Is Cancer Pain Control Improved by a Simple WHO Pain Analgesic Ladder Approach Combined With Tumor-Directed Treatment?
Mené en Italie auprès de 240 patients atteints de cancer, cet essai randomisé multicentrique compare l'efficacité de la morphine à faible dose ou des antalgiques opioïdes faibles pour prendre en charge et soulager les douleurs modérées des patients
The practical use of the WHO analgesic ladder has evolved over time; is there a need for a formal change? Taking into consideration that pain is the symptom most feared by patients and families, and that studies have demonstrated that 90% of patients with cancer experience pain1 and only 50% receive adequate pain control in unselected cancer cohorts,2 there is an urgent need for improvement. The solutions are clearly more complex than simply changing the WHO analgesic ladder. Systematic pain diagnosis during oncology consultations should be incorporated as a minimum requirement into standard inpatient and outpatient consultations. However, it is debatable how to address symptom management in general and pain management specifically in consultations where the primary focus is often how to treat the tumor and prolong life. Cancer pain is affected by many variables, such as tumor type and site, the extent of the disease, cancer therapy, and host factors (sex, genomics, and psychologic and social factors, among others), which challenge a simple solution to pain diagnosis. Is it possible to simplify both pain classification and management, with improved overall pain control as a result? In the article that accompanies this editorial, Bandieri et al3 challenge the concept of the WHO analgesic ladder, which consists of three steps (nonopioids [step 1], weak opioids [eg, codeine and tramadol; step 2], and strong opioids [eg, morphine, fentanyl, and oxycodone; step 3]), and consider whether a two-step approach will contribute to better overall pain control is questionable. This two-step concept is in accordance with the latest European Association for Palliative Care recommendations.4