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Minority cancer patients at risk for undertreatment

Wednesday April 18, 2012
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More than one third of patients with invasive cancer are undertreated for their pain, with minorities twice as likely to not receive analgesics, according to a study.

The researchers said the study was the largest prospective evaluation of cancer pain and related symptoms ever conducted in an outpatient setting.

"We’ve known for years that the undertreatment of pain is a significant public health problem in the cancer treatment process, and that minorities are at greatest risk for not receiving appropriate care," study author Charles Cleeland, PhD, professor and chairman of the Department of Symptom Research at the University of Texas MD Anderson Cancer Center, said in a news release.

"This new research tells us that our progress has been limited, with only a 10% overall reduction in inadequacy of pain management from our findings almost two decades ago.

The study, by researchers with MD Anderson and other institutions, enrolled patients with invasive breast, prostate, colon and lung cancers from 38 institutions across the country, at any point during their care. All were treated on an outpatient basis at either an academic medical center or community clinic. The researchers said they focused on the outpatient setting because while those hospitalized with significant pain may be evaluated by pain specialists, those treated on an outpatient basis are typically managed by their treating oncologists.

Patients completed a questionnaire providing their demographic and clinical information. Using a symptom assessment tool developed by Cleeland, the patients’ pain levels were evaluated, as was the level of analgesic that had been prescribed, if any. Assessment was repeated approximately one month later. The study’s primary objective was to assess the prevalence of pain medication in oncology outpatient practice.

The researchers indentified 3,023 patients at risk for pain, with 2,026 (67%), taking analgesics. Approximately a quarter of those analyzed were minority patients, including Hispanic (9%), black (12%), Asian (1%) and other (1%). Of the 2,026 patients at risk for pain, 1,356, or 67%, had adequate pain management.

But 20% of the patients who reported feeling severe pain were not receiving any analgesics, and of the 406 patients who were undertreated at an initial assessment, only 31% received appropriate treatment by the follow-up visit. The researchers found the odds of a non-Hispanic white patient having inadequate treatment for pain at both initial and follow-up assessments was about half that of a minority patient.

"Pain is one of the most feared symptoms of cancer, and it has tremendous impact on the quality of life and function of our patients," Michael Fisch, MD, associate professor and chairman of the Department of General Oncology at MD Anderson, and the study’s lead author, said in the news release. "These findings represent a significant discrepancy in treatment adequacy, with minority patients being twice as likely to be undertreated. This critical observation awakens us to a major opportunity in healthcare — to work hard to resolve this striking disparity."

The researchers cited a number of possible reasons for the discrepancy they found, including cultural and communication barriers, access to care, concerns about addiction and reluctance to admit pain, and access to effective patient education.

Implicit stereotyping and bias among healthcare providers, even in the absence of the providers’ awareness or intention, may also be a factor, Fisch said. However, Cleeland noted that at underserved clinics, both whites and minorities were inadequately treated for their pain, suggesting an overall lack of resources.

Study limitations included the small number of disease types examined, as well as an absence of data on patients’ comorbidites and socio-economic status.

Fisch and Cleeland agree that better symptom control must begin with open-minded physicians, appropriately gauging the needs of their patients, as well as more engaged patients and caregivers willing to communicate their pain levels and other symptoms. The researchers plan to follow up these findings by looking at additional symptoms of patients as well as their emotional distress and fatigue.

The study appeared April 16 on the website of the Journal of Clinical Oncology. To view the data and access the study via subscription or purchase, visit http://bit.ly/HDacUJ.


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