Has pain management in cancer patients with bone metastases improved? A seven-year review at an outpatient palliative radiotherapy clinic.

The primary objective of this study was to determine the prevalence of underdosage of analgesics for pain associated with bone metastases in outpatients referred to the Rapid Response Radiotherapy Program at the Odette Cancer Centre from 1999 to 2006. A prospective database containing data for all patients with bone metastases who were referred to the Rapid Response Radiotherapy Program for palliative radiotherapy from 1999 to 2006 was analyzed. The database included patient demographic information, including age at referral for radiation to the bone, gender, primary cancer site, and Karnofsky Performance Status; information on treatment-related factors, such as worst pain ratings and analgesic consumption in the past 24 hours (recorded as oral morphine equivalent doses); pain intensity ratings (none [rating=0], mild [rating=1-4], moderate [rating=5-6] or severe [rating=7-10]; and analgesic consumption (rated as none, nonopioids, weak opioids [e.g., codeine] and strong opioids [e.g., morphine and hydromorphone]). Patients who experienced moderate or severe pain and were prescribed no pain medication, nonopioids, or weak opioids were considered to be undermedicated. Between January 1999 and December 2006, 1,038 patients were included in the study database. Approximately 56% of patients were male and 44% were female. The median age was 68 years (range 28-95) and the median Karnofsky Performance Status was 70 (range 10-100). The percentages of undermedicated patients were 40% in 1999, 34% in 2000, 29% in 2001, 37% in 2003, 39% in 2004, 36% in 2005, and 48% in 2006. No appreciable decline was noted in the proportion of patients with moderate-to-severe pain who received no pain medication, nonopioids, or weak opioids during the study period. Despite the publication of pain management guidelines and the dissemination of data regarding the proportion of patients with bone metastases who are being prescribed inadequate analgesics, our findings suggest that a significant proportion of patients continue to be undermedicated.