Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Abstract
Pain is one of the most commonly
experienced and feared symptoms of
advanced cancer. Most cancer patients
experie...
Epidemiology
Cancer causes 20 percent of all
deaths each year in the US, with
approximately one million new cases
per year...
severe to very severe pain as observed in
a number of studies.12,22-26
Pain in pediatric patients. Child-
ren can complete...
The Single Narcotic Convention in
1961 established an International Nar-
cotic Central Board, which monitored
importsandex...
guidelines are well established. How-
ever, among oncologists of the Eastern
Cooperative Oncology Group, manage-
ment of c...
25. Grond J, Zech D, Diefenbach C, et al.:
Prevalence and pattern of symptoms in patients
with cancer pain: a prospective ...
Upcoming SlideShare
Loading in …5
×

Am j hosp palliat care 2004-davis-137-42

112 views

Published on

Epidemiology of cancer

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Am j hosp palliat care 2004-davis-137-42

  1. 1. Abstract Pain is one of the most commonly experienced and feared symptoms of advanced cancer. Most cancer patients experience pain, usually of moderate to severe intensity, and most also have a number of distinct pains. The most com- mon type of pain is related to bone metastases. Neuropathic pain occurs in one-third of patients, alone, or as a mix of nociceptive and neuropathic pain. The failure to manage pain proper- ly is due to several factors. In develop- ing countries, it is likely to be related to geography and limited resources. Legal restrictions also present barri- ers. In developed countries, failure to manage pain properly is usually relat- ed to a “disease” rather than a “symp- tom” model of care, which minimizes symptom management. Other factors include lack of physician education and failure to follow existing guidelines. Patients fear addiction, drug tolerance, and side effects. Despite adequate re- sources, pain is still undertreated. Key words: pain, opioids, pallia- tive care, epidemiology, cancer Introduction Pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage or an experience described in terms of such damage.1 Even though pain is associat- ed with tissue destruction, pain intensi- ty is not proportional to the type or extent of tissue damage. Pain is modu- lated at various sites within the nervous system, including the dorsal horn, peri- aqueductal gray, brain stem, medial thalamus, and anterior cingulate cortex.2 Pain is also influenced by past experience, mood, and cognitive func- tion. Therefore, pain perception is best described as a biopsychosocial experi- ence.3 Pain can be subdivided into: 1) somatic pain, 2) neuropathic pain, and 3) visceral pain.4,5 The prevalence of pain in cancer is governed by the type of cancer, stage, location of metasta- sis, and comorbidity.6 Incident pain, tenesmus, colic, and neuropathic pain are difficult to manage. Personal fac- tors associated with uncontrolled pain are delirium, depression, anxiety, and substance abuse.6 Psychological fac- tors that modulate pain experience are rarely initiators of pain in a cancer patient. Depression is associated with advanced disease and uncontrolled pain.7 Since advanced cancer patients experience a high prevalence and severity of nonpain symptoms, pain management must be combined with systematic symptom control embed- ded in the framework of palliative care.8 137American Journal of Hospice & Palliative Medicine Volume 21, Number 2, March/April 2004 Epidemiologyofcancerpainandfactors influencing poor pain control Mellar P. Davis, MP, MD, FCCP Declan Walsh, MSc, FACP, FRCP (Edin) MellarP.Davis,MP,MD,FCCP,DirectorofResearch, The Harry R. Horvitz Center for Palliative Medicine, ClevelandClinicFoundation,Cleveland,Ohio. Declan Walsh, MSc, FACP, FRCP (Edin), Medical Director, Director, The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio. Palliative oncology update at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
  2. 2. Epidemiology Cancer causes 20 percent of all deaths each year in the US, with approximately one million new cases per year. Of these patients, 500,000 or more die as a result of their cancer. Seventy percent of patients with advanced cancer experience moderate to severe pain. Many of these patients have chronic pain as a result of past treatment for their underlying disease.9 The incidence of cancer worldwide is six to seven million patients per year, with half or more occurring in develop- ing countries.9,10 Every year, approx- imately 4½ million patients die from cancer, and 3½ million suffer from can- cer pain daily. Only a fraction of those will receive adequate pain treatment.10 Cancer incidence increases with age. By the year 2015, the population in developing countries will increase by 60 percent, but the number of peo- ple over 65 will more than double. Therefore, despite a stable cancer incidence, the absolute number of cancer patients will also double. The westernization of many developing countries, particularly with regard to tobacco consumption, will further increase the incidence of cancer.11 Only 3 percent of the gross national product of the average developing coun- try is spent on healthcare.12 Global resources for cancer control are finan- cially limited. Therapies for advanced cancer are expensive, technologically involved, limited in benefit, and usually beyond the means of developing countries. Palliative medicine, though often relegated to secondary impor- tance in healthcare expenditures, is much more important and affordable in most countries.12 Pain characteristics in advanced cancer Patients with advanced cancer have an increased frequency and intensity of pain compared with early-stage cancer patients. During treatment for their cancer, 35 to 56 percent will have pain, with 20 to 34 percent experiencing severe pain. Pain type by percentage includes: 1) somatic nociceptive pain (50 percent); 2) neuropathic pain (33 percent); and 3) visceral nociceptive pain (20 percent), with a median num- ber of three types of pain per patient. Six to 17 percent of patients with nonmetastatic cancer have pain directly attributable to cancer compared to 35 to 56 percent of those with metastatic dis- ease. Pain is found in 76 percent of hos- pice patients,13 and 84 percent require opioids on the last day of life.14 Twenty to 34 percent of patients have severe pain, which directly influences their quality of life and daily function (i.e., pain interference). Early-stage lung cancer, breast cancer, cervical cancer, and ovarian cancer rarely produce pain. Prostate cancer and colon cancer pro- duce pain even in the early stages by obstruction of the urinary tract or fecal stream, respectively.15,16 Solid tumors produce more pain than leukemias and lymphomas. Induction therapies for acute leukemia are associated with pain in 40 to 50 percent of patients on days 16 through 20 due to mucositis from chemotherapy17 and neutropenia. Grond et al.18 investigated cancer pain etiologies and used a verbal catego- ry rating scale to separate pain into cate- gories: 1) pain related to cancer metas- tases; 2) pain related to cancer treatment; 3) pain associated with complications from cancer or its treatment (debility, herpes zoster, etc.); and 4) pain unrelated to cancer, treatment, or complications. Pain was found most frequently in pa- tients with advanced head and neck can- cers, gastrointestinal malignancies, and genitourinary tumors. Seventy-seven percent of patients with pain had a verbal rating of severe pain. Somatic nocicep- tive pain was most frequently found with breast cancer, genitourinary tumors, bone primaries, and lym- phoreticular malignancies. In compar- ison, head and neck cancers produced a mix of nociceptive and neuropathic pain. Not surprisingly, gastrointestinal cancers were associated with visceral nocicep- tive pain. Nearly 40 percent of patients had two pain syndromes, and 30 percent had three or more separate pain syn- dromes. Eighty percent of patients had more than one anatomical site of pain. The distribution of pain was nociceptive in 50 percent of patients, usually due to bone metastases. Twenty-five to 33 per- cent of patients had neuropathic pain, and a smaller subset had visceral pain. Ten to 20 percent of patients had pain caused by therapy rather than the under- lying malignancies. Fewer than 10 per- cent of patients had pain unrelated to their cancer. A survey by Twycross19 found one- third of patients with bone pain, one- third with neuropathic pain, and one- third with pain caused by soft tissue infiltration. One-third of patients also had visceral pain, and 11 percent had muscle spasms. In a second study by Twycross,20 the median number of dis- tinct pains was approximately three, and 40 percent of patients had more than four separate pains. After four weeks of pal- liative treatment, 78 percent of patients still had more than one type of pain, although the median number decreased to 1.5. By numerical scale, there was a graded influence of pain severity with pain interference. When the pain in- tensity rating exceeded 4 out of a possi- ble score of 10, daily activities were impaired. When pain intensity ex- ceeded 6, significant interference with enjoyment of life occurred.20 Pain in palliative outpatients. Painwaspresentin61percentofpatients attending a palliative day care clinic.21 The number of nonpain symptoms expe- rienced in addition to pain range from two to 11. Metastatic disease correlat- ed with the number of symptoms and the severity of pain. Associated non- pain symptoms included nausea, dysp- nea, insomnia, xerostoma, constipation, irritability, sadness or depression, and dizziness. One-quarter of patients had 138 American Journal of Hospice & Palliative Medicine Volume 21, Number 2, March/April 2004 at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
  3. 3. severe to very severe pain as observed in a number of studies.12,22-26 Pain in pediatric patients. Child- ren can complete a modified Memorial Symptom Assessment Scale (MSAS) adapted for children. As rated by the MSAS, pain occurred in more than 35 percent and was associated with a high degree of distress.27 Half of pediatric patients admitted to an inpatient unit had pain, and one-quarter of outpatients experienced pain.28 Treatment-related pain is more common than cancer- related pain in adults. Pain related to procedures (bone marrow, spinal taps) and pain associated with surgery or chemotherapy were the predominant factors influencing pain prevalence. Tumors cause pain in one-third of inpa- tients and 20 percent of outpatients. Tumor-related pain was mainly caused by bony invasion, which is similar to the findings for adults. Physicians tended to underevaluate and underestimate pain severity in children, as reflected in the patient self-assessment visual analog scales or face scales. Breakthrough pain Breakthrough pain (a transitory flare of an underlying chronic pain) occurs in most patients, and its incidence corre- lates with pain severity.29,30 Break- through pain has been described as inci- dent pain (pain related to movement), nonincident breakthrough pain, or end- of-dose failure pain. Incident pain relat- ed to bone metastases is the most com- mon cause of breakthrough pain. Sudden paroxysmal pain is a type of neuropathic pain, usually caused by compression or infiltration of peripheral nerves or spinal nerve roots. Episodic cramping abdominal pain is associated with obstruction of a hollow viscus. About 50 to 90 percent of patients with chronic pain have breakthrough pain. The severity of breakthrough pain may be independent of the chronic underlying pain, particularly incident pain, and frequently requires dosing independent of the around-the-clock analgesic dose for chronic pain. Breakthrough pain requires indepen- dent assessment. The underlying can- cer causes 76 percent of breakthrough pain, while 20 percent is related to treatment. The median pain duration is approximately 30 minutes. Most breakthrough pain is similar in charac- ter to the chronic underlying pain. Precipitating factors are found in 50 percent of the pain. Approximately one-third of breakthrough pain is somatic, 27 percent is neuropathic, and 20 percent is a mixture of neuro- pathic and nociceptive pain.29-32 Epidemiology of failed pain management Despite available universal guide- lines, most studies demonstrate a fail- ure to relieve pain in 38 to 74 percent of cancer patients.12,33,34 Palliative units that adopt the WHO stepladder analgesic guidelines successfully manage pain in 90 percent of patients.35-37 The failed quality of care in advanced cancer pain management is usually described in terms of one or two elements, though most failures are the result of multiple factors. The following are process barriers to pain management: • structural model of “disease”; • failure to assess pain; • lack of knowledge of opioid pharmacology, conversion, equi- analgesia, and rotation; • failure to use adjuvants; • failure to treat side effects; • fear of opioid side effects, anal- gesic tolerance, and addiction; • lack of priority given to symp- tom management; • analgesia based on prognosis rather than severity of pain; • failure to document drug, dose, timing, breakthrough pain, and laxatives; and • failure to follow up. As described by deWit and col- leagues,38 a Donabedian structure, process, and outcome model for health- care delivery can be used to evaluate the shortcomings with pain therapy.39 The Donabedian structure includes morphine availability both nationally and interna- tionally, arrangements for procurement ofmorphine,proceduralmanuals,guide- lines, assessment tools, patient educa- tion, and educational materials for healthcare providers. The Donadebian process describes the practice of guidelines within the patient-physician relationship. The process includes actual pain treatment practice with assessment tools, dose adjustments, opioid switch, the addition of adjuvants, continuity of care, the use of patient education tools, provisions to improve patient knowl- edgeabouttreatments,andtheconsistent practice of established guidelines. The Donabedian outcomes are assessment of response, quality of life, and patient sat- isfaction with treatment. The failure of pain management in developing coun- tries occurs mainly within the structural component of the Donabedian model. In developed countries, failure most fre- quently occurs within process of care. International treaties began in 1912 with the Opium Convention, which was created to minimize opioid abuse and prevent the illegal trade of opioids. These treaties required governments to ensure the availability of opioids for medicinal purposes. The International Opium Conventions of 1925 set up a permanent Central Opium Board that monitored production and consumption of opioids internationally. Until then, most opioid abuse resulted from diver- sion of legitimate sources. 139American Journal of Hospice & Palliative Medicine Volume 21, Number 2, March/April 2004 at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
  4. 4. The Single Narcotic Convention in 1961 established an International Nar- cotic Central Board, which monitored importsandexportsofopium.Incooper- ation with national governments, the board monitored opioid traffic to detect diversion. This board was also estab- lished to prevent a shortage of opioids for legitimate purposes. In the United States, the Drug Enforcement Agency (DEA) was established to register importers, manufacturers, and practi- tioners who handled opioids. The focus of these international treaties has been to prevent abuse, but they have failed to promote the legitimate use of opioids. The illicit diversion from legitimate sources of opium has become rare as a result of these treaties.40,41 The unintended victim of the war against illicit drug use is the cancer patient. Increased regulation leads directly to underprescribing and reduced per capita consumption of morphine nationally and internationally, but does not alter illicit drug use. The increase in regulations suggests to the public that opioids are dangerous substances to be avoided, and it implies that addiction to opioids is common. The definitions of addiction at the federal level are not per- fect, but it is clear that cancer patients do not fit the definition. However, at the state level, the definition of addiction by the state medical boards frequently fails to separate psychological dependence (addiction) from analgesic tolerance and physical dependence.42 Morphine ad- dictionissometimesdefinedas“habitual use,” even though the pain management guidelines encourage most patients with chronic cancer pain to use morphine habitually.42 In addition to the confus- ing and misleading definitions of addic- tion, another factor affecting opioid use is the failure of most state medical boards to promote the appropriate use of opioids. Unlike federal authorities, state law does not necessarily assure opioid availability, and it can limit the amounts prescribed. Some states require prescriptions in triplicate, which can reduce appropriate morphine use by 50 percent.41-46 Problems of pain management in developing countries India uses the same amount of mor- phine as Denmark, even though Denmark has 900 million fewer peo- ple. India is a poor country and spends six percent of its gross national prod- uct on healthcare. Antibiotic acquisi- tion and vaccines are given high prior- ity, while pain management and palliative medicine are of secondary importance.47 Geographically, 75 per- cent of India’s population is rural and most pain centers are located in urban areas. Patients are required to travel fre- quently to urban pain centers to renew their pain medications. Since there are 24 different languages spoken in India and one-third of the males and two- thirds of the females are illiterate, prop- er pain assessment and pain diaries are difficult to complete.47 Latin American countries face a number of different problems. In Argentina, the education of physicians in the field of opioid pharmacology is below par and often sporadic.48 Commercial opioids are expensive and acquisition strains the limited budget of the average citizen. There is no overarching policy concerning pal- liative care, nor are there adequate insurance provisions for palliative medicine and long-term domiciliary care. In Columbia, the national supply of opioids is inadequate and the anti- quated law fails to recognize the benefits of opioids in cancer pain management.49 In addition, the duration of opioid pre- scriptions is limited. The war on drugs has significantly hampered opioid avail- ability. The average parenteral dose of morphine in South American coun- tries is approximately 9 mg/d com- pared with 44 mg/d in the US.48-50 Opioid phobia is common in China, particularly in areas affected by the heroin traffic ranging from Laos to Vietnam and into southern China. Morphine is believed to be more addicting than pethidine (meperidine). Methadone is used only for addiction therapy. Other barriers to appropriate opioid use include inadequate assess- ment, excessive regulations, inade- quate physician knowledge of pain assessment, and limited access to potent opioids.51 Problems of pain management in developed countries Israel, where opioids are readily available, also faces problems with pain management.52 Healthcare workers have inadequate knowledge of opioids and a reluctance to prescribe morphine due to the fear of addiction. Ninety percent of physicians inadequately assess pain, and training in pain management is also inadequate.52 Most physicians are not able to convert doses between various opioids, nor can they calculate the conversion of oral to parenteral equiv- alents. Twenty percent of nurses are reluctant to adequately medicate patients.52 Patients under-report pain and are reluctant to take pain medica- tions out of fear of tolerance and addiction. In Canada, 67 percent of physicians felt their education in pain manage- ment was fair to poor.53,54 Fifty per- cent of physicians do not use WHO step three opioids as initial therapy for severe cancer pain; and inadequately titrate opioids. Assessment of patients is also inadequate. Some patients are reluctanttoreportpainortotakeopioids. In Germany, even when an appro- priate opioid is prescribed, 20 percent of pharmacists counsel patients against taking them, and one-third of general community physicians dis- continue the medication once the patient returns to their care, because of their own prejudice—not because the therapy was ineffective.55 In the United States, opioids are read- ily available and pain management 140 American Journal of Hospice & Palliative Medicine Volume 21, Number 2, March/April 2004 at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
  5. 5. guidelines are well established. How- ever, among oncologists of the Eastern Cooperative Oncology Group, manage- ment of cancer pain was felt to be less than optimal in 80 percent of patients.56 Poor pain assessment occurs in 75 per- cent of patients. Sixty-five percent of physicians express concerns about side effects, and most admit to being poorly trained in pain management. Thirty per- cent of physicians prescribe opioids based on prognosis rather than pain severity.56 Fewer than half of patients within the hospital have recorded pain assessments.57 Some professionals be- lieve there is a ceiling to step three opi- oids. There is underuse of adjuvant coanalgesics and a general ignorance of equianalgesic dosing. Nearly 40 percent of nurses are reluctant to give an adequate dose of pain medications. Characteristically, physicians undertreat by dose and nurses undertreat by extending intervals be- tween doses. Only 42 to 51 percent of patients within a cancer center receive adequate analgesics. Thirty percent of those patients experiencing pain are not treated. Almost two-thirds of patients are reluctant to take pain medications out of fear of tolerance, addiction, or side effects. Curiously, there is poor correla- tion between physician knowledge of opioid pharmacology and a physician’s prescribinghabits.Acultureofpoorpain management tends to be self-propagat- ing, and accountability for poorly con- trolled pain was rarely reinforced until recently.Apatientislesslikelytoreceive adequate analgesia if elderly, female, a member of a minority group, or within a lower socioeconomic group.58,59 Summary Pain is one of the most commonly experienced and feared symptoms of advanced cancer. Most cancer patients experience pain, usually of moderate to severe intensity, and most also have a number of distinct types of pain. Thefailuretomanagepainproperlyis due to several factors. In developing countries, it is likely to be related to geography and limited resources. Legal restrictions also present barriers. In developed countries, it is usually related to a “disease” rather than a “symptom” model of care, which minimizes symp- tom management. Other factors include lackofphysicianeducationandfailureto follow existing guidelines.59,60 Patients fear addiction, drug tolerance, and side effects. Despite adequate resources, pain is still undertreated. The WHO recog- nizes the importance of pain manage- ment as part of routine cancer care. The establishment of effective pain management requires comprehensive assessment, competency with anal- gesics, and communication with patients and families.61 References 1. International Association for the Study of Pain: Classification of chronic pain. Pain Suppl. 1986; 3: 51-56. 2. Twycross RG: Pain Relief in Advanced Can- cer. Edinburgh: Churchill Livingstone, 1994. 3. Melzak R, Torgerson WS: On the language of pain. Anesthesiology. 1971; 34: 50-59. 4. Payne R, Gonzales C: Pathophysiology of pain in cancer and other terminal diseases. In Doyle D, Hanks G, MacDonald N (eds.): Ox- ford Textbook of Palliative Medicine. Oxford: Oxford University Press, 1993; 140-148. 5. Portenoy RK: Cancer pain: pathophysiol- ogy and syndromes. Lancet. 1992; 339(8800): 1026-1031. 6. Andersen G, Sjogren P: Epidemiology of cancer pain. Ugeskr Laeger. 1998; 160(18): 2681-2684. 7. Ciaramella A, Poli P: Assessment of depres- sion among cancer patients: the role of pain, cancer type and treatment. Psychooncology. 2001; 10(2): 156-165. 8. Meuser T, Pietruck C, Radbruch L, et al.: Symptoms during cancer pain treatment fol- lowing WHO-guidelines: a longitudinal fol- low-up study of symptom prevalence, sever- ity and etiology. Pain. 2001; 93(3): 247-257. 9. Stjernsward J, Teoh N: The scope of the can- cer pain problem. In Foley KM, Bonica JJ, VentafriddaV(eds.):ProceedingsoftheSecond International Congress on Cancer Pain. Vol. 16. New York: Raven Press, Ltd., 1990; 7-12. 10. Boffetta P, Parkin DM: Cancer in devel- oping countries. CA Cancer J Clin. 1994; 44(2): 81-90. 11. Cherner LL (ed.): The Universal Health- care Almanac. Phoenix: Silver and Cherner Ltd., 1998. 12. Cleeland CS, Gonin R, Hatfield AK, et al.: Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994; 330(9): 592-596. 13. Kutner JS, Kassner CT, Nowels DE: Symptom burden at the end of life: hospice providers’ perceptions. J Pain Symptom Manage. 2001; 21(6): 473-480. 14. Hinkka H, Kosunen E, Kellokumpu- Lehtinen P, et al.: Assessment of pain control in cancer patients during the last week of life: comparison of health centre wards and a hos- pice. Support Care Cancer. 2001; 9(6): 428-34. 15. Young HH: The care of cancer of the prostate by radical perineal prostatectomy (prostato-seminal vesiculectomy): history, literature, and statistics of Young’s opera- tion. J Urol. 1945; 53: 188-256. 16.BaconHE:CanceroftheColon,Rectumand Anal Canal. Philadelphia: Lippencott, 1964. 17. Brahmer J, Smith BD, Grossman SA: Pain in Patients Undergoing Induction Chemotherapy for Acute Myelogenous Leukemia. Meeting Proceedings of ASCO. 1999; 18: 5829 (Abstract #2246). 18. Grond S, Zech D, Diefenbach C, et al.: As- sessment of cancer pain: a prospective evalua- tion in 2266 cancer patients referred to a pain service. Pain. 1996; 64(1): 107-114. 19. Twycross RG, Fairfield S: Pain in far- advanced cancer. Pain. 1982; 14(3): 303-310. 20. Twycross R, Harcourt J, Bergl S: A survey of pain in patients with advanced cancer. J Pain Symptom Manage. 1996; 12(5): 273-282. 21. Chang VT, Hwang SS, Feuerman M, et al.: Symptom and quality of life survey of medical oncology patients at a veterans affairs medical center: a role for symptom assessment. Cancer. 2000; 88(5): 1175-1183. 22. Vainio A, Auvinen A: Prevalence of symptoms among patients with advanced cancer: an international collaborative study. Symptom Prevalence Group. J Pain Symptom Manage. 1996; 12(1): 3-10. 23.PeteetJ,TayV,CohenG,etal.:Paincharac- teristics and treatment in an outpatient cancer population. Cancer. 1986; 57(6): 1259-1265. 24. Banning A, Sjogren P, Henricksen H: Pain causes in 200 patients referred to a multidisci- plinary cancer pain clinic. Pain. 1991; 45(1): 45-48. 141American Journal of Hospice & Palliative Medicine Volume 21, Number 2, March/April 2004 at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from
  6. 6. 25. Grond J, Zech D, Diefenbach C, et al.: Prevalence and pattern of symptoms in patients with cancer pain: a prospective evaluation of 1635 cancer patients referred to a pain clinic. J Pain Symptom Manage. 1994; 9(6): 372-382. 26. Schuit KW, Sleijfer DT, Meijler WJ, et al.: Symptoms and functional status of pa- tients with disseminated cancer visiting out- patient departments. J Pain Symptom Man- age. 1998; 16(5): 290-297. 27. Collins JJ, Byrnes ME, Dunkel IJ, et al.: The measurement of symptoms in children with cancer. J Pain Symptom Manage. 2000; 19(5): 363-377. 28. Miser AW, Dothage JA, Wesley RA, et al.: The prevalence of pain in a pediatric and young adult cancer population. Pain. 1987; 29(1): 73-83. 29. Reddy SK, Ngyen P: Breakthrough pain in cancer patients: new therapeutic ap- proaches to an old challenge. Current Review of Pain. 2000; 4(3): 242-247. 30. Portenoy RK, Hagen NA: Breakthrough pain: Definition, prevalence and characteris- tics. Pain. 1990; 41(3): 273-281. 31. Fine PG, Busch MA: Characterization of breakthrough pain by hospice patients and their caregivers. J Pain Symptom Manage. 1998; 16(3): 179-183. 32. Mercadante S, Arcuri E: Breakthrough pain in cancer patients: pathophysiology and treatment. Cancer Treatment Reviews. 1998; 24(6): 425-432. 33. Bonica JJ: Cancer pain. In Bonica JJ (ed.): The Management of Pain, Second Edition, Philadelphia: Lea and Febiger, 1990. 34. von Roenn JH, Cleeland CS, Gonin R. et al.: Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology Group. Ann of Intern Med. 1993; 119(2): 121-126. 35. Ventafridda V, Tamburini M, Caraceni A, et al.: A validation study of the W.H.O. method for cancer pain relief. Cancer. 1987; 59(4): 850-856. 36. Grond S, Zech D. Schug SA, et al: Validation of the World Health Organization guidelines for cancer pain relief during the last days and hours of life. J Pain Symptom Manage. 1991; 6(7): 411-422. 37. Walker VA, Hoskin PJ, Hanks GW, et al.: Evaluation of WHO analgesic guidelines for cancer pain in a hospital-based palliative care unit. J Pain Symptom Manage. 1988; 3(3): 145- 149. 38. de Wit R, van Dam F, Vielvoye-Kerkmeer A,etal.:Thetreatmentofchroniccancerpainin a cancer hospital in the Netherlands. J Pain Symptom Manage. 1999; 17(5): 333-350. 39. Donabedian A: Institutional and profes- sional responsibilities in quality assurance. Qua Assur Health Care. 1989; 1(1): 3-11. 40. Angarola RT: National and international regulation of opioid drugs: purpose, struc- tures, benefits and risks. J Pain Symptom Manage. 1990; 5(1 Suppl): S6-11. 41. Joranson DE: Federal and state regula- tions of opioids. J Pain Symptom Manage. 1990; 5(1 Suppl.): S12-23. 42. Joranson DE, Cleeland CS, Weissman DE, et al.: Opioids for chronic cancer and non-cancer pain: a survey of state medical board members. Fed Bull J Med Licensure Discipline. 1992; 79: 15-49. 43. Zenz M, Willweber-Strumpt A: Opio- phobia and cancer pain in Europe. Lancet. 1993; 341(8852): 1075-1076. 44. Joranson DE, Gilson AM: Regulatory barriers to pain management. Semin Oncol Nurs. 1998; 14(2): 158-163. 45. Joranson DE: Availability of opioids for cancer pain: recent trends, assessment of sys- tem barriers, New World Health Organization guidelines, and the risk of diversion. J Pain Symptom Manage. 1993; 8(6): 353-360. 46. Joranson DE: Are health-care reimburse- ment policies a barrier to acute and cancer pain management? J Pain Symptom Man- age. 1994; 9(4): 244-253. 47. Koshy RC, Rhodes D, Devi S, et al.: Cancer pain management in developing countries: a mosaic of complex issues result- ing in inadequate analgesia. Supportive Care in Cancer. 1998; 6: 430-437. 48. Wenk R: Status of Palliative Care Initiatives. In Payne R, Patt, RB, Hill CS: Assessment and Treatment of Cancer Pain (Progress in Pain Research and Manage- ment) Vol. 12. Seattle: International As- sociation for the Study of Pain, 1998; 3-10. 49. DeLima L: The Impact of the Illegal Drug Market and Parallel Distribution Systems on the Availability of Opioids for Pain Relief in Colombia. In Payne R, Patt, RB, Hill CS: Assessment and Treatment of Cancer Pain (Progress in Pain Research and Management) Vol. 12. Seattle: International Association for the Study of Pain, 1998. 50. Bruera E, Navigante A, Barugel M, et al.: Treatment of pain and other symptoms in cancer patients: patterns in a North American and South American hospital. J Pain Symptom Manage. 1990; 5(2): 78-82. 51. Yu S, Wang XS, Cheng Y, et al.: Special aspects of cancer pain management in a Chinese general hospital. European J Pain. 2001; 5 Suppl A: 15-20. 52. Sapir R, Catane R, Strauss-Liviatan N, et al.: Cancer pain: knowledge and attitudes of physicians in Israel. J Pain and Symptom Manage. 1999; 17(4): 266-276. 53. MacDonald N, Findlay HP, Bruera E: A Canadian survey of issues in cancer pain management. J Pain Symptom Manage. 1997; 14(6): 332-342. 54. MacDonald N, Ayoub J, Farley J, et al.: A Quebec survey of issues in cancer pain management. J Pain Symptom Manage. 2002; 23(1): 39-47. 55. Donner B, Raber M, Zenz M, et al.; Experiences with the prescription of opioids: a patient questionnaire. J Pain Symptom Manage. 1998; 15(4): 231-235. 56. Von Roenn JH, Cleeland CS, Gronin R, et al.: Physician attitudes and practice in can- cer pain management: A survey from the Eastern Cooperative Oncology Group. Ann Intern Med. 1993; 119(2): 121-126. 57. McMillan SC, Tittle M, Hagan S, et al.: Management of pain and pain-related symp- toms in hospitalized veterans with cancer. Cancer Nursing. 2000; 23(5): 327-336. 58. Bernabei R, Gambassi G, Lapane K, et al.: Management of pain in elderly patients with cancer. JAMA. 1998; 279(23): 1877-1882. 59. Anderson KO, Mendoza TR, Valero V: Minority cancer patients and their providers: pain management attitudes and practice. Cancer. 2000; 88(8): 1929-1938. 60. Payne R: Chronic pain: challenges in the assessment and management of cancer pain. J Pain Symptom Manage. 2000; 19(1 Suppl): S12-S5. 61. Lesage P, Portenoy RK: Trends in cancer pain management. Cancer Control. 1999; 6(2): 136-145. 142 American Journal of Hospice & Palliative Medicine Volume 21, Number 2, March/April 2004 at Universidad Nacional Aut Mexic on February 7, 2016ajh.sagepub.comDownloaded from

×