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| A1. Complete a comprehensive assessment if either of the following apply:
• a new patient reports a pain score of 2 or more on self-reported numerical rating scale of zero to 10 or pain score is 3 or more on the Abbey Pain Scale (see Screening)
Assess all the following to determine the individual’s pain management needs:
The Working Group considered this information to provide necessary context for other assessments
• Pain severity (using a validated tool) (NCCN, SIGN)
• Pain experience (location, interference, timing, description, aggravating and relieving factors) (ESMO, NCCN, NHS, SIGN)
• Current and previous management of pain (ESMO, NCCN, NHS, SIGN) and other symptoms
The Working Group considered this information to provide necessary context for other assessments
• Physical examination and, where needed, further investigations (NCCN, NHS, SIGN)
• Functional status (ESMO)
• Risk factors for poorly controlled pain (NCCN)
• Patient and family preferences (goals and expectations for comfort, advance directives) (NCCN)
• Factors suggesting an oncological emergency. (NCCN)
Reassess whenever there is a change in pain or a new pain is reported.
- 1 Assessment
- 2 Assessment checklist
- 2.1 [ ] Disease status and treatment
- 2.2 [ ] Pain severity
- 2.3 [ ] Pain experience
- 2.4 [ ] Description (type: neuropathic or nociceptive – see comment below)
- 2.5 [ ] Current and previous management of pain and other symptoms
- 2.6 [ ] Pain meaning, beliefs and knowledge
- 2.7 [ ] Psychosocial assessment
- 2.8 [ ] Cognitive functioning
- 2.9 Physical examination and further investigations
- 2.10 [ ] Risk factors for poorly controlled pain
- 2.11 [ ] Preferences for care based on individual’s goals and expectations for comfort
- 2.12 [ ] Oncological emergencies
- 3 References
- 4 Appendices
[ ] Disease status and treatment
[ ] Record the person’s disease status:
Anticancer treatments that may cause peripheral neuropathy
[ ] Pain severity
[ ] Pain experience
If the person has more than one pain, number each and complete all assessments for each pain (including any pain not caused by cancer).
[ ] Location
[ ] Interference with activities
If pain is impairing the person’s ability to perform activities of daily living, consider referral to a physiotherapist or occupational therapist for further assessment.
[ ] Timing
Aim to establish whether timing of pain is predictable or random and whether breakthrough analgesia might be needed preemptively.
[ ] Description (type: neuropathic or nociceptive – see comment below)
[ ] Assess and record the quality of pain. Allow the patient to describe his/her pain, prompting with the descriptors listed below if needed.
Descriptive terms for neuropathic pain have been taken from: Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs Pain 2001 May;92(1-2):147-57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11323136
[ ] Aggravating and relieving factors
[ ] Current and previous management of pain and other symptoms
[ ] Other symptoms
[ ] Pain meaning, beliefs and knowledge
Provide education tailored to patients’ and families’ knowledge, beliefs and attitudes about pain and pain treatment.
Suggested questions to ask person:
What do you think is causing the pain?
Has someone else in the family had cancer pain?
Is there anything you are afraid of related to the pain or its management?
Is there anything that worries you about the treatment of pain?
Source: Kissane D, Bultz B, Butow P, Finlay I, editors. Handbook of communication in oncology and palliative care. Oxford: Oxford University Press; 2010.
Suggested questions to assess risk of opioid misuse:
At any time in your life, have you ever used alcohol, cannabis, other drugs, or any substance that can lead to dependence, including a medicine normally prescribed by a doctor?
[For each substance named]
Do you think your use of [substance] was out of control?
Did the prospect of missing a drink/fix/dose of [substance] make you anxious or worried?
Did you worry about your use of [substance]?
Did you wish you could stop?
How difficult did you find it to stop or to go without [substance]?
Has anyone in your immediate family (e.g. a parent, brother or sister) ever been addicted to or dependent on any substance, including alcohol, other substances (such as cannabis or other drugs), or a medicine normally prescribed by a doctor?
Adapted from: Gossop M, Darke S, Griffiths P, et al. The Severity of Dependence Scale (SDS): psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users. Addiction 1995; 90: 607–14. Available from: www.ncbi.nlm.nih.gov/pubmed/7795497
Suggested questions to assess contribution of spiritual beliefs to pain and its management
Do you have spiritual beliefs that help you cope?
What importance does your faith or belief have in your life?
How does your faith or belief affect the way you think about your pain?
[ ] Cognitive functioning
If self-reporting of pain intensity is difficult due to cognitive impairment, use a tool validated for this population such as the Abbey Pain Scale
Physical examination and further investigations
A sudden change in the type or intensity of pain warrants further investigations.
[ ] Functional status
Consider using one of the following:
If pain is contributing to functional impairment, consider referral to physiotherapist, occupational therapist, social worker or palliative care team.
[ ] Risk factors for poorly controlled pain
If self-reporting of pain intensity is difficult due to cognitive impairment, use the Abbey Pain Scale
For patients whose ability to communicate with the treating team may be affected by a language barrier, use a healthcare interpreter.
The Brief Pain Inventory is available in many community languages (listed on the MD Anderson Cancer Center website).
[ ] Preferences for care based on individual’s goals and expectations for comfort
Suggested questions to ask person
What are you hoping to do with improved pain relief which you can't do now? (e.g. sleep better, be more active)
What aspects of daily life are you most hoping pain management can help with?
[ ] Oncological emergencies
Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs Pain 2001 May;92(1-2):147-57.
Gossop M, Darke S, Griffiths P, et al. The Severity of Dependence Scale (SDS): psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users. Addiction 1995; 90: 607–14.
Kissane D, Bultz B, Butow P, Finlay I, editors. Handbook of communication in oncology and palliative care. Oxford: Oxford University Press; 2010.
National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown, NSW: National Breast Cancer Centre; 2003. Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp90.pdf
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology. Adult cancer pain. Version 2.2015: NCCN; 2015. Available from: http://www.nccn.org
National Health Service Quality Improvement Scotland. Best practice statement. The management of pain in patients with cancer. Edinburgh: NHS Quality Improvement Scotland; 2009. Available from: http://www.palliativecareguidelines.scot.nhs.uk/documents/PAINCANCERREV_BPS_NOV09.pdf
National Institute of Health and Care Excellence Guideline Development Group. Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults. NICE clinical guideline 140. Manchester: NICE; 2012. Available from: http://www.nice.org.uk/nicemedia/live/13745/59285/59285.pdf
Ripamonti CI, Bandieri E, Roila F, ESMO Guidelines Working Group. Management of cancer pain: ESMO clinical practice guidelines. Ann Oncol 2011; 22(Suppl 6): vi69-vi67. Available from: http://annonc.oxfordjournals.org/content/22/suppl_6/vi69.long
Scottish Intercollegiate Guidelines Network. Control of pain in adults with cancer. A national clinical guideline [Version amended 18 July 2011] Edinburgh: SIGN; 2008. Available from: http://www.sign.ac.uk/pdf/SIGN106.pdf
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Appendix: The Eastern Cooperative Oncology Group (ECOG) Performance Status scale
|0||Fully active, able to carry on all pre-disease performance without restriction|
|1||Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work|
|2||Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours|
|3||Capable of only limited self-care, confined to bed or chair more than 50% of waking hours|
|4||Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair|
Source: Eastern Cooperative Oncology Group (Chair: Robert Comis) Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5:649-655. Available from: http://www.ecog.org/general/perf_stat.html.
Appendix: The Australia-modified Karnofsky Performance Status (AKPS) scale
|Score (Category)||Person’s function|
|100 (A)||Normal; no complaints; no evidence of disease|
|90 (A)||Able to carry on normal activity; minor signs or symptoms|
|80 (A)||Normal activity with effort; some signs or symptoms of disease|
|70 (B)||Cares for self; unable to carry on normal activity or to do active work|
|60 (B)||Requires occasional assistance but is able to care for most of his needs|
|50 (B)||Requires considerable assistance and frequent medical care|
|40 (C)||In bed more than 50% of the time|
|30 (C)||Almost completely bedfast|
|20 (C)||Totally bedfast and requiring extensive nursing care by professionals and/or family|
|10 (C)||Comatose or barely arousable|
Source: Abernethy AP, Shelby-James T, Fazekas BS, et al. The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice SRCTN81117481]. BMC Palliat Care 2005; 4: 7. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308820/?tool=pubmed.