J.L. WEBB

The most useful tools physicians have to treat cancer patients’ pain are their own ears and mouths.

That is the consensus of two specialists at MD Anderson Cancer Center Orlando, one of the preeminent comprehensive cancer care facilities in the southeastern United States.

“One of the (most important) things physicians can do to help their cancer patients cope with pain is to be open and honest about it. Specifically, ask the patient ‘Are you having any pain?,’ and do it in a nonjudgmental way,’’ said Dr. Chad Kollas, medical director of Palliative and Supportive Care at MD Anderson.
That sentiment is echoed by Dr. Mary Busowski, an internist in the medical oncology division there.

“First, it starts with an open dialogue about pain, and then you need to listen to what the barriers to treating the pain are,’’ Busowski said.

Tearing down those barriers is not easy.

According to the National Cancer Institute, patients very often are reluctant to be candid about their pain, especially with their oncologists. The fear of becoming addicted or impervious to pain medication is a common concern, although usually baseless. But perhaps the most prevalent worry of patients is that if the pain is progressing, so is the disease.

“They think that if they admit to having pain, they are giving up or giving in,’’ Busowski said. “They also fear addiction. I spend a lot of time educating patients and their families about the difference between addiction and the physiological dependence that comes with using narcotics for pain. People worry that pain equates to a progression of the disease. They’re afraid to admit that (may be the case), or they are afraid if they admit they are in pain that they somehow are letting cancer take over.’’

Kollas concurred. “Sometimes, patients are hesitant to ask about their pain if … it is worsening,” he said, adding that denying the pain is a way for them to deny their situation is getting worse.

Sometimes that concern is valid. “A lot of times, patients will have an increase in their pain related to the progression of their cancer, or if their cancer has spread to a new place. A lot of times, people will develop difficulty with back or hip pain, and that turns out to be related to spread of the cancer to the bone. When that occurs, it will produce a difference in their pain pattern,’’ he said.

“Actually I’ve found that (sometimes) patients’ pain will actually precede being able to identify changes on imaging studies that confirm that’s what is causing the pain,’’ said Kollas.

Busowski said she spends “a lot of time talking to people and convincing them it is okay to treat pain. Maybe they are reluctant to discuss it with their medical oncologist. The focus of that visit is treatment-centered and it’s a work list of tests and scans and schedules. So, maybe (the patients’ pain) doesn’t come up, or maybe they feel pressured to discuss other things (like test results) with the oncologist. When they come to see me, it’s a different focus,’’ she said.

At MD Anderson, Busowski is part of a team that includes surgical, thoracic, gynecological and radiation oncologists, as well as palliative medicine and cancer medicine, of which she is division chair. “I offer a different skill set than the medical oncologist, so many times (patients) view their visit with me differently. I’m a safe place … and it is a more comprehensive and less time-constrained visit,’’ she said.

Her role in addressing acute ambulatory issues puts Busowski “in a unique position to see all types of cancers and all varieties of treatments,’’ she said. “If you look at the trends in cancer treatment, and places like MD Anderson in Houston, and Moffitt (H. Lee Moffitt Cancer Center & Research Institute in Tampa), they recognize that there is a role for general internal medicine physicians who understand the unique problems in treating cancer patients,’’ Busowski said. “There are (patients) who come with a lot of morbidities that are going to impact not only the cancer treatment itself, but the outcomes.’’

Busowski said part of the medical center’s distinctiveness is physicians recognizing “that patients need different kinds of expertise that come from a general internist who can look at the co-morbidities, who can balance a medication list, who can look at side effects, and who can establish rapport with patients’’ on all those topics.

“There’s a lot of monitoring involved when you initiate pain therapy,’’ she said. “Number one, you want to monitor response to treatment. One reason for failure is (doctors) don’t always (do that). Number two, are the side effects. The patients and their families need to be educated and (physicians) need to be very pro-active’’ in furthering that education.”

For instance, Busowski continued, “I tell patients all the time ‘one of the worst things that will happen to you is you will get constipated. You’ll tolerate all the big, bad, horrible things we do to you–chemotherapy, radiation, surgery–but it’s the little things that will make or break your ability to cope with your treatment.’’’

Sometimes, it is not the patients, but the patients’ families’ physicians really need to listen to, she said.

“What are their fears and concerns? Often, it is the family members who are in control of dispensing medicine and recognizing when to treat pain. It’s just a matter of listening,’’ said Busowski. The 44-year-old physician has plenty of experience in that regard, having been a registered nurse for 15 years and a stay-at-home mom for nine years before becoming a medical doctor.

Kollas’ approach to establishing a dialogue with patients begins with convincing them their pain can be controlled. “If they understand that, they are more likely to participate in the discussion,’’ said Kollas.

Kollas and Busowski agree that having one doctor prescribe all the patients’ medication should be the standard. “The hand that writes the opioid is the hand that writes the laxative,’’ said Kollas. “It’s critical that one person is in charge of the medications. That way, you have a consistent approach to pain management.’’

But no cancer patient’s pain can be managed if the doctor isn’t aware of it. Toward that end, the National Cancer Institute is teaching doctors how to ask patients questions that elicit more specific answers, and has sponsored research aimed at empowering patients to take the lead in managing their pain.


August 2007