Improving Pain Assessment and Management in Routine Oncology Practice: The Role of Implementation Research
Mené au Royaume-Uni auprès de 1 921 patients atteints de cancer, cet essai randomisé compare l'intérêt, pour prendre en charge la douleur, des soins usuels standard et d'une approche intégrée du traitement de la douleur menée grâce à une évaluation spécifique faite au chevet du patient par le médecin
Résumé en anglais
Pain is a common and consequential symptom among patients with cancer. Moderate to severe pain is estimated to affect 38% of patients across all disease stages and 52% of patients with advanced, metastatic, or terminal disease.1 Poorly controlled symptoms, including pain, are associated with worse quality of life and greater impairments in daily functioning.2 They also frequently lead to emergency department visits, with many of these visits resulting in hospitalization.3 In addition, poorly controlled symptoms contribute to discontinuation of cancer treatments (eg, hormonal therapy for breast cancer4,5), which in turn increases the risk for recurrence and death.6
Three important and addressable barriers to more effective pain management can be identified. First, pain is not assessed in a standardized manner in many practice settings.7 Pain is a subjective phenomenon, best reported from the patient perspective, which can be accomplished readily with a validated patient-reported outcome (PRO) measure.8 These measures are used widely in clinical research, and their use as part of routine clinical care is increasingly common.9 Technologic developments are beginning to address the challenges in integrating PRO assessment into the clinical workflow and in ensuring that PRO data are available at the point of care to inform clinical decision making.10 Second, pain is not managed adequately in many patients. Failure to use appropriate analgesic medications is estimated to occur in 32% of patients with cancer with pain.11 Third, strategies that could yield widespread improvements in the routine assessment and management of cancer pain have not been systematically evaluated. In this regard, an important distinction can be drawn between efforts to disseminate versus implement recommended clinical practices.12 To date, efforts to improve assessment and management of cancer pain have focused primarily on dissemination (eg, publication and distribution of cancer pain–related guidelines and recommendations). Although this approach has produced some improvements, it could be much more effective if complemented with concerted efforts at implementation (eg, use of strategies designed to promote adoption and integration of evidence-based approaches to cancer pain assessment and management).
The article by Fallon et al13 that accompanies this editorial illustrates the use of an implementation research strategy. Findings are reported from a study in which 19 cancer inpatient units in the United Kingdom were randomly assigned to implement a clinician-delivered bedside pain assessment and management tool or to continue with usual care. Notably, the number of centers included in the study represents half the inpatient cancer units in the United Kingdom. The tool used, the Edinburgh Pain Assessment and Management Tool (EPAT), addresses the barriers described earlier by prompting clinicians to systematically assess pain using a brief set of questions and follow specific treatment algorithms linked to patient responses. The effects of EPAT were tested by comparing, at the cancer center level, the change in the percentage of patients with a clinically significant improvement in their pain. Comparisons were made for samples of patients with cancer-related pain seen before and after implementation in the EPAT arm and over corresponding intervals in the usual care arm.(...)
