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The pain of cancer

The Indian Express
22 September 2012

Recounting her father’s struggle with cancer was difficult for the young woman, even several years after his death. He’d endured first surgery and then chemotherapy and radiation, she said, and the cancer had gone into remission. He was thrilled, but the aggressive treatment left him with chronic, debilitating pain. Once active, he struggled to get around in his own home.

"It wasn’t the cancer that got him," the daughter said. "It was the pain."

Her father had turned to all of his doctors, with little relief. His surgeon had looked at his operative wounds, pronounced them well healed, then stated that they were in no way responsible for his disability. Both his cancer doctor and his radiation doctor congratulated him on being in remission but then declined to prescribe pain medications since they were no longer treating him and couldn’t provide ongoing follow–up and dosing guidance. His primary care doctor listened intently to his descriptions of his limitations, but then prescribed only small amounts of pain meds that offered fleeting relief at best.

"I’ll never forget what my father had to go through," she said, weeping. "I wouldn’t wish this on anyone."

Sadly, according to a new study in The Journal of Clinical Oncology, a significant percentage of cancer patients continue to suffer from pain as her father did.

Researchers who surveyed more than 3,000 cancer patients found that nearly two–thirds said they were in pain or receiving pain medications. Roughly a third felt they needed more painkillers to fully treat their symptoms.

A month after the patients saw their oncologists, the researchers again asked the patients about their pain. Instead of showing improvement, the percentage of patients who continued to be in pain remained unchanged.

Their pain, in other words, had not been treated.

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The findings are a sobering echo of research from nearly two decades ago that revealed that more than 40 percent of cancer patients did not receive adequate treatment for their pain. While patients were reluctant to ask for relief or to take prescribed pain medications, the researchers found that physicians were just as unwilling to prescribe the needed medications. Nearly a third of cancer specialists waited until the patient was only months away from death before offering maximum pain control.

These results were eye–opening for the oncology community and helped fuel a firestorm of initiatives in the late 1990s and early 2000s aimed at improving how doctors address pain in general. State medical boards began to mandate that all doctors take pain management courses before renewing their licenses to practice. In a move presaging today’s checklists, pain was declared a patient’s "fifth vital sign," a body function to be assessed after temperature, heart rate, respiration rate and blood pressure. Unfortunately, that new norm turned out to be not so different from the old.

While there had been a slight improvement in the number of patients whose pain was controlled, nearly a third of patients were still inadequately treated.

While the study offers important follow–up data to work conducted two decades earlier, it also represents a growing interest among researchers in the symptoms of cancer, particularly for the growing number of people who are living longer than patients from even a decade ago. Thanks to advances in cancer treatment, more than half of all cancer patients now live five years or more past their initial cancer diagnosis. "We need to be better prepared for this best–case scenario," said Dr Michael J Fisch, lead author of the study, because it’s one that can include not only more years of life but also persistent fatigue, arthritis, hot flashes, depression, sleep problems and chronic pain.

"Pain is all about the doctor–patient relationship and taking the whole person into account," Dr Fisch said. "Those things are not quick fixes."

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