Rosalind Adam

Educational interventions for cancer pain. A systematic review of systematic reviews with nested narrative review of randomized controlled trials

OBJECTIVES Educational interventions are one approach to improving cancer pain management. This review aims to determine whether educational interventions can improve cancer pain management and to characterize components of cancer pain educational interventions. METHODS Medline, EMBASE, CINAHL, and Cochrane databases were searched. Systematic reviews that assessed educational interventions to improve cancer pain management were included. Randomized controlled trials (RCTs) were identified from each review. A narrative approach was taken to summarizing the nature and components of interventions. RESULTS Eight systematic reviews and 34 randomized controlled trials (RCTs) were reviewed. Interventions targeting patients can achieve small to moderate reductions in pain intensity. Interventions targeting professionals can improve their knowledge but most trials have not assessed for resultant patient benefits. All interventions included at least one of seven core components: improving knowledge about the nature of cancer pain; aiding communication about cancer pain; enhancing pain assessment; improving analgesic prescribing; tackling barriers to analgesic non-adherence; teaching non-pharmacological pain management strategies; and promoting re-assessment. CONCLUSIONS Cancer pain educational interventions can improve pain outcomes. They are complex heterogeneous interventions which often contain a combination of active components. PRACTICE IMPLICATIONS Suggestions are made to aid the development of future interventions.

Use of a structured palliative care summary in patients with established cancer is associated with reduced hospital admissions by out-of-hours general practitioners in Grampian

Objectives Palliative care summaries are used by general practices to provide structured anticipatory care information to those providing care during the out-of-hours period. We hypothesised that the availability of a palliative care summary for individuals with established cancer would influence emergency hospital admission during the out-of-hours period. Methods Each consultation with Grampian Medical Emergency Department (GMED) is recorded on the ADASTRA software system and the nature of the consultation is Read coded. We retrospectively reviewed consultations between 1 January 2011 and 31 December 2011 which had been coded as ‘neoplasm’ or ‘terminal care’. The availability of a palliative care summary on ADASTRA and admission status were recorded. χ2 Test of association was performed. Binary logistic regression was used for multivariate analysis exploring the effect of a palliative care summary on admission, while adjusting for important confounders. Results 401 patients with established cancer were identified who had presented to GMED in 2011. 35.7% had a palliative care summary available on ADASTRA. Of the 401 contacts, 100 patients were admitted to hospital. Not having a palliative care summary made admission significantly more likely; χ2=12.480, p=0.001. (OR 2.425, 95% CI 1.412 to 4.165). Conclusions Availability of a structured palliative care plan can aid decision making in the out-of-hours period and prevent unplanned hospital admissions.

Does emergency presentation of cancer represent poor performance in primary care? Insights from a novel analysis of linked primary and secondary care data

Background:People diagnosed with cancer following emergency presentation have poorer short-term survival. To what extent this signifies a missed opportunity for earlier diagnosis in primary care remains unclear as little detailed data exist on the patient/general practitioner interaction beforehand.Methods:Analysis of primary care and regional data for 1802 cancer patients from Northeast Scotland. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) for patient and GP practice predictors of emergency presentation. Qualitative context coding of primary care interaction before emergency presentation.Results:Emergency presentations equalled 20% (n=365). Twenty-eight per cent had no relevant prior GP contact. Of those with prior GP contact 30% were admitted while waiting to be seen in secondary care, and 19% were missed opportunities for earlier diagnosis. Associated predictors: no prior GP contact (OR=3.89; CI 95% 2.14–7.09); having lung (OR=23.24; 95% CI 7.92–68.21), colorectal (OR=18.49; CI 95% 6.60–51.82) and upper GI cancer (OR=18.97; CI 95% 6.08–59.23); ethnicity (OR=2.78; CI 95% 1.27–6.06).Conclusions:Our novel approach has revealed that emergency cancer presentation is more complex than previously thought. Patient delay, prolonged referral pathways and missed opportunities by GPs all contribute, but emergency presentation can also represent effective care. Resources should be used proportionately to raise public and GP awareness and improve post-referral pathways.

Utilising out-of-hours primary care for assistance with cancer pain: a semi-structured interview study of patient and caregiver experiences.

BACKGROUND Pain is the most frequent complication of cancer and an important reason for out-of-hours (OOH) primary care contacts by patients with established cancer. Existing quantitative data give little insight into the reason for these contacts. Exploring such encounters of care could highlight ways to improve anticipatory cancer care and communication between daytime and OOH primary care services. AIM To explore the experiences, views, and opinions of patients and their caregivers who have used OOH primary care for help with managing cancer pain. DESIGN AND SETTING A semi-structured interview study with patients and caregivers who have utilised an OOH primary care service in Grampian, Scotland, because of pain related to cancer. METHOD Semi-structured interviews with 11 patients and four caregivers (n = 15), transcribed verbatim and analysed using framework analysis and, to a lesser extent, inductive thematic analysis. RESULTS Six key themes emerged: making sense of pain and predicting its likely course; beliefs about analgesics; priority daytime access; the importance of continuity of care and communication between all involved; barriers and facilitators to seeking help in the OOH period; and satisfaction/dissatisfaction with OOH care. Three prominent sub-themes were: patient knowledge; the influence of a caregiver on decision-making; and the benefits of having a palliative care summary. CONCLUSION Effective daytime and anticipatory care can positively influence OOH care. Interventions that aid patients in understanding cancer pain, communicating about pain, utilising analgesics effectively, and seeking appropriate and timely help may improve cancer pain management.

Can patient-reported measurements of pain be used to improve cancer pain management? A systematic review and meta-analysis

Purpose Cancer pain is a distressing and complex experience. It is feasible that the systematic collection and feedback of patient-reported outcome measurements (PROMs) relating to pain could enhance cancer pain management. We aimed to conduct a systematic review of interventions in which patient-reported pain data were collected and fed back to patients and/or professionals in order to improve cancer pain control. Methods MEDLINE, EMBASE and CINAHL databases were searched for randomised and non-randomised controlled trials in which patient-reported data were collected and fed back with the intention of improving pain management by adult patients or professionals. We conducted a narrative synthesis. We also conducted a meta-analysis of studies reporting pain intensity. Results 29 reports from 22 trials of 20 interventions were included. PROM measures were used to alert physicians to poorly controlled pain, to target pain education and to link treatment to management algorithms. Few interventions were underpinned by explicit behavioural theories. Interventions were inconsistently applied or infrequently led to changes in treatment. Narrative synthesis suggested that feedback of PROM data tended to increase discussions between patients and professionals about pain and/or symptoms overall. Meta-analysis of 12 studies showed a reduction in average pain intensity in intervention group participants compared with controls (mean difference=−0.59 (95% CI −0.87 to −0.30)). Conclusions Interventions that assess and feedback cancer pain data to patients and/or professionals have so far led to modest reductions in cancer pain intensity. Suggestions are given to inform and enhance future PROM feedback interventions.

Why are we not controlling cancer pain adequately in the community

Poorly controlled cancer pain has recently received a considerable amount of negative media attention, partly as a result of the publication of a report by Marie Curie Cancer Care that is based on interviews with patients at end of life and with their carers.1 The report highlighted a number of unmet needs. Insufficient access to pain relief and delays in administering analgesia were expressed as particular concerns. Interviewees described carers ‘ having to chase prescriptions ’, and nurses waiting around at night for prescriptions to arrive. Concerns were raised about uncoordinated and discontinuous care, and a failure to implement appropriate anticipatory care. Out-of-hours (OOH) services were criticised for being inefficient and lacking empathy. In a supplementary Marie Curie-commissioned survey of 1000 UK GPs,2 61% of GPs believed that their terminally ill patients got inadequate access to care at night and at weekends, and six out of 10 GPs believed that the majority of their terminally ill patients’ pain was not completely relieved. The perceived reasons cited for inadequate pain relief included lack of anticipatory prescribing and poor availability of pain relief during the OOH period. There is good evidence that cancer pain control at the end of life is suboptimal in the community. The Office for National Statistics bereavement survey (VOICES) in 2012 sampled 49 207 recently bereaved informants.3 Relief of pain was reported as being provided ‘ completely, all of the time ’ most frequently in hospices …

Rural dwellers are less likely to survive cancer – An international review and meta-analysis

Background: Existing research from several countries has suggested that rural‐dwellers may have poorer cancer survival than urban‐dwellers. However, to date, the global literature has not been systematically reviewed to determine whether a rural cancer survival disadvantage is a global phenomenon. Methods: Medline, CINAHL, and EMBASE were searched for studies comparing rural and urban cancer survival. At least two authors independently screened and selected studies. We included epidemiological studies comparing cancer survival between urban and rural residents (however defined) that also took socioeconomic status into account. A meta‐analysis was conducted using 11 studies with binary rural:urban classifications to determine the magnitude and direction of the association between rurality and differences in cancer survival. The mechanisms for urban‐rural cancer survival differences reported were narratively synthesised in all 39 studies. Findings: 39 studies were included in this review. All were retrospective observational studies conducted in developed countries. Rural‐dwellers were significantly more likely to die when they developed cancer compared to urban‐dwellers (HR 1.05 (95% CI 1.02 – 1.07). Potential mechanisms were aggregated into an ecological model under the following themes: Patient Level Characteristics; Institutions; Community, Culture and Environment; Policy and Service Organization. Interpretation: Rural residents were 5% less likely to survive cancer. This effect was consistently observed across studies conducted in various geographical regions and using multiple definitions of rurality. High quality mixed‐methods research is required to comprehensively evaluate the underlying factors. We have proposed an ecological model to provide a coherent framework for future explanatory research. Funding: None. HIGHLIGHTSRetrospective observational studies conducted in developed countries comparing urban and rural cancer survival and related outcomes.Increased risk in cancer death among rural/remote patients.Establishment of a theoretical framework to illustrate factors influencing cancer survival in these geographical regions.Support for further research on these themes.

What are the current challenges of managing cancer pain and could digital technologies help

Objectives Pain remains a problem for people with cancer despite effective treatments being available. We aimed to explore current pain management strategies used by patients, caregivers and professionals and to investigate opportunities for digital technologies to enhance cancer pain management. Methods A qualitative study comprising semistructured interviews and focus groups. Patients with cancer pain, their caregivers and health professionals from Northeast Scotland were recruited from a purposive sample of general practices. Professionals were recruited from regional networks. Results Fifty one participants took part in 33 interviews (eight patients alone, six patient/caregiver dyads and 19 professionals) and two focus groups (12 professionals). Living with cancer was hard work for patients and caregivers and comparable to a ‘full-time job’. Patients had personal goals which involved controlling pain intensity and balancing this with analgesic use, side effects, overall symptom burden and social/physical activities. Digital technologies were embraced by most patients, and made living life with advanced cancer easier and richer (eg, video calls with family). Technology was underutilised for pain and symptom management. There were suggestions that technology could support self-monitoring and communicating problems to professionals, but patients and professionals were concerned about technological monitoring adding to the work of managing illness. Conclusions Cancer pain management takes place in the context of multiple, sometimes competing personal goals. It is possible that technology could be used to help patients share individual symptom experiences and goals, thus enhancing tailored care. The challenge is for digital solutions to add value without adding undue burden.

Do patients' faces influence General Practitioners' cancer suspicions? A test of automatic processing of sociodemographic information

Background Delayed cancer diagnosis leads to poorer patient outcomes. During short consultations, General Practitioners (GPs) make quick decisions about likelihood of cancer. Patients’ facial cues are processed rapidly and may influence diagnosis. Aim To investigate whether patients’ facial characteristics influence immediate perception of cancer risk by GPs. Design and setting Web-based binary forced choice experiment with GPs from Northeast Scotland. Method GPs were presented with a series of pairs of face prototypes and asked to quickly select the patient more likely to have cancer. Faces were modified with respect to age, gender, and ethnicity. Choices were analysed using Chi-squared goodness-of-fit statistics with Bonferroni corrections. Results Eighty-two GPs participated. GPs were significantly more likely to suspect cancer in older patients. Gender influenced GP cancer suspicion, but this was modified by age: the male face was chosen as more likely to have cancer than the female face for young (72% of GPs;95% CI 61.0–87.0) and middle-aged faces (65.9%; 95% CI 54.7–75.5); but 63.4% (95% CI 52.2–73.3) decided the older female was more likely to have cancer than the older male (p = 0.015). GPs were significantly more likely to suspect cancer in the young Caucasian male (65.9% (95% CI 54.7, 75.5)) compared to the young Asian male (p = 0.004). Conclusion GPs’ first impressions about cancer risk are influenced by patient age, gender, and ethnicity. Tackling GP cognitive biases could be a promising way of reducing cancer diagnostic delays, particularly for younger patients.

Increased survival means increasing roles for primary care after cancer diagnosis

Morgan et al point out that cancer survival rates in the UK are improving.1 It is timely to consider the roles that GPs play following a cancer diagnosis. We would like to report highlights from a workshop (Cancer in Primary Care International Network [Ca-PRI] annual scientific meeting, Edinburgh, 2017), which explored the roles of GPs following a cancer diagnosis …