Resea ch A icle
Pa ien Pe spec i e on he Managemen
o Cance Pain in Spain
Jes´
us Ga c´
ıa-Foncillas, MD, PhD
1,2
, An onio An ´
on-To es, MD
2,3
,
Fe nando Caballe o-Ma ´
ınez, MD, PhD
4
, F ancisco J Campos, BS
4
,
Ma ga i a Feyjoo, MD
2,5
, Al onso G´
omez de Lian
˜o, MD
6
,
Diana Monge, MD, MPH, PhD
4
, and Ca los Camps, MD, PhD
2,7
Abs ac
Pain in cance is o en unde diagnosed and unde ea ed. B eak h ough pain, in pa icula , se e ely impac s he quali y o li e o
pa ien s. In his s udy, we e alua ed managemen and ca e o pain in Spain om he pa ien pe spec i e by assessing he
expe ience o 275 pa ien s who had su e ed b eak h ough pain. Al hough mos pa ien s had su e ed mode a e- o-se e e pain
in he las 24 hou s, pain elie was achie ed in he majo i y o cases. The body a eas wi h a highe pain in ensi y was el a ied
based on p ima y cance . Adhe ence o ea men was subpa , and pa ien s we e mode a ely conce ned abou addic ion o
ea men and ad e se e en s. Doc o s did no assess pain in e e y isi and he e is oom o imp o emen in i s classi ica ion.
Educa ion s a egies di ec ed owa d pa ien s and heal h ca e pe sonnel a e needed o imp o e pain assessmen , ollow-up,
and compliance. These could guide sha ed decision-making and imp o e communica ion abou cance pain o imp o e i s ca e.
Keywo ds
b eak h ough pain, cance pain, ch onic pain, pa ien expe ience, Spain
In oduc ion
Pain is a majo sou ce o dis ess associa ed wi h cance and
i signi ican ly impac s pa ien s’ quali y o li e, diagnosis
and ea men (1). Al hough i s p e alence a ies be ween
s udies, i has been es ima ed ha 55%o cance pa ien s
unde going ea men eel pain (2). Pain can be classi ied
in mul iple ways by e alua ing domains such as loca ion,
in ensi y, empo al pa e n, pa hophysiology, and e iology
(3,4). Howe e , no all domains a e e alua ed in all cases,
no a e o he ele an aspec s, such as cha ac e is ics o he
disease (p ima y diagnosis, ex en o he disease, me as a-
sis), demog aphics, and psychological s a us (3).
In o de o p o ide an adequa e and pe sonalized ea -
men o pain, i mus be p ope ly assessed and unde s ood.
One majo ype is b eak h ough cance pain (BTP), which is
a “ ansi o y exace ba ion o pain ha occu s, ei he spon a-
neously o associa ed wi h p edic able ac o s o no , e en
hough he baseline pain is ela i ely s able and well con-
olled” (5). The de ini ion o BTP is s ill a sou ce o deba e,
and he e is a iabili y on wha cons i u e i s minimum
in ensi y, du a ion, and numbe o la es (6–8). Addi ionally,
no all clinicians conside opioids should be used o con ol
his pain (6). The pa hophysiology o BTP is he e ogeneous,
bu he 2 main sub ypes a e inciden pain (ei he olun a y,
in olun a y o in e en ion- ela ed) and spon aneous pain
(which is unp edic able) (9). The p e alence o BTP a ies
be ween s udies (10), bu i s p esence is associa ed wi h
highe pain in ensi y, unc ional impai men , and a signi i-
can impac on quali y o li e (11,12). High p e alence a es
1
Se icio de Oncolog´
ıa M´
edica, Hospi al Uni e si a io Fundaci´
on Jim´
enez
D´
ıaz, Mad id, Spain
2
Fundaci´
on ECO, Mad id, Spain
3
Se icio de Oncolog´
ıa M´
edica, Hospi al Uni e si a io Miguel Se e ,
Za agoza, Spain
4
Facul ad de Medicina, Uni e sidad F ancisco de Vi o ia, Pozuelo de
Ala c´
on, Spain
5
Se icio de Oncolog´
ıa M´
edica, Hospi al Uni e si a io Sani as La Mo aleja,
Mad id, Spain
6
Se icio de Oncolog´
ıa M´
edica, Complejo Hospi ala io Uni e si a io
Insula Ma e no-In an il, Las Palmas de G an Cana ia, Spain
7
Se icio de Oncolog´
ıa M´
edica, Hospi al Gene al de Valencia, Valencia,
Spain
Co esponding Au ho :
Jes´
us Ga c´
ıa-Foncillas, MD, PhD, Se icio de Oncolog´
ıa M´
edica, Hospi al
Uni e si a io Fundaci´
on Jim´
enez D´
ıaz, Mad id, Spain.
Email: [email p o ec ed]
Jou nal o Pa ien Expe ience
2020, Vol. 7(6) 1417-1424
ªThe Au ho (s) 2020
A icle euse guidelines:
sagepub.com/jou nals-pe missions
DOI: 10.1177/2374373520978872
jou nals.sagepub.com/home/jpx
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o BTP in cance pa ien s we e ound in 2 ecen s udies in
Spain, one o which no ably showed ha hese high a es
we e no expec ed by doc o s (13,14).
Al hough managemen o cance pain has imp o ed in
ecen yea s, i is s ill an ongoing challenge, wi h clinician
and pa ien ba ie s—among o he s— ha need o be o e -
come (15). A hi d o pa ien s a e ound o be unde ea ed
o pain (16). On his no e, a s udy o 12 coun ies, no
including Spain, ound ha 12%o pa ien s epo ed heal h
ca e p o essionals did no ega d pain as a p oblem, and 50%
pe cei ed clinicians did no conside hei quali y o li e o
be impo an (17).
The Spanish Founda ion o Excellence and Quali y in
Oncology (Fundaci´on ECO) is commi ed o imp o ing ca e
o cance pa ien s. To his end, Fundaci´on ECO di ec ed his
pa ien -cen e ed s udy o unde s and hei expe ience and
unme needs ega ding pain. The aim o his a icle is o
p esen he indings o he su eys ca ied ou on pain
(including BTP), he ca e ecei ed, he deg ee o which pain
managemen was achie ed, and he impac on quali y o li e
as well as o discuss s a egies o add ess he iden i ied
needs.
Me hods
S udy Design
This was a c oss-sec ional, mul icen e , s udy. To calcula e
he sample size needed, we conside ed a ma gin o e o o
6%,a95%le el o con idence, and a esponse dis ibu ion o
50%. This esul ed in a equi ed sample size o 275 pa ien s.
To gua an ee his numbe was achie ed in he e en o pos-
sible wi hd awals, 47 oncologis s we e in i ed o pa icipa e,
hei numbe being p opo ional o he popula ion o hei
espec i e egions. Each oncologis ec ui ed 4 o 6 pa ien s
un il he equi ed sample size o 275 was eached. F om he
s udy s a ing da e, o 4 o 6 consecu i e days, he i s
eligible pa ien o each day was asked o pa icipa e in his
s udy. All pa ien s p o ided w i en in o med consen . Inclu-
sion c i e ia we e pa ien s who we e: o e 18 yea s old;
su e ing om pain associa ed wi h cance , including BTP;
and, i aking analgesics, ha ing ini ia ed ea men a leas
1 mon h p io o inclusion in his s udy. The only exclusion
c i e ion was he pa ien ’s lack o consen o pa icipa e.
An ad hoc ques ionnai e was p o ided o oncologic
pa ien s o assess pain associa ed wi h cance , including
BTP. Each oncologis collec ed he anonymized ques ion-
nai es and, once he las one was ecei ed, pa ien da a we e
agg ega ed and eco ded in a es ic ed-access online epo-
si o y pla o m designed o his s udy. The e was no pa ien
ollow-up a e he ques ionnai e was submi ed.
Due o he na u e o he s udy, submission o he Spanish
Agency o Medicines and Medical P oduc s was no
equi ed. Ne e heless, his s udy was pe o med in acco -
dance wi h he Decla a ion o Helsinki and submi ed o he
clinical esea ch e hics commi ee, who issued a a o able
opinion.
Va iables S udied
Desc ip i e pa ien a iables we e eco ded: demog aphics
(age, sex, le el o educa ion, au onomous egion o Spain)
and clinical a iables ( ype o cance , pain associa ed wi h
cance [ ype, in ensi y, loca ion, and p og ession], and
impac on quali y o li e). Desc ip i e pa ien opinion a i-
ables we e also eco ded: a i ude owa d pain on he pa o
he oncologis and o he heal h ca e p o essionals, quali y o
in o ma ion ecei ed ega ding pain and possible ea men ,
pain ollow-up, adhe ence o ecommended ea men s,
deg ee o pe sonaliza ion ecei ed, and gene al sa is ac ion
wi h ca e compa ed wi h he pa ien ’s expec a ions.
Da a Analysis
Con inuous a iables we e desc ibed using means +SD,
using medians and anges in cases o la ge dispe sion o da a.
Ca ego ical a iables we e desc ibed using equencies and
CIs. Con inuous a iables we e compa ed using independen
es s o Mann–Whi ney U es s, as app op ia e. All s a is-
ical analyses we e ca ied ou wi h SPSS e sion 21.0 (IBM
Co p)
Resul s
Oncologis P o ile
A o al o 47 oncologis s pa icipa ed in his s udy
(27 women, 20 men), wi h an a e age age o 38.9 (95%
CI: 36.8-41.0) yea s and a median age o 38 ( ange,
30-55). No signi ican di e ence in age was ound be ween
women (39.0 yea s) and men (38.7 yea s; P¼.094). P o es-
sional expe ience anged om 2 o 28 yea s, wi h an a e age
o 11.9 (95%CI: 10.1-13.7) and a median o 10 yea s. The e
was no signi ican di e ence in wo k expe ience be ween
women (12.1 yea s) and men (11.7 yea s; P¼.650). Mos
oncologis s (46, 97.9%) wo ked in he public heal h ca e
sys em, 3 o hem in combina ion wi h p i a e p ac ice; only
1 oncologis wo ked exclusi ely in a p i a e hospi al. Oncol-
ogis s saw an a e age o 20.4 (95%CI: 12-25) pa ien s pe
day, wi h 30.5%o hem epo ing BTP.
Pa ien Demog aphics
A o al o 275 pa ien s ep esen ing 11 o he 17 au onomous
egions o Spain we e included in his s udy (Table 1). The
a e age age was 62.4 (95%CI: 61.0-63.7) yea s and anged
om 19 o 86. O hese, 46.5%we e women. Rega ding
educa ion le el, 14.2%had no s udies, 36.0%had p ima y
le el s udies, and 16.0%had a uni e si y deg ee. The mos
common p ima y umo was lung (77, 28.0%), ollowed by
b eas (42, 15.3%) and colo ec al (36, 13.1%).
1418 Jou nal o Pa ien Expe ience 7(6)
A he ime o inclusion in he s udy, a conside able
numbe o pa ien s (250, 90.9%) el pain. Mos pa ien s
(190, 69%) epo ed eeling bo h ch onic pain and BTP
h oughou he disease, while 38 (13.8%) and 47 (17.1%)
el only ei he BTP o ch onic pain, espec i ely.
Pain Desc ip ion
Pa ien s epo ed he speci ic body a ea whe e hey el he
mos se e e pain. Among all cance ypes, he mos common
a eas o pain we e he abdomen (22.5%), o so (9.8%), neck
(6.6%), spine (6.2%), and hips (5.8%) (Table 2). The mos
a ec ed a eas di e ed based on he p ima y cance , wi h
lung cance pa ien s eeling mos pain in he spine (13%)
and he lumba a ea (11.7%), b eas cance pa ien s eeling
mos pain in he lumba a ea (23.8%) and he hips (19.1%),
and colo ec al cance pa ien s eeling mos pain in he abdo-
men (66.7%).
Pa ien s epo ed he minimum, a e age, and maximum
pain hey had el in he p e ious 24 hou s on a scale om 0
(lowes ) o 10 (highes ; Figu e 1). Almos hal (127, 46.2%)
o pa ien s epo ed a maximum pain o 8. Almos 70%o
pa ien s (192, 69.8%) el an a e age pain be ween 3 and 6,
and also a minimum pain unde 3 (195, 70.1%).
Pa ien s epo ed eeling pain o an a e age o 10.3 (95%
CI: 8.8-11.8) mon hs and a median o 6 ( ange, 0.5-84)
mon hs. The a e age ime pa ien s had expe ienced BTP was
6.5 (95%CI: 5.1-7.6) mon hs, wi h a median o 3 mon hs
( ange, 0.3-6). Only 3 pa ien s epo ed eeling no BTP.
When ques ioned abou he cause o pain, 179 (65.1%)
pa ien s belie ed hei pain was ela ed only o he cance ,
and 63 (22.9%) a ibu ed i o bo h he cance and he cance
ea men . Only 22 (8%) pa ien s belie ed hei pain was
caused by he cance ea men alone, and he emaining
11 (4%) pa ien s a ibu ed hei pain o o he causes o did
no espond.
Impac o Pain on Pa ien Quali y o Li e
Pa ien s epo ed he deg ee o which pain had a ec ed hei
li e, on a scale om 0 (no a ec ed) o 10 (se e ely a ec ed),
in he ollowing: gene al ac i i y, mood, walking, wo k,
ela ionships, sleep, and li e enjoymen . The domains mos
a ec ed we e li e enjoymen (a e age sco e, 6.34), gene al
ac i i y (6.31), and mood (6.2). Lowe a e age sco es we e
gi en o impac on wo k (6.03), ela ionships (5.03), and
sleep (5.47), wi h he lowes sco e being o walking (4.98).
Ca e ecei ed o Pain
Mos (213, 77.5%) pa ien s epo ed being in o med a diag-
nosis o he possibili y o eeling pain associa ed wi h can-
ce , 31 (11.3%) pa ien s epo ed no ecei ing his
in o ma ion, and ano he 31 (11.3%) did no emembe .
Mos (227, 82.5%) pa ien s also epo ed hei oncologis
in o med hem ha pain can be con olled, while
24 (8.7%) pa ien s said hey we e no in o med o his, and
ano he 24 (8.7%) did no emembe .
Rega ding mone a iza ion o pain, 197 (72.9%) pa ien s
epo ed hei doc o asked abou i on e e y isi ,
52 (19.3%) said i happened in mos isi s, 7 (2.6%) epo ed
hey we e asked abou i in less han hal he isi s, and
14 (5.2%) epo ed only occasionally being asked abou
pain. No pa ien epo ed no ha ing been asked. Pain dis-
cussion was mos commonly ini ia ed by doc o s (41.7%)
han by pa ien s (25.4%). Only in 16.9%o cases did he
doc o ask abou pain in ensi y; in 10.8%o o al cases, he
doc o examined he pa ien .
Oncologis s we e he main heal h ca e p o essionals
(65%) in ol ed in ea ing pain associa ed wi h cance , ol-
lowed by p ima y ca e doc o s (11.0%), pallia i e ca e doc-
o s (5.1%), anes he is s o pain uni doc o s (4.9%), and
adia ion oncologis s (4.6%).
Pe spec i es on Pain Relie Medica ion
Sa is ac ion wi h pain elie ea men was high, wi h 113
(43.1%) pa ien s epo ing being e y sa is ied and 133
(50.8%) being qui e sa is ied. Addic ion o ea men was a
cause o conce n in almos hal o pa ien s, who we e ei he
e y wo ied (38, 13.8%) o qui e wo ied (80, 29.1%) abou
i . Addi ionally, o e hal o pa ien s we e ei he e y
Table 1. Pa ien Cha ac e is ics.
N (%)
N¼275
Age, a e age yea s (95% CI) 62.4 (61.0-63.7)
Gende , emale 128 (46.5)
Educa ion le el
No schooling 39 (14.2)
P ima y 99 (36.0)
Junio high school 40 (14.5)
Senio high school/ oca ional 51 (18.5)
Uni e si y 44 (16.0)
Doc o a e 2 (0.7)
P ima y umo loca ion
Lung 77 (28.0)
B eas 42 (15.3)
Colo ec al 36 (13.1)
Head and neck 29 (10.5)
Panc eas 24 (8.7)
P os a e 22 (8.0)
Gynecologic 15 (5.5)
Melanoma 6 (2.2)
O he 24 (8.7)
Pain
No
a
25 (9.1)
Yes 250 (90.9)
Ch onic 47 (17.1)
B eak h ough 38 (13.8)
Ch onic and b eak h ough 190 (69.1)
a
No pain a he ime he pa ien was included in he s udy, o he han
common headaches, oo haches, con usions, and so on.
Ga c´
ıa-Foncillas e al 1419
Table 2. Pain Loca ion by Cance Type.
Body a ea wi h wo s pain
P ima y umo
To alHead and neck Gynecologic Colo ec al B eas Melanoma Panc eas P os a e Lung O he s
Head, n (%) 2 (6.90%) 0 (0.00%) 0 (0.00%) 1 (2.38%) 0 (0.00%) 1 (4.17%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 4 (1.45%)
Face, n (%) 2 (6.90%) 0 (0.00%) 0 (0.00%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 3 (1.09%)
Neck, n (%) 16 (55.17%) 0 (0.00%) 0 (0.00%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (1.30%) 0 (0.00%) 18 (6.55%)
Righ shoulde , n (%) 0 (0.00%) 0 (0.00%) 1 (2.78%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.55%) 3 (3.90%) 1 (4.17%) 6 (2.18%)
Le shoulde , n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 2 (33.33%) 0 (0.00%) 0 (0.00%) 7 (9.09%) 1 (4.17%) 10 (3.64%)
Shoulde s, n (%) 1 (3.45%) 0 (0.00%) 0 (0.00%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (1.30%) 0 (0.00%) 3 (1.09%)
Righ o so, n (%) 0 (0.00%) 1 (6.67%) 1 (2.78%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 7 (9.09%) 0 (0.00%) 10 (3.64%)
Le o so, n (%) 0 (0.00%) 0 (0.00%) 1 (2.78%) 6 (14.29%) 0 (0.00%) 1 (4.17%) 0 (0.00%) 7 (9.09%) 2 (8.33%) 17 (6.18%)
Righ a m, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 2 (2.60%) 0 (0.00%) 2 (0.73%)
Le a m, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.17%) 1 (0.36%)
Righ abdomen, n (%) 2 (6.90%) 3 (20.00%) 13 (36.11%) 0 (0.00%) 0 (0.00%) 11 (45.83%) 1 (4.55%) 3 (3.90%) 4 (16.67%) 37 (13.45%)
Le abdomen, n (%) 1 (3.45%) 3 (20.00%) 11 (30.56%) 0 (0.00%) 0 (0.00%) 6 (25.00%) 0 (0.00%) 4 (5.19%) 0 (0.00%) 25 (9.09%)
Hips, n (%) 0 (0.00%) 0 (0.00%) 2 (5.56%) 8 (19.05%) 0 (0.00%) 0 (0.00%) 1 (4.55%) 4 (5.19%) 1 (4.17%) 16 (5.82%)
Righ w is , n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.55%) 0 (0.00%) 0 (0.00%) 1 (0.36%)
Le w is , n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.55%) 0 (0.00%) 0 (0.00%) 1 (0.36%)
Geni als, n (%) 0 (0.00%) 3 (20.00%) 1 (2.78%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 2 (9.09%) 1 (1.30%) 4 (16.67%) 11 (4.00%)
Righ leg, n (%) 0 (0.00%) 1 (6.67%) 0 (0.00%) 0 (0.00%) 2 (33.33%) 0 (0.00%) 2 (9.09%) 2 (2.60%) 0 (0.00%) 7 (2.55%)
Le leg, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.17%) 0 (0.00%) 1 (1.30%) 1 (4.17%) 3 (1.09%)
Legs, n (%) 1 (3.45%) 1 (6.67%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.17%) 3 (1.09%)
Righ knee, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.17%) 1 (0.36%)
Le knee, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%)
Knees, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (0.36%)
Righ oo , n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (1.30%) 0 (0.00%) 1 (0.36%)
Head, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (1.30%) 0 (0.00%) 2 (0.73%)
Back o neck, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 2 (2.60%) 0 (0.00%) 3 (1.09%)
Le do sal, n (%) 2 (6.90%) 0 (0.00%) 0 (0.00%) 3 (7.14%) 0 (0.00%) 1 (4.17%) 1 (4.55%) 3 (3.90%) 0 (0.00%) 10 (3.64%)
Righ do sal, n (%) 1 (3.45%) 0 (0.00%) 2 (5.56%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 2 (2.60%) 0 (0.00%) 6 (2.18%)
Le lumba , n (%) 0 (0.00%) 1 (6.67%) 0 (0.00%) 1 (2.38%) 0 (0.00%) 0 (0.00%) 1 (4.55%) 2 (2.60%) 0 (0.00%) 5 (1.82%)
Righ lumba , n (%) 1 (3.45%) 0 (0.00%) 0 (0.00%) 2 (4.76%) 1 (16.67%) 0 (0.00%) 3 (13.64%) 2 (2.60%) 0 (0.00%) 9 (3.27%)
Lumba a ea, n (%) 0 (0.00%) 2 (13.33%) 0 (0.00%) 10 (23.81%) 0 (0.00%) 2 (8.33%) 4 (18.18%) 9 (11.69%) 2 (8.33%) 29 (10.55%)
Le bu ock, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.55%) 0 (0.00%) 1 (4.17%) 2 (0.73%)
Righ bu ock, n (%) 0 (0.00%) 0 (0.00%) 3 (8.33%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (1.30%) 0 (0.00%) 4 (1.45%)
Bu ocks, n (%) 0 (0.00%) 0 (0.00%) 1 (2.78%) 0 (0.00%) 1 (16.67%) 1 (4.17%) 1 (4.55%) 1 (1.30%) 1 (4.17%) 6 (2.18%)
Righ cal , n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (4.17%) 1 (0.36%)
Le cal , n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%)
Spine, n (%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 3 (7.14%) 0 (0.00%) 0 (0.00%) 2 (9.09%) 10 (12.99%) 2 (8.33%) 17 (6.18%)
To al, n (%) 29 (100.00%) 15 (100.00%) 36 (100.00%) 42 (100.00%) 6 (100.00%) 24 (100.00%) 22 (100.00%) 77 (100.00%) 24 (100.00%) 275 (100.00%)
1420
wo ied (36, 13.1%) o qui e wo ied (110, 40.0%) abou he
ad e se e en s o pain elie ea men .
Ques ions abou adhe ence o pain elie ea men
showed ha 46 (16.7%) pa ien s some imes o go o ake
he medica ion, 48 (17.5%) did no ake i a he indica ed
ime, 87 (31.6%) s opped aking i once hey el be e ,
and 142 (51.6%) s opped aking i i i did no ag ee wi h
hem. Howe e , ega ding ea men o BTP, almos all
(264, 96%) pa ien s ollowed ea men guidelines.
Rega ding ch onic pain managemen in he 24 hou s p io
o he pa ien s’ isi , 191 (69.5%) pa ien s epo ed elie
o e 70%. Eigh (2.9%) pa ien s expe ienced no o minimal
elie , unde 20%. In he case o BTP, 204 (74.2%) pa ien s
epo ed elie o e 70%, and 7 (2.5%) pa ien s expe ienced
no o minimal elie , unde 20%.
When asked abou hei deg ee o sa is ac ion wi h pain
elie ea men , only a small pe cen age o pa ien s epo ed
being qui e o e y unsa is ied wi h he e ec i eness
o ea men (36, 13.1%), ole ance o ad e se e ec s
(43, 15.6%), and o e all ea men (34, 12.4%).
Discussion
In his s udy, we e alua ed he pain ca e ha cance pa ien s
ecei e in Spain om a pa ien -cen e ed pe spec i e. We
ound ha mos pa ien s had su e ed mode a e- o-se e e
pain in he las 24 hou s and had su e ed om pain o an
a e age o 10.3 mon hs. We assessed he impac o pain on
quali y o li e, adhe ence o ea men , and doc o a i udes
o unde s and he di e en aspec s in ol ed in pain
managemen .
A sys ema ic e iew ound he a e age p e alence o
BTP was 61.0%, al hough he e was high a iabili y be ween
s udies, anging 33.3% o 95.0%, wi h highe a es co e-
sponding o pa ien s in hospice (10). A ecen s udy in Spain
ound ha 91.3%o cance pa ien s wi h pain had su e ed
om BTP, al hough almos hal o hem had been unde ec ed
by doc o s (13.) Ou s udy did no add ess p e alence
o BTP, as one o ou inclusion c i e ia was ha pa ien s
had su e ed BTP a some poin , al hough 3 o hem
la e epo ed in he ques ionnai e ha hey had no
expe ienced i .
The body a eas whe e pa ien s el mos pain a ied
depending on he p ima y cance , in ag eemen wi h epo s
by o he s (18). O e all pain p e alence has also been ound
o a y based on p ima y cance (14,17); howe e , we did
no e alua e his due o he da a being agg ega ed.
In con as o he inding ha pain is unde ea ed in
app oxima ely a hi d o cance pa ien s (16), mos pa ien s
(93.9%) in ou s udy we e sa is ied wi h he pain elie
achie ed wi h medica ion. This inding is also highe han
a p e ious s udy in Spain, epo ing ha almos hal o
pa ien s wi h BTP did no achie e pain con ol (14). While
we obse ed ha 96%o pa ien s adhe ed o ea men o
BTP, adhe ence o ch onic pain ea men was subpa , wi h 1
in 6 pa ien s o ge ing o ake he medica ion. The main
pa ien ba ie o adhe ence was nega i e side e ec s, wi h
o e hal o pa ien s no aking he medica ion o his ea-
son. Pa ien educa ion has p o en o imp o e quali y o li e
and adhe ence o ea men o cance pain (19–21) and o
dec ease pain in ensi y (19–23). Fu u e wo k in Spain could
ocus on ca ying ou pa ien educa ion s a egies using
Figu e 1. Pain se e i y in he las 24 hou s.
Ga c´
ıa-Foncillas e al 1421

se e al me hods (21): ace- o- ace coaching sessions,
ollow-up phone calls, and in o ma ional ideos, among o h-
e s. These ini ia i es could a ge pa ien compliance and
educa e on opioid ea men , i s associa ed ad e se e en s,
and addic ion, as hese we e a cause o conce n o app ox-
ima ely hal o pa ien s in ou s udy, which is in ag eemen
wi h epo s om o he coun ies (24–27).
Educa ion o all heal h ca e pe sonnel should also be
conside ed, gi en ha , in 35%o cases, pa ien s epo ed
ha pain was no ollowed by an oncologis . Pa ien s also
epo ed he doc o s examined hem in only 10.8%o cases
and assessed pain in ensi y in 16.9%o cases. On his no e,
oncologis s in his s udy saw an a e age o 20.4 pa ien s
pe day, a hi d o hem epo ing BTP, and a ecen Delphi
su ey ound ha Spanish oncologis s conside ed limi ed
ime o e alua e pa ien s o be a ba ie o managing
BTP (28). Classi ying pain in all o i s domains can p o ide
mo e in o ma ion and imp o e unde s anding o pa ien
needs o, ul ima ely, deli e a highe quali y o pain ca e.
S udies ha e shown ha physicians conside he e a e de i-
ciencies in pain managemen aining (29–31). On his no e,
a s udy in Spain ound ha almos hal o oncologis s had no
ead he guidelines on diagnosis and ea men o BTP (13).
This u he highligh s he need o no only educa e pa ien s
bu also heal h ca e p o essionals. Addi ionally, signi ican
di e ences we e ound on nu ses’ aining on pain manage-
men ac oss 12 Eu opean coun ies (32). Ini ia i es o
imp o e pain managemen by heal h ca e p o essionals
could include manda o y pallia i e ca e o a ions o ai-
nees, de eloping mul idisciplina y eams, c ea ing educa-
ional cou ses, and encou aging in e disciplina y wo k
(33). Mos pa ien s desi e sha ed decision-making in pain
managemen (34), which leads o mo e open communica ion
and highe pa ien sa is ac ion (35).
This s udy p o ides, o he i s ime, he pa ien pe spec-
i e on managemen o pain associa ed wi h cance in Spain.
We belie e ou indings can be use ul o heal h ca e p o-
essionals and decision make s o be e unde s and and
add ess pa ien needs. They can also se e as a basis o
implemen ing policies ha add ess he issues ound, such
as he need o e alua ing pain in se e al ways, mos no ably
examining he pa ien and g ading pain in ensi y. We sugges
placing a s onge ocus on educa ion o pa ien s and heal h
ca e p o essionals, and implemen ing s a egies ha encou -
age open communica ion abou pain.
Limi a ions
The main limi a ion o his s udy is he use o agg ega ed
da a o pa ien epo s, which p ecludes es ablishing associa-
ions be ween he pa ame e s e alua ed. Fo example, s udy-
ing he associa ion be ween ype o p ima y cance and pain
in ensi y, o ha be ween in o ma ion p o ided by he doc o
and adhe ence o ea men could help de elop guidelines
and s a egies owa d pe sonaliza ion o pain ca e. Also, ou
sample size is ela i ely small, wi h a p edominance o
3 cance ypes (lung, b eas , and colo ec al). Fu u e s udies
ha add ess hese limi a ions could u he es ablish links
be ween he pa ame e s e alua ed he e and imp o e pain
managemen . Finally, his s udy epo s he expe ience o
pa ien s and hei opinions; howe e , we canno con i m he
in o ma ion hey epo , and we canno ule ou a possible
bias in hei expec a ions o ca e.
Conclusion
We e alua ed he pe spec i e o cance pa ien s in Spain
ega ding ca e o pain and ound ha , al hough almos hal
o hem had el a e y high maximum pain in he p e ious
24 hou s, he as majo i y we e sa is ied wi h he deg ee o
pain managemen achie ed wi h analgesics. The body a eas
whe e pa ien s el mos pain we e he abdomen, o so, neck,
spine, and hips, p edominance a ying wi h p ima y cance
ype. The dimension o quali y o li e ha pa ien s consid-
e ed we e mo e a ec ed by pain was li e enjoymen and
gene al ac i i y. Ou indings highligh some a eas o
imp o emen in pain managemen and could guide s a egies
ha add ess hem.
Au ho s’ No e
This s udy was pe o med in acco dance wi h he Decla a ion o
Helsinki and submi ed o he Clinical Resea ch E hics Commi ee
a he San Ca los Clinical Hospi al in Mad id (Spain), who issued a
a o able opinion.
Acknowledgmen s
The au ho s hank all doc o s and pa ien s ha pa icipa ed in his
s udy. The au ho s also hank Angela Rynne Vidal, PhD, o p o-
iding w i ing and edi ing suppo , unded by Fundaci´on ECO.
Decla a ion o Con lic ing In e es s
The au ho (s) decla ed no po en ial con lic s o in e es wi h espec
o he esea ch, au ho ship, and/o publica ion o his a icle.
Funding
The au ho (s) disclosed eceip o he ollowing inancial suppo
o he esea ch, au ho ship, and/o publica ion o his a icle: This
wo k was suppo ed by Kyowa Ki in.
ORCID iDs
Jes´
us Ga c´ıa-Foncillas, MD, PhD h ps://o cid.o g/0000-0002-
7591-8006
Al onso G´omez de Lian
˜o, MD h ps://o cid.o g/0000-0002-
1844-8474
Diana Monge, MD, MPH, PhD h ps://o cid.o g/0000-0002-3593-
1820
Re e ences
1. Man yh PW. Cance pain and i s impac on diagnosis, su i al
and quali y o li e. Na Re Neu osci. 2006;7:797-809.
2. an den Beuken-Van E e dingen MHJ, Hochs enbach LMJ,
Joos en EAJ, Tjan-Heijnen VCG, Janssen DJA. Upda e on
p e alence o pain in pa ien s wi h cance : sys ema ic e iew
1422 Jou nal o Pa ien Expe ience 7(6)
and me a-analysis. J Pain Symp om Manage. 2016;51:
1070-1090.
3. Knudsen AK, Aass N, Fainsinge R, Ca aceni A, Kleps ad P,
Jo dhøy M, e al. Classi ica ion o pain in cance pa ien s—a
sys ema ic li e a u e e iew. Pallia Med. 2009;23:295-308.
4. Ca aceni A, Shkod a M. Cance pain assessmen and classi i-
ca ion. Cance s. 2019;11:510. Epub ahead o p in 2019. doi:
10.3390/cance s11040510
5. Da ies AN, Dickman A, Reid C, S e ens AM, Zeppe ella G,
Science Commi ee o he Associa ion o Pallia i e Medicine
o G ea B i ain and I eland. The managemen o cance -
ela ed b eak h ough pain: Recommenda ions o a ask g oup
o he Science Commi ee o he Associa ion o Pallia i e
Medicine o G ea B i ain and I eland. Eu opean J Pain.
2009;13:331-338.
6. Boce a J, de la To e A, Sampe D, Fa o MS´anchez-de la Rosa
R. Consensus and con o e sies in he de ini ion, assessmen ,
ea men and moni o ing o BTcP: esul s o a Delphi s udy.
Clin T ansl Oncol. 2016;18:1088-1097.
7. Me cadan e S, Lazza i M, Reale C, Cuomo A, Fusco F,
Ma che i P, e al. I alian oncological pain su ey (IOPS): a
mul icen e I alian s udy o b eak h ough pain pe o med in
di e en se ings. Clin J Pain. 2015;31:214-221.
8. Da ies A, Buchanan A, Zeppe ella G, Po a-Sales J, Lika R,
Weismay W, e al. B eak h ough cance pain: an obse a ional
s udy o 1000 Eu opean oncology pa ien s. J Pain Symp om
Manage. 2013;46:619-628.
9. Vellucci R, Media i RD, Gaspe oni S, Mammuca i M,
Ma inangeli F, Romualdi P, e al. Assessmen and ea men
o b eak h ough cance pain: om heo y o clinical p ac ice.
J Pain Res. 2017;10:2147-2155.
10. Deand ea S, Co li O, Consonni D, Villani W, Te esa G eco M,
Apolone G. P e alence o b eak h ough cance pain: a sys-
ema ic e iew and a pooled analysis o published li e a u e.
J Pain Symp om Manage. 2014;47:57-76.
11. Ca aceni A, Ma ini C, Zecca E, Po enoy RK, Ashby MA,
Hawson G, e al. B eak h ough pain cha ac e is ics and syn-
d omes in pa ien s wi h cance pain. An in e na ional su ey.
Pallia Med. 2004;18:177-183.
12. Hje ms ad MJ, Kaasa S, Ca aceni A, Loge JH, Pede sen T,
Haugen DF, e al. Cha ac e is ics o b eak h ough cance pain
and i s in luence on quali y o li e in an in e na ional coho o
pa ien s wi h cance . BMJ Suppo Pallia Ca e. 2016;6:
344-352.
13. Camps He e o C, Reina Zoilo JJ, Monge Ma in D, Caballe o
Ma ´ınez F, Guillem Po a F, A anda Aguila E, e al. Ac i e
s udy: unde ec ed p e alence and clinical ine ia in he ea -
men o b eak h ough cance pain (BTcP). Clin T ansl Oncol.
2019;21:380-390.
14. Pe ez-He nandez C, Blasco A, Ganda a A, Man
˜as A, Jes´
us
Rod ´ıguez-L´opez M, Ma ´ınez V, e al. P e alence and cha -
ac e iza ion o b eak h ough pain in pa ien s wi h cance in
Spain: he CARPE-DIO s udy. Sci Rep. 2019;9:17701.
15. Sca bo ough BM, Smi h CB. Op imal pain managemen o
pa ien s wi h cance in he mode n e a. CA: A Cance J Clin.
2018;68:182-196.
16. G eco MT, Robe o A, Co li O, Deand ea S, Bandie i E,
Ca u o S, e al. Quali y o cance pain managemen : an upda e
o a sys ema ic e iew o unde ea men o pa ien s wi h can-
ce . J Clin Oncol. 2014;32:4149-4154.
17. B ei ik H, Che ny N, Colle B, de Conno F, Filbe M, Foube
AJ, e al. Cance - ela ed pain: a pan-Eu opean su ey o p e-
alence, ea men , and pa ien a i udes. Ann Oncol. 2009;20:
1420-1433.
18. G ond S, Zech D, Die enbach C, Radb uch L, Lehmann KA.
Assessmen o cance pain: a p ospec i e e alua ion in 2266
cance pa ien s e e ed o a pain se ice. Pain. 1996;64:
107-114.
19. Jahn P, Kuss O, Schmid H, Baue A, Ki zman el M, Jo dan K,
e al. Imp o emen o pain- ela ed sel -managemen o cance
pa ien s h ough a modula ansi ional nu sing in e en ion:
a clus e - andomized mul icen e ial. Pain. 2014;155:
746-754.
20. Lin CC, Chou PL, Wu SL, Chang YC, Lai YL. Long- e m
e ec i eness o a pa ien and amily pain educa ion p og am
on o e coming ba ie s o managemen o cance pain. Pain.
2006;122:271-281.
21. Oldenmenge WH, Gee ling JI, Mos o aya I, Visse s KCP, de
G ae A, Reyne s AKL, e al. A sys ema ic e iew o he
e ec i eness o pa ien -based educa ional in e en ions o
imp o e cance - ela ed pain. Cance T ea Re . 2018;63:
96-103.
22. Miaskowski C, Dodd M, Wes C, Schumache K, Paul SM,
T ipa hy D, e al. Randomized clinical ial o he e ec i eness
o a sel -ca e in e en ion o imp o e cance pain managemen .
J Clin Oncol. 2004;22:1713-1720.
23. Oli e JW, K a i z RL, Kaplan SH, Meye s FJ. Indi idualized
pa ien educa ion and coaching o imp o e pain con ol among
cance ou pa ien s. J Clin Oncol. 2001;19:2206-2212.
24. Po e VT, Wiseman CE, Dunn SM, Boyle FM. Pa ien ba ie s
o op imal cance pain con ol. Psychooncology. 2003;12:
153-160.
25. Wa d SE, Goldbe g N, Mille -McCauley V, Muelle C, Nolan
A, Plank DP, e al. Pa ien - ela ed ba ie s o managemen o
cance pain. Pain. 1993;52:319-324.
26. Makhlou SM, Pini S, Ahmed S, Benne ML. Managing pain
in people wi h cance —a sys ema ic e iew o he a i udes and
knowledge o p o essionals, pa ien s, ca egi e s and public.
J Cance Educ. 2020;35:214-240.
27. Sa as M, Bay ak a -Ekincioglu A, Celebi N. An e alua ion o
cance pa ien s’ opinions abou use o opioid analgesics and he
ole o clinical pha macis in pa ien educa ion in Tu key. In
J Clin Pha m. Epub ahead o p in 2020. doi:10.1007/s11096-
020-01098-x
28. He e o CC, To es AA, C uz-He n´andez JJ, C uz-He n´andez
JJ, Ca a o A, Cons enla M, e al. Wo king owa ds a consensus
on he oncological app oach o b eak h ough pain: a Delphi
su ey o Spanish expe s. J Pain Res. 2019;12:2349-2358.
29. Odonko CA, Osei-Bonsu E, Te eh O, Te eh O, Haig A,
Samuel Maye R, e al. Minding he gaps in cance pain man-
agemen educa ion: a mul icen e s udy o clinical esiden s
Ga c´
ıa-Foncillas e al 1423
and ellows in a low- e sus high- esou ce se ing. J Global
Oncol. 2016;2:387-396.
30. B eue B, Chang VT, on Roenn JH, on Gun en C, Neugu AJ,
Kaplan R, e al. How well do medical oncologis s manage ch onic
cance pain? A na ional su ey. Oncologis . 2015;20:202-209.
31. Villegas Es ´e ez F, L´opez Ala c´on MD, Alonso Baba o A,
Gayoso LO, De Cas o Ca pen
˜oJ,Le ´ıa-Gelabe M, e al.
B eak h ough cance pain ea men in Spain: physicians’ pe -
cep ion o cu en opioids u iliza ion and p esc ip ion. Cu
Med Res Opin. 2020;36:1383-1391.
32. Wengs o¨m Y, Runds o¨m C, Gee ling J, Pappa T, Weisse J,
Williams SC, e al. The managemen o b eak h ough cance
pain—educa ional needs a Eu opean nu sing su ey. Eu
J Cance Ca e. 2014;23:121. Epub ahead o p in 2014.
doi:10.1111/ecc.12118
33. Robbins JR, Kila i D, Johns on F.Pallia i e ca e educa ion o
oncologis s: how a e we doing? Ann Pallia Med. 2019;8:
356-359.
34. B an JM, S icke CT, Pe ok A, Sih-Meynie R, Wujcik D.
Sha ed decision-making p e e ences and pain cha ac e iza ion
in pa ien s wi h cance . J Clin Oncol. 2018;36:30.
35. Kehl KL, Land um MB, A o a NK, Ganz PA, an Ryn M,
Mack JW, e al. Associa ion o ac ual and p e e ed decision
oles wi h pa ien - epo ed quali y o ca e. JAMA Oncol. 2015;
1:50-58. doi:10.1001/jamaoncol.2014.112
Au ho Biog aphies
Jes´
us Ga c´
ıa-Foncillas, MD, PhD, is he head o he Cance ins i-
u e a he Uni e si y Hospi al “Fundaci´
on Jim´
enez Diaz”, Mad id,
Spain and is also a p o esso o Oncology a he Au onomous Uni-
e si y o Mad id. He ob ained his deg ee in Medicine om Uni-
e si y o Za agoza (Za agoza, Spain) and his PhD om Uni e si y
o Na a a, Pamplona, Spain. P o Ga c´ıa-Foncillas has au ho ed
mo e han 260 publica ions.
An onio An ´
on-To es, MD, is he head o he Medical Oncology
Uni a Hospi al Uni e si a io Miguel Se e , Za agoza, Spain. He
is also an associa e p o esso o Medicine a Za agoza Uni e si y.
P o An ´on-To es is a membe o he Eu opean Socie y o Med-
ical Oncology, he Spanish Socie y o Medical Oncology, and he
Ame ican Socie y o Clinical Oncology, among o he s.
Fe nando Caballe o-Ma ´
ınez, MD, PhD, is he dean o Medicine
a Uni e sidad F ancisco de Vi o ia, Mad id, Spain. He is also a
p o esso o Medicine and scien i ic di ec o a Uni e sidad F an-
cisco de Vi o ia. D Caballe o-Ma ´ınez has ecei ed se e al
awa ds o his esea ch and eaching expe ience, and has au ho ed
mo e han 70 publica ions.
F ancisco J Campos, BS, is he head o he Consul ing and
Resea ch Uni a Uni e sidad F ancisco de Vi o ia, Mad id, Spain,
whe e he de elops scien i ic p og ams and secu es unding o sup-
po hem. He g adua ed in Chemis y a Au onomous Uni e si y o
Mad id and has published o e 10 a icles.
Ma ga i a Feyjoo, MD, is he head o he Medical Oncology Uni
a Hospi al Uni e si a io Sani as La Mo aleja, Mad id, Spain, and
also eaches a Uni e sidad F ancisco de Vi o ia, Mad id, Spain. D
Feyjoo wo ked o 8 yea s in he pha maceu ical indus y and is a
membe o Spanish Socie y o Medical Oncology.
Al onso G´
omez de Lian
˜o, MD, is he head o he Geni ou ina y
Oncology Uni a Complejo Hospi ala io Uni e si a io Insula
Ma e no-In an il, Las Palmas, Spain. He s udied Medicine a
Salamanca Uni e si y and ained in Medical Oncology a Hos-
pi al San a C eu i San Pau. He hen comple ed a ellowship in
clinical and immuno he apy esea ch a S Ba holomew’s Hos-
pi al, London, unde he supe ision o P o Thomas Powles.
His ca ee o da e has been de o ed o clinical and ansla ional
esea ch in he ield o geni ou ina y umou s. He is also a
membe o he Eu opean Socie y o Medical Oncology, he
Spanish Socie y o Medical Oncology, and he Spanish Oncol-
ogy Geni ou ina y G oup.
Diana Monge, MD, MPH, PhD, is a p o esso a Uni e sidad
F ancisco de Vi o ia, Mad id, Spain. She g adua ed in Medicine
om Au onomous Uni e si y o Mad id and ob ained a PhD in
P e en ion and Public Heal h om King Juan Ca los Uni e si y,
Mad id, Spain. D Monge has au ho ed 30 a icles.
Ca los Camps, MD, PhD, is he head o he Medical Oncology
Uni a Gene al Valencia Hospi al, Valencia, Spain, and a p o esso
o Medicine a Valencia Uni e si y. He is a membe o he scien-
i ic commi ee o se e al ins i u ions and a membe o scien i ic
socie ies, such as he Eu opean Socie y o Medical Oncology, he
Spanish Socie y o Medical Oncology, and he Ame ican Socie y
o Clinical Oncology. P o Camps has supe ised 12 doc o al he-
sis and is he au ho o mo e han 250 publica ions.
1424 Jou nal o Pa ien Expe ience 7(6)