Jpn J Clin Oncol 2004;34(1)37–42
Adequacy of Cancer Pain Management in a Japanese Cancer Hospital
Toru Okuyama1,2,4, Xin Shelley Wang1, Tatsuo Akechi2,3, Tito R. Mendoza1, Takashi Hosaka4, Charles S. Cleeland1
and Yosuke Uchitomi2
1Department of Symptom Research, Division of Anesthesiology and Critical Care, University of Texas M. D. Anderson
Cancer Center, Houston, TX, USA, 2Psycho-Oncology Division and 3Psychiatry Division, National Cancer Center
Research Institute East, Kashiwa, Chiba, Japan, 4Course of Specialized Clinical Care, Psychiatry, Tokai University
School of Medicine, Isehara, Kanagawa, Japan
Received August 28, 2003; accepted December 2, 2003
Background: Pain is one of the most frequent and deleterious symptoms in cancer patients.
This study was carried out to investigate the adequacy of pain management at the National
Cancer Center Hospital East, Japan.
Methods: The available data were obtained from 138 ambulatory cancer patients with pain.
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The data included pain severity, which patients reported using the Japanese version of the M. D.
Anderson Symptom Inventory, along with such medical information as cancer and treatment
information and currently prescribed analgesics. Adequacy of pain management was assessed
using the Pain Management Index, which revealed whether prescribed analgesic drugs were
congruent with pain severity.
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Results: Physicians undertreated pain in 70% of patients. Patients with non-advanced cancer
(local cancer or no evidence of any recurrent cancer) were more likely to receive inadequate
treatment than those with advanced cancer [P = 0.009, odds ratio = 0.18, Exp (95% CI) lower
= 0.05, higher = 0.64] in the exploratory logistic regression analysis. Additionally, we found
significant differences among physicians in ability to manage cancer pain, unrelated to a
physician’s years of experience as an oncologist.
Conclusions: This study suggests that cancer pain management is insufficient at the investi-
by guest on February 13, 2011
gated institute. Remedial action should be taken, including increasing awareness of symptom
management in medical staff and incorporating existing knowledge into routine clinical prac-
tice.
Key words: neoplasms – pain – pain management index – palliative care – symptom management
INTRODUCTION
(PMI) is a well-validated method of assessing the adequacy
of pain management. Developed by Cleeland (6), the PMI is
Despite significant advances in past decades, cancer remains
based on cancer pain treatment guidelines established by the
the primary cause of death in Japan. About 300 000 people die
World Health Organization (7) and the Agency for Health Care
from cancer every year, representing a third of total deaths in
Policy Research (8). Pain management is considered adequate
Japan (1). Throughout their clinical course, cancer patients
when there is congruence between the patient’s reported level
frequently suffer from a variety of symptoms, such as pain,
of pain and the appropriateness of the prescribed analgesic
dyspnea and fatigue (2,3), that impair their bodily functions
drug. The PMI provides a comparison of the most potent
and quality of life. Palliation of these symptoms has been
analgesics prescribed for a patient’s reported pain (detailed
recognized as crucial to improving the quality of life for cancer
calculation method is described in the ‘Statistical method’ sec-
patients (4).
tion). The PMI has been widely used and enables researchers
Pain remains one of the most common and deleterious symp-
to compare the adequacy of pain across countries, races and
toms suffered by cancer patients and is the critical theme in
institutes (Table 1) (9–18).
current cancer medicine (5). The Pain Management Index
Few studies, however, have investigated the adequacy of can-
cer pain treatment in Japan. Uki et al. investigated cancer pain
treatment at the Saitama Cancer Center in Japan and found that
For reprints and all correspondence: Yosuke Uchitomi, Psycho-Oncology
only 27% of cancer patients in their study had a negative PMI
Division, National Cancer Center Research Institute East, 6-5-1,
(9). This proportion was the lowest among PMI studies con-
Kashiwanoha, Kashiwa, Chiba 277-8577, Japan.
E-mail: yuchitom@east.ncc.go.jp
ducted in many countries, indicating that adequate cancer pain
© 2004 Foundation for Promotion of Cancer Research

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38
Cancer pain management
Table 1. Pain Management Indices and morphine consumption among countries
Country (reference citation) Subjects’ unique characteristics
n
% of Patients with negative PMI
Amount of morphine consumption*
Cancer related
Demographic related
Japan (9)
–
–
121
27
3438
USA (10)
Metastatic or recurrent
Hispanic
64
28
20 585
USA (10)
Metastatic or recurrent
African American
44
31
20 585
USA (11)
Metastatic
–
597
42
20 585
USA (12)
–
–
313
49
20 585
USA (13)
–
Hispanic & non-white
281
77
20 585
France (14)
–
–
270
51
21 672
Netherlands (15)
–
–
305
51
4234
China (16)
–
–
147
67
663
Greece (17)
–
–
220
76
1550
India (18)
–
–
200
79
1652
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*Expressed as daily defined doses (DDD) per million inhabitants per day during the years 1994–1998 (19). DDD of morphine is 30 mg.
management was practiced in Saitama Cancer Center. How-
PATIENT-REPORTED PAIN SEVERITY
ever, these results may not be indicative of the status of cancer
The subjects in the study were given the MDASI-J as their self-
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pain management in Japan as a whole. One suggestive indica-
reporting instrument, with one pain item on this scale used as a
tor of poor pain management in Japan is the small amount of
pain measure. This questionnaire, developed by Cleeland et al.,
morphine consumed in Japan [3438 daily defined doses (DDD)
consists of 13 symptom items and six interference items with
per million inhabitants per day during 1994–1998, ranking 30th
0-to-10 numeric scale ratings (20). The symptom items asked
worldwide], which is only 18% of the amount consumed in the
the patient to identify the worst level of each symptom in the
USA (20 585 DDD, ranking 7th worldwide) (19).
last 24 hours, with anchor points of 0 (not at all) to 10 (as bad
by guest on February 13, 2011
In the present study, we applied the PMI to investigate the
as you can imagine). The validity and reliability of the
adequacy of pain management at Japan’s National Cancer
MDASI-J is well established (21).
Center Hospital East. We also investigated the characteristics
of patients at greater risk for under-medication with analgesic
ANALGESIC PRESCRIPTION AND OTHER MEDICAL
drugs. Furthermore, we examined whether there were differ-
INFORMATION
ences among physicians in ability to manage cancer pain.
Information on prescribed analgesic drugs, cancer type and
history of anticancer treatment were obtained from the
PATIENTS AND METHODS
patients’ medical records and from an electrical clinical
management database, using a specific checklist.
In this study, we employed an existing database which has been
Attending physicians were asked to determine the patient’s
developed to study fatigue. The subjects of this database were
performance status as defined by the Eastern Cooperative
randomly selected cancer patients receiving treatment at the
Oncology Group (ECOG).
outpatient clinics of the National Cancer Center Hospital East,
Japan. To be eligible, the patients: (i) had to have a pathologi-
STATISTICAL METHODS
cal diagnosis of cancer, (ii) must have been informed of their
The PMI was calculated as follows. The most potent analgesic
cancer diagnosis, (iii) had to be able to understand and com-
prescribed was classified at one of four levels: 0 = no analge-
plete the questionnaires and (iv) could not be suffering from
sics, 1 = nonopioid analgesics, 2 = weak opioid, 3 = strong
severe mental or cognitive disorders. Data from patients with
opioid. Patients’ self-reports of pain on the MDASI-J were
pain [defined as patients who reported pain as 1 or greater on
classified into three groups based on how pain interferes with
the pain item of the Japanese-language version of the M. D.
function (22): 0 = no pain, 1 = mild pain (1–4); 2 = moderate
Anderson Symptom Inventory (MDASI-J, described below)],
pain (5–6); and 3 = severe pain (7–10). The PMI, calculated by
were extracted from this database.
subtracting the pain level from the analgesic level, can thus
The study was approved by the Institutional Review Boards
range from –3 to 3, with the lower value representing greater
of the National Cancer Center, Japan. Written consent was
undertreatment. Negative PMI scores are considered to be an
given by each patient after being fully informed of the study.
indicator of underestimation regarding analgesics, and scores
of 0 or more are considered to be very conservative indicators

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Jpn J Clin Oncol 2004;34(1)
39
Table 2. Demographic and clinical characteristics of the samples (n = 138)
Characteristic
n
%
Mean age ± SD, years (median)
62.5 ± 11.3 (64)
Gender
Female
58
42
Education level
Junior high school or less
42
30
Marital status
Married
101
73
Job status
Full/part time
24
17
Cancer site
Lung
33
24
Gastrointestinal
29
21
Liver
18
13
Clinical stage
Recurrence
55
40
I
26
10
II
20
8
III
35
14
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IV
72
29
No staging / missing
8
3
Metastasis
Present
52
38
ECOG performance status
0
41
30
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1
63
46
2
29
21
3
4
3
4
1
1
History of anti-cancer treatment within a month
Surgery
2
1
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Chemotherapy
32
23
Radiotherapy
5
4
of acceptable treatment. The PMI does not account for dosage
were used to screen possible correlates of the PMI. A predictor
of analgesics, schedule, patients’ compliance or adjuvant pain
was considered a candidate if it had a marginal association
medication.
(P ≤ 0.25). The retained predictors and those extracted in the
Logistic regression analysis was used to clarify factors corre-
first step were gathered and entered into a multiple logistic
lated with the PMI. The PMI was dichotomized as 1 (negative
regression analysis with stepwise selection.
PMI or undertreatment of pain) or 0 (0 or greater PMI) and
Additionally, we investigated individual variation in PMI by
entered as a dependent variable. We performed regression analy-
physician. First we conducted the Fisher exact test to examine
ses in two stages. First, we conducted confirmatory regression
the relationship between patients having positive PMI and
analysis to examine whether previously identified risk factors
their physicians. Second, we calculated Pearson correlations to
associated with pain undertreatment would hold in this sample.
investigate whether an individual physician’s years of experi-
Second, we did an exploratory analysis to investigate factors
ence as an oncologist was correlated with the average PMI
associated with inadequate pain management, while control-
value for his or her patients.
ling for the effect of the risk factors we identified in the first
All statistical tests were two-tailed. All statistical procedures
stage of the analysis.
were performed using SPSS 10.0 for Windows statistical soft-
Previous studies reported that gender (female) (9–11), age
ware (SPSS Institute Inc., 1999).
[older (11), younger (14)], education (low) (16), physical con-
dition [better ECOG performance status (11,13,14), without
RESULTS
metastasis (14)], race (minority) (11), discrepancy between
patient and physician estimates of pain severity (greater) (9–
PARTICIPANT CHARACTERISTICS
11,14), patient reluctance to report pain (10) and lack of staff
time (10) are significant predictors of inadequate cancer pain
Patient sampling was conducted at the outpatient clinics of six
treatment. However, data collected for this study only included
oncology divisions (palliative care, thoracic oncology, gastro-
the first five variables. In the second stage, univariate analyses
intestinal oncology, head and neck oncology, hepatobiliary

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40
Cancer pain management
Table 3. Patient’s pain severity and prescribed analgesics (n = 138)
Pain severity*
Prescribed analgesic (percentage of whole population)
None
NSAID†
Weak opioid
Strong opioid
Subtotal
Mild (1–4)
55 (40)‡
18 (13)
3 (2)
6 (4)
82 (59)
Moderate (5–6)
14 (10)‡
7 (5)c
1 (1)
4 (3)
26 (19)
Severe (7–10)
13 (9)‡
7 (5)c
1 (1)c
9 (7)
30 (22)
Subtotal
82 (59)
32 (23)
5 (4)
19 (14)
138 (100)
*Based on the pain item on the MDASI-J.
†Non-steroidal anti-inflammatory drug.
‡Groups with negative PMI (70.3%).
Table 4. Factors associated with inadequate pain management: confirmatory analysis (n = 138)
Independent variable*
Beta
SE
P value
Odds ratio
Exp (95% CI)
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Lower
Higher
Age
–0.57
0.44
0.20
0.57
0.24
1.35
Gender
0.38
0.41
0.36
1.46
0.65
3.26
Education
0.26
0.43
0.55
1.30
0.56
3.01
Performance status
–0.92
0.44
0.04
0.40
0.17
0.94
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Metastasis
–0.93
0.45
0.04
0.40
0.16
0.96
*Independent variables were coded as follows. Age: 1 = 70 or older, 0 = 69 or younger; Gender: 1 = female, 0 = male; Educa-
tion: 1 = at least high school, 0 = less than high school; Performance status (defined by ECOG): 1 = 2 or greater (poor condi-
tion), 0 = 0 or 1 (good condition); Metastasis: 1 = presence, 0 = absence.
Dependent variable coding: 1 = negative PMI group (receiving inadequate pain treatment), 0 = 0 or positive PMI group.
by guest on February 13, 2011
and pancreatic oncology and chemotherapeutic oncology). A
INADEQUACY OF ANALGESIC DRUG THERAPY: THE NEGATIVE
potential pool of 282 outpatients was identified for the study.
PMI
The available data was obtained from 138 patients, whose socio-
Forty-one percent of the patients were prescribed analgesics.
demographic and clinical characteristics are shown in Table 2.
Eighteen percent were receiving opioid analgesic treatment:
Male participants accounted for 58% of the sample; the mean
14% were taking strong opioids and 4% were taking weak
age was 62.6 years (range 21–84 years, SD ± 11.3). The most
ones. Table 3 shows the association between pain intensity and
frequent cancer sites were lung (24%), gastrointestinal (21%)
prescribed analgesics. The proportion of patients with negative
and liver (13%). Twenty-four percent of patients were in severe
PMI was 70.3%, which indicated undertreatment of pain and
condition, with an ECOG performance status score of 2 or
less-than-adequate analgesics based on WHO guidelines.
more. Of the 144 patients who were excluded from the study,
19 (7% of identified patients) were ineligible for the following
FACTORS ASSOCIATED WITH A NEGATIVE PMI
reasons: eight for cognitive disturbance, seven for illness and
four for other reasons. Eight patients (3%) refused to partici-
The results of a confirmatory analysis showed that patients
pate and two (1%) were not able to complete the question-
with better ECOG performance status scores and those without
naires. We were unable to contact one patient (<1%). One
metastasis were undertreated more frequently than other
hundred and fourteen patients (40%) were excluded because of
patients in the study (Table 4). An exploratory univariate analy-
lack of pain.
sis of disease phase, job status and marital status revealed that
Patients were seen by a total of 18 oncologists, all of whom
disease phase and job status were significant factors. Since the
were male. The mean of the oncologists’ years of experience
concepts of metastasis and disease phase were similar and cor-
was 10.0 years (SD = 4.9, median = 8 years).
related significantly (P < 0.001, chi-squared test), metastasis
was excluded from the final model. Thus, three variables (per-
P
formance status, job status and disease phase) were entered in
AIN SEVERITY IN THIS POPULATION
the final logistic regression analysis as independent variables.
Using a previously validated pain severity classification (6),
Results showed that disease phase was the only factor signifi-
22% of patients reported severe pain (7 or greater) on the
cantly associated with inadequate pain management, indicating
MDASI-J, 19% reported moderate pain (5–6) and 59%
that patients with non-advanced cancer (local cancer or no
reported mild pain (1–4).
evidence of any recurrent cancer) were more likely to receive

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Jpn J Clin Oncol 2004;34(1)
41
Table 5. Factors associated with inadequate pain management: exploratory analysis (n = 138)
Independent variable
Beta
SE
P value
Odds ratio
Exp (95% CI)
Lower
Higher
Advanced cancer*
–1.72
0.66
0.01
0.18
0.05
0.64
*Coded as 1 = advanced cancer, 2 = non-advanced cancer (no evidence of any recurrent cancer or local cancer).
Dependent variable coding: 1 = negative PMI group (receiving inadequate pain treatment), 0 = 0 or positive PMI group.
inadequate treatment than those with advanced cancer [P =
(8,23,24). The Joint Commission on Accreditation of Health-
0.01, odds ratio = 0.18, Exp (95% CI) lower = 0.05, higher =
care Organizations, an independent non-profit organization
0.64] (Table 5).
established to improve the safety and quality of medical care
through the provision of health care accreditation and related
DIFFERENCE IN ABILITY OF THE CANCER PAIN MANAGEMENT
services in the USA, developed a standard in 2001 that estab-
BY PHYSICIANS
lished new requirements for the assessment and management
of pain in accredited hospitals and other healthcare settings
We found a significant difference in the proportion of patients
(25). Key concepts include: (i) recognize the patient’s right to
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having positive PMI by physician (P < 0.001, Fisher exact
appropriate assessment and management of pain; (ii) assess the
test). We did not find a significant correlation between years of
nature and intensity of pain in all patients; (iii) record the
experience as an oncologist and the average PMI by physician
results of the assessment in a way that facilitates regular
(r = –0.06, P = 0.83, Pearson correlation).
reassessment and follow-up; (iv) determine and ensure staff
competency in pain assessment and management, and address
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DISCUSSION
pain assessment and management in new-staff orientation; (v)
establish policies and procedures that support the appropriate
Pain is one of the most frequent and distressing symptoms
prescription or ordering of effective pain medications; (vi)
experienced by cancer patients and affects their quality of life.
educate patients and their families about the importance of
Few studies have examined the adequacy of cancer pain man-
effective pain management; (vii) address patient needs for
agement in Japan, either generally or at single institutes, since
symptom management in the discharge planning process; and
Dr Uki’s report in 1998 (9). Nonetheless, accumulating data
by guest on February 13, 2011
(viii) collect data to monitor the appropriateness and effec-
regarding the adequacy of cancer pain management is crucial
tiveness of pain management. All healthcare institutes must
to improve symptom management. We believe this study will
address this standard to provide better pain management.
underscore the importance of cancer pain management and
promote a nationwide study to investigate the true status of
Pain should be actively treated even when the patient’s phys-
cancer pain management in Japan.
ical condition seems to be good and even when it is mild, since
our previous study showed that pain rated as low as 2 on a 0-to-
We found that 70% of ambulatory cancer patients with pain
at the investigated institute received inadequate treatment for
10-point numerical scale was severe enough to interfere with
their pain. This rate was almost twice that reported by Uki (9)
daily life activities (26). However, when we performed con-
for the Saitama Cancer Center, Japan. Dr Takeda, the former
firmatory analysis of better performance status and the absence
president of the Saitama Cancer Center, was pioneering cancer
of metastasis and exploratory analysis of non-advanced disease
pain management in Japan as early as the 1980s. Under his
stages, our results indicated that patients in better condition
leadership, the Saitama Cancer Center has provided excellent
were more likely to be inadequately treated, consistent with
pain management as a WHO Collaborating Center Cancer for
the previous pain studies (11,13,14). Unfortunately, we did not
Pain Relief and Quality of Life in Japan. Dr Takeda provided
have information on physicians’ assessments of patients’ pain
his staff with pain management manuals from the WHO, from
severity because we were using an existing data set. Nonethe-
a medical association and from the Ministry of Health and
less, previous studies have indicated that discrepancy in the
Welfare (currently the Ministry of Health, Labor and Welfare).
assessment of pain severity between patients and physicians is
He also vigorously gave in-hospital lectures and seminars pro-
a strong predictor of inadequate pain management (9–11,14).
moted by the WHO, the Ministry of Health and Welfare and
Inclusion of this factor in future studies would strengthen the
the Institute itself (personal communication with Dr Uki,
findings.
Saitama Cancer Center). In comparison, few specific institu-
Interestingly, we found differences among individual physi-
tional efforts have been made to improve cancer pain manage-
cians in their ability to manage cancer pain, regardless of their
ment at the National Cancer Center Hospital East. This
years of oncology experience. We know of few studies that
disparity in institutional effort may explain the difference in the
have investigated the characteristics of physicians who have
quality of the pain management between these two hospitals.
difficulty controlling cancer pain. Such information would be
Various health care system barriers, including the low prior-
useful in detecting those physicians who need some kind of
ity given to cancer pain management, have been reported
educational training to increase their pain management skills.

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42
Cancer pain management
Careful interpretation of the results must be made for the fol-
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Document Outline

• Adequacy of Cancer Pain Management in a Japanese Cancer Hospital
  • Adequacy of Cancer Pain Management in a Japanese Cancer Hospital
    • Adequacy of Cancer Pain Management in a Japanese Cancer Hospital
      • Adequacy of Cancer Pain Management in a Japanese Cancer Hospital
        • Adequacy of Cancer Pain Management in a Japanese Cancer Hospital
    • Okuyama,T.
      • Okuyama,T.
        • Okuyama,T.
        • Toru
      • Wang,X.S.
        • Wang,X.S.
        • Xin Shelley
      • Akechi,T.
        • Akechi,T.
        • Tatsuo
      • Mendoza,T.R.
        • Mendoza,T.R.
        • Tito R.
      • Hosaka,T.
        • Hosaka,T.
        • Takashi
      • Cleeland,C.S.
        • Cleeland,C.S.
        • Charles S.
      • Uchitomi,Y.
        • Uchitomi,Y.
        • Yosuke
    • Department of Symptom Research, Division of Anesthesiology and Critical Care, University of Texas...
      • Department of Symptom Research, Division of Anesthesiology and Critical Care, University of Texas...
      • Psycho-Oncology Division and
      • Psychiatry Division, National Cancer Center Research Institute East, Kashiwa, Chiba, Japan,
      • Course of Specialized Clinical Care, Psychiatry, Tokai University School of Medicine, Isehara, Ka...
    • Received August 28, 2003
      • Received August 28, 2003
      • accepted December 2, 2003
    • Background:
      • Background:
        • Background:
      • Methods:
        • Methods:
      • Results:
        • Results:
      • Conclusions:
        • Conclusions:
    • Key words: neoplasms … pain … pain management index … palliative care … symptom management
      • Key words: neoplasms … pain … pain management index … palliative care … symptom management
  • INTRODUCTION
    • INTRODUCTION
      • INTRODUCTION
    • PATIENTS AND METHODS
      • PATIENTS AND METHODS
      • Patient-reported Pain Severity
        • Patient-reported Pain Severity
      • Analgesic Prescription and Other Medical Information
        • Analgesic Prescription and Other Medical Information
      • Statistical Methods
        • Statistical Methods
    • RESULTS
      • RESULTS
      • Participant Characteristics
        • Participant Characteristics
      • Pain severity in This Population
        • Pain severity in This Population
      • Inadequacy of Analgesic Drug Therapy: the Negative PMI
        • Inadequacy of Analgesic Drug Therapy: the Negative PMI
      • Factors Associated with a Negative PMI
        • Factors Associated with a Negative PMI
      • Difference in Ability of the Cancer Pain Management by Physicians
        • Difference in Ability of the Cancer Pain Management by Physicians
    • DISCUSSION
      • DISCUSSION
    • Acknowledgments
      • Acknowledgments
    • References
      • References
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