"The reliability and validity of many of these instruments have been established in cancer patients," the report said. "Less is known about clinically useful cutoff scores and assessment of meaningful changes over the course of illness. There are few established symptom assessment instruments for children, older adults, individuals with cognitive impairments, and individuals from different ethnic and cultural groups."
Treatment of pain, depression, and fatigue pose problems throughout the course of cancer, and the treatment of these side effects may relieve or, conversely, exacerbate others. Because cancer pain shares mechanisms with pain from other causes, treatment approaches can be extrapolated from other pain management models, including the World Health Organization’s three-step analgesic ladder.
Treatment for cancer-related depression is substantially the same as in other medical conditions, the panel said. A variety of antidepressants have shown benefit in randomized, controlled studies, and meta-analyses of cognitive-behavior and psychosocial interventions have substantiated modest benefit.
The panel said there is little convincing evidence that effective therapies exist to counter fatigue, but did note that epoetin alfa(Drug information on epoetin alfa) (Epogen, Procrit) "is an effective intervention for patients with anemia-related fatigue."
Barriers to providing effective pain relief to cancer patients involve providers, patients and their families, and the health care system, the report said.
Among providers, these barriers include a lack of awareness of the patient’s pain, inadequate training in pain management, a lack of time and resources, seeing the cure of cancer as a higher priority than treating symptoms, and concern about legal and regulatory sanctions for overusing narcotics. Patients and families may believe that pain is inevitable with cancer and nothing can be done for it; they may fear that addiction will develop and that reporting pain will distract providers from treating the cancer. Medication costs may also be a factor.
System barriers include a lack of communication between oncologists and primary care providers, poorly coordinated care, the priority of cure over symptom management, regulatory barriers to effective pain control, and a lack of reimbursement for symptom management.