Sensitivity to change of the Spanish validated Memorial PainAssessment Card in cancer patients

Jorge Contreras · Francisco Valcárcel · Manuel Domine · Yolanda Escobar

Received: 14 April 2008 / Accepted: 17 July 2008

R E S E A R C H A R T I C L E S

Clin Transl Oncol (2008) 10:654-659DOI 10.1007/s12094-008-0266-x

AbstractIntroduction Pain intensity is a good parameter to assess ef-fective treatment of cancer and palliative care. The Memori-al Pain Assessment Card (MPAC) is a quick, easy and reli-able measure of quality of life in cancer patients. TheMPAC was validated in Spanish in 2004. This study evalu-ated the sensitivity to change Spanish version of the MPAC. Material and methods An epidemiological, prospective, 1-month, multicentre study, conducted at 4 oncology servic-es. Patients evaluated suffered chronic cancer pain andwere in a susceptible situation of change. The MPAC wasadministrated at baseline, at one week and at one month,including the 4 subscales (pain relief [VASPR], pain inten-sity measured by VAS [VASPI] and by an 8-item descriptor[Tursky], and psychological distress [VASMOOD]). Satis-faction of patients and health-care professionals with theMPAC was also evaluated.

Results A total of 54 patients were studied. All of theMPAC subscales showed sensitivity to change during thefollow-up. The subscale values at visit 1 vs. visit 3 were:VASPR 4.5±1.9 vs. 6.3±2.3, VASPI 6.6±1.6 vs. 3.5±1.9and VASMOOD 5.5±2.1 vs. 4.0±2.1). Patients and health-care professionals agreed in the facility use MPAC card(63% and 71% of cases, respectively). Conclusions The present study showed sensitivity tochange among the different MPAC subscales of the Span-ish version. Moreover, the MPAC Spanish version hasproven to be a good tool accepted by health-care-profes-sionals and patients. Due to its facility of administration, itmay allow a useful and quick evaluation of cancer-relatedpain in the clinical practice.

Keywords Oncologic pain · MPAC scale ·Sensitivity to change

Introduction

Pain is a prevalent symptom in cancer patients, affecting upto 50% of patients undergoing active cancer treatment and upto 90% of those with advanced disease. Although adequaterelief can be achieved in the majority of cancer patients, painis often treated inadequately in traditional settings [1, 2].

The most common cancer pain is from tumours thatmetastasise to the bone. About 60–80% of cancer patientswith bone metastasis experience pain [3]. The second mostcommon cancer pain is caused by tumours infiltrating thenerve and hollow viscera. Tumours near neural structuresmay cause the most severe pain. The third most commonpain associated with cancer occurs as a result of che mo the -rapy, radiation or surgery.

Effective approaches to palliative care are available toimprove the quality of life for cancer patients. Valid and re-liable assessment of pain is important for the diagnosis dis-eases, and for the evaluation of treatment response and side

J. Contreras (�)Servicio de Oncología RadioterápicaHospital Carlos HayaAvda. Carlos Haya, s/nES-29010 Málaga, Spaine-mail: jorge.contreras.sspa@juntadeandalucia.es

F. ValcárcelServicio de Oncología RadioterápicaHospital Puerta de HierroMadrid, Spain

M. DomineServicio de Oncología MédicaFundación Jiménez DíazMadrid, Spain

Y. EscobarServicio de Oncología MédicaHospital General Universitario Gregorio MarañónMadrid, Spain

Clin Transl Oncol (2008) 10:654-659 655

effects. Palliation implies improvement in either the dura-tion or quality of life remaining [4, 5].

The measurement of pain intensity is a good parameterfor an effective treatment of cancer and palliative care [6,7]. There are different ways to measure pain intensity: ver-bal pain scale, numeric pain scale and mixed scales. More-over, there is another pain scale, the “visual analogue scale(VAS)”, which is more efficient, sensitive and reproducible[8]. However, the VAS scale is one-dimensional and onlyassesses pain intensity but not other aspects such as inca-pacity, affective alterations, etc. There are multidimension-al pain questionnaires that evaluate multiple dimensions as-sociated to pain such as the McGill questionnaire [9].Moreover, there is a short-form McGill Pain Questionnaire(MPQ), which is a useful tool in situations in which thestandard MPQ takes too long to be administrated [10].

The increasing interest in palliative care and interventionsfor symptom control in cancer patients has developed the needfor precise cancer pain evaluation, as a fundamental compo-nent of quality of life (QOL) assessment [11]. The MemorialPain Assessment Card (MPAC) is a self-assessment card ofcancer pain validated in the Memorial Sloan-Kettering CancerCenter of New York in 1987 and widely used in the UnitedStates [12]. In 2004 a Spanish version of the MPAC was vali-dated. All three MPAC subscales (pain intensity, VASPI;Tursky scale; and pain mood, VASMOOD scale) were validat-ed. However, the validation of the pain relief scale (VASPR)required a follow-up study to be confirmed [13].

The aims of the present study were (1) to assess thesensitivity to change of all the Spanish version MPAC sub-scales and (2) to evaluate the agreement between patientsand medical personnel in the card use facility.

Material and methods

Subjects

Patients with solid tumour or haematologic cancer, contin-uous chronic cancer pain, baseline pain intensity of ≥3 in avisual analogue scale (VAS) and who had previously giventheir written consent to be included in the study were in-cluded consecutively. Patients without a suitable knowl-edge of Spanish and/or an inability to understand and signthe written consent were excluded from the study.

Study design

A prospective, multicentre study was conducted at 4 oncol-ogy services (two medical oncology and two radiotherapyoncology services) to assess the sensitivity to change of theSpanish version of the MPAC scale. The recruitment periodwas from March 2005 to April 2006.

The study included a baseline visit (visit 1), one weekvisit (visit 2) and one month visit (visit 3) during the fol-

low-up period. At the baseline visit, data related to the di-agnostics of oncologic illness (cancer aetiology, tumour ex-tension, pain origin and oncologic treatment) were collect-ed. At each visit, the MPAC subscale values wereevaluated. The patient and health-care-professionals satis-faction questionnaire with the MPAC card (self-developedby the study) was recruited at the last patient visit.

Assessment instrument

The MPAC is a four-sided card. One side gives a list of ad-jectives to describe the intensity of the pain (Tursky scale)and on the other 3 there is a line 100 mm long to assess theintensity of the pain (VASPI), the degree of pain reliefachieved (VASPR) and the patient’s mood (VASMOOD).The evaluation in this last scale has been modified with re-spect to the English version, with the left end of the scalethe best mood and the right end the worst mood.

The MPAC size is 21.6×27.94 cm and is folded in halftwice so that the patient can be quickly shown the foursides. Figure 1 shows the Spanish version of the MPAC.

Sample size

The sample size was calculated considering the primaryendpoint of the study: to assess the sensitivity to change inthe Spanish validated MPAC in cancer patients.

A sample of 19 patients will provide a 90% power to de-tect a minimum of 2 points of difference in the VAS scalebetween the last and the first visit. Two points of standarddeviation and a significance of 0.01 were considered.

To evaluate the sensitivity to change in the oncologyand radiotherapy oncology services, and to make up for thelosses that are assumed in 20%, it will be necessary to in-clude a total sample of 48 patients.

Statistical analysis

Statistical analyses were done using the SAS statisticalsoftware (version 8.2). The sensitivity to change was as-sessed by the Wilcoxon test. The relation between the VASpain and the MPAC subscales was evaluated by theKruskal–Wallis test. Spearman correlations were used toassess correlations among subscales of the MPAC (VASPI,VASMOOD and VASPR).

Results

Baseline characteristics

A total of 54 patients were studied (41 men and 13 wo -men). The mean age was 57.2 years (±SD of 11.2). The sex

656 Clin Transl Oncol (2008) 10:654-659

imbalance and the lack of elderly people could result in abias (Table 1).

A clinical history showed that the most frequent canceraetiology was pleuropulmonary cancer (40.7%), followedby head and neck cancer (25.9%) and breast cancer(14.8%). Moreover, most of the patients presented metasta-sis (74.1%).

Cancer treatment was mostly palliative (79.6%), pa-tients being treated with chemotherapy (38.9%), radiother-apy (31.5%) or a combination of both (27.8%). All patientsreceived some analgesic intervention and mostly pharma-cologic treatment with opioids (Table 1).

Comparison of the MPAC subscales among the follow-upstudy

The comparison of the MPAC subscales was done amongall evaluable patients at visit 1 (baseline visit) and visit 2(one week visit). However, at one month of the follow-up(visit 3), 22.2% of patients had discontinued the study (1death, 7 given up the follow-up and 4 hospitalised due todisease worsening). Furthermore, more than half of the pa-tients changed their oncologic treatment (at visits 2 and 3,68.5% and 51.1%, respectively) (Table 2).

All the subscales showed sensitivity to change during thefollow-up. The rate of the VASPR subscale reflected a grad-ual increase of pain relief with mean values of 4.5±1.9 (visit1), 5.1±2.2 (visit 2) and 6.3±2.3 (visit 3) during the follow-up. Moreover, the pain intensity punctuation (VASPI) dimin-ished, showing mean values of 6.6±1.6 (visit 1), 4.6±2.2(visit 2) and 3.5±1.9 (visit 3). The Tursky and the psycho-logical distress subscales showed pain relief too (mean VAS-MOOD values of 5.5±2.1, 4.9±2.3 and 4.0±2.1) (Table 2).

The changes in the three VAS subscales were statisti-cally significant between visits 1 and 3 (p<0.0001 VASPI,p=0.0002 VASPR and p=0.0008 VASMOOD). At the sec-

4MOOD SCALE

Worst mood Best mood

Fig. 1 Memorial Pain Assessment Card, Spanish version (MPAC)For adolescents and adults, the card is folded along the broken line so that each measure is presented separately in the numbered order

3RELIEF SCALE

No relief Complete

or pain reliefof pain

1PAIN SCALE

Least Worstpossible possible

pain pain

2Moderate Just noticeable

Strong No pain

Mild

Excruciating Severe

Weak

Table 1 Baseline characteristics: 54 patients

Baseline characteristics

Age, years mean±SD 57.2±11.2Gender, n (%) male 41 (75.9)Cancer aetiology, n (%)Pleuropulmonary cancer 22 (40.7)

Head and neck cancer 14 (25.9)Breast cancer 8 (14.8)Digestive cancer 7 (13)Urinary system cancer 3 (5.6)

Tumour extension, n (%)Metastasis 40 (74.1)Regional localisation 11 (20.4)Local 3 (5.6)

Treatment intention, n (%)Palliative 43 (79.6)Curative 11 (20.4)

Pain origin, n (%)Tumour 47 (87)Treatment 7 (13)

Oncologic treatment, n (%)Radiotherapy 17 (31.5)Chemotherapy 21 (38.9)Radiotherapy and chemotherapy 15 (27.8)

Other specific oncologic treatments, n (%)Hormonotherapya 1 (1.9)Vertebroplasty 1 (1.9)Zometaa (zoledronic acid) 1 (1.9)

Analgesic intervention, n (%) 54 (100)Pharmacological treatment, n (%) 53 (98.1)

aPatients with radiotherapy and specific treatment

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ond visit (first week) only the VASPI subscale showed sig-nificant differences with regard to the baseline visit(p<0.0001) (Table 2).

The study of the correlations between the MPAC sub-scales showed significant relationships between them atvisits 2 and 3 (p≤0.021), whereas at the baseline visit onlyVASMOOD and VASPI subscales were significantly corre-lated (p=0.029) (Table 3). As expected, VASPI and VASPRcorrelated negatively, as well as VASPI and VASMOOD.The strongest relationship was observed between VASPIand VASPR at visit 2 (correlation coefficient r=-0.64).

Patients and health-care professionals’ degreeof satisfaction with use of the MPAC

Among 41 patients evaluated, 58.5% qualified the use ofMPAC as comfortable and 26.8% as very comfortable,while only 2.4% considered it as uncomfortable. Moreover,63.4% and 24.4% thought that the card was easy or veryeasy to use and only 4.9% considered it difficult to use(Table 4).

It was observed that almost half of the patients (48.8%)agreed and 24.4% totally agreed with the information sup-plied by the MPAC, while 26.8% totally disagreed with theinformativity of the MPAC questionnaire. Similarly, 56.1%of the patients thought that the card increased the doctor’sefficiency and 24.4% completely agreed with this informa-tion. Finally, about half of the patients (48.8%) would rec-ommend the MPAC card, and almost one third of the pa-tients (29.3%) entirely agreed to recommend it.

With respect to the opinion of the health-care profes-sionals (49 valid data), most of those polled (93.9%)agreed with the advantages of the MPAC, despite it involv-ing extra work for them (93.9%). The majority of them con-sidered the use of MPAC for patients to be easy (71.4%) orvery easy (26.5%) (Table 5).

Most of the health-care professionals (79.6%) consid-ered that the MPAC influences their prescriptions, whereas20.4% of them are indifferent to its results. Finally, allhealth-care-professionals polled in the survey the spreedrecommendation of the MPAC use (65.3% declared toagree and 34.7% totally agreed).

Table 2 Rate of the MPAC subscales and means differences during the 1-month follow-up period

MPAC scaleProspective follow-up

Visit 1 Visit 2 Visit 3

MPAC performed, n (%) 54 (100) 54 (100) 42 (77.8)Treatment change, n (%) – 37 (68.5) 24 (51.1)VASPR, mean±SD 4.5 (1.9) 5.1 (2.2) 6.3 (2.3)VASMOOD, mean±SD 5.5±2.1 4.9±2.3 4.0±2.1Tursky Excruciating, n (%) 15 (27.8) 2 (3.7) –Strong, n (%) 21 (38.9) 18 (33.3) 7 (16.7)Severe, n (%) 12 (22.2) 8 (14.8) 6 (14.3)Moderate, n (%) 6 (11.1) 17 (31.5) 19 (45.2)Just noticeable, n (%) – 2 (3.7) 7 (16.7)Weak, n (%) – 2 (3.7) 2 (4.8)Mild, n (%) – 3 (5.6) –No pain, n (%) – 2 (3.7) 1 (2.4)VASPI, mean±SD 6.57±1.7 4.58±2.2 3.49±2.0Mean differences ±SD

Visit 3-visit 1 Visit 2-visit 1 Visits 1-2-3b

VASPI –2.9±2.9a –1.9±2.5a <0.0001VASMOOD –1.2±2.3a –0.5±2.5 0.1167VASPR 1.8±2.8a 0.6±2.5 <0.0001

aWilcoxon signed ranks test (p<0.05)bFriedman test (p<0.05)

Table 3 Spearman correlation coefficients (and p-values) amongVASPI, VASPR and VASMOOD subscales

VASPI VASPR

Baseline visit (visit 1)VASPI –VASPR –0.050 (0.7145) –VASMOOD 0.297 (0.0291)* –0.09 (0.4792)

One week visit (visit 2)VASPI –VASPR –0.644 (<0.0001)* –VASMOOD 0.438 (0.0009)* –0.312 (0.0213)*

One month visit (visit 3)VASPI –VASPR –0.447 (0.0029)* –VASMOOD 0.460 (0.0022)* –0.353 (0.0217)*

*Statistically significant Spearman correlations

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Discussion

The usefulness of the MPAC to improve the knowledgeabout unmeasured palliative effects of cancer treatment hasbeen previously proven [5, 14]. Moreover, a study carriedout among pancreas cancer patients showed that one thirdof them had inadequate pain control despite the use of oralanalgesics; however, the authors stated that these patientscould be easily identified with the use of the MPAC card[15]. Furthermore, the MPAC questionnaire is very fast tofill in, it only takes 20 seconds, compared to other ques-tionnaires. Therefore, the Spanish version of the MPACwould be an important and easy tool to use in the assess-ment of cancer patients in Spain.

At present, there are three scales commonly employedfor measuring cancer pain intensity: the simple descriptorscale (SDS), the visual analogue scale (VAS) and the nu-meric pain intensity rating scale (NRS). The last one has

been found to be a simple and valid alternative to measurecancer pain intensity in some disease states. Paice and Co-hen [16] showed that NRS provides a useful alternative tothe VAS, particularly in acute ill patients that are unable tocomplete the VAS. However, all these scales are one-di-mensional and assess the pain intensity but not other as-pects such as incapacity, affective alterations, etc. As alter-natives to the unidimensional there are many quality of life(QoL) questionnaires, but they are less easy to use and verytime consuming. The MPAC scale is much easier to admin-istrate than a QoL questionnaire, and allows multidimen-sional evaluation of patient status. There are some studiescomparing the use of MPAC with other measurements ofQoL, and all of them showed significant correlations [5,14, 15, 17]. However, other studies noticed that the MPACmeasure of quality of life is not useful for assessment in aterminally ill cancer population. Shannon et al. [18] foundthat about half of advanced cancer patients were able to

Table 4 Degree of patient satisfaction with the MPAC

Item 1. Convenience Very satisfied 11 (26.8%)Satisfied 24 (58.5%)Indifferent 5 (12.2%)Unsatisfied 1 (2.4%)

Item 2. Ease of use Very easy 10 (24.4%)Easy 26 (63.4%)Indifferent 3 (7.3%)Difficult 2 (4.9%)

Item 3. Informativity Totally agree 10 (24.4%)Agree 20 (48.8%)Indifferent 11 (26.8%)

Item 4. Increasing the efficiency of the doctor Totally agree 10 (24.4%)Agree 23 (56.1%)Indifferent 8 (19.5%)

Item 5. Possible recommendation to other patients Totally agree 12 (29.3%)Agree 20 (48.8%)Indifferent 8 (19.5%)Disagreement 1 (2.4%)

Total number of patients evaluated was 41 (100%)

Table 5 Degree of health-care professional satisfaction with the MPAC

IItem 1. Overload Nothing 2 (4.1%)A little 46 (93.9%)Enough 1 (2.0%)

Item 2. Ease of use for the patient Very easy 13 (26.5%)Easy 35 (71.4%)Indifferent 1 (2.0%)

Item 3. Informativity Totally agree 12 (24.5%)Agree 35 (71.4%)Indifferent 2 (4.1%)

Item 4. Influence in the analgesic prescription Totally agree 16 (32.7%)Agree 23 (46.9%)Indifferent 10 (20.4%)

Item 5. Recommendation to use the questionnaire Totally agree 17 (34.7%)Agree 32 (65.3%)

Total number of health-care professionals evaluated was 49 (100%)

Clin Transl Oncol (2008) 10:654-659 659

complete the MPAC. Nevertheless, our study, which in-cludes patients with chronic cancer pain and a VAS≥3,showed that most patients (77.8%) answered the follow-upquestionnaire. Dropping out of the study was the main rea-son for not completing the follow-up questionnaire.

On the other hand, this study has revealed significantcorrelations between the different subscales during the fol-low-up, except for the baseline visit, where only the VASPIand VASMOOD subscales were correlated. Moreover, thechanges in punctuations obtained in the subscales amongthe different visits were statistically significant, which con-firms the sensitivity to change of the Spanish version of theMPAC. In our study VASPI rate was reduced by 44% inone month, which indicates quite good pain managementin these patients.

The degree of patient satisfaction with the MPAC cardwas good. Mostly, they considered it as easy or very easyto use (87.8%), they agreed with the information provided(73.2%) and considered it as comfortable or very comfort-able (85.3%); 78.1% would probably recommend it to oth-er patients and 80.5% thought that the card increases thedoctor’s efficiency. Nonetheless, the degree of satisfaction

with the MPAC card was higher among the health-careprofessionals than among the patients, despite implying ex-tra work for them. Mainly, they considered it as easy orvery easy to use for the patient (97.9%) and providing use-ful information (95.9%), and all of them would recom-mend generalising its use. A similar percentage (79.6%)agreed with the influence of the MPAC in the analgesicprescription. Consequently, in the future it would be inter-esting to assess the possible effects of the use of MPAC inanalgesic effectiveness.

Despite some methodological limits, such as the samplesize, which may not be representative of the general popula-tion, the present study showed sensitivity to change amongthe different MPAC subscales of the Spanish version, andvalidated the VASPR subscale. Moreover, the Spanish ver-sion of the MPAC has proven to be a good tool accepted byboth health-care professionals and patients. Thus, in thenear future, we recommend its use in follow-up cancer pa-tients with the aim of optimising pain treatment.

Acknowledgements The authors would like to express their thanks tothe Infociencia S.L. Medical Writing Department.

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