Knowledge, Practices, and Perceived Barriers in Cancer Pain Management at Oncology Units: A Cross-Sectional Survey of Medical Staff in China

Figures & data

Table 1 Demographic Characteristics of Medical Staffs (n=1262)

Demographics		n (%)
Gender	Male	386 (30.6)
	Female	876 (69.4)
Region	Eastern region	360 (28.5)
	Central region	698 (55.3)
	Western region	204 (16.2)
Education level	Under bachelor’s degree	88 (7.0)
	Undergraduate	764 (60.5)
	Master	357 (28.3)
	Doctor	53 (4.2)
Years of working experience in oncology	≤3	245 (19.4)
	3~10	569 (45.1)
	10~20	303 (24.0)
	≥20	145 (11.5)
Occupation position	Primary	518 (41.1)
	Middle	509 (40.3)
	Senior	235 (18.6)
Profession	Physician	459 (36.4)
	Nurse	486 (38.5)
	Pharmacist	317 (25.1)
Cancer pain management training	No	273 (21.6)
	Yes	989 (78.4)

Table 2 Medical Staff’ Knowledge of Cancer Pain Guidelines

Guidelines	n (%)
	Very Unfamiliar	Unfamiliar	General	Familiar	Very Familiar
WHO three-step analgesic ladder	22(1.7)	47(3.7)	116(9.2)	196(15.5)	881(69.8)
NCCN guideline for Adult Cancer Pain	122(9.7)	172(13.6)	294(23.3)	297(23.5)	377(29.9)
ASCO guideline for Management of Chronic Pain in Adults with Cancer Pain	185(14.7)	225(17.8)	354(28.1)	273(21.6)	225(17.8)
ESMO guideline for Cancer Pain Treatment	208(16.5)	252(20.0)	347(27.5)	244(19.3)	211(16.7)
European guidelines for opioid analgesia in cancer pain	344(27.3)	292(23.1)	328(26.0)	163(12.9)	135(10.7)
Expert consensus on intractable cancer pain in China	246(19.5)	245(19.4)	287(22.7)	238(18.9)	246(19.5)

Abbreviations: WHO, World Health Organization; NCCN, National Comprehensive Cancer Network; ASCO, American Society of Clinical Oncology; ESMO, European Society for Medical Oncology.

Table 3 Correct Response Rate for Knowledge of Cancer Pain Management

Question	Correct Response
	n (%)
1. Which of the following is wrong about the three-step medication principle for cancer pain?^a	1134 (90.0)
2. Which statement is wrong regarding tramadol?^a	718 (56.9)
3. For patients with moderate-to-severe pain, the first choice of analgesic drugs is ^a	1161 (92.0)
4. Which adverse reaction of opioids is not tolerated by the patients?^a	965 (76.5)
5. Which of the following analgesics is not recommended for cancer pain management?^a	1124 (89.1)
6. 10 mg morphine (iv.) is equivalent to: fentanyl (iv.)^a	688 (54.5)
7. Which of the following is not a contraindication of morphine?^a	631 (50.0)
8. Which of the following is an agonist-antagonist mixture of opioid partial receptors?^a	660 (52.3)
9. Which of the following drugs is not a commonly used adjuvant analgesic?^a	669 (53.0)
10. For the patients with breakout pain, the first route of administration is^a	1098 (87.0)
11. A patient received 30 mg sustained release of morphine every 12 hours. When converted to fentanyl transdermal patch; the patch dose should be^a	505 (40.0)
12. How much downward titration should we consider for patients with uncontrollable adverse reactions after opioid therapy and for pain scores≤ 3?^a	447 (35.4)
13. Which analgesic is relatively appropriate for cancer pain patients with intractable constipation?^a	1039 (82.3)
14. Different analgesics have different analgesic intensity. If the analgesic intensity of morphine is 1, the analgesic intensity of tramadol is ^a	694 (55.0)
15. The content of paracetamol in acetaminophen oxycodone is ^a	798 (63.2)
16. The potential risk factors for misuse/abuse of opioids are^b	757 (60.0)
17. The commonly used tools for pain assessment are^b	1032 (81.8)
18. Which drug can be chosen when patients receiving opioid therapy have an itch?^b	734 (58.2)
19. Adjuvant analgesics include^b	611 (48.4)
20. Which of the following is true for NSAIDs?^b	632 (50.1)
21. When a 200mg dose of oral morphine is converted to oral methadone, the conversion ratio should be 20:1.^c	379 (30.0)
22. In the preventive treatment of opioid-induced constipation, the dosage of laxatives should not be increased when the dose of opioid is increased. ^c	417 (33.0)
23. Codeine has analgesic effect on all patients.^c	1056 (83.7)
24. The assessment of pain should be mainly based on the patient’s self-report.^c	996 (78.9)
25. Opioid receptor agonist-antagonist can be used in the treatment of opioid-induced pruritus.^c	702 (55.6)
26. After the use of the fentanyl patch, an appropriate hot compress on the medication site can increase drug absorption and result in a better analgesic effect.^c	1152 (91.3)
27. The analgesic effect of buprenorphine increases with the increase in the dosage.^c	1015 (80.4)
28. High dose methadone (120 mg and above) may lead to QTc prolongation and tip torsion, which may lead to sudden cardiac arrest and ultimately death.^c	852 (67.5)
29. Opioid analgesics have a high risk of addiction.^c	342 (27.1)
30. There is no need to adjust the dosage of codeine in patients with severe liver damage.^c	1092 (84.9)

Notes: ^a Single choice question; ^b multiple choice question; ^c true/false question.

Table 4 The Related Factors That Influence Knowledge of Medical Staffs on Cancer Pain Management

Variables	Category	Good Knowledge^a	χ2	P value^b
		n (%)
Gender	Male	284 (73.6)	26.702	<0.001
	Female	511 (58.3)
Region	Eastern region	253 (70.3)	12.579	0.002
	Central region	413 (59.2)
	Western region	129 (63.2)
Education level	Under bachelor’s degree	39 (44.3)	69.172	<0.001
	Undergraduate	435 (56.9)
	Master	274 (76.7)
	Doctor	47 (88.7)
Years of working experience in oncology	≤3	106 (43.3)	63.852	<0.001
	3~10	358 (62.9)
	10~20	222 (73.3)
	≥20	109 (75.2)
Occupation position	Primary	247 (47.7)	93.532	<0.001
	Middle	361 (70.9)
	Senior	187 (79.6)
Profession	Physician	347 (75.6)	109.951	<0.001
	Nurse	219 (45.1)
	Pharmacist	229 (72.2)
Cancer pain management training	No	119 (43.6)	56.274	<0.001
	Yes	676 (68.4)

Notes: ^aGood knowledge: the score is greater than 18; ^bP value by Chi-square test, P values < 0.05 were considered as statistically significant.

Table 5 Logistic Regression Analysis of Related Factors Associated with Good Knowledge of Cancer Pain Management

Variables	Category	Good Knowledge on Pain Management
		B	OR	95% CI	P value
Gender	Male (Ref)
	Female	−0.089	0.915	0.637–1.313	0.628
Region	Eastern region (Ref)
	Central region	−0.079	0.924	0.677–1.262	0.621
	Western region	−0.06	0.942	0.626–1.418	0.774
Education level	Under bachelor’s degree (Ref)
	Undergraduate	0.053	1.054	0.645–1.722	0.833
	Master	0.48	1.615	0.905–2.882	0.104
	Doctor	1.030	2.801	1.002–7.828	0.049^d
Years of working experience in oncology	≤3 (Ref)
	3~10	0.424	1.528	1.066–2.191	0.021^d
	10~20	0.730	2.074	1.251–3.438	0.005^e
	≥20	0.812	2.253	1.163–4.365	0.016^d
Occupation position	Primary (Ref)
	Middle	0.297	1.346	0.944–1.919	0.101
	Senior	0.358	1.430	0.798–2.561	0.229
Profession	Physician (Ref)
	Nurse	−0.994	0.370	0.245–0.558	<0.001^e
	Pharmacist	−0.011	0.989	0.676–1.446	0.954
Cancer pain management training	No (Ref)
	Yes	1.178	3.249	2.384–4.429	<0.001^e

Notes: ^dp <0.05; ^ep < 0.01.

Abbreviations: B, regression coefficient; OR, odds ratio; CI, confidence interval.

Table 6 Stratified Analysis of Cancer Pain-Related Training Among Different Demographic Factors

Variables	Category	Good Knowledge^a [n (%)]		χ2	P	OR	95% CI
		No Training	Training
Gender	Male	54 (19.0)	230 (81.0)	40.658	<0.001^b	4.607	2.826–7.509
	Female	65 (12.7)	446 (87.3)	30.988	<0.001^b	2.625	1.367–2.079
	Eastern region	41 (16.2)	212 (83.8)	14.958	<0.001^b	2.733	1.625–4.598
Region	Central region	54 (13.1)	359 (86.9)	17.813	<0.001^b	2.289	1.549–3.383
	Western region	24 (18.6)	105 (81.4)	34.253	<0.001^b	6.210	3.279–11.761
Education level	Under bachelor’s degree	11 (28.2)	28 (71.8)	3.913	0.053	2.444	0.999–5.977
	Undergraduate	65 (14.9)	370 (85.1)	27.288	<0.001^b	2.277	1.595–3.250
	Master	41 (15.0)	233 (85.0)	31.936	<0.001^b	3.751	2.162–6.506
	Doctor	2 (4.3)	45 (95.7)	25.245	0.008^b	22.500	2.655–190.678
Years of working experience in oncology	≤3	25 (23.6)	81 (76.4)	3.032	0.091	1.655	0.936–2.926
	3~10	61 (17.0)	297 (83.0)	11.940	0.001^b	2.026	1.352–3.036
	10~20	24 (10.8)	198 (89.2)	34.808	<0.001^b	5.672	3.072–10.471
	≥20	9 (8.3)	100 (91.7)	13.740	0.001^b	5.556	2.101–14.589
Occupation position	Primary	52 (21.1)	195 (78.9)	3.744	0.054	1.488	0.994–2.229
	Middle	53 (14.7)	308 (85.3)	40.639	<0.001^b	3.962	2.555–6.145
	Senior	14 (7.5)	173 (92.5)	26.020	<0.001^b	6.776	3.033–15.142
Profession	Physician	50 (14.4)	297 (85.6)	60.389	<0.001^b	5.940	3.689–9.565
	Nurse	24 (11.0)	195 (89.0)	11.155	0.001^b	2.355	1.411–3.930
	Pharmacist	45 (19.7)	184 (80.3)	18.213	<0.001^b	3.108	1.824–5.296

Notes: ^a Good knowledge: the score is greater than 18; ^bp < 0.01.

Abbreviations: OR, odds ratio; CI, confidence interval.

Table 7 Medical Staff’ Perceived Barriers to Cancer Pain Management

Potential Barriers		n (%)
Related to health care systems	Strict regulation of opioids	532 (50.2)
	Limited stock of different opioids types and formats	622 (49.3)
	Insufficient multidisciplinary participation	780 (61.8)
	Medication and intervention costs	693 (54.9)
Related to medical staff	Lack of good solution for complicated refractory cancer pain	984 (78.0)
	Difficulty in individualized analgesia	988 (78.3)
	Insufficient knowledge of cancer pain management	858 (68.0)
	Lack of access to different opioid types and formats	600 (47.5)
	Poor patient education	732 (58.0)
	Fear of addiction	497 (39.4)
Patient-related	Insufficient knowledge of cancer pain management	1017 (80.6)
	Poor medication compliance	1029 (81.5)
	Fear of addiction	928 (73.5)
	Reluctance to report pain	688 (54.52)
	Poor accuracy in describing pain	733 (58.1)
	Ability to pay for cancer medication	590 (46.7)
	Fear of adverse reactions	734 (58.2)
	Family support	573 (45.4)