◊ SUMMARY:

This review aimed to quantify the benefit of patient-based educational interventions in the management of cancer pain. A systematic review and meta-analysis of experimentally randomised and non-randomised controlled clinical trials identified from six databases from inception to November 2007 was performed. Main outcome measures were effects on knowledge and attitudes towards cancer pain and analgesia, and pain intensity. Twenty-one trials (19 randomised) totalling 3501 patients met inclusion criteria, and 15 were included in the meta-analysis.

Compared to usual care or control, educational interventions improved knowledge and attitudes by half a point on 0–5 rating scale, reduced average pain intensity by over one point on 0–10 rating scale and reduced worst pain intensity by just under one point. Equivocal evidence was found for the effect of education on self-efficacy, but no significant benefit on medication adherence or on reducing interference with daily activities. Patient based educational interventions can result in modest but significant benefits in the management of cancer pain, and are probably underused alongside more traditional analgesic approaches.

◊ Reviewed by J. Van Zundert, MD, PhD, FIPP,
Department of Anaesthesiology and Multidisciplinary Pain Centre,
Ziekenhuis Oost-Limburg,
Genk, Belgium

This meta-analysis highlights the importance of patient education and counselling as part of pain management in cancer patients. In the discussion authors state: “Clinicians may be surprised to learn that for patients with cancer pain who are already on opioid therapy, ‘prescribing’ an educational intervention (mean additional reduction in pain intensity on 0–10 scale of about 1 point), may be more effective than the addition of some types of co-analgesic therapies. For example, prescribing gabapentin or paracetamol achieved mean reductions of 0.8 points, and 0.4–0.6 points, respectively, in randomised controlled trials of around 1 week in duration”

The analysed studies and hence the review have two major weaknesses: (1) the type of education is poorly defined and (2) the concept of harm or adverse effects resulting from educational interventions is not assessed.

The rationale of educational programs is that reducing the recognised barriers of pain management will lead to increased medication adherence and in turn to less pain. Moreover, it was demonstrated that with patients’ perceived control over pain related distress decreased and functional status improved.

Interestingly, one study reported significantly better medication adherence, whereas there was no such improvement in two other studies that used a medication side effect checklist. Education did not influence interference of pain with daily activities.

Educational programs indeed increase the knowledge of patients regarding pain, its management and the potential side effects. Though not evaluated in this review, patients who received proper education may more likely report pain, general discomfort and side effects; this may have biased study results. However, in daily practice a better educated patient who verbalizes his concerns is also a more cooperative patient. A timely and accurate reporting of unsatisfactory efficacy or side effects should guide the treating physician in adapting the treatment scheme.

Education and appropriate information is a must in the management of pain in general and even more in that from cancer pain. The type of information and the way to deliver it cannot be standardized. After a basic training the patients’ understanding of pain and analgesia should be reassured and misunderstandings be cleared. An important point that was not addressed in the systematic review is the projection of realistic expectations. Education should also address the fact that the patient will have to cope with unbearable pain and/or incapacity.

The authors state that specialist nurses and pharmacists may be most suitable to lead the educational programs, supported by written or audio-visual take-away material. However, education is a continuous process built by contributions from different parties. The primary (legal) responsibility of informing the patient relies with the treating physician. He/she should be the coordinator of patient care, including training and information sessions. The physician acts as “conductor of the orchestra” which means that every player has an important role but that it is the one of the treating physician to coordinate and assure coherency of interventions. The information flow within the team is a crucial factor for success. Educating care givers is necessary, but sharing the information that the patient provides to the different team members is crucial.

The patient management plan is commonly defined in multidisciplinary consultations of the “cancer specialist” and palliative care/pain physician. The advanced planning, which is gaining more and more acceptance, comprises a clear description of what may happen to the patient and how the team will react to changes in his/her condition. The expected steps in the evolution of the disease are documented in a clinical pathway, a system that also describes the role of each team member. Patient education is one factor of the treatment plan. Its effects should be assessed and adapted in the same way as pharmacological treatments.