Assessment of Cancer Pain Management Knowledge in Southwest China: A Survey of 259 Physicians from Small City and County Hospitals

Introduction

Cancer pain management is a global challenge.^1,2 Pain can be well controlled for more than 85% of all cancer patients. However, according to statistics published by the American Cancer Society in 2002, 50%–70% of cancer patients experience some degree of pain, and their pain usually intensifies as the disease progresses. ³

Unlike most developed countries, China has not adopted symptom control and palliative care as a practice specialty. ⁴ Because cancer is often diagnosed in advanced stages in China, a higher percentage of patients do experience pain, ⁵ and a majority of these patients go to county hospitals or clinics to receive pain treatment. ⁴ As a result, physicians in county hospitals and clinics are, in effect, the frontline soldiers in managing cancer pain.

However, little has been known about their ability to manage patients' pain. Here we report a survey-based study on cancer pain management among 300 first-year fellows in the Second Affiliated Hospital of the Third Military Medical University in Chongqing, China, which is a major 1200-bed hospital receiving 600,000 outpatients and 20,000 inpatients per year in southwest China. The survey assessed the fellows' knowledge and attitudes regarding cancer pain and its treatment, their current pain management practices, and their perceptions of barriers to optimal pain management. ⁶

Methods

Two hundred and fifty-nine physicians in fellowship training participated in the survey. The majority came from southwest China, including the provinces of Sichuan, Guizhou, Hubei, Hunan, Xinjiang, Yunnan, and Chongqing. The physicians' average age was approximately 30 years. Table 1 shows additional characteristics of these respondents. Three hundred paper questionnaires were distributed to the fellows after their orientation meetings September 1st, 2011 and April 2nd, 2012.

The questionnaire on cancer pain was developed by Cleeland and the Pair Research Group at the University of Wisconsin, used by the Eastern Cooperative Oncology Group (ECOG), ⁶ and translated into Chinese and validated by Ying Guo, MD and Hong Guo, MD. The questionnaire assesses clinicians' estimates of the magnitude of pain as a problem for cancer patients; their attitudes about the adequacy of pain management for cancer pain; and how they manage pain in their practice setting, their training and experiences. The questionnaire includes sections on controlling the pain of a hypothetical patient and on personal experiences with family members with cancer, moderate to severe pain, or substance abuse.

Participation was voluntary and no incentives were offered. Descriptive statistics for every response were used—frequencies, percentages, means, and ranges. Because some of the fellows did not answer each question completely, the reported responses are accompanied by the 259 fellows who answered each question. Physicians took about 40 minutes to complete the questionnaire.

Results

Discussion

The 1986 World Health Organization (WHO) guidelines for managing cancer pain stated that a country's usage of morphine is an important indicator of the quality of its pain control.^7,8 In recent years the Chinese government has made great efforts to improve cancer pain management. However, the country's medical morphine usage remains lower than the global average.^9–11 Successful implementation of cancer pain management requires not only government support but also assurance of professional competence in pain control.

This survey revealed discordance between the proportion of respondents who believed they were competent and the proportion who were unable to answer some questions or who gave incorrect answers. Moreover, the majority of the physicians surveyed lacked sufficient knowledge about opioid conversion. ¹²

The reasons for these discrepancies are multifactorial. Some physicians may not be familiar with or have never heard of some of the drugs listed in our questionnaire, such as the fentanyl patch, methadone, and oxycontin. Students often receive insufficient training in pain control during medical school. ¹³ Greater education in these areas must be a priority and should include pharmacological information on opioids and instruction on how to choose and titrate these drugs. In many regions, physicians do not have access to formal resident training programs, ¹⁴ a deficiency that should be addressed.

We also found that new fellows are very cautious about choosing strong sustained-release opioids for prolonged moderate-to-severe cancer pain. The reason for this caution may be that prescribing opioids is very complicated in China and that the use of these drugs is under strict scrutiny. ¹⁵ Sustained-release opioids are not in stock in small hospitals and clinics, and prescriptions for opioids are limited to 15 days per prescription for cancer patients. Physicians must provide triplicate prescriptions, including two written in red handwriting and one printed from the electronic medical record. Security measures in the clinic include a special red outpatient medical record notebook, copies of the ID cards of patients and their relatives who pick up the medicines, proof of cancer (the pathology report for a new patient), and informed consent (signed by patients or their relatives) regarding treatment with opioids.

The physicians in this survey were more concerned about the possibility of addiction to opioids (75%) than were those in previous studies.^6,16 In studies conducted by ECOG and MD Anderson, the percentages of physicians who were concerned about addiction were only 2% and 12%, respectively.^6,16

Based on the WHO definition, drug tolerance and physical dependency on morphine during treatment for cancer pain are rare and cannot be regarded as drug addiction. ¹⁷ Chinese physicians' attitudes may have been affected by the painful history of the Opium Wars. ¹⁸ The high cost of opioids in sustained-release form may also contribute to physicians' hesitation to prescribe opioids. ¹⁹

These results indicate that inadequate pain assessment is the most important barrier to optimal pain management, a finding similar to those of previous reports from ECOG and MD Anderson.^6,16

In this paper we did not assess patients' influence on the ability to manage cancer pain. Patient-perceived barriers to pain management have been conceptualized into two groups: fear of using opioids and miscommunication about pain between patients and clinicians.^20,21 Asian patients often have a more negative attitude toward pain and pain control than do western patients, and these attitudinal differences may partially explain the higher prevalence of undertreated pain among patients in China. ²² Therefore, both medical professional education and patient education are required to optimize cancer pain management.

Conclusion

Pain management should be added to standard clinical training curricula. Continuing medical education, with specific case discussions and demonstrations, also is needed to help build educational programs for symptom management. ²³ The routine use of pain assessment tools such as the Memorial Pain Assessment Card and the VAS Pain Scale^24,25 would enhance clinicians' communication with patients and improve pain management. In addition, palliative care departments should be established in medical schools to provide teaching and clinical experience. Providing relief of cancer pain will require support from governments, health organizations, and the public.^26,27