Patient Perspective on the Management of Cancer Pain in Spain

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 C ea i e Commons Non Comme cial CC BY-NC: This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion-NonComme cial 4.0 License (h ps://c ea i ecommons.o g/licenses/by-nc/4.0/) which pe mi s non-comme cial use, ep oduc ion and dis ibu ion o he wo k wi hou u he pe mission p o ided he o iginal wo k is a ibu ed as speci ied on he SAGE and Open Access pages (h ps://us.sagepub.com/en-us/nam/open-access-a -sage). 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)