A study by Bemabei and colleagues (1998) took advantage of a large database to examine the treatment of pain in cancer patients cared for in nursing homes. Using the Resident Assessment Instrument and the Minimum Data Set (MDS), part of the Health Care Financing Administration’s (HCFA’s) Demonstration Project, the investigators found that 38 percent of nursing home residents with cancer from a five-state area complained of, or showed evidence of, daily pain. The study found that 26 percent of these patients with daily pain got no analgesics at all. Patients over 85 years were more likely to receive no analgesia, as were minorities. Only about half of the patients in pain were receiving opioids, and only 13 percent of patients over 85 were receiving these stronger analgesics.

Many cancer specialists recognize that symptom control is often suboptimal. Medical oncologists were surveyed about their treatment of cancer pain in a study conducted by ECOG (von Roenn et al., 1993). Only half of the physicians surveyed indicated that cancer pain control was good or very good in their practice setting. Seventy-five percent of the physicians indicated that the most important barrier to cancer pain management was inadequate pain assessment. More than 60 percent of physicians were reluctant to prescribe analgesics or cited the unwillingness of patients to report pain or take opioids as barriers. Inadequate knowledge about cancer pain management was reported by more than half the physicians who responded. The survey acknowledged that a substandard level of education about cancer pain management and a reluctance to address it in practice existed at all levels of professional health care.

A recent study (Cleeland et al., 2000) repeated the ECOG study format with physician members of the Radiation Therapy Oncology Group. On average, physicians estimated that two-thirds of cancer patients suffered pain for longer than one month. Assessing a case scenario, 23 percent would wait until the patient’s prognosis was six months or less before starting maximal analgesia, indicating a very conservative approach to pain management. Adjuvants and prophylactic side-effect management were underutilized in the treatment plan for the case presented. Perceived barriers to good pain management were very similar to the ECOG study, with poor pain assessment being ranked number one. Compounded by inadequate training for physicians in the palliative treatment of cancer, these problems influence decisions made in the management of incurable cancer and profoundly affect end-of-life care.

In spite of recent concerns over symptom management at the end of life, provoked in large part by the debate over euthanasia, there is substantial evidence that symptoms that could, in principle, be well managed are undertreated, especially for patients who are still in active treatment. There is evidence that many symptoms could be controlled more adequately if we systematically applied the knowledge that we now have about symptom management.