Survey shows potential gaps in oncologists' pain management practices

Oncologists may not always adequately treat pain in cancer patients, according to a recent survey.

Researchers at Beth Israel Medical Center in New York mailed an anonymous survey to 2,000 oncologists randomly chosen from the American Medical Association's 2009 Physician Master File. The intent of the survey was to determine oncologists' attitudes, knowledge and practices related to managing cancer pain. The survey was mailed four times, sequentially, with intervals of 1.5 to 2.5 months between mailings. A shortened version of the survey questionnaire was used for the third and fourth mailings to try to improve response rates.

The questionnaire asked physicians to provide information on age, sex, years in practice, state in which their practice was located, and quality of training. Numeric rating scales from 0 to 10 were used to determine physicians' attitudes and practices for pain management, while other questions assessed referral to pain or palliative medicine specialists and CME hours related to pain. The survey also included two clinical vignettes about challenging pain management situations. The first involved decision making about increasing opioid dosage when a relatively high dose was not controlling pain, and the second addressed decision making about dose titration and/or addition of a drug for breakthrough pain in a similar situation. The results of the survey were published online Nov. 15 by the Journal of Clinical Oncology.

Three hundred fifty-four oncologists responded to the initial questionnaire and 256 responded to one of the shortened versions, for an overall response rate of 32%. The median age was 56 years, and 20% of respondents were women. Respondents rated their specialty's ability to manage cancer pain relatively highly (median score, 7; interquartile range, 6 to 8) but rated their peers as more conservative than themselves in prescribing pain management (median score, 3; interquartile range, 2 to 5). Low ratings were given to quality of pain management training during medical school and residency (median scores, 3 and 5; interquartile ranges, 5 to 7 and 3 to 7, respectively). Responders' scores indicated that poor assessment (median score, 6; interquartile range, 4 to 7) and reluctance of patients to take opioids (median score, 6; interquartile range, 3 to 7) were the most important barriers to effective pain management. Physician reluctance to prescribe opioids (median score, 5; interquartile range, 3 to 7) and a perception of excessive regulation (median score, 4; interquartile range, 2 to 7) were also considered barriers. Sixty percent of oncologists responding to the first clinical vignette and 87% of those responding to the second chose treatments that pain specialists would have considered unacceptable. Only 14% and 16% of respondents reported referring patients frequently to pain and palliative care specialists.

The authors noted that their study had a relatively low response rate, which may limit the generalizability of their results, and that their survey could not address all of the factors that may relate to oncologists' pain management practices. However, they concluded that their results indicate limitations in oncologists' approaches to managing pain in cancer patients and that these limitations may be affecting care. “The longstanding acceptance for pain management as a best practice in oncology provides a foundation for renewed efforts to educate in this area,” the authors wrote. They called for measures including quality improvement activities, increased screening, and electronic reminders to help improve practice.