Introduction

From Cancer Guidelines Wiki
Contents Introduction Recommendations Overview Patient-centred care Screening Assessment
Self-management Pharmacological Mx Non-pharmacological Mx Practice improvement Resources Opioid formulations References

Introduction

Scope of this guideline

This guideline provides brief, point-of-care recommendations for screening, assessment and management of cancer-related pain in adults. It focuses on chronic pain rather than acute pain caused by cancer treatments or pain in cancer survivors (which is best addressed by referral to a specialist pain medicine physician). Future work is planned to develop guidelines for the management of acute pain in people with cancer.

The guideline makes recommendations about both pharmacological and non-pharmacological management as well as patient awareness and self-management. These recommendations are specific to adults and should not be used as a guide to pain management in children with cancer.

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Who this guideline is intended for

This guideline is intended for Australian health professionals of all disciplines caring for people with cancer. These recommendations are not intended to replace expert clinical judgment, but to enable those without specialist knowledge to provide the essentials of care.

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Background

An estimated 30–75% of people with cancer experience pain, and pain is under-treated in up to half of cases.[1][2][3][4][5] Failure to manage pain is due to barriers at all levels - patient, caregiver, health professional and healthcare system. [6][7][8][9][10][11][12][13][14] The first guideline to focus on management of cancer pain was released by the World Health Organisation in 1986.[15] Since then, a large number of guidelines have become available internationally. Research has demonstrated that implementation of evidence-based clinical practice guidelines for cancer pain can improve the processes of care and patient outcomes.[10]

The need for an Australian guideline

The management of cancer pain in Australia has been identified as an important area for improvement by both the National Institute of Clinical Studies (National Health and Medical Research Council) and the Cancer Institute New South Wales.[16][17] Timely access to best-practice, evidence-based assessment and care for patients in pain is one of six major goals identified by the Australian National Pain Strategy, [18] which was developed by clinicians and consumers at the 2010 National Pain Summit.[19] Painaustralia was formed in early 2011 to to facilitate implementation of the NPS, with consumers included among its founding members and steering committee. Consumer input was invited with the Consumer Health Forum of Australia with representatives from Arthritis NSW and Palliative Care Queensland. Further consumer input was provided by individuals with cancer and caregivers.

The National Pain Summit’s Cancer Pain and Palliative Care Working Group recommended that primary objectives should be the promotion of pain management guidelines and systems to ensure adequate assessment and management of cancer pain. As a starting point, the Cancer Pain and Palliative Care Working Group determined that existing international and overseas guidelines should be adapted for Australian clinical practice.

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Development of this guideline

An Organising Committee (Table 1) was formed in October 2010 to plan and oversee development of this guideline. To better understand clinician needs, a national survey of current practice was administered online from August 2011 to April 2012. Five hundred and twenty seven health professionals responded from a wide range of disciplines. Respondents were strongly supportive of Australian guidelines and implementation strategies but advocated for these to make use of existing international guidelines rather than allow local guidelines to proliferate unnecessarily.[20] The Organising Committee decided to use the ADAPTE approach [21] to adapt international guidelines to the Australian setting. ADAPTE specifies that guideline adaptation follow a three phase process of Set-up, Adaptation and Finalization.

During Set-up, the Organising Committee agreed that synthesis and adaptation of a number of guidelines would be required rather than selecting a single candidate guideline for adaptation. A Working Party was convened to provide expert guidance (Table 2) and held its inaugural meeting in January 2012. Meetings were held bi-monthly. Two panels of expert clinicians (Table 3) individually provided expert consultation to the Working Party on pharmacological management and management of adverse effects.

During the Adaptation phase, discussions were initially aimed at more clearly defining the focal Population, Intervention, Professionals, Outcomes and Health setting (PIPOH) for the adapted guideline. Existing guidelines were identified via the reference lists of previous reviews [22][23][24] and searches of online databases and clearing houses and were screened according to the following eight criteria:

  • a primary focus on adults with chronic cancer pain
  • relevance across tumour types and stages
  • inclusion of recommendations for assessment and/or management of pain by means of either pharmacological or non-pharmacological intervention
  • capacity to inform pain assessment and management across disciplines and settings
  • published in the previous 3 years (i.e. 2008 or later)
  • national or international (i.e., not centre-specific)
  • available in English
  • independently rated as 'recommended' or 'strongly recommended' by two members of the Working Party based on criteria of the Appraisal of Guidelines Research & Evaluation (AGREE) Instrument.[21]

The following guidelines met all criteria and were considered for adaptation:

The Working Party compared recommendations between the source guidelines and assessed each according to currency, the quality of evidence on which they were based, and applicability to the Australian setting. Recommendations identified as the most suitable were either directly adopted or modified as necessary.

In clinical situations where no recommendation applicable to the Australian setting was available, the Working Party developed recommendations based on members’ clinical expertise and experience. Recommendations of this kind are distinguished from those adapted from existing guidelines by the term 'Consensus'.

Recommendations for pharmacological pain management and recommendations for management of adverse effects were referred to two panels of expert clinicians (Table 3).

The Working Party was guided throughout by principles of holistic person-centred care and a concern for potential inappropriate prescribing, especially in elderly patients.

For each of the recommendations in this Australia guideline, we cite as sources:

  • one or more adapted guideline(s). To see the grade of each recommendation within its source guideline or the level of evidence on which recommendations are based, users should refer to the original guidelines (links provided).
  • other Australian authorities.
  • considerations taken into account by our Working Party and panels of Australian expert clinicians when developing consensus recommendations.

Where available, we refer readers to other Australian clinical practice guidelines for the management of specific clinical problems (e.g. psychosocial concerns).

Table 1. The Australian Adult Cancer Pain Management Guideline Organising Committee

Patricia Davidson

(Co-chair)

Nurse

Director, Centre for Cardiovascular and Chronic Care, University of Technology Sydney (UTS)

Professor of Cardiovascular Research, St Vincent's Hospital, Sydney

Sydney, NSW
Melanie Lovell

(Co-chair)

Palliative care physician

Staff Specialist, Palliative Medicine, Greenwich Hospital

Visiting Medical Office, Mater Hospital

Clinical Senior Lecturer, Northern Clinical School, The University of Sydney

Sydney, NSW
Meera Agar Palliative care physician

Director of Palliative Care, Braeside Hospital

Conjoint Associate Professor, South Western Sydney Clinical School, University of New South Wales (UNSW)

Conjoint Associate Professor, School of Medicine, The University of Notre Dame, Australia

Director of Clinical Trials, Ingham Institute of Applied Medical Research

Sydney, NSW
Anna Green

(Administrative support)

Research Administrative Coordinator, Centre for Cardiovascular and Chronic Care, UTS Sydney, NSW
Tim Luckett

(Project Manager)

Program Coordinator, Improving Palliative Care through Clinical Trials (ImPaCCT)

Research Fellow, Faculty of Health, UTS and South Western Sydney Clinical School, UNSW

Sydney, NSW

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Table 2. The Australian Adult Cancer Pain Management Guideline Working Party
Memeber Position Location Conflict of interest statement
Melanie Lovell

(Chair)

Palliative care physician

Staff Specialist, Palliative Medicine, Greenwich Hospital

Visiting Medical Office, Mater Hospital

Clinical Senior Lecturer, Northern Clinical School

Sydney, NSW No conflict of interest (COI)
Meera Agar Palliative care physician

Director of Palliative Care, Braeside Hospital

Conjoint Associate Professor, South Western Sydney Clinical School, University of New South Wales (UNSW)

Conjoint Associate Professor, School of Medicine, The University of Notre Dame, Australia

Clinical trials Director, Ingham Institute of Applied Medical Research

Sydney, NSW No COI
Frances Boyle Medical oncologist

Director, The Patricia Ritchie Centre for Cancer Care and Research, The Mater Hospital North Sydney.

Professor of Medical Oncology, Northern Clinical School, The University of Sydney

Honorary Medical Officer, Royal North Shore and Greenwich Hospitals, Sydney

Visiting Medical Oncologist, North Shore Private Hospital, Sydney

Medical Oncologist, Melanoma Institute of Australia

Medical Director, Pam McLean Centre, The University of Sydney

Sydney, NSW Member of Advisory Board for Takeda Pharmaceuticals Australia Pty Ltd
Tim Luckett

(Coordination and administrative support)

Program Coordinator, Improving Palliative Care through Clinical Trials (ImPaCCT)

Research Fellow, Faculty of Health, UTS

Research Associate, South Western Sydney Clinical School, UNSW

Sydney, NSW No COI
Jane Phillips Nurse

Professor Palliative Nursing, School of Nursing, The Cunningham Centre for Palliative Care and The University of Notre Dame, Australia

Sydney, NSW No COI
John Stubbs Consumer

Cancer Voices Australia (until June 2012)

canSpeak (July 2012 onwards)

Sydney, NSW No COI

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Table 3. Expert panels of clinicians who provided consultation to the Working Party

Pharmacological management panel
David Currow Palliative care physician

Professor and Chair of Palliative and Supportive Services, Flinders University

Chief Cancer Officer and Chief Executive Officer, the Cancer Institute NSW

Adelaide, South Australia
Jan Maree Davis Director of Palliative Care, St George Hospital

President, NSW Society of Palliative Medicine

Senior Research Fellow, Faculty of Medicine, UNSW

Sydney, NSW
Janet Hardy Palliative care physician

Director of Palliative and Supportive Care, Mater Health Services Brisbane

Brisbane, Queensland
Christine Sanderson Palliative care physician

Staff Specialist, Palliative Medicine, Calvary Health Care Sydney

Research Fellow, Palliative and Supportive Services, Flinders University

Sydney, NSW
Odette Spruyt Palliative care physician

Director of Pain and Palliative Care, Peter MacCallum Cancer Centre

Melbourne, Victoria
Management of adverse effects panel
Melanie Benson Palliative care physician

Staff Specialist, Palliative Medicine, The Alfred

Melbourne, Victoria
Katherine Clark Palliative care physician

Director and Area Director of Palliative Care, Calvary Mater Newcastle

Conjoint Professor, School of Medicine and Public Health, The University of Newcastle

Newcastle, NSW
Winston Liauw Medical oncologist

Clinical pharmacologist

Staff Specialist, Medical Oncology, St George Cancer Care Centre Sydney

Conjoint Associate Professor, Faculty of Medicine, UNSW

Chair, Chair Cancer Institute NSW Clinical Research Ethics Committee

Member of the Board, National Prescribing Service

Visiting Medical Officer, Southern Oncology Specialists and St George Private Hospital

Sydney, NSW

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Conflicting interest statements and management

Working Party members were asked to declare any interests relevant to the guideline development, prior to commencement. Members were asked to update their information if they became aware of any changes to their interests.

All declarations were added to a register of interests as listed in the table above. The register was made available to the Working Party throughout the development of the guideline, allowing members to take any potential conflicts of interest into consideration during discussions, decision making and formulation of recommendations.

The guidelines have now entered the updating phase. Guideline Working Party members are responsible to update their conflict of interest statements if a new interest arises.

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Funding

Development of this guideline was funded by Improving Palliative Care through Clinical Trials (ImPaCCT) and HammondCare.

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Updating the guideline

This guideline will be updated each year from 2013 to include recommendations added to new editions of the source guidelines or any new guidelines that meet criteria for quality and applicability.

The developers of this guideline acknowledge that the recommendations in the first edition may not fully meet the information needs of Australian clinicians. Users are invited to use the blue CCA comment button.png buttons to submit clinical questions for consideration in the next edition. Selected clinical questions will be answered by systematic reviews or new Australian research.

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Acknowledgements

Jutta von Dincklage, Product Manager (Wiki Development), Cancer Council Australia

Jenni Harman, Medical writer, Meducation Australia

Mary-Rose Birch, HammondCare, for her role in developing the patient-held resources and pilot work

painaustralia (http://www.painaustralia.org.au)

The Working Party thanks Cancer Council Australia for hosting the online consultation draft of this guideline on their website.

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References

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Notes

* ↑ NICE 2012 became available just as a draft of recommendations based on the other five guidelines was being finalised. Draft adapted recommendations for opioid use were checked against those of the NICE guideline for consistency.

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