Current Pain and Headache Reports

, Volume 15, Issue 4, pp 231–234

Epidemiology of Cancer Pain

Authors

    • Department of Anesthesiology & Critical Care MedicineUniversity of Pittsburgh School of Medicine
Invited Commentary

DOI: 10.1007/s11916-011-0208-0

Cite this article as:
Marcus, D.A. Curr Pain Headache Rep (2011) 15: 231. doi:10.1007/s11916-011-0208-0

Abstract

About half of cancer patients experience pain, most commonly due to their primary cancer. Pain severity is at least moderate for most patients experiencing cancer-related pain. Pain may also persist in long-term cancer survivors. Cancer-related pain adds to mood disturbance and disability in cancer patients. Despite the frequent occurrence and substantial impact from cancer pain, both patient and provider barriers limit the identification and treatment of pain in cancer patients.

Keywords

BarrierMeta-analysisPrevalenceSurvivorsCancer painEpidemiology of cancer pain

Introduction

According to data from the World Health Organization, cancer is the leading cause of death worldwide, accounting for about 13% of all deaths [1]. The National Cancer Institute estimates that over 1.5 million people were diagnosed with cancer in 2010 [2]. They further estimated that 41% of people would be diagnosed with cancer at some point during their lives.

Pain may occur in cancer patients due to the cancer itself, cancer treatment, or from noncancer health conditions. A survey of 100 cancer patients with pain reported that pain was most commonly caused directly from the cancer itself (Fig. 1) [3]. In this study, pain was most frequently reported as occurring in the chest, abdomen, and extremities (20% for each location). Usual pain intensity was moderate to severe for 73% of patients. Pain occurred intermittently for 53% of patients and continuously for 47%.
https://static-content.springer.com/image/art%3A10.1007%2Fs11916-011-0208-0/MediaObjects/11916_2011_208_Fig1_HTML.gif
Fig. 1

Cause of pain in cancer patients (Data from Gutsgell et al. [3])

Prevalence of Cancer Pain

Pain is a presenting symptom in 20% to 50% of patients with cancer [4]. A meta-analysis of 52 studies calculated pooled prevalence rates of cancer pain, with over half of cancer patients experiencing a pain complaint (Fig. 2) [5]. Pain prevalence was highest among patients with head/neck cancer, although pain was reported by over half of patients with all cancer types (Table 1).
https://static-content.springer.com/image/art%3A10.1007%2Fs11916-011-0208-0/MediaObjects/11916_2011_208_Fig2_HTML.gif
Fig. 2

Prevalence of cancer pain (Data from van den Beuken-van Everdingen et al. [6])

Table 1

Pooled cancer pain prevalence by cancer type

Cancer location

Average pain prevalence,%

Head/neck

70

Gynecological

60

Gastrointestinal

59

Lung/bronchus

55

Breast

54

Urogenital

52

(Data from van den Beuken-van Everdingen et al. [6])

Pain is seen in at least half of patients actively involved in cancer treatment. A survey of 179 cancer patients seen at the Cleveland Clinic identified cancer pain in 65% of patients [6]. Interestingly, patients younger than 65 years were significantly more likely to experience pain compared with older patients. A longitudinal study likewise showed more pain flares in younger patients with cancer pain [7]. The Indiana Cancer Pain and Depression study surveyed community-based oncology patients, with 49% of screened patients identified as having pain and/or depression symptoms [8]. Pain occurred in two of three enrolled patients. Pain was considered to be cancer-related for 67% of patients reporting pain. Among these, the most common pain location was the back (32%), followed by the abdomen (16%), shoulders (13%), and hips (11%). Most patients (56%) rated their average pain severity as moderate (4–6 on a 0- to 10-point pain severity scale); however, worst pain was rated ≥6 for 77% of patients. Not unexpectedly, pain was significantly associated with worse quality of life and overall disability. A survey of 312 Chinese American oncology patients likewise identified frequent or persistent pain in 52% of patients [9].

Pain is also a frequent chronic sequela in long-term cancer survivors [10]. A recent literature review reported the following statistics for pain among patients who had successfully completed cancer treatment:
  • Pain and functional limitations related to breast cancer treatment were reported for 26% to 47% during the first 6 months after treatment, with pain or functional limitations in 20% to 23% at 6 to 12 months after treatment, in 21% to 41% at 1 to 2 years after treatment, and in 19% to 41% at 2 to 5 years after treatment;

  • Pain/functional limitations were reported from 54% of prostate cancer survivors up to 5 years after treatment;

  • Pain was present in 27% of colorectal cancer survivors more than 5 years after their diagnosis. Pain was attributed to cancer by 12% of colorectal cancer survivors;

  • Among patients with gynecological cancer, one study showed pain decreased slightly 6 months after treatment and then remained stable up to 24 months after treatment.

These data highlight the fairly common occurrence of persistent pain in cancer patients, even among those patients who are considered cured from their cancer.

Impact of Cancer Pain

Cancer pain has been linked to increased emotional distress, with this distress reduced with cancer pain treatment [11]. Longer pain duration and greater pain severity are correlated with increased risk for depression [12]. Furthermore, among cancer patients with pain in the Indiana Cancer Pain and Depression study, patients with pain were disabled an average of 12 to 20 days over the preceding 4 weeks, with 28% to 55% reporting being unable to work due to health-related reasons [8].

Pain in long-term survivors may be particularly difficult for patients who may not have anticipated needing to deal with chronic pain after they no longer were actively involved with cancer care [13]. For some patients, losing the support provided by health care providers during cancer treatment when they are still dealing with pain complaints leads to worsened quality of life. Pain also may result in concerns about disease recurrence, as well as impairments in sleep and mood. Pain has further been shown to contribute to long-term disability in cancer survivors.

Barriers to Cancer Pain Management

Although pain is common in cancer patients, both patient and practitioner factors contribute to poor cancer pain assessment and management (Table 2) [14]. Two out of three doctors feel insufficiently prepared to manage cancer pain [15]. About three out of four oncologists and palliative care doctors likewise feel they inadequately assess pain and pain response in their patients [16]. Furthermore, half of doctors are concerned about legal issues related to prescribing opioids for patients with cancer pain, and three out of four doctors believe opioid use for cancer pain is associated with high rates of addiction and abuse [15].
Table 2

Barriers to cancer pain management

Patient factors

Provider factors

• Reluctance to report pain

• Poor communication about pain experience

• Poor treatment adherence

• Preference for weaker analgesics

• Cognitive issues and affective distress may limit reporting

• Failure to assess pain or use pain-measuring instruments routinely

• Fear of addiction or developing tolerance

• Inadequate knowledge about pain management and opioid dosing

• Fear of side effects

• Excessive concerns about opioid side effects, respiratory depression, and addiction

• Effort to be a “good patient” by tolerating pain

 

• Belief that doctor should focus on cancer cure rather than pain relief

 

• Concerns about negative views of family, friends, coworkers if patient uses pain medications

 

(Data from Jacobsen et al. [14])

Ethnic Differences in Cancer Pain Treatment

A survey of 75 cancer patients found several similar barriers to effective pain management across ethnic groups [17]. All groups reported problems communicating with their health care providers about their cancer pain. All ethnic groups likewise believed that cancer pain was taken more seriously when reported by male patients. While whites typically requested Western medicine options for pain, nonwhites tended to seek “natural remedies” that minimized interference with their normal routine.

Asian cancer patients may need additional queries about pain issues. In the survey described above, Asians in particular believed that cancer pain was a universal human experience that should not be emphasized [17]. In addition, a literature review concluded that perceived barriers to cancer pain management are significantly higher among Asian patients compared with Western patients [18]. In particular, concerns about disease progression, tolerance, and fatalism were stronger barriers among Asian cancer patients. A study of Chinese Americans likewise showed additional barriers in this population [19].

Conclusions

About half of cancer patients experience pain, which is usually due to their primary cancer and moderately severe. Long-term cancer survivors frequently continue to experience pain, for which they often have been unprepared. Despite the frequent occurrence of substantial and often disabling pain, both patient and provider barriers contribute to failure to identify and adequately treat cancer-related pain. Pain assessment should be considered a routine part of cancer management, with pain severity asked at each patient assessment and visit. Health care providers need to 1) proactively ask about possible pain symptoms, even when not voluntarily offered by patients; 2) let patients know that pain management is an important part of treatment; and, 3) reassure patients that pain does not necessarily suggest that cancer has become terminal or incurable.

Disclosure

No potential conflicts of interest relevant to this article were reported.

Copyright information

© Springer Science+Business Media, LLC 2011