Undetected prevalence and clinical inertia in the treatment of breakthrough cancer pain

Breakthrough cancer pain (BTcP) is a transient condition in oncology patients. Currently, there is no unanimous consensus on diagnostic criteria for BTcP. The Association for Palliative Medicine of Great Britain and Ireland (APM) has described BTcP as “a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain” (Davies et al., 2018).


Recent clinical data have revealed that the most episodes of BTcP are not detected or treated, or they are handled inappropriately and insufficiently treated (Herrero et al., 2018)
In addition, its clinical management can be suboptimal because of the potential coexistence of several forms of BTcP in individual patients (Canal-Sotelo et al., 20181) and the fact that treatment depends on both pain and patient-related factors (Davies et al., 2018).


One of the major issues that contributes to poor therapeutic intervention is the failure to intensify treatment whenever treatment goals proposed by guidelines are not met, a phenomenon defined as clinical inertia (CI) (Herrero et al., 2018). Several studies indicate that CI can be triggered by three major factors:

  • physician factors, e.g. overestimation of care and disagreement with evidence-based goals or lack of professional experience (O’Connor et al. 2005, Herrero et al., 2018);
  • patient factors, e.g. unawareness of the need to intensify care and side effects associated with intensive therapy (O’Connor et al. 2005);
  • office system factors, e.g. lack of patient follow-up and lack of data to monitor the quality of care (O’Connor et al. 2005).

Not intensifying therapy in oncology patients who do not respond adequately to treatment is the most common cause of CI (Herrero et al., 2018). A recent observational study, published in Clinical and Translational Oncology, has shown that 37.4% of 540 oncology patients were not correctly identified as experiencing BTcP and therefore were not appropriately treated (Herrero et al., 2018).

In conclusion, according to Experts, several measures can enhance the management of patients affected by BTcP, including:

  • specific medical education programmes (Herrero et al., 2018);
  • accurate information directed to patients and caregivers (Herrero et al., 2018);
  • improved doctor-patient communication (Working Group Nientemale DEI, 2016).


References

  • Canal-Sotelo J, Trujillano-Cabello J, Larkin P, Arraràs-Torrelles N, González-Rubió R, Rocaspana-Garcia M, et al. Prevalence and characteristics of breakthrough cancer pain in an outpatient clinic in a Catalan teaching hospital: incorporation of the Edmonton Classification System for Cancer pain into the diagnostic algorithm. BMC Palliat Care 2018;17:81.
  • Davies AN, Elsner F, Filbet MJ, Porta-Sales J, Ripamonti C, Santini D, et al. Breakthrough cancer pain (BTcP) management: a review of international and national guidelines. BMJ Support Palliat Care, 2018;0:1–9.
  • Herrero CC, Reina Zoilo JJ, Monge Martín D, Caballero Martínez F, Guillem Porta V, Aranda Aguilar E, et al. Active study: undetected prevalence and clinical inertia in the treatment of breakthrough cancer pain (BTcP). Clin Transl Oncol 2018; 2018 Aug 9, doi: 10.1007/s12094-018-1925-1. [Epub ahead of print]
  • O’Connor PJ, Sperl-Hillen JM, Johnson PE, Rush WA, Biltz G. Clinical inertia and outpatient medical errors. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005, p. 293–308.
  • Working Group Nientemale DEI, Vellucci R, Fanelli G, Pannuti R, Peruselli C, Adamo S, et al. What to do, and what not to do, when diagnosing and treating breakthrough cancer pain (BTcP): expert opinion. Drugs 2016;76:315–330.