Background & Aims
the most feared symptom of cancer which is frequently undertreated. One of the main reasons for inadequately treated cancer pain is inadequate assessment without using a comprehensive and simple tool. There is no universally accepted pain classification tool for cancer pain assessment. Edmonton Classification System-Cancer Pain (ECS-CP) is one such tool for assessing multidimensional aspect of cancer pain. However, its use in developing countries is reported to be very limited.Hence, we conducted this study with the primary objective to evaluate the prevalence of ECS-CP pain classification features in a tertiary care public hospital of Northern India in patients suffering from breast and gynecological cancer.
Methods
This prospective, cross sectional observational study enrolled 100 breast and gynecological cancer patients aged more than 18 years presenting to a single tertiary care center in Northern India. After receiving ethics approval, CTRI registration (CTRI/2022/01/039663, registered on Jan 21, 2022), and patients’ informed consent, the study was carried out between Feb 2022 and October 2022.
A researcher completed the ECS-CP. Pain intensity (NRS), health related quality of life (EuroQOL) and Hospital Anxiety and Distress scale (HADS) were also assessed. Patients were reassessed at two weeks for NRS, and daily opioid consumption used to manage pain. The primary objective of study was to assess prevalence of five classification features of ECS-CP in a tertiary care public hospital of Northern India. Secondary objectives were to assess pain intensity, opioids and adjuvants used, HRQOL; and association of various pain classification features with pain intensity and HRQOL.
Results
A total of 100 female patients, with a median age of 50 years (range: 18-80), were included.
Mean duration of pain was 23.12 ± 16.75 days. Prevalence of ECS-CP features were as follows; nociceptive pain 52%, neuropathic pain 48%, incident pain 29% and psychological distress 75%.Anxiety was present in 51% (30% moderate and 21% severe) and depression was present in in 65% (52% moderate and 21% severe). No evidence of addictive behavior and cognitive impairment was found. Mean time taken to complete both ECS-CP and EURO-QOL was 20±2 minutes. The mean pain intensity at baseline was 4.85±1.90, which significantly reduced to 3.1±2.4 at the two-week follow-up. Mean of the utility index of EuroQOL5D5L score was 0.723±0.225. There was a positive correlation between neuropathic pain and NRS. Significantly greater use of opioid in patients with neuropathic pain (12.8± 30.25mg) than with nociceptive pain (1.7±2.8mg).
Conclusions
In a developing country busy outpatient pain and palliative care clinic of a tertiary care setting, ECS-CP is a simple and comprehensive classification system for cancer pain assessment with reported prevalence of neuropathic pain (48%), incident pain 29% and psychological distress (75%) in gynecological and breast cancer patients. ECS-CP can be used in routine clinical assessment of cancer patients in a busy developing country outpatient setting.
References
1.Snijders RAH, Brom L, Theunissen M, van den Beuken-van Everdingen MHJ. Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis. Cancers 2023, 15, 591. https://doi.org/ 10.3390/cancers15030591
2.Fallon M, Giusti R, Aielli F, Hoskin P, Rolke R, Sharma M, Ripamonti CI. ESMO Guidelines Committee. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018; 29; 166-191
3.Fainsinger RL, Nekolaichuk CL. Cancer pain assessment- Can we predict the need for specialist input? Eur J Cancer. 2008; 44:1072-1077
4.Fainsinger RL, Nekolaichuk C. Muller V. Assessing and classifying cancer pain: Can we develop an internationally accepted common language? J Palliat Care. 2014; 30 :279-283
5.Bennett MI, Kaasa S, Barke A, Korwisi B, Rief W, Treede RD. IASP Taskforce for the Classification of Chronic Pain. The IASP Classification of Chronic Pain for ICD-11: Chronic Cancer-Related Pain. Pain. 2019; 160:38–44
6.Hwang SS, Chang VT, Fairclough DL, Kasimis B. Development of a cancer pain prognostic scale. J Pain Symptom Manage. 2002; 24: 366-378
7.Bruera E, MacMillian K, Hanson J, Mac Donald RN. The Edmonton staging system for cancer Pain: Preliminary report. Pain. 1983; 37: 203-209.
8.Bruera E, Schoeller T, Wenk R, MacEachern T, Marcelino S, Hanson J, Suarez-Almazor M. A prospective multi center assessment of the Edmonton staging system for cancer pain. J Pain Symptom Manage. 1995; 10: 348-35
9.Fainsinger RL, Nekolaichuk CL. A TNM classification system for cancer pain: The Edmonton classification system for cancer pain (ECS-CP). Support Care Cancer 2008;16: 547-555
10.Hjermstad MJ, Fainsinger R, Kaasa S; European Palliative Care Research Collaborative (EPCRC). Assessment and classification of cancer pain. Curr Opin Support Palliat Care. 2009; 3: 24-30.
11.Boonstra AM, Stewart RE, Köke AJ, Oosterwijk RF, Swaan JL, Schreurs KM, Schiphorst Preuper HR. Cut-Off Points for Mild, Moderate, and Severe Pain on the Numeric Rating Scale for Pain in Patients with Chronic Musculoskeletal Pain: Variability and Influence of Sex and Catastrophizing. Front Psychol. 2016; 7: 1466. doi: 10.3389/fpsyg.2016.01466.
12.Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, Cunin G, Fermanian J, Ginies P, Grun-Overdyking A, Jafari-Schluep H, Lantéri-Minet M, Laurent B, Mick G, Serrie A, Valade D, Vicaut E. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005; 114: 29-36
13.Saxena AK, Khrolia D, Chilkoti GT, Malhotra RK. Validation of Complete Hindi Version of Douleur Neuropathique 4 Questionnaire for Assessment of Neuropathic Pain. Indian J Palliat Care. 2021; 27: 257-263
14.Zigmond AS, Snaith RP. The Hospital anxiety and depression scale. Acta psychiatry Scand. 1983; 67: 361-370.
15.Rishi P, Rishi E, Maitray A Agarwal A, Nair S, Gopalakrishnan S. Hospital Anxiety and Depression Scale assessment of 100 patients before and after using low vision care: A prospective study in a tertiary eye-care setting. Indian J Ophthalmol 2017; 65: 1203–1208.
16.Ewing JA. Detecting alcoholism. Indi version of The CAGE questionnaire. JAMA. 1984; 252: 1905-1907
17.Ganguli M, Ratcliff G, Chandra V, Sharma, S Gilby J, Pandav R, Dekosky, S. A Hindi version of the MMSE: the development of a cognitive screening instrument for a largely illiterate rural elderly population in India. International Journal of Geriatric Psychiatry. 1995; 10: 367-377.
18.Sallam K, Amr M. The use of mini mental state examination and the clock drawing test for dementia in tertiary care hospital. J Clin Diagn Res. 2013;7: 484-488
19.Pickard AS, De Leon MC, Kohlmann T, Cella D, Rosenbloom, S. Psychometric comparison of the standard EQ-5D to a 5-level version in cancer patients. Med Care. 2007; 45: 259-263
20.Jyani G, Sharma A, Prinja S, Kar SS, Trivedi M, Patro BK, Goyal A, Purba FD, Finch AP, Rajsekar K, Raman S, Stolk E, Kaur M. Development of an EQ-5D Value Set for India Using an Extended Design (DEVINE) Study: The Indian 5-Level Version EQ-5D Value Set. Value Health. 2022; 25: 1218-1226
21.Belayneh M, Fainsinger R, Nekolaichuk C, Muller V, Bouchard S, Downar J, Galloway L, Ghosh S, Hawley P, Herx L, Kmet A, Lawlor P. Edmonton Classification System for Cancer Pain: Comparison of Pain Classification Features and Pain Intensity across Diverse Palliative Care Settings in Canada. J Palliat Med. 2023; 26: 366-375
22.Fainsinger RL, Nekolaichuk C, Lawlor PG, Hagen N, Bercovitch M, Fisch M, Galloway L, Kaye G, Landman W, Spruyt O, Zhukovsky D, Bruera E, Hanson J. An international multicenter validation study of a pain classification system for cancer patients. Eur J Cancer. 2010; 46: 2896–2904.
23.Sulistio M, Ling N, Finkelstein T, Tee HJ, Gorelik A, Kissane D, Michael N. The Edmonton Classification System for Cancer Pain in Patients with Bone Metastasis: a descriptive cohort study. Support Care Cancer. 2023; 31: 305. doi: 10.1007/s00520-023-07711-9.
24.Nekolaichuk CL, Fainsinger RL, Aass N, Hjermstad MJ, Knudsen AK, Klepstad P, Currow DC, Kaasa S. European Palliative Care Research Collaborative (EPCRC). The Edmonton Classification System for Cancer Pain: comparison of pain classification features and pain intensity across diverse palliative care settings in eight countries. J Palliat Med. 2013;16: 516–523.
25.Nijs J, Leysen L, Andriaenssens N, Aguilar Ferrandiz ME, Devoogdt N, Tassenoy A, Ickmans K, Goubert D, van Wilgen CP, Wijma AJ, Kuppens K, Hoelen W, Hoelen A, Moloney N, Meeus M. Pain following cancer treatment: guidelines for clinical classification of predominant neuropathic pain, nociceptive and central sensation pain. Acta oncol. 2016; 55: 659-663.
26.Fainsinger RL, Fairchild A, Nekolaichuk C, Lawlor P, Lowe S, Hanson J. Is pain intensity a predictor of the complexity of cancer pain management? J Clin Oncol 2009; 27: 585–590.
Presenting Author
Babita Ghai
Poster Authors
BABITA GHAI,MBBS, MD, DNB
MBBS, MD, DNB
Postgraduate Institute of Medical Education and Research Chandigarh
Lead Author
Ravi Musturi
MD
Postgraduate Institute of Medical Education and Research Chandigarh, India
Lead Author
Rajni Sharma
Postgraduate Institute of Medical Education and Research Chandigarh
Lead Author
Bhavana Rai
MD
Postgraduate Institute of Medical Education and Research Chandigarh
Lead Author
Jeetinder Makkar
Postgraduate Institute of Medical Education and Research Chandigarh
Lead Author
Budhi Yadav
MD
Postgraduate Institute of Medical Education and Research Chandigarh
Lead Author
Topics
- Assessment and Diagnosis