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Risk Factors for Inadequate Treatment of Cancer-Related Pain Among African American and Latino Cancer Patients
Karen O. Anderson, PhD, MPH
Department of Symptom Research
The University of Texas
M.D. Anderson Cancer Center
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Institute of Medicine Report on Unequal Treatment
Racial and ethnic disparities in healthcare
exist. These disparities are consistent and
extensive across a range of medical
conditions and health care services…they
are associated with worse outcomes…and
therefore, are unacceptable.Institute of Medicine Report on Unequal Treatment, 2002
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Documenting the Problem
Research findings from the 80’s found Research findings from the 80’s found that: that:
Many cancer patients have Many cancer patients have significant pain for a long period significant pain for a long period of time. of time.
Cancer pain is often poorly Cancer pain is often poorly treated. treated.
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Results From ECOG Pain Studies
More than one-third with metastatic More than one-third with metastatic cancer reported pain that interfered with cancer reported pain that interfered with their function.their function.
Forty percent of patients with pain were Forty percent of patients with pain were not prescribed analgesics strong not prescribed analgesics strong enough to effectively treat their pain.enough to effectively treat their pain.
Cleeland et al, NEJM, 1994Cleeland et al, NEJM, 1994
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Patients at Risk for Inadequate Pain Management
Patients cared for at minority treatment Patients cared for at minority treatment centers were three times more likely to centers were three times more likely to be undermedicated with analgesics.be undermedicated with analgesics.
Discrepancy between patient and Discrepancy between patient and provider estimates of pain severity.provider estimates of pain severity.
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ECOG Minority Study: Findings
• Negative Pain Management Index
– Majority patients: 38%
– Minority patients: 65%
– Cleeland et al, Annals Internal Med, 1997
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PREMO Goals
• Identify pain management needs of African American and Hispanic patients with cancer and pain.
• Develop culturally appropriate patient education materials.
• Conduct a clinical trial to evaluate the efficacy of an educational intervention.
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PREMO Sites
• Houston
– UT MD Anderson Cancer Center
– Two Harris County Hospitals
– VAMC
• Miami
– One County Hospital
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Pain-Related Variables among Minority Cancer Patients
Patient GroupPercent with severe pain
African American 72%
Hispanic 57%
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Objectives of the Clinical Trial
• To determine if patient education improves pain control in African American and Hispanic patients with cancer-related pain
• To determine if patient education reduces the impact of pain
• To determine if patient education improves quality of life
– Anderson et al., JCO, 2004
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Randomized Clinical Trial
• Pain Education
– Video and booklet on cancer pain and pain treatment
– Gender and heritage specific materials
– How to report pain
– How to take analgesics
• Control Group
– Nutrition video and booklet
– Controls for an educational treatment
– Nutrition for cancer patients
– English and Spanish versions
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Educational Materials
• Emphasize pain relief
• Teach how to report pain
• Model patient communication
• Reduce fears of opioids
• Cultural issues
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Eligibility Criteria
• Diagnosis of cancer
• Pain due to cancer or cancer treatment
• Pain worst score of 4 or greater on BPI
• African American or Hispanic heritage
• ECOG performance status of 0, 1, or 2
• No current palliative radiotherapy
• No major surgery within past 30 days
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Assessment Schema
• Intake (T1, Day 1)
– BPI - long form
– SF-12 Health Survey
– Pain Control Scale
– MD Pain Assessment
• Time 2 (Day 15-28)
– BPI - short form
– SF-12 Health Survey
– Pain Control Scale
– MD Pain Assessment
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Assessment schema
• Time 3 (week 6-7)
– BPI - short form
– SF-12 Health Survey
– Pain Control Scale
– MD Pain Assessment
– Compliance form
• Time 4 (week 8-10)
– BPI - short form
– SF-12 Health Survey
– Pain Control Scale
– MD Pain Assessment
– Compliance form
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Accrual in the Clinical Trial (n = 97)
• 36 breast cancer patients (39%)
• 61 cancer patients with other solid tumors or hematological malignancies
– 23% GI
– 18% lung
– 10% GU/Gyn
– 4% head and neck
– 6% other
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Demographics
• 66% female
• 39% married, 61% single
• 54% Hispanic, 46% African American
• 52% high school education
• 46% disabled, 15% retired, 11% jobs
– 20% homemakers, 9% other
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Disease-related Variables
• 63% good ECOG performance status
– 54% education, 72% control group
• 66% chemotherapy
• 14% hormonal therapy
• 65% metastatic disease
• 66% severe pain
• 52% pain > 6 months
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Mean Pain Severity over Time for Education and Control Groups
3
4
5
6
7
8
9
10
T1 T2 T3 T4
Education
Control
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Mean Pain Severity over Time for African American Patients
3
4
5
6
7
8
9
10
T1 T2 T3 T4
Education
Control
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Mean Pain Interference over Time for Education and Control Groups
3
4
5
6
7
8
9
10
T1 T2 T3 T4
Education
Control
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Perceived Pain Control over Time for Education and Control Groups
10
15
20
25
30
35
40
T1 T2 T3 T4
Education
Control
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Mean SF-12 Physical Component Summary Scores
0
10
20
30
40
50
60
Time 1 Time 2 Time 3 Time 4
Education
Control
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Mean SF-12 Mental Component Summary Scores
0
10
20
30
40
50
60
Time 1 Time 2 Time 3 Time 4
Education
Control
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Physicians’ Underestimates of Patients’ Pain
Group Time 1 Time 2 Time 3 Time 4
Education 77% 67% 87% 88%
Control 68% 70% 52% 75%
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Negative Pain Management Index
Group Time 1 Time 2 Time 3
Education 60% 32% 50%
Control 49% 38% 42%
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Conclusions
• Pain education did not improve pain intensity for Hispanic patients
• Pain education led to short-term reduction in pain intensity for African American patients
• No impact on perceived pain control or quality of life
• Individualized education or treatment protocols may be more beneficial
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Why?
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Top Barriers to Cancer Pain Management
Barrier Percentage
Inadequate pain assessment 71
Patient reluctance to report 56
Inadequate staff knowledge 54
Reluctance to prescribe 40
Patient reluctance to take 36
Lack of staff time 34
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Pain-Related Attitudes
Item Hispanic African American
Caucasian
Need more information
55% 43% 16%
Need more medication
28% 33% 11%
Need stronger medication
39% 47% 17%
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Pain-Related Behaviors and Attitudes
Item Hispanic African American
Caucasian
Taking prn meds
62% 66% 60%
Taking < 2 times/day
80% 83% 52%
Side effects 26% 29% 21%
Overuse concern
36% 22% 22%
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Pain-Related Attitudes
Concern African American
Hispanic
Be strong 93% 76%
Addiction 79% 59%
Tolerance 57% 71%
Not effective 69% 71%
Not bother MD 71% 59%
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Use of Alternative Treatments
Technique African American
Hispanic
Prayer 83% 47%
Over the counter meds
33% 35%
Special teas or herbs
25% 18%
Relaxation 33% 12%
Vitamins 25% 12%
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Communication
• “The doctor understands me because he speaks Spanish.”
• “If I continue to have pain, the doctor said contact me as soon as you can.”
• “Wow, what a relief.”
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Communication
• “You don’t remember everything...It would be good to have something written.”
• “If the doctors or nurses had more time… or to have a stable nurse.”
• “She uses a lot of big words that I don’t understand.”
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Concerns about Pain Medications
• “Does one die when one takes morphine?”
• “The doctor said don’t take too much if you don’t have to.”
• “They tell me that the medicine is addictive.”
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Risk Factors for Inadequate Pain Treatment
• Marital Status
– Single: 74% under treated
– Married: 58% under treated
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Risk Factors for Inadequate Pain Treatment
• Ethnicity
– Latino patients: 59% under treated
– African American patients: 48% under treated
– P = 0.10
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Risk Factors for Inadequate Pain Treatment
• Performance Status
– Poor performance status: 36% under treated
– Good performance status: 45% under treated
– P = 0.11
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Risk Factors for Inadequate Pain Treatment
• Physician Assessment
– Inadequate: 58% under medicated
– Adequate: 37% under medicated
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Conclusions
• Pain interventions for underserved minority patients must target physicians and patients
• Standardized pain assessment
• Pain treatment guidelines
• Pain education for patients needs to be individualized
• Specific barriers can be identified
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Eliminate Disparities
“Our greatest opportunities for reducing health disparities are in empowering individuals to make informed health care decisions and in providing the skills, education, and care necessary to improve health. The underlying premise of Healthy People 2010 is that the health of the individual is inseparable from the health of the larger community.” David Satcher, MD, PHD
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Research Team
• Charles S. Cleeland, PhD
• Richard Payne, MD
• Guadalupe Palos, RN, LMSW, DrPH
• Tito Mendoza, PhD
• Vicente Valero, MD
• Arlene Nazario, MD
• Stephen Richman, MD