Prevalence and management of pain in Italian patients with advanced non-small-cell lung cancer

Pain is a common symptom experienced by cancer patients (Cleary, 2000). Pain prevalence and severity do increase with the extension of disease: about half of all cancer patients report some degree of pain, but this percentage rises to 74% in the advanced and terminal stages (Bonica, 1990). Among cancer patients with advanced disease, pain is moderate to severe in 40–50% and very severe or excruciating in 25–30% (Daut and Cleeland, 1982). Lung cancer is the first cause of cancer death (Parkin, 2001) and it is mostly diagnosed at an advanced stage. Lung cancer-related pain depends on the location of the primary tumour, its loco-regional extension and metastatic spread. Pain may be secondary to peripheral growth of the primary tumour (e.g. pleural or chest wall involvement) or to nerve involvement (pain in the arm or in the shoulder, or the classic Pancoast syndrome). Sometimes a visceral pain can occur, unrelated to the invasion of local structures, presenting as a nonspecific and vague chest pain referred to the ipsilateral hemithorax (Ginsberg et al, 1997). Pain can finally be related to metastatic disease, for example, bone metastases, that occur in approximately one-third of patients (Coleman, 1997), or brain metastases, that can cause headache and symptoms related to intracranial hypertension. Moreover, pain may be unrelated to cancer itself, and rather depend from coexisting diseases (e.g. osteoarthritis), particularly common in elderly patients. Disease symptoms can have a great impact on functional status and quality of life (QoL). Pain is without any doubt among the most distressing symptoms experienced by cancer patients. A recent study of patients with chronic nonmalignant pain reported significant correlations between severity of pain and QoL (Becker et al, 1997). Pain, psychological control and spiritual uncertainty have been indicated as the best predictors of QoL scores in cancer patients (Ferrell et al, 1995). In 216 patients with metastatic cancer, Wang et al (1999) found that increasing severity of pain was associated with worsening health-related functioning. Despite the existence of published and well-known guidelines for cancer pain management recommended by the World Health Organization (World Health Organization, 1996), undertreatment of pain remains an outstanding problem for the correct treatment of cancer patients, as already emerged from several studies conducted in different countries (Cleeland et al, 1994; Larue et al, 1995; Zenz et al, 1995; Wang et al, 1999). This is disappointing because, with a correct use of WHO analgesic ladder, up to 88% of patients is reported to obtain satisfactory relief from pain (Ventafridda et al, 1987; Zech et al, 1995). It is recommended that treatment should start at the step of the analgesic ladder appropriate for the severity of pain, and all patients with moderate-to-severe cancer pain, regardless of aetiology, should receive a trial of opioid analgesia (Jacox et al, 1994). However, very frequently this does not happen. Objective of this study is to describe the prevalence of pain among patients affected by advanced non-small-cell lung cancer (NSCLC), the impact of pain on health-related QoL and the adequacy of pharmacologic management of pain.