, Charles Cleeland, James F. Cleary, Edith P. Mitchell, Lynne I. Wagner, and Michael J. Fisch

JCO.2013.50.6071; published online on December 23, 2013;