Patient-controlled analgesia in cancer pain management across African healthcare settings: a scoping review protocol

Abstract

Background

Cancer pain management is critical, especially at advanced stages. This is particularly important in Africa as most cancers are typically diagnosed at advanced stages. Given the central role of adequate pain management in advanced cancer care, this scoping review aims to examine the utilisation of patient-controlled analgesia (PCA) in cancer pain management within African healthcare settings.

Methods and analysis

This scoping review will apply the Arksey and O’Malley framework. A systematic search will be conducted in PubMed, African Journals Online and Google Scholar, focusing on studies conducted in Africa involving PCA and cancer pain. A two-step screening process will be used, title/abstract screening and full-text screening, with inclusion criteria emphasising relevance to cancer pain, PCA usage and African context. A thematic analysis approach will categorise data into themes related to PCA utilisation, effectiveness, barriers and outcomes. Tables and figures will be used for presentation.

Ethics and dissemination

This review will involve a secondary analysis of already published literature; therefore, ethical approval is not required. The findings of our scoping review will be published in an open-access, peer-reviewed journal on completion.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This scoping review provides a comprehensive overview of the available literature on utilisation and effectiveness of patient-controlled analgesia (PCA) in cancer pain management across African healthcare settings.

• This scoping review poses research questions that are clear, specific and well defined, guiding the focus of the review and enabling a systematic examination of the literature.

• We acknowledge the potential for language bias in this review as we limit our inclusion criteria to English-language publications.

• Our restriction to studies conducted exclusively in Africa may also introduce geographical bias and thus may limit the generalisability of the findings, as utilisation of PCA for cancer pain management could vary in different continents.

Background

Pain management for patients with cancer is currently recognised as a leading concern for both patients and palliative care teams worldwide.¹ Cancer pain has long been acknowledged in clinical practice, and despite efforts by the WHO to establish an international standard of care for appropriate management, up to 30% of patients still do not get appropriate pain management. This makes cancer pain a major public health concern.^{2 3}

The International Association for the Study of Pain defines pain as the following: ‘An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’.⁴ Chronic pain, on the other hand, is defined as any pain persisting beyond 3 months. Chronic pain in cancer may be due to inflammation or mechanical causes (ie, tumour mass compressing a nerve).⁵

Cancer survival rates have risen considerably in the 21st century as a result of targeted and improved treatment options. On the other hand, the annual number of cancer cases worldwide is projected to increase from 14 million in 2012 to 23.8 million by 2032.⁶ This creates an increasing challenge in managing cancer-related chronic pain and the side effects of various treatment regimens. For example, many individuals diagnosed with cancer must endure chronic pain due to surgery, treatment or the side effects of treatment, such as pathological fractures following radiotherapy.7,9 Uncontrolled pain can significantly affect patients’ quality of life in important areas such as sleep, reduced physical and social activity, and food.¹ 75%–90% of patients with advanced cancer, including between 30% and 50% of patients receiving treatment for curative purposes, endure chronic pain severe enough to require opioid prescription.^{1 7}

In many third-world countries, a considerable proportion of patients with cancer are diagnosed at advanced stages of the disease, leaving pain relief and palliative care as the primary viable treatment options. When more advanced treatment options are ineffective, the focus switches to efficiently managing symptoms and preserving these patients’ comfort and well-being. The incidence of cancer pain at advanced stages in developing countries is estimated at 70%–80%.¹⁰ Thus, there is an increased need for pain control in patients with cancer in Africa that is not matched by the current use of analgesics such as opioids.¹¹ In comparison to other continents, Africa has the lowest average utilisation of narcotics, with 50 daily doses per million persons per day. The Americas, on the other hand, are currently the highest consumers of opioids, with over 14 000 daily doses per million persons per day.¹² Although there has been a worldwide increase in opioid consumption, an estimated 92% of these medications are consumed by patients in developed countries, leaving the remaining 8% in third-world countries, which account for up to 83% of the world’s population.¹¹ This highlights a potentially critical gap in pain management in Africa.

The use of patient-controlled analgesia (PCA) for pain relief dates as far back as 1971 following its introduction by Philip H Sechzer. Pumps were then first made commercially available in 1976.¹³ The aim of PCA is to provide patients with appropriate pain relief depending on the selected dosage and timing. This is achieved by allowing patients to administer a preset dose of analgesic at any time by press of a button. Each bolus may be given alone or as part of a background infusion. The routes of administration for these medications may be through intravenous, subcutaneous, epidural or intrathecal, or transdermal routes. Opioids such as morphine, hydromorphone, remifentanil and meperidine are commonly given through the intravenous route. On the other hand, local anaesthetics such as bupivacaine and L-bupivacaine are given via the epidural route. Dissociative agents such as ketamine or other analgesics are also viable options. The current mainstay of PCA remains opioids and local anaesthetics.^{13 14} PCA has demonstrated better effectiveness at pain control than non-patient-controlled opioid injections and results in better patient satisfaction.¹⁴

Due to the documented effectiveness of this strategy in managing acute pain, PCA delivery devices have been proposed for treatment of chronic pain in patients with cancer. PCA provides various benefits in cancer pain management, including reduced delay in administering analgesia from the time of request, improved speed and ease of dose titration, flexibility in meeting patients’ varying analgesic dosage demands and day-to-day changes in patient needs.¹⁵

While PCA has a number of well-established benefits, this method of administering medications has disadvantages as well. These include, among other things, mistrust of the PCA pump, worries about overdosing, prolonged use and fear of adverse reactions. Mistrust brought on by insufficient patient training on the machine’s operation is another element that could lead to less-than-ideal PCA use.¹⁶ PCA is associated with common opioid-induced adverse effects, including drowsiness, respiratory depression, disorientation, nausea, vomiting, itching and urine retention.^{17 18} To use PCA safely, all parties involved must actively participate, including the patient, their family and friends, and the healthcare professionals. These key players should be incorporated into overall educational strategies. It is also critical to routinely review the competency of people administering PCA in order to maintain optimal pain evaluation and treatment.¹⁹

The aim of this scoping review is to examine the use of PCA in cancer pain management within African healthcare settings.

Methods

This scoping review will apply the methodological framework of Arksey and O’Malley,²⁰ improved by Levac et al.²¹ The stages in carrying out this scoping review will include the following: (1) identifying the research questions, (2) identifying relevant studies, (3) selecting the study, (4) charting the data and (5) summarising the data. This protocol was reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews.²²

Identifying the research questions

This scoping review seeks to answer the following questions:

• What is the extent of utilisation of PCA in the management of cancer pain across African healthcare settings?

• What is the evidence regarding the effectiveness of PCA in providing pain relief for patients with cancer?

• To what extent does PCA affect the quality of life of patients having cancer pain?

• What are the factors influencing the adoption and utilisation of PCA for cancer pain management in African healthcare contexts?

• What barriers and challenges are associated with implementing PCA for cancer pain management in African healthcare systems?

• What outcomes, including adverse events, are associated with PCA usage for cancer pain management in African populations?

Identifying relevant studies

We will conduct a systematic search of relevant literature across three databases: PubMed, African Journals Online and Google Scholar. These databases were chosen for their wide coverage of healthcare and medical literature, particularly related to African healthcare contexts. The search strategy for each database was carefully designed with the guidance of a senior librarian with expertise in database searching. The search strategy incorporates a carefully selected set of keywords and medical subject headings terms, aligned with the research questions. The search strategy for PubMed is shown in table 1.

Table 1. PubMed search strategy.

Database

Search strategy

PubMed

“patient controlled analgesia”[MeSH Terms] OR (“analgesia”[All Fields] AND “patient controlled”[All Fields]) OR “patient-controlled analgesia”[All Fields] OR (“patient”[All Fields] AND “controlled”[All Fields] AND “analgesia”[All Fields]) OR “patient controlled analgesia”[All Fields] AND “cancer pain”[MeSH Terms] OR (“cancer”[All Fields] AND “pain”[All Fields]) OR “cancer pain”[All Fields] AND (“Africa”[MeSH Terms] OR “African”[All Fields])

MeSHmedical subject headings

Selecting the study

The study selection process is crucial to ensuring the reliability and validity of this scoping review. We will use a rigorous two-step screening system to reduce the possibility of bias and enhance the transparency of our selection process.

Stage 1: title and abstract screening

Two independent reviewers will thoroughly examine the titles and abstracts of all retrieved studies against our predetermined inclusion and exclusion criteria during the first stage of study selection. The criteria provide a solid foundation for judging how relevant each study is to our research questions.

Inclusion criteria

Studies that will be included must meet the following criteria:

• Must have been carried out in an African country.

• Must have been done on African populations with cancer-related pain.

• Must have used PCA in any form to manage cancer-related pain.

Exclusion criteria

• Studies not related to cancer pain.

• Studies not using PCA for cancer pain management.

• Studies conducted outside Africa.

• Non-English publications.

• Systematic reviews, scoping reviews, letters to editors and case reports.

Each study will be evaluated independently by the reviewers for adherence to these criteria.

Stage 2: full-text screening

Following screening of titles and abstracts, studies that meet the inclusion criteria will proceed to the second level of screening. During this step, the full-text versions of the selected studies will be retrieved and evaluated by the same two reviewers. The reviewers will carefully independently evaluate the content of each study during the full-text screening to assess whether it matches our research questions and inclusion criteria. The full-text articles will be used to extract any additional information needed for decision-making. In the event of disagreements or uncertainties, a discussion will be held to reach a consensus. If no consensus is reached, a third author will be consulted to make the final decision.

Charting the data

Data obtained will be recorded on a Microsoft Excel spreadsheet. Information that will be obtained will include author details, study type, year it was carried out, country where it was carried out, sample size, types of cancer, type of PCA and agent used, pain scores before and after use of PCA, barriers and facilitators of PCA uptake, and factors influencing uptake.

Summarising the data

A thematic analysis approach will be employed to summarise and synthesise the findings. Data will be organised based on the research questions, and key themes related to PCA utilisation, effectiveness, barriers and outcomes will be identified. The review team will meet regularly to discuss and refine the emerging themes. The results will be presented in tabular and graphical formats, as appropriate, to facilitate clear understanding of the data. Tables will be designed to highlight key findings, trends and patterns. The results of our review will also be compared with those done in other countries.

Patient and public involvement

None.

Ethics and dissemination

This scoping review will analyse publicly available published literature; thus, no ethical approval is needed. The results of this review will be published in an international, peer-reviewed journal on completion.