Analgesic management in radiation oncology for painful bone metastases
Background Radiotherapy (RT) effectively palliates bone metastases, but pain relief may be delayed and need analgesic management. National Comprehensive Cancer Network (NCCN) Guidelines for Adult Cancer Pain recommend alteration of analgesic regimen for a pain intensity rating (PIR) of ≥4/10 (range, 0-10; 0 denotes no pain and 10, worst pain imaginable).
Purpose To evaluate frequencies of analgesic regimen assessment and intervention in radiation oncology (RO) consultations for bone metastases and evaluate the impact of a dedicated palliative RO service.
Methods Investigators reviewed consultation notes for 271 patients with bone metastases who were treated at 2 cancer centers at time points before and after implementation of a palliative RO service at Center 1. The service had not been implemented at Center 2 during the study time periods. The analgesic regimen assessment rate was recorded for symptomatic patients, and the analgesic intervention rate was recorded for those with a PIR of ≥4.
Results The median PIR for painful metastases was 5 (interquartile range [IQR], 2-7), and 51% of those assessed had a PIR of ≥4. Analgesic regimen was reported for 38% of symptomatic patients. Analgesic intervention occurred for 17% of patients with a PIR of ≥4. Palliative RO service patients had higher rates of analgesic assessment (59.5% vs 33.5%, respectively; P = .002) and intervention (31.6% vs 9.2%, P = .01) compared with those not seen in the service. There was no significant difference in analgesic assessment or intervention between nondedicated palliative RO care at the 2 centers.
Limitations Retrospective design, reliance on documentation for evaluating analgesic management
Conclusions At 2 cancer centers, half of the patients with bone metastases who received RT had a PIR of ≥4, yet only a minority had analgesic assessment and intervention, indicating a need for quality improvement in RO. Integrated palliative RO care is associated with improved analgesic management in accordance with NCCN guidelines.
Accepted for publication December 6, 2017
Correspondence michael.garcia@ucsf.edu
Disclosures The authors report no disclosures/conflicts of interest.
Citation JCSO 2018;16(1):e8-e13
©2018 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0388
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Bone metastases are a common cause of pain in patients with advanced cancer, with about three-quarters of patients with bone metastases experiencing pain as the dominant symptom.1 Inadequately treated cancer pain impairs patient quality of life, and is associated with higher rates of depression, anxiety, and fatigue. Palliative radiotherapy (RT) is effective in alleviating pain from bone metastases.4 Local field external beam radiotherapy can provide some pain relief at the site of treated metastasis in 80%-90% of cases, with complete pain relief in 50%-60% of cases.5,6 However, maximal pain relief from RT is delayed, in some cases taking days to up to multiple weeks to attain.7,8 Therefore, optimal management of bone metastases pain may require the use of analgesics until RT takes adequate effect.
National Comprehensive Cancer Network (NCCN) Guidelines for Adult Cancer Pain (v. 2.2015) recommend that pain intensity rating (PIR; range, 0-10, where 0 denotes no pain and 10, worst pain imaginable) be used to quantify pain for all symptomatic patients. These guidelines also recommend the pain medication regimen be assessed for all symptomatic patients. For patients with moderate or severe pain (PIR of ≥4), NCCN guidelines recommend that analgesic regimen be intervened upon by alteration of the analgesic regimen (initiating, rotating, or titrating analgesic) or consideration of referral to pain/symptom management specialty.
Previous findings have demonstrated inadequate analgesic management for cancer pain,2,9 including within the radiation oncology (RO) clinic, suggesting that patients seen in consultation for palliative RT may experience uncontrolled pain for days to weeks before the onset of relief from RT. Possible reasons for inadequate acute pain intervention in the RO clinic may be provider discomfort with analgesic management and infrequent formal integration of palliative care within RO.10
Limited single-institution data from the few institutions with dedicated palliative RO services have suggested that these services improve the quality of palliative care delivery, as demonstrated by providers perceptions’ of the clinical impact of a dedicated service11 and the implementation of expedited palliative RT delivery for acute cancer pain.12,13 To our knowledge, the impact of a dedicated palliative RO service on analgesic management for cancer pain has not been assessed.
Here, we report how often patients with symptomatic bone metastases had assessments of existing analgesic regimens and interventions at RO consultation at 2 cancer centers. Center 1 had implemented a dedicated palliative RO service in 2011, consisting of rotating attending physicians and residents as well as dedicated palliative care trained nurse practitioners and a fellow, with the service structured around daily rounds,11 whereas Center 2 had not yet implemented a dedicated service. Using data from both centers, we assessed the impact of a palliative RO service on analgesic assessment and management in patients with bone metastases.
