=abstract=

background : cancer pain in the elderly is a very challenging problem for

clinicians.
objective: the aim of study is to evaluate the differences of cancer prevale
nce rate and pain management between young and elderly patients.
me thods : the nationwide cancer pain survey was done in 2001. the total
number of patients who enrolled in the survey were 7,507. the patients were
grouped into three: a) 5,266 patients whose age are less than 65 years-old;
b) 1,723 patients whose age are less than 65 to 75 years-old and; c) 518 p
atients with more than 75 years of age. we did a comparative analysis among
the three groups regarding the prevalence rate, pain management and
satisfaction rate, and the side effects of analgesics between age groups. (==>we
analysed cancer pain prevalence rate, pain management and satisfaction ra
te of pain management, and side effects of analgesics between age groups.
<==original)
result s : the prevalence rate of cancer pain was 50.0%, 55.9%, and 58.
3% in ages less than 65, 65 to 75, and more than 75 years, respectively. th
e prevalence rate of cancer pain was higher for the patients in the advanced
stage with poor performance status, but no difference between age groups
based on their performance status. using logistic regression analysis, we
found out that performance status appears to be a significant factor for cancer
pain while age is not (==> important but age was not a significant facto
r<===original) . severe cancer pain occurred in 8.0% of the subjects, and is
most prevalent in the advanced stage. side effects of analgesics on the
other hand were observed in 24.5%. and urinary retention has a higher incid
ence among elderly patients.
conclu sions : performance status affects the prevalence rate of cancer pain
more significantly than the age of a patient as proven by a logistic regression
analysis. (==>by logistic regression analysis, performance status was most
important for prevalence rate of cancer pain and age was not a significant
factor<==). there were no differences of pain management and satisfaction
rate of pain management between young and elderly patients in korea.

key wo rds : cancer pain; age, opioids

introduction

recently elderly population is increased rapidly in our nation. to treat elder

ly cancer patient is challenging problem for oncologist. according to usa re
ports, although malignant tumors occur at all ages, cancer disproportionat
ely strikes individuals in the age group 65 years and older. data from the n
ational cancer institute surveillance, epidemiology, and end results progra
m for 1998-2002, revealed that 56% of all newly diagnosed cancer patient
s and 71% of cancer deaths are in this age group1).
pain is the most common and dismal symptom in cancer patients. the caus
es of failure to adequate pain control are that inappropriate cancer pain as
sessment, absence of appropriate analgesics and avoidance of narcotic an
algesics. why is pain under-treated especially in elderly cancer patients?
except above reason, older patients are less likely to complain about pain
for many causes. and also at the aspect of physicians, clinicians erroneous
ly believe that the elderly patients are less sensitive to pain. clinicians do
n't assess pain intensity properly so pain in under-reported. clinicians con
cern that old patients don't tolerate strong opioids so they give weak dose
of pain medications. so we want to know actual condition about pain mana
gement in elderly patients. according to nationwide cancer pain survey in
over 7,500 patients, we can evaluate the differences of cancer prevalence
rate and pain management between young and elderly patients.
mat erials and m ethods

the nationwide cancer pain survey was done from 9th april to 14th april 20
01 supported by janssen korea. the 7,507 cancer patients were surveyed i
n nationwide 72 hospitals by 138 clinicians. the patients were divided into
three groups, below 65 years-old, between 65 and 74 years-old, and abov
e 75 years-old. 5,266 (70.1%) was below 65 years-old, 1,723 (23.0%) was
between 65-74 years-old, and 518 (6.9%) was above 75 years-old. male
patients was 4,151 (55.3%) and female patients was 3,353 (44.7%). we ana
lysed cancer pain prevalence rate, pain management and satisfaction rate
of pain management, and side effects of analgesics between age groups.

result s

1. prevalence rate of cancer pain according to age and sex

the prevalence rate of cancer pain is 3,899/7507 (51.9%). the prevalence r
ate of cancer pain by age groups were 2634/5266 (50.0%) in below 65 yea
rs-old, 963/1723 (55.9%) in between 65 and 75 years-old and 302/518 (5
8.3%) in above 75 years-old patients. the prevalence rate of cancer pain
was higher in male (p=0.007) and admitted (p=0.013) elderly patients (p=0.
013)(table 1).

2. prevalence rate of cancer pain according to cancer type

the prevalence rate of cancer pain in most higher in pancreatic cancer. the
prevalence rate of cancer pain according to cancer types are pancreatic c
ancer 77.8%, cups 67.4%, hepatoma 66.8%, lung cancer 63.5%, multiple m
yeloma 62.8%, head and neck cancer 61.8%, esophageal cancer 53.6%, br
east and colorectal cancer 50.3%, stomach cancer 47.8%, cervical cancer
44.6%, malignant lymphoma 35.8%, leukemia 33.6%, in order of frequency.
leukemia has significantly different prevalence rate of cancer pain accordi
ng to age (p=0.001)(table 2).

3. prevalence rate of cancer pain according to cancer stage

the prevalence rate of cancer pain according to cancer stage was as follo
ws; stage Ⅰ 34.8%, stage Ⅱ 42.9%, stage Ⅲ 50.3%, stage Ⅳ 64.1%. incre
ased stage has higher rate of cancer pain prevalence. cancer pain prevale
nce rates according to age in stage Ⅳ was 62.1% in less than 65 years-ol
d, 68.3% in between 65 and 75 years-old, and 66.7% in above 75 years-ol
d (p=0.008)(table 3).

4. prevalence rate of cancer pain according to performance status

the prevalence rates of cancer pain according to performance status was e
cog 0 in 26.7%, ecog 1 in 51.7%, ecog 2 in 71.2%, ecog 3 in 82.8%, ecog 4
in 85.9%. the patient with poor performance status had higher prevalence
rate of cancer pain. there was no different cancer pain prevalence rate ac
cording to performance status by age (table 4).

5. visual analogue pain score according to age

the visual analogue score was as follows: vas 0 in 46.4%, vas 1-3 in 30.
9%, vas 4-6 in 14.7%, and vas 7-10 in 8.0%. the prevalence rate of sever
e cancer pain was 7.6% in less than 65 years-old, 8.5% in between 65-74
years-old, and 11.5% in above 7years-old 11.5%. the elderly patients had
more severe cancer pain but there was no statistical difference (table 5).
6. prevalence rate of severe cancer pain according to stage
the prevalence rate of cancer pain according to stage was as follows; stag
e Ⅰ 3.0%, stage Ⅱ 3.9%, stage Ⅲ 5.9%, stage Ⅳ 12.3%. the higher stage
have more severe pain. the prevalence rates of severe cancer pain in stag
e Ⅲ (p=0.009) and stage Ⅳ (p=0.007) were significantly higher in elderly
patients (table 6).

7. prevalence rate of strong opioids according to vas score

the prescription rate of strong opioids were 36.8% in vas 4-6, 49.7% in va
s 7-10 patients. there was no statistically significant different prescription
rate of strong opioids between age group (table 7).

8. satisfaction rate of pain management

the results of satisfaction rate were as follows; satisfaction in 36.7%, mod
erate satisfaction in 42.%, an unsatisfaction in 20.6%. there was no statisti
cally significant different satisfaction rate of pain management between ag
e group (table 8).

9. side effects of analgesic treatment

the side effects of analgesic treatment was 24.5% in total patients. constip
ation was most common side effect in 11.2%. and nausea 6.3%, drowsines
s 4.5%, dry mouth 4.3%, vomiting 1.8% and urinary retention 1.6%, in orde
r of frequency. elderly patients had more frequent urinary retention, 4.7%
in less than 65 years-old, 9.5% in between 65-75 years-old, and 11.6% in
above 75 years-old (p=0.006)(table 9).
discus sion
cancer pain is most common and severe symptom that cancer patients suff
ered. cancer pain is closely connected to quality of life. cancer pain is inti
mately associated with physiologic and psychiatric effect. when cancer pai
n is not controlled adequately, it is accompanied with insomnia, anorexia,
nausea and vomiting, and deteriorate patient's quality of life. there are ma
ny causes that pain treatment failure. it is divided to reasons to doctors a
nd patients. the causes of doctors are misunderstanding of cancer pain, lac
k of will to treat cancer, absence of cancer treatment guideline. the cause
of patients especially in elderly patients is lack of analgesics. persons age
65 and older are more likely than younger adults to experience chronic pai
n but less likely to obtain pain relief. nociception appears not to change wi
th age or with the development of dementia, although a person's perceptio
n of pain and willingness to report it may change. control of depression an
d anxiety greatly facilitates pain management. as a patient's number of me
dications increases, so does the risk of adverse reactions; therefore, care
is required when adding any new medication to the drug regimen. depressi
on, anxiety, functional decline, dementia, drug abuse, hallucination and suf
fering are all domains of pain's empire. it behooves each of us to learn mo
re and to aggressively use the tools available to overcome this enemy of p
eace and comfort. but there must be caution to uses antipsychotic drug. be
cause elderly patients with dementia weak for drug intolerance.
as a patient's age increases, does the likelihood of chronic pain relate to c
ancer. patient's age 65 and older experience more pain but are less likely
to obtain pain relief than younger adults, because late-life pain manageme
nt is often complicated by: comorbid conditions that may influence pain, an
insufficient number of health care providers who are well-trained in geriat
rics or pain management, inadequate assessment for pain and a reluctance
by clinicians and patients to use opioid pain medications2). pain is common
in patients age 65 and older. among those living in the community, 25 to 5
0% suffer from major pain problems3,4). in the nursing home, the prevalenc
e of pain is 45 to 80%, and the prevalence of analgesic use is 40 to 50% 5,
6)
. on the other study reports that total of 1,341 individuals, 39%, 49%, and
41% of those aged 65-74, 75-84, and > or = 85 years, respectively) repor
ted daily pain. of patients with daily pain, 25% received a who level 1 dru
g; 6%, a who level 2 drug; and 3%, a who level 3 drug(eg, morphine sulfat
e)7). the factors related to cancer prevalence are age, sex, race, marital st
ate, performance, depression and cognitive function. patients 85 years or
older were less likely to receive analgesics compared with the younger pa
tients7), so daily pain is more prevalent among frail elderly patients living i
n the community and is often untreated, particularly among older and dem
ented patients.
elderly patients pain responses were measured with the following pain int
ensity rating scales: vertical visual analog scale (vas), 21-point numeric r
ating scale (nrs), verbal descriptor scale (vds), 11-point verbal numeric ra
ting scale (vns), faces pain scale (fps), and pain thermometer. all 5 pain sc
ales were effective in discriminating different levels of pain sensation; ho
wever the vds was most sensitive and reliable8). although age did not impa
ct failure to properly use pain intensity rating scale, but rather those condi
tions more commonly associated with advanced age, including cognitive an
d psychomotor impairment did. given the potential impact of pain, it is imp
ortant that health care providers evaluate pain carefully. both the evaluati
on of treatments in controlled studies and the implementation and evaluati
on of interventions in the care of the older adult require an accurate asses
sment of clinical pain. establishing a trusting, caring relationship that ackn
owledges suffering and demonstrates caring is an important first step tow
ard pain management in elderly patients. elderly patients think that pain is
normal process of cancer so they don't manifest pain accurately. cancer p
atient deny pain because they worry about worsening of cancer. the cause
s of pain treatment failure are absence of pain expression, inadequate pain
assessment, misunderstanding of opioid analgesics, mistake about elderly
patients pain physiology, avoidance of equipping opioid analgesics in nursi
ng home and lack of opioid analgesic inspector9,10).
american geriatric society show the guideline of elderly patient's chronic a
nd persistent pain11). pain-guidelines advise opioids to be added to nsaids
and paracetamol (acetaminophen) as a next step in analgesic treatment an
d ibupropen and naproxen used to control of musculoskeletal (e.g, low bac
k pain, osteoarthritis pain, and pain in previous fracture sites)11). opioid an
algesics are first line drug to treat moderate to severe cancer pain 12). the s
ide effects of opioid analgesics are well known so when clinicians order fir
st line opioid analgesics guide line recommend oral opioid analgesics10).
the side effects of opioid analgesics are constipation, nausea, drowsiness,
mouth dryness, vomiting, and urinary retention. increasingly age, most co
mmon side effect is urinary retention. especially elderly patients, clinician
s should caution about occurrence of respiratory depression and confusio
n. meperidine has been associated with a host adverse events in seniors a
nd should be avoided in older people13). meperidine leads to the formation
of a metabolite, normeperidine, which accumulates beyond the analgesic d
uration of meperidine. normeperidine acts as a central stimulant that lower
s seizure threshold when used chronically. additionally, meperidine has be
en associated with an increased risk of falls, likelihood of sedation, and ps
ychotomimetic activity when compared with other opioids14,15). the
opioid analgesics sensitivity of elderly patients is higher because drug dist
ribution usually is different. opioid receptors of the brain are decreased an
d changes in blood flow to organs, protein binding, and body composition t
hat occur with aging16). opioid can remain in elderly patient longer and high
concentration, so when prescribing analgesics for elderly patients, it is be
st to (1) use drugs that have a short half-life, if available, (2) prescribe on
e drug at a time, (3) begin with low doses, (4) be aware of additive effect
s, and (5) continue drug trials for an adequate duration17).
we study about prevalence rate of cancer pain, the actual condition of pain
control and the satisfaction rate of pain management in elderly patient. the
performance status was most important for prevalence rate of cancer pain
and age was not a significant factor for prevalence rate of cancer pain. the
re were no differences of pain management and satisfaction rate of pain m
anagement between young and elderly patients in korea. the number of eld
erly cancer patients will increase, so oncologist should prepare for the tas
k of pain assessment and management. oncologist concern about education
of cancer patient pain control, to improvement about cancer pain misconce
ption.

conclu sion

in elderly patients, the prevalence rate of cancer pain was higher in ma

les. the prevalence rate of severe cancer pain was higher in advanced
stage than younger patients. there is no relation between age group an
d pain prevalence rate in logistic regression. and also perfomance statu
s and prescription rate of strong opioids was not different between age
groups.