Prospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Oncol. Feb 10, 2017; 8(1): 75-85
Published online Feb 10, 2017. doi: 10.5306/wjco.v8.i1.75
Salient concerns in using analgesia for cancer pain among outpatients: A cluster analysis study
Salimah H Meghani, George J Knafl
Salimah H Meghani, Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104-4217, United States
George J Knafl, University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, NC 27599, United States
Author contributions: Meghani SH designed the study, participated in the acquisition of the data, drafted the manuscript and interpreted the data; Knafl GJ conducted the data analysis, drafted the manuscript, and participated in the interpretation and presentation of the data; both authors revised the article critically for important intellectual content.
Supported by National Institutes of Health/National Institute of Nursing Research, No. NIH/NINR RC1-NR011591.
Institutional review board statement: The study was reviewed and approved by the Institutional Review Board of the University of Pennsylvania (Philadelphia).
Informed consent statement: All study participants provided informed written consent prior to study data collection.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Salimah H Meghani, PhD, MBE, RN, FAAN, Associate Professor, Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, Leonard Davis Institute of Health Economics, University of Pennsylvania, Claire M. Fagin Hall 418 Curie Boulevard, Room 337, Philadelphia, PA 19104-4217, United States. meghanis@nursing.upenn.edu
Telephone: +1-215-5737128 Fax: +1-215-5737507
Received: August 21, 2016
Peer-review started: August 23, 2016
First decision: October 21, 2016
Revised: December 1, 2016
Accepted: December 13, 2016
Article in press: December 14, 2016
Published online: February 10, 2017
Abstract
AIM

To identify unique clusters of patients based on their concerns in using analgesia for cancer pain and predictors of the cluster membership.

METHODS

This was a 3-mo prospective observational study (n = 207). Patients were included if they were adults (≥ 18 years), diagnosed with solid tumors or multiple myelomas, and had at least one prescription of around-the-clock pain medication for cancer or cancer-treatment-related pain. Patients were recruited from two outpatient medical oncology clinics within a large health system in Philadelphia. A choice-based conjoint (CBC) analysis experiment was used to elicit analgesic treatment preferences (utilities). Patients employed trade-offs based on five analgesic attributes (percent relief from analgesics, type of analgesic, type of side-effects, severity of side-effects, out of pocket cost). Patients were clustered based on CBC utilities using novel adaptive statistical methods. Multiple logistic regression was used to identify predictors of cluster membership.

RESULTS

The analyses found 4 unique clusters: Most patients made trade-offs based on the expectation of pain relief (cluster 1, 41%). For a subset, the main underlying concern was type of analgesic prescribed, i.e., opioid vs non-opioid (cluster 2, 11%) and type of analgesic side effects (cluster 4, 21%), respectively. About one in four made trade-offs based on multiple concerns simultaneously including pain relief, type of side effects, and severity of side effects (cluster 3, 28%). In multivariable analysis, to identify predictors of cluster membership, clinical and socioeconomic factors (education, health literacy, income, social support) rather than analgesic attitudes and beliefs were found important; only the belief, i.e., pain medications can mask changes in health or keep you from knowing what is going on in your body was found significant in predicting two of the four clusters [cluster 1 (-); cluster 4 (+)].

CONCLUSION

Most patients appear to be driven by a single salient concern in using analgesia for cancer pain. Addressing these concerns, perhaps through real time clinical assessments, may improve patients’ analgesic adherence patterns and cancer pain outcomes.

Keywords: Cancer pain, Analgesia, Opioids, Preferences, Conjoint analysis, Side-effects

Core tip: Lack of adherence to analgesia for cancer pain is a prevalent clinical problem. The 2016 Centers for Disease Control and Prevention guidelines provide recommendations to clinicians for opioid prescription. However, this focus will be incomplete without understanding what concerns anchor patients’ decisions to use analgesia for cancer pain. We used a trade-off analysis technique and novel adaptive methods to first show that unique clusters of patients exist based on the main concerns that anchor their preferences for analgesia for cancer pain. We then identified factors that predict membership in each preference cluster. We found that socioeconomic factors, including education, health literacy, income (rather than attitudes and beliefs about analgesics) played a role in predicting three out of four clusters. Most analgesic beliefs and concerns, including the widely indicated addiction concerns, did not predict cluster membership.