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 Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 7-10

The prevalence of undertreatment of cancer pain in a Nigerian teaching hospital


1 Department of Surgery, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria
2 Department of Surgery, University Health Services, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication22-Sep-2012

Correspondence Address:
Jerry G Makama
Department of Surgery, Ahmadu Bello University Teaching Hospital, Shika Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


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  Abstract 

Background: Pain is a major problem for patients with cancer and it is often perceived and regarded as inevitable. Cancer pain is treatable, however. Its undertreatment has been a major problem and this is well documented. The aim of this study is to determine the prevalence of undertreatment of cancer pain in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.
Materials and Methods: This was a cross-sectional study involving adult cancer patients, who were hospitalized in surgical wards of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria in the month of June 2009. The outcome of treatment and the position of the patient's clinical pain status were weighted using the pain management scale. Data obtained was analyzed using SPSS 11.5 version.
Results: A total of 67 cancer patients were admitted in both male and female surgical wards. There were 27 (40.3%) males and 40 (59.7%) females. The age range was 17-75 years with a mean of 44.9 years. The study showed 33 (49.3%) patients had negative scores, 4 (6.0%) had positive scores, while 30 (44.8%) had zero score using the pain management scale score. Therefore, the prevalence of undertreatment, which is equivalent to the patients with negative score, in our center was 49.3%.
Conclusion: The prevalence of undertreatment of cancer pain is high in our environment and several factors may be responsible for this high rate. There is the need for training of medical personnel and all health professionals on cancer pain management.

Keywords: Cancer pain, prevalence of cancer pain, treatment of cancer pain


How to cite this article:
Makama JG, Khalid L, Stephen GE, Joshua IA. The prevalence of undertreatment of cancer pain in a Nigerian teaching hospital. Arch Int Surg 2012;2:7-10

How to cite this URL:
Makama JG, Khalid L, Stephen GE, Joshua IA. The prevalence of undertreatment of cancer pain in a Nigerian teaching hospital. Arch Int Surg [serial online] 2012 [cited 2021 May 12];2:7-10. Available from: https://www.archintsurg.org/text.asp?2012/2/1/7/101253


  Introduction Top


Pain is a major health care problem of patients with cancer. [1],[2] It is often regarded in most instances as an inevitable manifestation of cancer. Cancer pain is treatable, [3] but success requires a holistic approach and adequate knowledge of the pathophysiology of the pain and the pharmacology of the pain relieving drugs. [3],[4]

Drug treatment is the mainstay of pain management. [5] However, despite the availability of many guidelines for cancer pain management, undertreatment has been a major problem and is well documented in many reports. [1],[4],[6] Undertreatment is often conceptualized in terms of barriers related to the health care provider, the patient, the family, the institution, and society. [7] The aim of this study, therefore, is to determine the point prevalence of undertreatment of cancer pain in our environment.


  Materials and Methods Top


This was a cross-sectional study involving adult cancer patients who were hospitalized in surgical wards of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, in the month of June 2009. The study, which was the first of its kind in this institution, was approved by the Ethical Review Committee of the hospital. The patients completed a structured questionnaire after giving a verbal consent regarding the presence or otherwise of pain, its degree of severity, the treatment protocol, and the quality of treatment the patient was currently on. The assessment of pain, using either visual or linear analogue, was done once on the third day of admission of each participant. The treatment protocol vis-à-vis the reported degree of pain in each patient was cross-checked. The treatment protocol was as follows: (1) no pain, no treatment was instituted; (2) mild pain, oral nonsteroidal anti-inflammatory drugs (NSAIDs) were instituted; moderate pain, weak parenteral opioids were instituted; while severe pain, strong parenteral opioids were instituted. The outcome and the position of the patient's clinical pain status were weighted using the pain management scale score (PMSS) [Table 1]. The proportions of patients with negative scores were considered to be undertreated; those with zero scores were considered to have received appropriate treatment while those with positive scores were considered to be overtreated. The data obtained were analyzed using SPSS (version 11.5).
Table 1: Pain management scale score

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  Results Top


A total of 67 cancer patients admitted in both male and female surgical wards were studied. Twenty-seven (40.3%) were males and 40 (59.7%) were females. The age range was 17-75 years (44.9 mean). As at the time of assessment, 58 (86.6%) of the patients had pain while 9 (13.4%) were pain free following treatment.

The number of patients in each degree of pain and the proportion that was receiving appropriate treatment showed that most of those with severe pain were receiving inappropriate treatment. This is shown in [Table 2] and [Figure 1].
Figure 1: Patients in each degree of pain and the proportion that is receiving appropriate treatment

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Table 2: Patients in each degree of pain and the proportion that is receiving appropriate treatment

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The intensity of pain versus treatment protocol showed that majority of patients with severe pain were still receiving NSAIDs [Figure 2].
Figure 2: The intensity of pain versus treatment protocol

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The outcome and the position of the patients' clinical pain status were weighted using the PMSS and the results [Table 1] showed 33 (49.3%) patients had negative scores, 4 (6.0%) had positive scores, while 30 (44.8%) had zero score.

The Undertreatment Index (UTI) [Table 3] was determined as follows:
Proportion of undertreatment (UT) divided by proportion of undertreatment (UT) plus appropriate treatment (AT) time hundred. (UT/UT+AT x 100) 33/33+ 30 x 100 = 52.4
Table 3: Pain management scale score of 67 cancer patients

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This was greater than 50, indicating that a significant number of patients were undertreated in our center.


  Discussion Top


The number of cancer patients has rapidly increased in recent times [2],[3] and pain has been noted to be one of the most frequent and disturbing symptoms of these patients. [2],[3],[4] It has been reported that more than two-thirds of cancer patients experience pain during the course of their illness. [8] Despite the widespread acceptance of highly effective therapeutic strategy for the management of cancer pain, previous reports [1],[4] indicate that 40-50% of patients in routine practice settings fail to achieve adequate relief. Several factors have been considered to be responsible for this undertreatment of cancer pain. [1],[4],[7] In this report, 49.8% of the cancer patients had undertreatment of their pain, which is in agreement with previous reports.

Until recently, there were no formal guidelines for the education of cancer specialists in the management of cancer pain. Improved outcome can only be achieved if the problem is recognized and education of clinicians in well-established techniques of pain assessment and management becomes common place.

The evaluation of pain intensity is pivotal to therapeutic decision- making. [9],[10] It indicates the urgency with which pain relief is needed and influences the selection of analgesic drugs and route of administration. In our report, majority of our patients had severe pain and a reasonable number (56%) were on NSAIDs and weak opioids.

Patients with cancer pain commonly experience it at more than one site, particularly those with advanced tumor where there is distant metastasis. [8] Although PMSS may not be used for prescribing drugs for an individual, it provides a rough estimate of how pain is treated in the population. Therefore, regular use of this scale to assess the rate of undertreatment, appropriate treatment, and overtreatment in the population where an individual practices should be advocated.

The basic therapeutic strategy of managing cancer pain has been the three-step analgesic ladder designed by the World Health Organization (WHO). [3],[11] A correct use of the WHO ladder of analgesia on cancer pain has been successful in over 90% of cases. [5],[11] However, this approach has recently been criticized because it advocates a therapeutic intervention based mainly on pain intensity, independently of other physiopathological mechanism of pain.

A number of other studies have reported inadequate pain control in 40-70% of cancer patients. [1],[4],[5] This has led to a critical review of cancer pain management resulting in the recent emergence of a new concept of "fail pain control" caused by a number of obstacles.

Barriers to the correct treatment of cancer patients have been identified in the recent years. [12] These barriers have been classified into three: system, professional, and patient barriers. In the system barrier, low priority is given to cancer pain management due to legal and regulatory obstacles to the use of opioids. [7],[12] This is compounded by the present inadequate palliative care programs, the high cost of opioids, geographic dispersion, and "opioids phobia." [7],[12] It has been reported [12] that the clinician's barrier to correct cancer pain management consists of lack of physician education and failure to follow existing guidelines, poor assessment of pain, and lack of proactive questioning about pain. Other clinician's barriers include poor knowledge of the pharmacology of opioids, failure to use adjuvants, concern about and failure to treat opioids' side effects. The patient's barriers have also been identified to be related to reluctance in taking pain medications, reluctance to report pain, and the fear of not being considered a good patient. [7] There is a notion that health professionals should not be distracted from dealing with the main problem, that is the tumor, and that pain is innately related to the cancer and as such cannot be eliminated is a major problem in the management of these patients. The limitation of this study was that comparison of the prevalence of pain between pre- and postoperative cancer patients was not feasible because it was point prevalence and the assessment was done once on the third day of admission. This consideration is absolutely important in a follow-up study.

In conclusion, there is significant undertreatment of cancer pain in our center. Cancer patients require adequate pain control at every stage of their disease and throughout the course of their treatment. [13],[14] Efforts to reduce the high prevalence of undertreatment of cancer pain in various centers may have to be emphasized and further training for medical practitioners and all health professionals on cancer pain management may be required.

 
  References Top

1.Deandrea S, Montanari M, Moja L, Apolone G. The Prevalence of undertreatment in cancer pain: A review of published literature. Ann Oncol 2008;19:1985-91.  Back to cited text no. 1
    
2.Cleeland C. Research in cancer pain: what we know and what we need to know. Cancer 1991;67(Suppl):823-7.  Back to cited text no. 2
    
3.Van den Beuken-van Everdigen MH, de Rike JM, Kessels AG et al. Prevalence of pain in patients with cancer: A systemic review of the past 40 years. Ann Oncol 2007;18:1437-49.  Back to cited text no. 3
    
4.World Health Organization. Cancer pain relief. 2 nd ed. Geneva: World Health Organization; 1994.  Back to cited text no. 4
    
5.Breibart W, Rosenfield BD, Passik SD. The undertreatment of pain in ambulatory AIDS patients. Pain 1996;65:243-9.  Back to cited text no. 5
    
6.Zenz M, Zenz T, Tryba M. Severe undertreatment of cancer pain: A 3-year survey of the German situation. J Pain Symptom Manage 1995;10:187-91.  Back to cited text no. 6
    
7.Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management. stepping up the quality of its evaluation. JAMA 1995;247:1870-3.  Back to cited text no. 7
    
8.Ward SE, Goldberg N, Miller McCauley V et al. Patient's related barriers to management of cancer pain: A cross institutional investigation. Pain 1987;(Suppl):S136.  Back to cited text no. 8
    
9.Cascinu S, Giordani P, Agostinelli R, et al. Pain and its treatment in hospitalized patients with metastatic cancer. Support Care Cancer 2003;11:587-92.  Back to cited text no. 9
[PUBMED]    
10.Okuyama T, Wang XS, Akechi T, et al. Adequacy of cancer pain management in a Japanese cancer hospital. Jpn J Clin Oncol 2004;34:37-42.  Back to cited text no. 10
[PUBMED]    
11.Jensen MP. The validity and reliability of pain measures in adults with cancer. J Pain 2003;4:2-21.  Back to cited text no. 11
[PUBMED]    
12.Rowbotham MC. What is a "clinically meaningful" reduction in pain? Pain 2001;94:131-2.  Back to cited text no. 12
[PUBMED]    
13.Davis MP, Walsh D. Epidemiology of cancer pain and factors influencing poor pain control. Am J Hosp Palliat Care 2004;21:137-42.  Back to cited text no. 13
[PUBMED]    
14.Shwartzman P Friger M, Shami A, et al. Pain control in ambulatory cancer patients- can we do better? J Pain Symptom Manage 2003;26:716-22.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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