Pain is a frequent and pervasive problem for older persons with cancer, affecting approximately 80% of this population.1 Treating older adults with cancer can be complex because of the presence of comorbid conditions that may impact chronic pain.2 Once pain is identified and the cause is known, it is sometimes necessary to target specific pain mechanisms.3 Hence, a comprehensive assessment of each individual patient is essential in order to identify all of the conditions contributing to pain.
Older persons with cancer also experience pain directly related to disease or treatment modalities, such as radiation therapy or surgery. Cancer-related chronic pain is not limited to those who are receiving end-of-life care but may be present in patients for whom cure or control of the underlying cancer is the treatment goal. With continuing advances in cancer treatment, patients can be expected to live longer, thus requiring ongoing extended pain management.
Despite the many advances in pain management over the past few decades, and the numerous guidelines and evidenced-based measures available to physicians and practitioners for treating cancer-related pain, undertreatment of pain in cancer patients continues to be a problem.4
It is through a thorough pain assessment that clinicians can understand how to help their patients. Since pain is subjective and there is no objective way to measure it, a satisfactory method of pain assessment is the foundation needed to properly control pain in older patients with cancer.
Methods of Pain Assessment
When it comes to assessing pain intensity, there are many different scales available that have proven to be valid. In a cross-sectional multicenter study of 240 advanced cancer patients with pain, background pain and current pain intensity were assessed using a 6-point verbal rating scale as well as an 11-point (0-10) numeric rating scale. During this study, the numeric rating scale was shown to be most consistent and reproducible, suggesting that during cancer pain exacerbations, patients use numeric rating scales more appropriately and effectively.5 According to Herr and colleagues, older adults, particularly those with cognitive impairment, tend to prefer vertical rather than horizontal scales.6 Whenever pain is assessed, no matter which scale is used, it is important to ensure that the scale is well understood by the clinician who is presenting the scale to the patient.
Pain Assessment in Older Adults
A study reviewing emergency department records of older adult patients found that 34% had no objective assessment of pain documented.7 Pain assessment and reassessment are essential to managing and treating pain appropriately; however, such reassessments are often lacking. When a patient is able to self-report, simply using a pain scale to determine pain intensity is not the completion of pain assessment. One obstacle in this population is the inability of older adults to self-report with accuracy.
Pain Assessment in Individuals With Cancer
Thorough pain assessment is done by both the nurse and the clinician to determine all aspects of the patient’s pain. As self-report is the standard of care, this assessment is obtained from the patient. It is important for clinicians to determine the location and intensity of the pain; whether the pain interferes with daily activities; the timing (onset, duration, course, persistent or intermittent), quality, and description of the pain; any aggravating and alleviating factors; any other associated symptoms; and any current or past treatments and why these were started or stopped and by whom. It is important to obtain a complete history and physical so that polypharmacy can be avoided. At the end of the assessment, a pain diagnosis and an individualized pain treatment plan should be established, based on mutually agreed upon goals.8
Treatment of Chronic Cancer Pain
Many studies on the treatment of pain specifically related to older adults with cancer pain have been conducted. For example, one cross-sectional study in 2004 by the National Nursing Home Society of 1174 nursing homes in the United States examined pain prevalence, pain treatment, and associated factors in 303 older residents assigned to a hospice specialty unit. Of these residents, 11.4% had a cancer diagnosis, 36.63% had experienced pain in the past 7 days, and of those with observed or reported pain, 86.4% had received analgesics, with 65.5% receiving an opiate preparation. While it is clear that residents with pain are receiving some pharmacologic intervention, the lack of pain medication in the prior 24-hour period suggests the potential for inadequate pain control overall.9With the knowledge that 45% to 80% of nursing home residents endure substantial pain, it is disconcerting to know that these medications are not being provided to clients on a more regular basis.2 These studies highlight the need for more diligent assessment and reassessment of pain to ensure that patients’ pain is continually addressed and managed.
Nonpharmacologic treatments for cancer pain are also available; however, there are fewer rigorous clinical trials investigating the use and effectiveness of nonpharmacologic therapies in managing cancer pain, and these treatments need additional research before recommendations for practice can be made. The Cancer Health Empowerment for Living without Pain (Ca-HELP) study was a randomized trial sponsored by the American Cancer Society that was completed in Sacramento, California. This study included 265 cancer patients with pain of at least moderate severity who were randomly assigned to receive either educationally enhanced usual care (EUC) or tailored education and coaching (TEC), to demonstrate that a brief, tailored patient activation intervention may promote better cancer pain care and outcomes.10 This study showed that TEC, compared with EUC, resulted in improved pain communication self-efficacy and temporary improvement in pain-related impairment, but no improvement in the pain severity itself.11
A quasi-experimental, comparative study in 187 ambulatory-care cancer patients tested an educational intervention called “Passport to Comfort,” which focused on reducing barriers to pain and fatigue management through educational sessions. To be included, patients with breast, lung, colon, or prostate cancers had to report pain and/or fatigue of at least 4 or greater on an 11-point (0-10) numeric scale. The intervention, which included 4 educational sessions, was shown to be effective in both reducing patient barriers to pain and fatigue management as well as increasing patient knowledge regarding pain and fatigue.12 When treating chronic cancer pain, we should continue to explore educational interventions in the older adult population, as these might be beneficial to our patients.
Barriers to Cancer Pain Management
There are numerous barriers to treating pain in older adults, including that they are more tolerant of pain, that they cannot tolerate the use of opioids for cancer pain, and that they experience less pain and/or are less sensitive to pain.13 Also, it is a common misconception that older adults with decreased cognitive function experience less pain or are completely unaware of pain. In a cross-sectional, correlational study, Allen and colleagues explored the associations between pain and cognitive function among cancer patients and their family caregivers.14 What they found was that, contrary to expectations, patients with cognitive impairment reported more intense pain than did patients with intact cognitive function.
Barriers that can be common to all adults have been documented well in the literature. Patients’ beliefs and actions lead to underreporting and thus undertreatment of pain. Some patients are reluctant to report pain because they are fearful of side effects from pain medications; they feel pain control is not a realistic goal; they do not want to distract their physicians from continuing to treat their cancer; or they might feel that the pain means their disease is progressing. Physicians and practitioners face barriers as well. These include failing to adequately assess pain or recognize barriers the patient is experiencing; lack of knowledge regarding treatment options for pain or side effects; and not understanding key concepts such as addiction, tolerance, dosing, and communication.12
Implications for Research and Nursing Practice
There is a gap in the literature in regard to pain control in long-term cancer cases. More research is needed to determine how much more effective an interdisciplinary team is at not only managing but also assessing pain in cancer patients. More research is also needed specifically related to chronic cancer pain and how often practitioners are assessing this pain in both inpatient and outpatient settings.
Nurses are also vital in the assessment of pain, and this is a core competency that must be mastered in all clinical settings. Individualized, comprehensive, continued assessment allows the nurse to relay vital information to the clinician regarding the patient, which is why it is so important that nurses receive continued education on pain assessment and that there be continued research to determine best nursing practices for assessment in various settings.
When patients are confronted with a diagnosis of cancer, they are fearful of the future and what life now holds for them. Despite practitioners’ best attempts to reassure patients and answer their questions, patients cannot help but think they are about to embark on a long painful road. As practitioners, we must not only reassure patients that there are options for pain treatment but also ensure that thorough assessment and reassessment of pain continues and is integrated into all aspects of care. In order to give patients the best possible pain control, it is important to continue to implement evidence-based treatment protocols and utilize guidelines for pain, specific not only to cancer patients but also to the older adult. This is a special population, one that will have special psychological needs and will, in many circumstances, be dealing with this diagnosis for the rest of their life, thus requiring ongoing long-term management of pain.
- Rao A, Cohen HJ. Symptom management in the elderly cancer patient: fatigue, pain, and depression. J Natl Cancer Inst Monogr. 2004;32:150-157.
- Miaskowski C. Effective management of pain in older adults with cancer. Oncol Nurs Forum. 2010; 37(suppl):5-6.
- American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57:1331-1346.
- Deandrea S, Montanari M, Moja L, et al. Prevalence of undertreatment in cancer pain: a review of published literature. Ann Oncol. 2008;19:1985-1991.
- Brunelli C, Zecca E, Martini C, et al. Comparison of numerical and verbal rating scales to measure painexacerbations in patients with chronic cancer pain. Health Qual Life Outcomes. 2010;22:42.
- Herr K, Spratt KF, Garand L, et al. Evaluation of the Iowa pain thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: a preliminary study. Pain Med. 2007;8:585-600.
- Herr K, Titler M. Acute pain assessment and pharmacological management practices for the older adult with a hip fracture: review of ED trends. J Emerg Nurs. 2009;35:312-320.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Version 2.2011. www.nccn.org/professionals/physician_gls/PDF/pain.pdf. Accessed September 6, 2011.
- Hanlon JT, Perera S, Sevick MA, et al. Pain and its treatment in older nursing home hospice/palliative care residents. J Am Med Dir Assoc. 2010;11:579-583.
- Kravitz RL, Tancredi DJ, Street RL Jr, et al. Cancer Health Empowerment for Living without Pain (Ca-HELP): study design and rationale for a tailored education and coaching intervention to enhance care of cancer-related pain. BMC Cancer. 2009;9:319.
- Kravitz RL, Tancredi DJ, Grennan T, et al. Cancer Health Empowerment for Living without Pain (Ca-HELP): effects of a tailored education and coaching intervention on pain and impairment. Pain. 2011; 152:1572-1582.
- Borneman T, Koczywas M, Sun VC, et al. Reducing patient barriers to pain and fatigue management. J Pain Symptom Manage. 2010;39:486-501.
- Miaskowski C, Cleary J, Burney R, et al. Guideline for the Management of Cancer Pain in Adults and Children. 3rd ed. Glenview, IL: American Pain Society; 2005.
- Allen RS, Haley WE, Small BJ, et al. Pain reports by older hospice cancer patients and family caregivers: the role of cognitive functioning. Gerontologist. 2002;42:507-514.