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Improving Palliative Care for Cancer
fatigue, worry, distress, poor sleep, lack of appetite, and dry mouth (Cleeland et al., 2000).
It is less well recognized that many cancer survivors continue to experience physical, affective, or cognitive symptoms even when their disease is in remission or treatment has ended. These symptoms may be due to physiological changes associated with prior treatments, delayed side effects of treatment, or long-term consequences of the disease. For example, survivors of bone marrow transplantation may report cognitive impairment, physical symptoms, or emotional distress many years after the transplant (Andrykowski et al., 1995; McQuellon et al., 1996; Prieto et al., 1996).
Evidence for Inadequate Symptom Management
Recent studies have described the prevalence and severity of pain due to cancer and have documented that pain is often undertreated with available analgesics (Cleeland et al., 1994). These studies present a model for the study of other major symptoms, such as depression and fatigue. Approximately 55 percent of outpatients with metastatic cancer have disease-related pain, and 36 percent have pain of sufficient severity to impair their function and quality of life despite current analgesic therapy. Despite national and international guidelines for its management, many patients with pain are not prescribed an analgesic appropriate to the severity of their pain (Cleeland et al., 1994). Evidence suggests that patients in minority groups may have an even greater risk for undertreatment of pain (Anderson et al., 2000; Cleeland et al., 1997).
Two studies of outpatients with metastatic or recurrent cancer receiving treatment at Eastern Cooperative Oncology Group (ECOG) institutions found that more than 40 percent of those with pain were not prescribed analgesics strong enough to match the severity of their pain (Cleeland et al., 1994, 1997). A discrepancy between the physician’s and patient’s rating of the severity of the pain was a major predictor of undermedication for pain (Cleeland et al., 1994). Pain has to be appreciated before it can be treated. In addition, patients seen at centers that treated predominantly minority patients were three times more likely than those treated elsewhere to have inadequate pain management (Cleeland et al., 1997). Other factors that predicted inadequate pain treatment included age of 70 years or older, female sex, and better performance status. These results support the opinion of oncology physicians that poor assessment of symptoms is a major barrier to adequate symptom management (Cleeland et al., 2000; von Roenn et al., 1993). They also suggest that careful and accurate symptom assessment is particularly important for cancer patients from minority groups, elderly patients, female patients, and patients who appear to be functioning well.