Pain is frequently encountered in patients with cancer, due to cancer itself, to cancer treatment, or to an independent cause. It is linked with various mechanisms as inflammatory, neuropathic, somatic or visceral, acute or chronic. It has a negative impact on patients' quality of life, and probably on patients' survival. Cancer pain treatment is based on the efficacy of various approaches such symptomatic or specific interventions. Cancer pain management is often considered as poor, as found in the results of French surveys. Some explanations and proposals are offered.

La douleur est fréquemment rencontrée en cancérologie, du fait de la maladie, du traitement de la maladie, ou d’une raison intercurrente. Ses mécanismes sont variés, elle peut être inflammatoire, neuropathique, somatique, viscérale, aiguë, chronique. Elle a un impact négatif sur la qualité de vie et potentiellement sur la survie. Son traitement fait appel à diverses approches, symptomatiques ou plus spécifiques. La prise en charge est fréquemment considérée comme peu satisfaisante, comme cela a été retrouvé en France. Quelques explications et propositions sont avancées.

Les moyens pour ameliorer la qualite de la prise en charge de la douleur postoperatoire (DPO) sont ceux qui sont utilises de facon plus generale pour l’implantation dans la pratique clinique des donnees de la medecine basee sur les preuves [1]. La reussite dans l’implantation de nouvelles pratiques semblent dependre de facon equilibree de la pertinence des recommandations proposees mais egalement du contexte et de l’environnement et enfin des methodes utilisees pour implanter les nouvelles pratiques [2]. Les methodes utilisees peuvent comprendre une approche d’education des professionnels, d’evaluation avec retour d’information, d’assistance a la decision, d’organisation d’equipe, d’education et d’information du patient et d’incitation financiere. Le plus souvent l’approche est globale et associe plusieurs aspects de l’amelioration du soin. Une analyse de causalite directe entre l’impact sur les resultats et une modification de l’organisation est le plus souvent impossible. En revanche, quelques notions generales peuvent etre tirees de cette litterature. Nous allons donc reprendre dans cette premiere partie les moyens d’amelioration de la qualite pour la prise en charge de la DPO et les donnees de la litterature qui permettent de definir leur impact sur la qualite.

Quality improvement and its evaluation for postoperative pain management A. Belbachir , D. Fletcher *, F. Larue c a Service d’anesthésie-réanimation, hôpital Cochin ,27 rue du Faubourg-Saint-Jacques, 75014 Paris, France b Service d’anesthésie-réanimation, hôpital Raymond-Poincaré, 104, boulevard Raymond-Poincaré 92380, Garches, France c Service d’anesthésie-réanimation, hôpital Longjumeau, 159, rue du Président-François-Mitterrand, 91164 Longjumeau, France

European Journal of PainVolume 10, Issue S1 p. S246-S246 949 PAIN PREVALENCE, INTENSITY AND TREATMENT BETWEEN CANCER PATIENTS: A 12 YEARS INTERNAL SURVEY IN FRANCE L. Brasseur, L. Brasseur CET Douleur, Service Anesthesie Reanimation Hǒpital A. Pare, BoulogneSearch for more papers by this authorA. Beauchet, A. Beauchet Departement d'Information Hospitaliere et de Santé Publique, Hǒpital A. Pare, BoulogneSearch for more papers by this authorF. Larue, F. Larue Consultation d'Analgesie, Service Anesthesie Reanimation, Centre Hospitalier, LongjumeauSearch for more papers by this authorD. Bouhassira, D. Bouhassira Unité 792, INSERM, Hǒpital A. Pare, FranceSearch for more papers by this authorP. Aegerter, P. Aegerter Departement d'Information Hospitaliere et de Santé Publique, Hǒpital A. Pare, BoulogneSearch for more papers by this author L. Brasseur, L. Brasseur CET Douleur, Service Anesthesie Reanimation Hǒpital A. Pare, BoulogneSearch for more papers by this authorA. Beauchet, A. Beauchet Departement d'Information Hospitaliere et de Santé Publique, Hǒpital A. Pare, BoulogneSearch for more papers by this authorF. Larue, F. Larue Consultation d'Analgesie, Service Anesthesie Reanimation, Centre Hospitalier, LongjumeauSearch for more papers by this authorD. Bouhassira, D. Bouhassira Unité 792, INSERM, Hǒpital A. Pare, FranceSearch for more papers by this authorP. Aegerter, P. Aegerter Departement d'Information Hospitaliere et de Santé Publique, Hǒpital A. Pare, BoulogneSearch for more papers by this author First published: 13 January 2012 https://doi.org/10.1016/S1090-3801(06)60952-XCitations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume10, IssueS1September 2006Pages S246-S246 RelatedInformation

CONTEXT The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the federation of French Cancer Centers (FNCLCC), the 20 French cancer centers, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES To develop clinical practice guidelines for the use of opioid analgesics with the exception of oral morphine and for opioid rotation related to the treatment of nociceptive pain in adults with cancer according to the definitions of the Standards, Options and Recommendations project. METHODS In 1996, a working group, set up by the FNCLCC published clinical practice guidelines for pain management in adult and paediatric patients with cancer: In the light of the evolution of knowledge, and practice these guidelines need to be updated The section on "médical analgesic treatments" in the document published in 1996 was examined by the working group to identify which questions should be updated. These questions and the relevant key words were used to develop a search strategy which was used to search Medline, and for particular questions, Embase, from January 1994 to March 1999, for relevant references, published in English or French. RESULTS For this update, only a few randomised clinical trials were identified, and their conclusions were generally weak. Thus much of the information in this document is based on the World Health Organisation (WHO) guidelines and represents the "state of the art" on this subject in France and is supported by expert agreement. Some changes to the original SOR are presented, particularly for the prescription of new opioids and opioid rotation. The full text of this SOR is available on the FNCLCC web site (http ://www.fnclcc.fr).

All patients have the right to expect to receive the best therapeutic means available to reduce their suffering. Recent evaluation of the French ministerial 3-year plan for the fight against pain by the French Society of Public Health (http://www.sfsp-france.org/Plan-Lutte-Douleur/Plan-Lutte-Douleur.htm) and observations of current practice show that the information and training of health professionals in this area should be continued. The necessity to fight against cancer pain has only recently become a priority. In 1996 a working group, set up by the French National Federation of Cancer Centres (Federation Nationale des Centres de Lutte Contre le Cancer–FNCLCC), published clinical practice guidelines for pain management in adult and paediatric patients with cancer (Krakowski et al, 1996). These guidelines now require updating, but in this document only the pharmacological treatment of pain arising from excess nociception in adults with cancer is covered. The other sections of the original guideline are currently being updated in the context of a collaboration between the FNCLCC and the SETD (Society for the Study and Treatment of Pain (Societe d'Etude et de Traitement de la Douleur) French section of the International Association for the Study of Pain (IASP) subgroup on cancer pain).

UNLABELLED:Pain management has become a notable feature of public health policy and mass media communication in France over the past few years. To assess the evolution of the knowledge and attitudes of the French population with respect to pain management and morphine use, telephone surveys using similar questionnaires were conducted in 1990 (n = 1001) and 1996 (n = 1006). The proportion of respondents who would take pain management adequacy into consideration when selecting a surgical facility increased from 52% to 81% (P < 0.001), as did the proportion who associated morphine with pain treatment (from 44% to 80%; P < 0.001) or who would not be afraid of becoming addicted to morphine after it had been prescribed for pain relief (from 26% to 69%; P < 0.001). However, the proportion of respondents who agreed that morphine can be prescribed to patients with pain increased only slightly. In 1996, 58% of the respondents believed that their knowledge had improved over the past 5 yr and associated this improvement first with television, followed by written press articles and by interaction with physicians. Increased awareness of pain management possibilities among the public may generate increased demand on health professionals to provide adequate and precise information addressing each patient's needs. IMPLICATIONS:The results of two representative surveys conducted over a 6-yr interval show significant improvements of knowledge and attitudes regarding pain and its management in the French general population. However, these results point to the need for additional specific information that should be provided through patient-physician interactions.

To assess how well physicians recognize common symptoms in HIV patients and identify factors associated with symptom recognition, a multicenter cross-sectional survey was performed in a random sample of 118 hospitalized and 172 ambulatory HIV patients, and their attending physicians. Patients' reports of 16 different symptoms were compared to physicians' reports of whether each symptom was present and/or specific treatments prescribed. Overall, fatigue anxiety, skin problems, fever; and weight loss were more often recognized fry physicians than other symptoms. Agreement between patients and physicians was poor to moderate, with Kappa statistics ranging from 0.17 (dry mouth) to 0.58 (fever). Recognition was independently more likely for ambulatory patients (adjusted odds ratio 1.69, P < 0.001) and for patients seen as sicker (adjusted odds ratio 1.88 P < 0.001).Appropriate symptom management requires improved symptom recognition. More systematic clinical examinations, including attentive patient interview are needed. J. Pain Symptom Manage 1999;18:263-270. (C) U.S. Cancer Pain Relief Committee, 1999.

Objectives: To measure the prevalence, severity, and impact of pain on quality of life for HIV patients; to identify factors associated with undertreatment of pain.Design: Multicentre cross sectional survey.Settings: 34 HIV treatment facilities, including inpatient hospital wards, day hospitals, and ambulatory care clinics, in 13 cities throughout France.Subjects: 315 HIV patients at different stages of the disease.Main outcome measures: Patients: recorded presence and severity of pain and rated quality of life, Doctors: reported disease status, estimate of pain severity, and analgesic treatment ordered.Results: From 30% (17/56) of outpatients to 62% (73/118) of inpatients reported pain due to HIV disease. Pain severity significantly decreased patients' quality of life. Doctors underestimated pain severity in 52% (70/135) of HIV patients reporting pain. Underestimation of pain severity was more likely for patients who reported moderate (odds ratio 24) or severe pain (165) and less likely for patients whose pain source was identified or who were perceived as more depressed, Of the patients reporting moderate or severe pain, 57% (61/107) did not receive any analgesic treatment; only 22% (23/107) received at least weak opioids. Likelihood of analgesic prescription increased when doctors estimated pain to be more severe and regarded patients as sicker.Conclusions: Pain is a common and debilitating symptom of HIV disease which is gravely underestimated and undertreated.

World Health Organization (WHO) has recommended since 1986 simple methods to control pain due to cancer. The use of analgesic medications, appropriate to the severity of pain reported by the patient, is the key point of WHO guidelines. It has been shown that the use of analgesic medication and particularly of morphine to control severe pain is insufficient for a majority of patients worldwide. This communication presents the main results of French national studies among representative samples of cancer patients and physicians (primary care physicians and medical oncologists) faced with cancer pain. These studies confirm that cancer pain is inadequately treated for 51% of patients and identify among French physicians attitudinal barriers to the proper use of morphine. Results are discussed with regard to the national policy against pain now in progress in France.

La douleur du cancer reste un probleme de Sante publique mette si 50% des cancers sont aujourd'hui guerissables et si une grande majorite de malades peut actuellement etre soulagee. La reconnaissance des insuffisances dans ce domaine a suscite, plus ou moins recemment, des efforts de la part des soignants, des enseignants et des decideurs politiques a travers le monde. Ce document est destine a aider les medecins impliques dans les soins cancerologiques a mieux comprendre la douleur cancereuse et les symptomes associes. Il aborde aussi brievement le traitement de la douleur du sida car la demarche de prise en charge antalgique en est assez proche et l'evolution du sida peut etre d'ordre cancerologique. Il s'agit aussi d'un grave probleme mondial de Sante publique. Ce document s'est donne cinq objectifs pour ameliorer la prise en charge de la douleur cancereuse : - offrir aux medecins un document de reference base sur une synthese de la litterature pour traiter la douleur cancereuse ; - rappeler aux medecins que la douleur cancereuse peut avoir des causes multiples liees a la maladie et au traitement, se modifier dans le temps, etre destructrice sur le plan physique, psychologique, spirituel et social si elle est negligee ; etre soulagee par differentes methodes souvent simples ; - promouvoir l'evaluation, le diagnostic et le traitement rapides de la douleur cancereuse ; - donner les regles d'utilisation des opioides et faire definitivement disparaitre toutes craintes concernant les risques de toxicomanie chez les malades cancereux algiques bien traites ; - renforcer la volonte des medecins a faire communiquer malades et familles a propos de toute douleur insuffisamment calmee, recente ou non, pour susciter une prise en charge rapide et efficace. Une prise en charge de la douleur, au-dela du soulagement, permet d'aider le malade a maintenir sa qualite de vie et ainsi sa place dans sa famille et dans la societe. L'analgesie, c'est-a-dire la disparition totale de douleur, ne peut pas toujours etre obtenue, mais un bon niveau d'antalgie peut le plus souvent etre atteint par des methodes appropriees appliquees avec attention. Ce document tient compte de la grande variabilite des situations et des malades. Il veut donner au clinicien les moyens d'une approche pratique de la douleur cancereuse mais aussi, dans une certaine mesure, d'autres situations douloureuses. Il veut mettre en avant certains concepts essentiels pour une prise en charge efficace : - approche pluridisciplinaire pour traiter au mieux et avant tout le cancer ; - approche pluridisciplinaire impliquant tous les membres de l'equipe soignante hospitaliere et de ville et tous les consultants necessaires avec, si possible, la participation du malade et de sa famille ; - prise en charge planifiee et personnalisee avec l'accord du malade, de sa famille et de tous les intervenants ; - evaluation continue dans le temps de la douleur ; - utilisation conjointe de moyens medicamenteux et non medicamenteux pour prevenir et traiter la douleur ; - approche institutionnelle formelle, clairement definie, avec attribution des responsabilites et etablissement d'un plan d'assurance qualite dans le domaine de la douleur cancereuse. Le premier chapitre est consacre aux generalites : une des recommandations cles est que les medecins doivent assurer aux malades et aux familles que la plupart des douleurs peuvent etre traitees efficacement et sans danger. Les insuffisances dans le traitement de la douleur sont identifiees.

La douleur du cancer reste un probleme de Sante publique mette si 50% des cancers sont aujourd'hui guerissables et si une grande majorite de malades peut actuellement etre soulagee. La reconnaissance des insuffisances dans ce domaine a suscite, plus ou moins recemment, des efforts de la part des soignants, des enseignants et des decideurs politiques a travers le monde. Ce document est destine a aider les medecins impliques dans les soins cancerologiques a mieux comprendre la douleur cancereuse et les symptomes associes. Il aborde aussi brievement le traitement de la douleur du sida car la demarche de prise en charge antalgique en est assez proche et l'evolution du sida peut etre d'ordre cancerologique. Il s'agit aussi d'un grave probleme mondial de Sante publique. Ce document s'est donne cinq objectifs pour ameliorer la prise en charge de la douleur cancereuse : - offrir aux medecins un document de reference base sur une synthese de la litterature pour traiter la douleur cancereuse ; - rappeler aux medecins que la douleur cancereuse peut avoir des causes multiples liees a la maladie et au traitement, se modifier dans le temps, etre destructrice sur le plan physique, psychologique, spirituel et social si elle est negligee ; etre soulagee par differentes methodes souvent simples ; - promouvoir l'evaluation, le diagnostic et le traitement rapides de la douleur cancereuse ; - donner les regles d'utilisation des opioides et faire definitivement disparaitre toutes craintes concernant les risques de toxicomanie chez les malades cancereux algiques bien traites ; - renforcer la volonte des medecins a faire communiquer malades et familles a propos de toute douleur insuffisamment calmee, recente ou non, pour susciter une prise en charge rapide et efficace. Une prise en charge de la douleur, au-dela du soulagement, permet d'aider le malade a maintenir sa qualite de vie et ainsi sa place dans sa famille et dans la societe. L'analgesie, c'est-a-dire la disparition totale de douleur, ne peut pas toujours etre obtenue, mais un bon niveau d'antalgie peut le plus souvent etre atteint par des methodes appropriees appliquees avec attention. Ce document tient compte de la grande variabilite des situations et des malades. Il veut donner au clinicien les moyens d'une approche pratique de la douleur cancereuse mais aussi, dans une certaine mesure, d'autres situations douloureuses. Il veut mettre en avant certains concepts essentiels pour une prise en charge efficace : - approche pluridisciplinaire pour traiter au mieux et avant tout le cancer ; - approche pluridisciplinaire impliquant tous les membres de l'equipe soignante hospitaliere et de ville et tous les consultants necessaires avec, si possible, la participation du malade et de sa famille ; - prise en charge planifiee et personnalisee avec l'accord du malade, de sa famille et de tous les intervenants ; - evaluation continue dans le temps de la douleur ; - utilisation conjointe de moyens medicamenteux et non medicamenteux pour prevenir et traiter la douleur ; - approche institutionnelle formelle, clairement definie, avec attribution des responsabilites et etablissement d'un plan d'assurance qualite dans le domaine de la douleur cancereuse. Le premier chapitre est consacre aux generalites : une des recommandations cles est que les medecins doivent assurer aux malades et aux familles que la plupart des douleurs peuvent etre traitees efficacement et sans danger. Les insuffisances dans le traitement de la douleur sont identifiees.

World Health Organization (WHO) has recommended since 1986 simple methods to control pain due to cancer. The use of analgesic medications, appropriate to the severity of pain reported by the patient, is the key point of WHO guidelines. It has been shown that the use of analgesic medication and particularly of morphine to control severe pain is insufficient for a majority of patients worldwide. This communication presents the main results of French national studies among representative samples of cancer patients and physicians (primary care physicians and medical oncologists) faced with cancer pain. These studies confirm that cancer pain is inadequately treated for 51 % of patients and identify among French physicians attitudinal barriers to the proper use of morphine. Results are discussed with regard to the national policy against pain now in progress in France.

Objective-To describe the treatment of cancer pain in France and to evaluate the predictive factors for inadequate management.Design-Multicentre, representative cross sectional survey.Setting-20 treatment centres, including cancer centres, university hospitals, state hospitals, private clinics, and one homecare setting (in which patients are supported at home).Subjects-605 patients with cancer.Main measures-Patients rated prevalence and severity of pain and functional impairment related to pain. Doctors reported patients' cancer characteristic, performance status, pain severity, and analgesic drugs ordered.Results-57% (340/601) of patients with cancer reported pain due to their disease, and, of those with pain, 69% (224/325) rated their worst pain at a level that impaired their ability to function. 30% (84/279) were reported as receiving no drugs for their pain. Of the 270 patients in pain for whom information on treatment was available 51% (137/270) were not receiving adequate pain relief, according to an index based on the World Health Organisation's guidelines. French doctors were found to underestimate the severity of their patients' pain. Younger patients, patients without metastatic disease, patients with a better performance status, and patients who rated their pain as more severe than their doctors did were at greater risk for undertreatment of their pain.Conclusions-In the light of the high prevalence and the severity of pain among patients with cancer, the assessment and treatment of cancer pain in France remain inadequate, emphasising the need for changes in patient care.