Consider Quality of Life and Patient Preference When Choosing Pain Relief

SHEFFIELD, UK-What should the research question be when investigatinga new approach to cancer pain? The most obvious answer is, Doesit relieve pain? But David Brooks, MB, of the University of Sheffield,argues that this is not enough. Researchers must also ask aboutside effects, quality of life, and patient preference.

Speaking at a symposium held in association with the 8th WorldCongress on Pain, Dr. Brooks described a multicenter, open, randomized,crossover trial comparing transdermal fentanyl (Duragesic) withsustained-release oral morphine. The subjects were 202 patientswith cancer pain who were previously receiving stable doses oforal morphine.

No significant difference in pain relief was seen between thetwo drugs among the 110 patients who completed the trial. "Thiswas no surprise since the trial was designed so that only patientswho had stable opioid responsive pain were included," Dr.Brooks said. "So for this kind of trial, pain assessmentalone is inadequate as a single outcome measure."

However, in this study, researchers also included questions aboutpatient preference; 90% of the study subjects did, in fact, havea preference, with 36% preferring morphine and 54% fentanyl. "Patientpreference gives an overall assessment of the therapy from thepatient's point of view," he said. "It gets patientsto weigh various effects individually."

As an example, he said, for one patient a bad-tasting medicationmeans the whole day is taken up with anticipatory nausea thinkingabout it, whereas another patient may simply take the bad tastein stride.

The point, Dr. Brook believes, is that physicians must individualizepain treatment. "No one therapy is likely to be universallysuperior on every symptom subscale," he said.

In the fentanyl study, for some quality of life issues, fentanylwas generally preferable to morphine; it caused less interruptionof daily activities and was more convenient to take. But interestingly,for no single quality of life item was fentanyl or morphine universallypreferred.

Since some symptoms may be more or less important to differentpatients, symptom subscales must be examined individually. Inthe fentanyl study, patients reported more sleep disturbanceswith fentanyl (30%) than with morphine (20%), but less constipationwith fentanyl (15%) than with morphine (35%).

"This is the sort of information we can share with our patientsto give them a more informed choice," Dr. Brooks said.