February 2018 VOL 9, NO 2
Nurse-Led Pain Education Reduces Pain Intensity in Patients with Painful Bone Metastases
In patients undergoing radiation therapy for painful bone metastases, results from a multicenter randomized trial suggest that pain management education may reduce pain intensity. According to data presented at the 2017 Palliative and Supportive Care in Oncology Symposium, controlled pain, which was defined as a pain score lower than 5 (out of 10), was reached faster and by more patients with the addition of nurse-led pain education compared with standard of care. However, no significant differences were found between the groups in quality of life.
“Although radiotherapy is an effective treatment for painful bone metastases, with over 70% responders, pain is not always sufficiently controlled,” said Jenske I. Geerling, Nurse Practitioner, Palliative Care, University Medical Center Groningen, the Netherlands.
As Ms Geerling reported, analysis from the Dutch Bone Metastases Study showed that during weekly follow-up 35% of patients reported a pain score of at least 5 (out of 10) despite pain medication.
“Research has shown that pain management education may improve patient empowerment and consequently may reduce pain intensity, but a nurse-led pain education for patients undergoing radiotherapy for painful bone metastases has never been investigated before,” said Ms Geerling.
In this multicenter, phase 3 study, conducted between March 2011 and April 2016, patients referred for radiation therapy for painful bone metastases were randomized into 2 arms. Patients in the intervention arm received nurse-led pain education and follow-up phone calls at weeks 1, 4, 8, and 12. Patients in the control arm received care as usual and information leaflets about cancer pain, radiotherapy, and opioid use at baseline.
The nurse-led pain education consisted of a structured interview to assess the pain. Patients’ knowledge was assessed using 8 statements, such as “pain medication should only be given when pain is severe” or “most patients will become addicted to pain medication.” Based on that knowledge assessment, tailored education was then provided by the research nurse, with relatives invited to join the education session. Afterward, a workbook with pain-related topics was given, and questions about pain management were addressed in follow-up phone calls.
To assess the severity of clinical pain and its impact on functioning, investigators used the Brief Pain Inventory. The European Organization for Research and Treatment of Cancer quality-of-life questionnaires about palliative care and bone metastases were used to assess physical functioning, functional interference, emotional functioning, psychosocial aspects, and overall quality of life. The primary end point was worst pain intensity at the 12-week follow-up. The secondary end point was quality of life.
Controlled Pain Reached Faster
As Ms Geerling reported, investigators randomized a total of 354 patients to intervention (n = 176) and control (n = 178). A total of 38 patients were excluded from the study, mostly because of pain scores lower than 5 at baseline. At 12 weeks, 185 patients, including 95 patients in the education intervention arm, had completed follow-up. Baseline characteristics were similar in both groups (mean age, 65 years; 56% male).
“At 12 weeks of follow-up, 30% of patients in the intervention group had a pain score of more than 5, compared with 47% of patients in the control,” said Ms Geerling, who noted that this was a statistically significant difference.
In addition, patients randomized to the nurse-led education reached pain control faster than their counterparts in the control arm. It took an average of 31 days for patients in the intervention arm to reach pain intensity lower than 5, whereas patients in the control arm needed an average of 51 days to achieve the same pain control (P = .026). This was also a significant difference, the authors noted.
Despite the improvements in pain control, however, no significant differences in quality of life were observed between groups at any time point.
“There were improvements in functional interference and physical functioning for both groups, but on psychosocial aspects, emotional functioning, and overall quality of life, there were no differences between baseline and 12-week follow-up,” Ms Geerling concluded.