Good. . .but Bad News TO THE EDITOR: We read with interest the paper by Greco et al.1 The authors conclude that that cancer pain management is improving. After analyzing the literature in two different periods, they have found a better quality of cancer pain management reported in the last 6 years. While all researchers and clinicians would be happy with better quality of cancer pain management, the bad news is that this conclusion is not accurate based on the parameters compared by the authors. The Pain Management Index (PMI) score continues to be used inappropriately as an indirect measure of quality of pain management.2 The achievement of an appropriate analgesic treatment cannot be based on this score, calculated by drug class and pain intensity. This index was originally developed by Cleeland et al3 to measure physicians’ response to patients’ pain, which is a generic attitude in prescription, including for example drugs prescribed but not necessary administered. Thus, PMI does not provide any measure of adequacy of a pain treatment. With this score any patient receiving the class of strong opioids is considered adequately treated and there is no consideration of pain intensity, opioid type, or even opioid dose.4 In addition, the distinction of strong and weak opioids is obsolete. Socalled strong opioids can be used at low doses in lieu of weak opioids, and some previously considered weak opioids such as hydrocodone have been found to be more potent than strong opioids.5,6 Despite these obvious limitations, PMI has been occasionally used by researchers to provide information about pain management. It is quite obvious that this score will provide an excessively optimistic view of the situation. The inaccurate nature of this score has been addressed in a survey conducted in a large sample of oncologic wards. Despite receiving strong opioids (therefore good pain control, according to PMI), approximately 85% of patients had their pain uncontrolled.4 This observation underlines that cancer pain is undertreated despite the use of strong opioids and that PMI cannot be considered a cutoff for judging adequacy of an analgesic treatment. Indeed, there are multiple reasons to be worried about cancer pain management. While medical oncologists recognized the importance of opioid therapy, when challenged with a clinical scenario, poor knowledge about assessment and opioid use was observed.7 These findings suggest that an opioid prescription should not be interpreted as evidence of adequate analgesic treatment. Rather, it is likely that palliative care principles, including pain management, are not applied

early in the course of illness and multiprofessional integration could improve the quality of pain management. Recent scientific evidence has shown that patients receiving early palliative care had less aggressive care, better quality of life, and longer survival.8,9 Palliative care should be started in hospitals providing an interdisciplinary supportive or palliative care team to support patients with cancer throughout the disease trajectory, rather than restricting the action area only in the last weeks of life.10 PMI cannot be considered as a tool to assess adequacy or to monitor changes in cancer pain management.

Sebastiano Mercadante La Maddalena Cancer Center, Palermo, Italy

Eduardo Bruera The University of Texas MD Anderson Cancer Center, Houston, TX


Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Greco MT, Roberto A, Corli O, et al: Quality of cancer pain management: An update of a systematic review of under treatment of patients with cancer. J Clin Oncol 32:4149-4154, 2014 2. Mercadante S: Comments on Wang et al. Pain 74:106, 1998 3. Cleeland CS, Gonin R, Hatfield AK, et al: Pain and its treatment in outpatient with metastatic cancer. N Engl J Med 330:592-596, 1994 4. Mercadante S, Roila F, Bertetto O, et al: Prevalence and treatment of cancer pain in Italian oncological wards centres: A cross-sectional survey. Support Care Cancer 16:1203-1211, 2008 5. Mercadante S, Porzio G, Ferrera P, et al: Low morphine doses in opioidnaive cancer patients with pain. J Pain Symptom Manage 31:242-247, 2006 6. Reddy A, Yennurajalingam S, Desai H, et al: The opioid rotation ratio of hydrocodone to strong opioids in cancer patients. Oncologist 19:1186-1193, 2014 7. Breuer B, Fleishman SB, Cruciani RA, et al: Medical oncologists’ attitudes and practice in cancer pain management: A national survey. J Clin Oncol 29:4769-4775, 2011 8. Temel J, Greer J, Muzikansky A, et al: Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med 363:733-742, 2010 9. Zimmermann C, Swami N, Krzyzanowska M, et al: Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet 383:1721-1730, 2014 10. Bruera E, Hui D: Palliative care units: The best option for the most distressed. Arch Intern Med 171:1601, 2011

DOI: 10.1200/JCO.2014.60.6152; published online ahead of print at www.jco.org on April 20, 2015

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Journal of Clinical Oncology, Vol 33, No 18 (June 20), 2015: pp -2119

© 2015 by American Society of Clinical Oncology

Information downloaded from jco.ascopubs.org and provided by at CAMBRIDGE UNIV MEDICAL LIBRARY on August 11, Copyright © 2015 American of Clinical Oncology. All rights reserved. 2015Society from




Good. . .but Bad News The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Sebastiano Mercadante No relationship to disclose

© 2015 by American Society of Clinical Oncology

Eduardo Bruera No relationship to disclose


Information downloaded from jco.ascopubs.org and provided by at CAMBRIDGE UNIV MEDICAL LIBRARY on August 11, Copyright © 2015 American of Clinical Oncology. All rights reserved. 2015Society from

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