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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Given the multi-institutional nature of this study, it may be that general practice differences confound the impact of the dedicated palliative RO service at Center 1. However, with excluding Center 2, the dedicated service was still strongly associated with a higher rate of analgesic assessment within Center 1 and was almost significantly associated with appropriate analgesic intervention within Center 1.
We used a PIR of ≥4 as a threshold for appropriate analgesic regimen intervention because it is what is recommended by the NCCN guidelines. However, close attention should be paid to the impact that any amount of pain has on an individual patient. The functional, spiritual, and existential impact of pain is unique to each patient’s experience, and optimal symptom management should take those elements into account.
Conclusion
In conclusion, this study indicates that advanced cancer patient pain assessment and intervention according to NCCN cancer pain management guidelines is not common in the RO setting, and it is an area that should be targeted for quality improvement because of the positive implications for patient well-being. Pain assessment and intervention were greater in the setting of a dedicated structure for palliative care within RO, suggesting that the integration of palliative care within RO is a promising means of improving quality of pain management.
This work was presented at the 2016 ASCO Palliative Care in Oncology Symposium (September 9-10, 2016), where this work received a Conquer Cancer Foundation Merit Award.
