Epidemiology of Cancer Pain
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- Marcus, D.A. Curr Pain Headache Rep (2011) 15: 231. doi:10.1007/s11916-011-0208-0
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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.
KeywordsBarrierMeta-analysisPrevalenceSurvivorsCancer painEpidemiology of cancer pain
According to data from the World Health Organization, cancer is the leading cause of death worldwide, accounting for about 13% of all deaths . The National Cancer Institute estimates that over 1.5 million people were diagnosed with cancer in 2010 . They further estimated that 41% of people would be diagnosed with cancer at some point during their lives.
Prevalence of Cancer Pain
Pooled cancer pain prevalence by cancer type
Average pain prevalence,%
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 . 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 . 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 . 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 .
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.
Impact of Cancer Pain
Cancer pain has been linked to increased emotional distress, with this distress reduced with cancer pain treatment . Longer pain duration and greater pain severity are correlated with increased risk for depression . 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 .
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 . 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
Barriers to cancer pain management
• 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
Ethnic Differences in Cancer Pain Treatment
A survey of 75 cancer patients found several similar barriers to effective pain management across ethnic groups . 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 . In addition, a literature review concluded that perceived barriers to cancer pain management are significantly higher among Asian patients compared with Western patients . 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 .
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.
No potential conflicts of interest relevant to this article were reported.