The Management of Cancer Pain, Volumes 1 and 2
Evidence Report/Technology Assessment Number 35
Prepared by the New England Medical Center EPC, Boston, MA
Published by the Agency for Healthcare Research and Quality, Rockville, MD
AHRQ Publication No. 02-E002, October 2001
www.ahrq.gov/clinic/capaininv.htm
Numerous treatment modalities and approaches have been described for the management of cancer pain. Some are more general, whereas others target specific problems and pain syndromes. The emergent paradigm of evidence-based practice prompts us to review these treatments with closer scrutiny. This two-volume publication, therefore, makes a very timely appearance.
The report is a robust systematic review summarizing published evidence on the prevalence of cancer-related pain and the efficacy of drug and non-drug therapies for treatment of cancer pain, with a focus on randomized controlled trials. A team from the New England Medical Center Evidence-Based Practice Center was commissioned by the Agency for Health Care Research and Quality (AHRQ) in the United States to undertake this monumental task. Twenty-four epidemiological surveys of cancer pain, 188 randomized controlled trials of cancer pain treatments, and 100 non-randomized studies were included in the final analysis and abstracted in evidence tables. Volume 1 describes the methods used to conduct the review and summarizes the results and the evidence tables are contained in Volume 2.
The investigators use 6 major questions and 20 secondary questions to frame the review. The questions address various issues such as the epidemiological characteristics of cancer-related pain and the relative efficacy of opioids, NSAIDs, antidepressants, anticonvulsants, psychostimulants, calcium channel blockers (among others) in treating neuropathic cancer pain. Questions related to the effectiveness, side-effect profiles, and patient preferences of different opioids; opioid formulations; and routes of administration (including the oral, rectal, parenteral and intraspinal routes) are tackled. The relative analgesic efficacy of treatments such as chemotherapy, bisphosphonates, calcitonin, radiation, or radionuclide therapy is reviewed. The evidence related to the roles of non-pharmacological physical or psychological treatments such as relaxation, massage, and music in the management of cancer-related pain and alternative therapies such as herbs and vitamins is also explored.
Chapter 1 provides an overview of the report and chapter 2 documents, step by step, the methodology employed. Chapter 3 contains the results. Studies are summarized in the text and graded individually and collectively with regard to their robustness and applicability to each question posed. Although much of the focus is on randomized controlled trials, the investigators also report supplemental analyses. For example, they compare the results of meta-analysis of randomized controlled trials and meta-analysis of non-randomized studies. Non-randomized observational studies examining the implementation of WHO guidelines for the management of cancer pain are also analyzed. The main conclusions are stated in chapter 4 and areas for future research are highlighted in chapter 5. A comprehensive bibliography and list of references is included. The format of the report probably made it difficult to include an index, but the list of contents makes up for this shortcoming. The investigators make it clear that the report is a literature synthesis and neither a clinical practice guideline nor a survey of current practice. They emphasize that it is intended to provide background information.
This two-volume publication is an invaluable resource for clinicians, educators, researchers, and policy-makers involved in caring for patients with cancer pain. It is easy to read, scientifically sound, and clinically applicable, with thought-provoking conclusions.
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