Transcript Patient-Level Factors in Pain Treatment Disparities Among

Risk Factors for Inadequate
Treatment of Cancer-Related Pain
Among African American and
Latino Cancer Patients
Karen O. Anderson, PhD, MPH
Department of Symptom Research
The University of Texas
M.D. Anderson Cancer Center
Institute of Medicine Report on Unequal
Treatment

Racial and ethnic disparities in healthcare
exist. These disparities are consistent and
extensive across a range of medical
conditions and health care services…they
are associated with worse outcomes…and
therefore, are unacceptable.
Institute of Medicine Report on Unequal Treatment, 2002
Documenting the Problem
Research findings from the 80’s found
that:

Many cancer patients have significant
pain for a long period of time.

Cancer pain is often poorly treated.
Results From
ECOG Pain Studies

More than one-third with metastatic
cancer reported pain that interfered with
their function.

Forty percent of patients with pain were
not prescribed analgesics strong
enough to effectively treat their pain.
Cleeland et al, NEJM, 1994
Patients at Risk for
Inadequate Pain Management

Patients cared for at minority treatment
centers were three times more likely to
be undermedicated with analgesics.

Discrepancy between patient and
provider estimates of pain severity.
ECOG Minority Study: Findings
• Negative Pain Management Index
– Majority patients: 38%
– Minority patients: 65%
– Cleeland et al, Annals Internal Med, 1997
PREMO Goals
• Identify pain management needs of
African American and Hispanic patients
with cancer and pain.
• Develop culturally appropriate patient
education materials.
• Conduct a clinical trial to evaluate the
efficacy of an educational intervention.
PREMO Sites
• Houston
– UT MD Anderson Cancer Center
– Two Harris County Hospitals
– VAMC
• Miami
– One County Hospital
Pain-Related Variables among Minority
Cancer Patients
Patient Group
African American
Hispanic
Percent with
severe pain
72%
57%
Objectives of the Clinical Trial
• To determine if patient education
improves pain control in African American
and Hispanic patients with cancer-related
pain
• To determine if patient education reduces
the impact of pain
• To determine if patient education
improves quality of life
– Anderson et al., JCO, 2004
Randomized Clinical Trial
• Pain Education
– Video and booklet on
cancer pain and pain
treatment
– Gender and heritage
specific materials
– How to report pain
– How to take analgesics
• Control Group
– Nutrition video and
booklet
– Controls for an
educational treatment
– Nutrition for cancer
patients
– English and Spanish
versions
Educational Materials
• Emphasize pain relief
• Teach how to report pain
• Model patient communication
• Reduce fears of opioids
• Cultural issues
Eligibility Criteria
• Diagnosis of cancer
• Pain due to cancer or cancer treatment
• Pain worst score of 4 or greater on BPI
• African American or Hispanic heritage
• ECOG performance status of 0, 1, or 2
• No current palliative radiotherapy
• No major surgery within past 30 days
Assessment Schema
• Intake (T1, Day 1)
• Time 2 (Day 15-28)
– BPI - long form
– BPI - short form
– SF-12 Health Survey
– SF-12 Health Survey
– Pain Control Scale
– Pain Control Scale
– MD Pain Assessment
– MD Pain Assessment
Assessment schema
• Time 3 (week 6-7)
• Time 4 (week 8-10)
– BPI - short form
– BPI - short form
– SF-12 Health Survey
– SF-12 Health Survey
– Pain Control Scale
– Pain Control Scale
– MD Pain Assessment
– MD Pain Assessment
– Compliance form
– Compliance form
Accrual in the Clinical Trial (n = 97)
• 36 breast cancer patients (39%)
• 61 cancer patients with other solid tumors
or hematological malignancies
– 23% GI
– 18% lung
– 10% GU/Gyn
– 4% head and neck
– 6% other
Demographics
• 66% female
• 39% married, 61% single
• 54% Hispanic, 46% African American
• 52% high school education
• 46% disabled, 15% retired, 11% jobs
– 20% homemakers, 9% other
Disease-related Variables
• 63% good ECOG performance status
– 54% education, 72% control group
• 66% chemotherapy
• 14% hormonal therapy
• 65% metastatic disease
• 66% severe pain
• 52% pain > 6 months
Mean Pain Severity over Time for
Education and Control Groups
10
9
8
7
Education
Control
6
5
4
3
T1
T2
T3
T4
Mean Pain Severity over Time for
African American Patients
10
9
8
7
Education
Control
6
5
4
3
T1
T2
T3
T4
Mean Pain Interference over Time for
Education and Control Groups
10
9
8
7
Education
Control
6
5
4
3
T1
T2
T3
T4
Perceived Pain Control over Time for
Education and Control Groups
40
35
30
Education
Control
25
20
15
10
T1
T2
T3
T4
Mean SF-12 Physical Component
Summary Scores
60
50
40
Education
Control
30
20
10
0
Time 1
Time 2
Time 3
Time 4
Mean SF-12 Mental Component
Summary Scores
60
50
40
Education
Control
30
20
10
0
Time 1
Time 2
Time 3
Time 4
Physicians’ Underestimates of
Patients’ Pain
Group
Time 1
Time 2
Time 3
Time 4
Education
77%
67%
87%
88%
Control
68%
70%
52%
75%
Negative Pain Management Index
Group
Time 1
Time 2
Time 3
Education
60%
32%
50%
Control
49%
38%
42%
Conclusions
• Pain education did not improve pain intensity for
Hispanic patients
• Pain education led to short-term reduction in pain
intensity for African American patients
• No impact on perceived pain control or quality of
life
• Individualized education or treatment protocols
may be more beneficial
Why?
Top Barriers to Cancer Pain Management
Barrier
Percentage
Inadequate pain assessment
71
Patient reluctance to report
56
Inadequate staff knowledge
54
Reluctance to prescribe
40
Patient reluctance to take
36
Lack of staff time
34
Pain-Related Attitudes
Item
Hispanic
African
American
Caucasian
Need more
information
55%
43%
16%
Need more
medication
28%
33%
11%
Need
stronger
medication
39%
47%
17%
Pain-Related Behaviors and Attitudes
Item
Hispanic
African
American
Caucasian
Taking prn
meds
62%
66%
60%
Taking < 2
times/day
80%
83%
52%
Side effects
26%
29%
21%
Overuse
concern
36%
22%
22%
Pain-Related Attitudes
Concern
Hispanic
Be strong
African
American
93%
Addiction
79%
59%
Tolerance
57%
71%
Not effective
69%
71%
Not bother MD
71%
59%
76%
Use of Alternative Treatments
Technique
African
American
83%
Hispanic
Over the
counter meds
Special teas or
herbs
Relaxation
33%
35%
25%
18%
33%
12%
Vitamins
25%
12%
Prayer
47%
Communication
• “The doctor understands me because he speaks Spanish.”
• “If I continue to have pain, the doctor said contact me as
soon as you can.”
• “Wow, what a relief.”
Communication
• “You don’t remember everything...It would be
good to have something written.”
• “If the doctors or nurses had more time… or to
have a stable nurse.”
• “She uses a lot of big words that I don’t
understand.”
Concerns about Pain Medications
• “Does one die when one takes
morphine?”
• “The doctor said don’t take too much if
you don’t have to.”
• “They tell me that the medicine is
addictive.”
Risk Factors for
Inadequate Pain Treatment
• Marital Status
– Single: 74% under treated
– Married: 58% under treated
Risk Factors for
Inadequate Pain Treatment
• Ethnicity
– Latino patients: 59% under treated
– African American patients: 48% under treated
– P = 0.10
Risk Factors for
Inadequate Pain Treatment
• Performance Status
– Poor performance status: 36% under treated
– Good performance status: 45% under treated
– P = 0.11
Risk Factors for
Inadequate Pain Treatment
• Physician Assessment
– Inadequate: 58% under medicated
– Adequate: 37% under medicated
Conclusions
• Pain interventions for underserved minority
patients must target physicians and patients
• Standardized pain assessment
• Pain treatment guidelines
• Pain education for patients needs to be
individualized
• Specific barriers can be identified
Eliminate Disparities
“Our greatest opportunities for reducing
health disparities are in empowering
individuals to make informed health care
decisions and in providing the skills,
education, and care necessary to improve
health. The underlying premise of Healthy
People 2010 is that the health of the
individual is inseparable from the health of
the larger community.” David Satcher, MD, PHD
Research Team
• Charles S. Cleeland, PhD
• Richard Payne, MD
• Guadalupe Palos, RN, LMSW, DrPH
• Tito Mendoza, PhD
• Vicente Valero, MD
• Arlene Nazario, MD
• Stephen Richman, MD