Abstract
Stein Kaasa, MD, speaks to Dominic Chamberlain, Assistant Commissioning Editor: Stein Kaasa specializes in oncology and palliative medicine. In 1993 he was appointed as the first professor in palliative medicine in Scandinavia and he was one of the founders of the palliative care unit in Trondheim (Norway). He also was the founder of the European Palliative Care Research Centre. He has been president of the European Association for Palliative Care, coordinator for one EU-funded project and is Work Package Leader of several EU-funded research collaboratives and international partnerships on research and policy development. Kaasa has been an important advocate for evidence-based practice and has worked extensively to get palliative care research on the agenda, both nationally and internationally. Through his role as Cancer Director in Norway he coordinated and led the development of guidelines for different cancer diseases. Important areas of work were the development of regional cancer treatment guidelines and integration of patient disease trajectories into the existing guidelines. Currently he is Vice Managing Director at St Olavs Hospital, Trondheim University Hospital (Norway), Professor of palliative medicine at the Faculty of Medicine, Norwegian University of Science and Technology and leads the European Palliative Care Research Centre and chairs the European Association for Palliative Care Research Network. Professor Kaasa has published more than 450 articles and book chapters. He has authored the Nordic Textbook of Palliative Care and is coauthor and editor of the Oxford Textbook of Palliative Medicine. Professor Kaasa advises many international journals – either as an advisory board member or as a reviewer (Journal of Pain and Symptom Management, Palliative Medicine, Journal of Palliative Medicine, Oncology, Journal of Clinical Oncology, Pain and The Lancet Oncology).
Q What sparked your interest in pain management & specifically palliative care in cancer patients?
My background and training is in medical oncology and radiotherapy. When I did my training to be a specialist in oncology I worked with lung cancer patients and I became interested in the extensive use of chemotherapy close to end of life and that brought me into research in the area of health-related quality of life assessment and so I began a research career focusing on subjective symptoms including pain. That brought about my interest in palliative care in general and pain management specifically.
Q Is there a particular achievement you are most proud of in your career so far?
Seen from an oncological perspective I think I am most proud of the change myself and others brought about when we started to discuss what the focus should be when we treat patients who have an incurable cancer. We realized that we need to focus not only on the treatment of the tumor and survival of the patient, but we also need to focus on symptom management and quality of life. I think that historically this has been very important. Second, I was awarded the first palliative care professorship in the Nordic countries in 1993 and built up a palliative care program including pain management from 1993 onwards. Third has been the development of the international research collaboration within Europe within pain and palliative care.
Q What major changes have you observed in cancer pain management over the last decade?
I think the most important changes have occurred over a slightly longer period. The first change I observed, which was very important, was the introduction of slow-release morphine in the mid 1980s. Before this time we used methadone as the drug of choice, which is a more problematic drug to use in general practice and in general hospital care. From an oncological perspective the more extensive use of palliative radiotherapy for bone metastasis has been important as well as the randomized studies evaluating the effect of one fraction. I was personally involved in one of these studies, which has shown that one fraction of radiotherapy is just as effective as ten fractions. This means, for example, that a patient with prostate cancer can come in to the outpatient facility, receive radiotherapy the same day and then go home. I think that is very important. Finally a key change includes the new rapid-acting opioids, the shift of focus onto different types of cancer pain: breakthrough pain and neuropathic pain among others, as well as better classification and better treatment guidelines.
Q You recently published a study on the effect of exercise on cancer pain, how important do you think non-pharmacological interventions are for pain in this population & what would you like to see implemented to encourage their use clinically?
I think that physical exercise is an important approach for all types of illnesses, not only cancer. From a societal point of view it is important to exercise to prevent diseases such as diabetes and chronic heart disease among others. When you have cancer or another chronic condition, being active is highly important. With regards to pain, we now know that if you are active you can prevent and also treat pain. For example, in patients with chronic nonmalignant pain, the patients who are active report less pain. I think that we need more intervention studies, which can help us to understand what type of exercise is best and assess how best to combine exercise with psychological support and with drugs.
Q Do you think clinicians have a particular role in encouraging or implementing exercise?
I think that exercise should be something we constantly advise our patients to do. I think we also need to assess how we can best organize this in an outpatient clinic. We need to see whether everything should be done by the treating doctor or if you need to build up other types of healthcare organizations. For example, right now, here in Trondheim, we are opening an exercise program for patients who are treated for cancer in general. Personally, I think it is necessary that these types of interventions are prescribed by the physician. However, I don‘t think we can expect the physician to do everything him- or her-self so we may need to get exercise specialists including physiotherapists who can set up and run this type of program.
Q You also recently published a study on developing a computerized pain body map in patients with advanced cancer, can you tell us a bit about this & how innovations such as this could affect clinical practice?
The rationale came from the realization that we are now moving into an era where all patient records will be electronic and we have, in my mind, a unique opportunity to develop new ways of collecting information from patients using electronic devices. The development of new electronic devices is progressing extremely rapidly, in fact, I am currently writing an article about new electronic devices for collecting information on pain and other symptoms, and whereas 5–10 years ago there were a lot of barriers and skepticism within the healthcare provider group, now with electronic media, such as Facebook and text messaging among others, being so common I think the skepticism is fading away. Unfortunately, I do not think that the healthcare system is catching up rapidly enough to see how we can use new information technology to communicate, give advice and collect information on subjective symptoms like pain. I think this is a unique opportunity to embrace developments as it is, in my mind, not only a data collection platform but also a communication platform.
Q You are the chair of the European Palliative Care Research Centre, what is the aim of the organization & what does your role entail?
The aim of the organization is actually to bring together professionals and experts who have the interest and the skills to plan, converse, analyze and publish large multicenter studies. This is important because we have seen, in pain and palliative care, that we need more and larger interventional studies and that we need to do these studies internationally to recruit enough subjects. My role is to be the daily leader of the center. We have a large group of people working with us here in Trondheim and at different sites across Europe, including Milan (Italy), Edinburgh, London (UK) and Copenhagen (Denmark) among other countries and cities. Additionally, we are trying to set up a structure whereby we can build up research competence within pain and palliative care. We are also having an international PhD program and trying to build a post-doc network for researchers within pain and palliative care.
Q Looking forward, what areas of research within pain management in cancer do you think are the most exciting, & what advances do you anticipate as a result of this research?
I think there are several areas. First the new cancer drugs that might prevent the development of pain and other symptoms so that cancer treatment can be tailored to the patient. Second, although I cannot predict the exact drug, I foresee, and hope, we will see new drugs arrive that are more specific for targeting patients‘ pain, because, although very effective, opioids are a sort of general drug and they also have a lot of side effects. I hope that we can get other drugs and other treatment approaches that can prevent us from using opioids so early on in the disease. That said, there are two sides to the message, because on the other hand a lot of patients are receiving opioids too late, because there are still barriers such as doctors and other healthcare providers who are hesitant in prescribing opioids. I also think that oncologists should have more focus on symptom prevention.
Q Is there a specific research area you will be pursuing in the future & what do you hope to achieve?
I think the multimodal approach is important (I talked about physical exercise combined with pain drugs and anticancer treatments). I think we need to give multimodal treatments for pain and other symptoms and that we need to individualize the treatment. We discussed the new technology platforms and programs that might help us to give more rapid adjustment of the treatments and more rapid access to information regarding the symptoms and pain. We need to improve the understanding of cancer pain, as there are many subgroups of pain syndromes. I think electronic devices that collect more information from the patient at no cost (except for the electronic devices which are getting cheaper), for data collection information between the hospital, the general practitioner and the patient will improve pain management. Furthermore, I think that as I said, I hope to see new populations and new drugs in the future.
Q Do you have a particular message to our readership or the general clinical community?
A very simple message, I think, is that we need to improve the diagnosis of pain, we need to improve data collection in order to make the appropriate diagnosis and we need to inform the patients about the possibilities of treatment in order to prevent patients going around with a lot of symptoms, including pain over time because they are afraid of telling the physician about it. More openness, more availability of information and more improved communication of the healthcare provider and the patient. It doesn‘t cost anything, it is just an issue of attitude, use of new information technology and professional competence.
Disclaimer
The opinions expressed in this interview are those of the interviewee and do not necessarily reflect the views of Future Medicine Ltd.
Financial & competing interests disclosure
S Kaasa has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.