Title

Management of Chronic Pain in Survivors of Adult Cancers

Authoring Organization

Publication Month/Year

July 25, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Target Patient Population

Any adult who has been diagnosed with cancer and is experiencing pain that lasts ≥ 3 months, irrespective of cause.

Target Provider Population

Health care practitioners who provide care to cancer survivors.

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Home health, Long term care

Intended Users

Physician assistant, physician, physical therapist, nurse practitioner, nurse

Scope

Counseling, Rehabilitation, Management

Diseases/Conditions (MeSH)

D000072716 - Cancer Pain, D059350 - Chronic Pain

Keywords

chronic pain, cancer survivors

Source Citation

DOI: 10.1200/JCO.2016.68.5206 Journal of Clinical Oncology 34, no. 27 (September 20, 2016) 3325-3345.

Supplemental Methodology Resources

Data Supplement, Methodology Supplement

Methodology

Number of Source Documents
63
Literature Search Start Date
January 1, 1995
Literature Search End Date
December 31, 2015
Description of External Review Process
The ASCO Clinical Practice Guidelines Committee (CPGC) convened an Expert Panel with multidisciplinary representation in medical oncology, radiation oncology, cardiology, exercise physiology, family medicine, cancer prevention, cancer survivorship, patient/advocacy representation, and guideline implementation. The draft was submitted to two external reviewers with content expertise. It was rated as high quality, and it was agreed it would be useful in practice. Specific feedback on Table 5 suggested that oncologists would find the information, as presented, overwhelming. As such, the table was revised and broken into two separate tables in an attempt to make the presentation less complicated. Other comments, such as acknowledging the paucity of evidence in the abstract and highlighting the fact that many recommendations are based on expert consensus, and the inclusion of a strong statement on the need for research in this area, were reviewed by the expert panel and integrated into the final manuscript before approval by the Clinical Practice Guideline Committee. No dates were provided.
Specialties Involved
Family Medicine, Internal Medicine General, Oncology, Pain Medicine
Description of Systematic Review
The Protocol specifies the purpose of the guideline product, target patient population, clinical outcomes of interest, key features of the systematic literature review, and a proposed timeline for completion. ASCO staff, the Expert Panel Co‐Chairs, and possibly other panel members selected by the Co‐Chairs (the Expert Panel Steering Committee), will typically draft the protocol for full panel review. A standard protocol worksheet is used for consistency. Once the Co‐Chairs have approved a first draft of the Protocol, the Protocol will be shared with the full Expert Panel. At the discretion of the Guidelines Director, the CPGC leadership and/or the CPGC Methodology Subcommittee may review the Protocol to make suggestions for revision intended to clarify aspects of the plan for developing the guideline. These suggestions are sent to the Expert Panel Co‐Chairs. Work on the systematic literature review can proceed upon the sign‐off of the Protocol by the Expert Panel.
List of Questions
This clinical practice guideline addresses how chronic pain in survivors of adult cancers should be managed.
Description of Study Criteria
Literature search results were reviewed and deemed appropriate for full text review by two ASCO staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in the manuscript and/or in Data Supplements 1.
Description of Search Strategy
PubMed library was searched for evidence reporting on outcomes of interest. Outcomes of interest included symptom relief, pain intensity, quality of life, functional outcomes, adverse events, misuse or diversion, and risk assessment or mitigation.
Description of Study Selection
An assessment of study quality was performed for all the included evidence by one methodologist. Systematic reviews and meta-analyses were assessed for quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR). Literature search results were reviewed and deemed appropriate for full text review by two ASCO staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in the manuscript and/or in Data Supplements 1 and 2.
Description of Evidence Analysis Methods
ASCO guideline recommendations are crafted, in part, using the GuideLines Into DEcision Support (GLIDES) methodology. ASCO adopted a five‐step approach to carry out quality appraisal, strength of evidence ratings and strength of recommendations ratings. The ASCO approach was primarily adapted from those developed by the AHRQ,, USPSTF, and GRADE, however with the validation of the GRADE methodology, the sole use of GRADE is being evaluated by the Clinical Practice Guidelines Committee.
Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect. Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect. Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect. Insufficient: Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.
Description of Recommendation Grading
ASCO uses a formal consensus methodology based on the modified Delphi technique in clinically important areas where there is limited evidence or a lack of high‐quality evidence to inform clinical guidance recommendations. Evidence Based: There was sufficient evidence from published studies to inform a recommendation to guide clinical practice. Formal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the Supporting Documents" field). Informal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). No recommendation: There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.
Description of Funding Source
ASCO provides funding for Guideline Development.
Company/Author Disclosures
ASCO Conflict of Interest Policy complies with the CMSS Code for Interactions with Companies. ASCO requires disclosure by individuals involved in drafting, reviewing, and approving guideline recommendations.
Percentage of Authors Reporting COI
100