1. ASSESSMENT AND DIAGNOSIS
Welcome to this presentation in the series “Know Cancer related Pain”. In this module we will be discussing the assessment and diagnosis of cancer related pain.

2. Importance of Pain Assessment
Pain is a significant predictor of morbidity and mortality.
Screen for red flags requiring immediate investigation and/or referral
Identify underlying cause
Pain is better managed if the underlying causes are determined and addressed
Recognize type of pain to help guide selection of appropriate therapies for treatment of pain
Determine baseline pain intensity to future enable assessment of efficacy of treatment
Pain is a significant predictor of morbidity and mortality. It is therefore imperative to screen for any red flags that require immediate attention, and to consider referrals where necessary. Identifying the underlying cause of pain is critical, since pain is better managed if the underlying cause is determined and addressed. The type of pain should be recognized to help guide selection of appropriate therapies for the treatment of pain, and baseline pain should be determined to enable future assessment of treatment efficacy.
Forde G, Stanos S. J Fam Pract 2007; 56(8 Suppl Hot Topics):S21-30; Sokka T, Pincus T. Poster presentation at ACR 2005.

3. Comprehensive Pain Assessment
Assess effects of pain on patient’s function
Characterize pain
location, distribution, duration, frequency, quality, precipitants
Complete risk assessment
Take detailed history (e.g., comorbidities, prior treatment)
Clarify etiology, pathophysiology
This slide lists the components of a complete pain assessment. These include a complete pain assessment of location, duration, frequency, and quality, a complete medication history, a physical exam, an assessment of patient function, a risk assessment, and a medical clarification of comorbidities, possible pain sources and aberrant pain.
Conduct physical examination
National Pharmaceutical Council, Joint Commission on Accreditation of Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. Reston, VA: 2001; Passik SD, Kirsh KL CNS Drug 2004; 18(1):13-25.

4. Pain Assessment: PQRST Mnemonic
Provocative and Palliative factors
Quality
Region and Radiation
Severity
Timing, Treatment
The PQRST mnemonic can be used to assess pain. The individual letters of the mnemonic stand for the following: “P” stands for assessing provocative and palliative factors, “Q” stands for assessing the quality of the pain, “R” stands for assessing the region and radiation of the pain, “S” stands for assessing the severity of the pain, and “T” stands for assessing the timing of the pain, as well as any treatments that have been previously tried.
Budassi Sheehy S, Miller Barber J (eds). Emergency Nursing: Principles and Practice. 3rd ed. Mosby; St. Louis, MO: 1992.

5. Locate the Pain
This slide gives an example of a body map that can be used to determine the precise location of pain symptoms and sensory signs.
Body maps are useful for the precise location of pain symptoms and sensory signs.*
*In cases of referred pain, the location of the pain and of the injury or nerve lesion/dysfunction may not be correlated
Gilron I et al. CMAJ 2006; 175(3):265-75; Walk D et al. Clin J Pain 2009; 25(7):

6. Pain History Components
Location of pain
Onset
Provocative or palliative factors
Quality
Radiation and related symptoms
Severity (intensity, effect on function)
Temporal pattern (continuous vs. intermittent)
Taking a patient’s pain history involves checking the following components: The location of pain, the pain onset, any provocative or palliative factors, the pain quality, the pain radiation and related symptoms, the pain severity, and the temporal pattern of the pain. Cognitive functioning and gender differences may affect a person’s self- report of pain; therefore, caregivers are commonly used as proxies for obtaining pain reports.
Cognitive functioning and gender differences may affect a person’s self-report of pain; therefore, caregivers are commonly used as proxies for obtaining pain reports
Parala-Metz A, Davis M. Cancer pain. Available at: Accessed March 19, 2015; Allen RS et al. Gerontologist. 2002;42:

7. Physical Examination Assess tumor response
Narrow differential diagnoses
Lead to appropriate diagnostic testing and empiric treatment in the presence of new complaints
A physical examination of patients with cancer pain should involve assessing the tumor response, and narrowing the differential diagnoses. A physical exam can lead to appropriate diagnostic testing and empiric treatment in the presence of new complaints. Patients with cancer indicate the physical exam is a highly positive aspect of their care.
Patients with cancer indicate the physical exam is a highly positive aspect of their care
Kadakia KC et al. Cancer. 2014;120(14):

8. Physical Examination
Most patients perceive the physical exam as strongly positive
Most feel that being examined provides a symbolic and pragmatic meaning
Exam has meaning beyond that of an investigative bedside tool
Symbolic: provides reassurance, caring, and hope
Pragmatic: results might directly affect diagnostic, prognostic, or therapeutic assessments
Increasing age is an independent predictor of a more positive perception of the physical exam
May provide an avenue to discuss issues and avoid unnecessary tests
Most patients perceive the physical exam as a strongly positive experience, and feel that being examined has both a symbolic and pragmatic meaning. An exam has meaning beyond that of an investigative bedside tool, but also provides reassurance, caring, and hope, and its results might directly affect diagnostic, prognostic, or therapeutic assessments. Increasing age is an independent predictor of a more positive perception of the physical exam. Finally, a physical exam may provide an avenue to discuss issues and avoid unnecessary tests.
Kadakia KC et al. Cancer. 2014;120(14):

9. Tools for the assessment of cancer pain
In this section of the presentation, we will review some tools for the assessment of cancer pain.

10. Impact of Pain on Function
Assessing Acute Pain
Pain Intensity
Impact of Pain on Function
Visual analog scale (VAS)
Self-rating on a 0–100 mm scale
Numerical rating scale
Self-rating on a 11-point scale: 0 = no pain to 10 = worst pain
Time-specific pain intensity
“My pain at this time is: none, mild, moderate, severe” (0 to 3 rating)
Time-specific pain relief
“My pain relief at this time is: none, a little, some, a lot, complete” (0 to 4 rating)
American Pain Society (APS) questionnaire
The degree to which pain interferes with patient function, such as mood, walking and sleep
Brief Pain Inventory (BPI)
Evaluates severity, impact and impairment on daily living, mood and enjoyment of life
This slide list some assessment tools for pain intensity and pain burden. Ideally, the assessment tool employed to should be easy to administer, have a low respondent burden, and be easy to use and interpret. The selection of assessment tools may depend on the literacy, numeracy and cognitive abilities of the patient.
Coll AM et al. J Adv Nursing 2004; 46(2): ; Dihle A et al. J Pain 2006; 7(4):272-80; Keller S et al. Clin J Pain 2004; 20(5):

11. Brief Pain Inventory
The slide shows the Brief Pain Inventory, which assesses the severity, impact on daily function, and location of pain, as well as pain medications ,and amount of pain relief in the past 24 hours or the past week. The Brief Pain Inventory is available in two formats. The short form takes 5 minutes to complete, and the long form takes 10 minutes.
Cleeland CS, Ryan KM. Ann Acad Med Singapore 1994; 23(2):

12. Determine Pain Intensity
Simple Descriptive Pain Intensity Scale
Mild pain
Moderate pain
Severe pain
Very severe pain
No pain
Worst pain
0–10 Numeric Pain Intensity Scale 1 2 3 4 5 6 7 8 9 10
No pain
Moderate pain
Worst possible pain
This slide displays three of the most common pain intensity scales. The selection of which scale to use may depend on the literacy, numeracy and cognitive abilities of the patient.
Faces Pain Scale – Revised
International Association for the Study of Pain. Faces Pain Scale – Revised. Available at: Accessed: July 15, 2013; Iverson RE et al. Plast Reconstr Surg 2006; 118(4):

13. APS Questionnaire Measures 6 aspects of pain quality:
Pain severity and relief
Impact of pain on activity, sleep and negative emotions
Side effects of treatment
Helpfulness of information about pain treatment
Ability to participate in pain treatment decisions
Use of non-pharmacological strategies
The American Pain Society Questionnaire measures pain severity and relief, impact of pain on activity, sleep, as well as negative emotions, side effects of treatment, the helpfulness of information about pain treatment, the patient’s ability to participate in pain treatment decisions, and the use of non-pharmacological strategies.
Gordon DB et al. J Pain 2010; 11(11):

14. APS Questionnaire
This slide shows an example of the American Pain Society Questionnaire.
Gordon DB et al. J Pain 2010; 11(11):

15. Tools to Assess Psychiatric/Psychosocial Comorbidities
In this section we’ll review some tools to assess psychiatric and/or psychosocial comorbidities of cancer-related pain.

16. Depression Scales
First, we’ll turn our attention to depression scales.

17. PHQ-9 This slide gives an example of the PHQ-9.
Kroenke K et al. J Gen Intern Med. 2001;16(9):

18. Hospital Anxiety and Depression Scale
The Hospital Anxiety and Depression Scale screens for clinically significant anxiety and depressive symptoms in medically ill patients. It is comprised of two sub scales, namely one for depression and one for anxiety. This slide gives an example of some of the items on the scale.
A = anxiety; D = depression
Zigmond AS, Snaith RP. Acta Psychiatr Scand. 1983;67:

19. Hamilton Depression Rating Scale (HAM-D)
The Hamilton Depression Rating Scale is the most widely used clinician-administered depression assessment scale. The original version contains 17 items pertaining to symptoms of depression experienced over the past week.

20. Montgomery-Åsberg Depression Rating Scale
The Montgomery-Åsberg Depression Rating Scale measures changes in symptoms of depression secondary to treatment. This clinician-rated scale is designed to be used in patients with major depressive disorder. It is used to measure the degree of severity of depressive symptoms and is a sensitive measure of change in symptom severity during treatment of depression.
Montgomery SA, Asberg M. Br J Psychiatry. 1979;134:382-9.

21. Beck Depression Inventory
The Beck Depression Inventory is considered the gold standard of self-rating scales. It was initially developed to assess the efficacy of psycho-analytically oriented psychotherapy in depressed subjects. This scale was designed to measure the severity of depressive symptoms that the test taker is experiencing “at that moment.”
Beck AT et al. Arch Gen Psychiatry. 1961;4:

22. Anxiety Scales
This section of the presentation reviews some rating scales for anxiety.

23. Beck Anxiety Inventory
The Beck Anxiety Inventory is a brief measure of anxiety with a focus on somatic symptoms of anxiety. It is designed to discriminate between anxiety and depression. The scale is a self-report or interviewer administered questionnaire and includes assessment of symptoms such as nervousness, dizziness, and inability to relax. Respondents indicate how much they have been bothered by each symptom over the last week.
Beck AT et al. J Consult Clin Psychol. 1988;56(6):893-7.

24. Hamilton Anxiety Rating Scale (HAM-A)
This slide gives an example of the questions on the Hamilton Anxiety rating Scale.
Hamilton M. Br J Med Psychol. 1959;32:50-5.

25. Hospital Anxiety and Depression Scale - Anxiety
Question
Frequency
Score
I feel tense or “wound up”
Most of the time
A lot of the time
Occasionally
Not at all 3 2 1
I get a sort of frightened feeling as if something awful is about to happen
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn’t worry me
Worrying thoughts go through my mind
A great deal of the time
From time to time, but not often
Only occasionally
I can sit at ease and feel relaxed
Definitely
Usually
Not often
I get a sort of frightened feeling like “butterflies” in the stomach
Quite often
Very often
I feel restless as I have to be on the move
Very much indeed
Quite a lot
Not very much
I get sudden feelings of panic
Very often indeed
Not very often
Not often at all
The Hospital and Depression Scale – Anxiety is a brief measure of generalized symptoms of anxiety and fear. It includes specific items that assess generalized anxiety including tension, worry, fear, panic, difficulties in relaxing, and restlessness, and can be used to detect and quantify the magnitude of anxiety symptoms but it cannot detect specific anxiety disorders.
Zigmond AS, Snaith RP. Acta Psychiatr Scand. 1983;67:

26. Quality of Life Scale for Cancer Patients
In the next section we’ll discuss some quality of life scales for Cancer Patients.

27. HRQoL Tools Used in Oncology
General
Short Form 36 (SF-36)
Hospital and Anxiety Depression Scale (HADS)
Cancer Specific
EORTC QLQ-30
Functional Assessment of Cancer Therapy – General (FACT-G)
Rotterdam Symptom Checklist (RSCL)
This slide gives a list of both general and cancer specific tools used to measure health related quality of life in cancer patients.
Bottomley A. Oncologist. 2002;7(2):120-5.

28. SF-36® scales measure physical and mental components of health
Short Form 36 (SF-36®)
The SF-36 is a multi-purpose, short-form health survey with 36 questions. It yields an 8-scale profile of functional health and well-being scores, as well as psychometrically based physical and mental health summary measures. The SF-36 is suitable for self- administration, computerized administration, or administration by a trained interviewer in person or by telephone, to persons age 14 and older.
SF-36® scales measure physical and mental components of health
Ware, JE Jr. Available at:

29. Hospital Anxiety and Depression Scale
The Hospital Anxiety and Depression Scale screens for clinically significant anxiety and depressive symptoms in medically ill patients. It is comprised of two sub scales, namely one for depression and one for anxiety. This slide gives an example of some of the items on the scale.
A = anxiety; D = depression
Zigmond AS, Snaith RP. Acta Psychiatr Scand. 1983;67:

30. EORTC QLQ-C30
Questionnaire to assess quality of life of patients with cancer
For use in clinical trials (copyrighted)
30 questions rated on a 4-point Likert scale
Nine multi-item scales
Functional: physical, role, cognitive, emotional, social
Symptom: fatigue, pain, nausea and vomiting
Global health and quality of life
Several single-item symptom measures also included
The EORTC QLQ-C30 is a questionnaire to assess quality of life of patients with cancer. It is intended for use in clinical trials, and consists of 30 questions rated on a 4-point Likert scale. It comprises 9 multi-item scales assessing functional, symptom related, and global health and quality of life.
EORTC = European Organization for the Research and Treatment of Cancer
Aaronson NK et al. J Natl Cancer Inst ;85(5):

31. Functional Assessment of Cancer Therapy – General (FACT-G)
33-item scale for patients receiving cancer therapy
Easy to administer
Brief
Reliable
Valid
Responsive to clinical change
The Functional Assessment of Cancer Therapy – General is a 33-item scale for patients receiving cancer therapy. It is easy to administer, brief, reliable, valid, and responsive to clinical change. An example of the scale is shown on the slide.
Cella DF et al. J Clin Oncol. 1993;11:570-9.

32. Rotterdam Symptom Checklist (RSCL)
Self-report measure
4 main scales:
Physical symptom distress
Psychological distress
Activity level
Overall global life quality
4-point Likert-type scales
The Rotterdam Symptom Checklist is a self-report measure comprised of 4 main scales, namely physical symptom distress, psychological distress, activity level, and overall global life quality.
De Haes JCJM et al. The Rotterdam Symptom Checklist. Available at: Accessed March 20, 2015.

33. Tools to Assess Neuropathic Pain
The next section will cover some tools to asses neuropathic pain.

34. Sensitivity and Specificity of Neuropathic Pain Screening Tools
Name
Description
Sensitivity*
Specificity*
Interview-based
NPQ
10 sensory-related items + 2 affect items
66%
74%
ID-Pain
5 sensory items + 1 pain location NR
painDETECT
7 sensory items + 2 spatial characteristics items
85%
80%
Interview + physical tests
LANSS
5 symptom items + 2 clinical exam items
82–91%
80–94%
DN4
7 symptom items + 3 clinical exam items
83%
90%
This slide summarizes the screening tools currently used for neuropathic pain, providing the sensitivity and specificity for each, when available.
Tests incorporating both interview questions and physical tests have higher sensitivity and specificity than tools that rely only on interview questions
*Compared with clinical diagnosis
DN4 = Douleur neuropathic en 4 questions; LANSS = Leeds Assessment of Neuropathic Symptoms and Signs; NPQ = Neuropathic Pain Questionnaire; NR = not reported
Bennett MI et al. Pain 2007; 127(3):

35. LANSS Scale Completed by physician in office
Differentiates neuropathic from nociceptive pain
5 pain questions and 2 skin sensitivity tests
Identifies contribution of neuropathic mechanisms to pain
Validated
This slide shows the LANSS scale, which distinguishes neuropathic symptoms and signs from those arising through nociceptive pain. It is completed by a physician in the office, and includes 5 pain questions and 2 skin sensitivity tests.
LANSS = Leeds Assessment of Neuropathic Symptoms and Signs
Bennett M. Pain 2001; 92(1-2):

36. DN4 Completed by physician in office
Differentiates neuropathic from nociceptive pain
2 pain questions (7 items)
2 skin sensitivity tests (3 items)
Score 4 is an indicator for neuropathic pain
Validated
This slide shows the DN4 diagnostic questionnaire, which differentiates neuropathic pain from non-neuropathic pain. It is completed by a physician in the office, and comprises 2 pain questions, as well as 2 skin sensitivity tests.
DN4 = Douleur neuropathique en 4 questions Bouhassira D et al. Pain 2005; 114(1-2):29-36.

37. painDETECT Patient-based, easy-to-use screening questionnaire
Developed to distinguish between neuropathic pain and non-neuropathic pain*
Validated: high sensitivity, specificity and positive predictive accuracy
Seven questions about quality and three about severity of pain
Questions about location, radiation and time course
This slide illustrates the painDETECT questionnaire, which provides a simple, validated screening tool to detect neuropathic pain components in patients with chronic low back pain. The questionnaire is validated, with high sensitivity, specificity and positive predictive accuracy. It consists of seven questions about quality and three about severity of pain, as well as questions about location, radiation and time course of the pain.
*Validation was in patients with low back pain
Freynhagen R et al. Curr Med Res Opin 2006; 22(10):

38. ID Pain Patient-completed screening tool
Includes 6 yes/no questions and pain-location diagram
Developed to differentiate between nociceptive and neuropathic pain
Validated
The ID pain questionnaire is a patient-completed screening tool that was designed to differentiate between nociceptive and neuropathic pain. The questionnaire is a validated, patient-completed screening tool, that includes 6 yes/no questions and a pain-location diagram.
Portenoy R. Curr Med Res Opin 2006; 22(8):

39. Imaging in the Diagnosis and Management of Cancer Pain
Imaging of bone metastasis
Spinal tumor imaging
Plexus tumor imaging
Celiac plexus imaging
Tumor ablation
Image-guided pain therapy
Image guidance to place a biopsy needle, therapeutic catheter, or ablation needle in the target
Vertebral tumor image-guided interventions
Vertebroplasty, percutaneous nerve blocks
This slide lists some uses of imaging techniques in the management of cancer related pain. These include the imaging of bone metastases, spinal tumor imaging, the visualization plexus tumors, celiac plexus imaging, as well as image-guided pain therapy and image-guided interventions for vertebral tumors.
Cuevas C, Shibata D. Curr Pain Headache Rep. 2009;13:

40. Literature Cited
Aaronson, N. K., Ahmedzai, S., Bergman, B., Bullinger, M., Cull, A., Duez, N. J., … de Haes, J. C. (1993). The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute, 85(5), 365–376. Allen, R. S., Haley, W. E., Small, B. J., & McMillan, S. C. (2002). Pain reports by older hospice cancer patients and family caregivers: the role of cognitive functioning. The Gerontologist, 42(4), 507–514. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893–897. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Bottomley, A. (2002). The cancer patient and quality of life. The Oncologist, 7(2), 120–125. Budassi Sheely, S., & Miller Barber, J. (1992). Emergency Nursing: Principles and Practice. (3rd Ed.). St Louis: Mosby. Cancer Pain. (n.d.). Retrieved June 19, 2015, from

41. Literature Cited (Continued)
Cella, D. F., Tulsky, D. S., Gray, G., Sarafian, B., Linn, E., Bonomi, A., … Brannon, J. (1993). The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 11(3), 570–579. Cleeland, C. S., & Ryan, K. M. (1994). Pain assessment: global use of the Brief Pain Inventory. Annals of the Academy of Medicine, Singapore, 23(2), 129–138. Coll, A. M., Ameen, J. R. M., & Mead, D. (2004). Postoperative pain assessment tools in day surgery: literature review. Journal of Advanced Nursing, 46(2), 124– Dihle, A., Helseth, S., Kongsgaard, U. E., Paul, S. M., & Miaskowski, C. (2006). Using the American Pain Society’s patient outcome questionnaire to evaluate the quality of postoperative pain management in a sample of Norwegian patients. The Journal of Pain: Official Journal of the American Pain Society, 7(4), 272– Forde, G., & Stanos, S. (2007). Practical management strategies for the chronic pain patient. The Journal of Family Practice, 56(8 Suppl Hot Topics), S21–30. Gilron, I., Watson, C. P. N., Cahill, C. M., & Moulin, D. E. (2006). Neuropathic pain: a practical guide for the clinician. CMAJ: Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 175(3), 265–275.

42. Literature Cited (Continued 1)
Gordon, D. B., Polomano, R. C., Pellino, T. A., Turk, D. C., McCracken, L. M., Sherwood, G., … Farrar, J. T. (2010). Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: preliminary psychometric evaluation. The Journal of Pain: Official Journal of the American Pain Society, 11(11), 1172– Hamilton, M. (1959). The assessment of anxiety states by rating. The British Journal of Medical Psychology, 32(1), 50–55. Iverson, R. E., Lynch, D. J., & ASPS Committee on Patient Safety. (2006). Practice advisory on pain management and prevention of postoperative nausea and vomiting. Plastic and Reconstructive Surgery, 118(4), 1060– Kadakia, K. C., Hui, D., Chisholm, G. B., Frisbee-Hume, S. E., Williams, J. L., & Bruera, E. (2014). Cancer patients’ perceptions regarding the value of the physical examination: a survey study. Cancer, 120(14), 2215– Keller, S., Bann, C. M., Dodd, S. L., Schein, J., Mendoza, T. R., & Cleeland, C. S. (2004). Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. The Clinical Journal of Pain, 20(5), 309–318. Kreme, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.

43. Literature Cited (Continued 2)
Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. The British Journal of Psychiatry: The Journal of Mental Science, 134, 382–389. National Pharmaceutical Council, Joint Commission on Accreditation of Healthcare Organizations. (2001). Pain: Current Understanding of Assessment, Management, and Treatments. Reston, VA. Passik, S. D., & Kirsh, K. L. (2004). Opioid therapy in patients with a history of substance abuse. CNS Drugs, 18(1), 13–25. The Rotterdam Symptom Checklist. (n.d.). Retrieved June 19, 2015, from Walk, D., Sehgal, N., Moeller-Bertram, T., Edwards, R. R., Wasan, A., Wallace, M., … Backonja, M.-M. (2009). Quantitative sensory testing and mapping: a review of nonautomated quantitative methods for examination of the patient with neuropathic pain. The Clinical Journal of Pain, 25(7), 632– Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. ,0