risk factors for inadequate treatment of cancer-related pain among african american and latino...

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

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

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.

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

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.

ECOG Minority Study: Findings

• Negative Pain Management Index

– Majority patients: 38%

– Minority patients: 65%

– Cleeland et al, Annals Internal Med, 1997

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.

PREMO Sites

• Houston

– UT MD Anderson Cancer Center

– Two Harris County Hospitals

– VAMC

• Miami

– One County Hospital

Pain-Related Variables among Minority Cancer Patients

Patient GroupPercent with severe pain

African American 72%

Hispanic 57%

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

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

Educational Materials

• Emphasize pain relief

• Teach how to report pain

• Model patient communication

• Reduce fears of opioids

• Cultural issues

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

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

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

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

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

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

Mean Pain Severity over Time for Education and Control Groups

3

4

5

6

7

8

9

10

T1 T2 T3 T4

Education

Control

Mean Pain Severity over Time for African American Patients

3

4

5

6

7

8

9

10

T1 T2 T3 T4

Education

Control

Mean Pain Interference over Time for Education and Control Groups

3

4

5

6

7

8

9

10

T1 T2 T3 T4

Education

Control

Perceived Pain Control over Time for Education and Control Groups

10

15

20

25

30

35

40

T1 T2 T3 T4

Education

Control

Mean SF-12 Physical Component Summary Scores

0

10

20

30

40

50

60

Time 1 Time 2 Time 3 Time 4

Education

Control

Mean SF-12 Mental Component Summary Scores

0

10

20

30

40

50

60

Time 1 Time 2 Time 3 Time 4

Education

Control

Physicians’ Underestimates of Patients’ Pain

Group Time 1 Time 2 Time 3 Time 4

Education 77% 67% 87% 88%

Control 68% 70% 52% 75%

Negative Pain Management Index

Group Time 1 Time 2 Time 3

Education 60% 32% 50%

Control 49% 38% 42%

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

Why?

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

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%

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%

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%

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%

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.”

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.”

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.”

Risk Factors for Inadequate Pain Treatment

• Marital Status

– Single: 74% under treated

– Married: 58% under treated

Risk Factors for Inadequate Pain Treatment

• Ethnicity

– Latino patients: 59% under treated

– African American patients: 48% under treated

– P = 0.10

Risk Factors for Inadequate Pain Treatment

• Performance Status

– Poor performance status: 36% under treated

– Good performance status: 45% under treated

– P = 0.11

Risk Factors for Inadequate Pain Treatment

• Physician Assessment

– Inadequate: 58% under medicated

– Adequate: 37% under medicated

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

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

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