REVIEWARTICLE

Non-pharmacological cancer pain interventions in populationswith social disparities: a systematic review and meta-analysis

Anna Santos Salas1 & Jorge Fuentes Contreras2 & Susan Armijo-Olivo3 &

Humam Saltaji4 & Sharon Watanabe5 & Thane Chambers6 & Lori Walter7 &

Greta G. Cummings1

Received: 26 June 2015 /Accepted: 26 October 2015# Springer-Verlag Berlin Heidelberg 2015

AbstractIntroduction Global advances in pain relief have improvedthe quality of life of cancer populations. Yet, variation in can-cer pain outcomes has been found in populations with socialdisparities compared to mainstream groups. Populations withsocial disparities bear an inequitable distribution of resourcessuch as ethnic minorities, low income individuals, and womenin vulnerable circumstances.Research purpose A systematic review and meta-analysis ofthe effect of non-pharmacological cancer pain interventions incancer populations with social disparities of income, ethnicity,or gender.Methods Randomized controlled trials, controlled trials, andbefore and after studies were targeted through comprehensivemultidatabase searches. Two reviewers independently

screened titles/abstracts for potentially relevant studies andreviewed the full text of relevant articles for inclusion. Datawere extracted from included studies by one reviewer andverified by another reviewer. Four reviewers independentlycompleted quality assessment. Studies were grouped by inter-vention. Effects were evaluated for heterogeneity and pooled.Results The search found 5219 potential records. Full text of26 reports was evaluated. Three randomized controlled trials(RCTs) met inclusion criteria, targeting ethnic minorities andunderserved populations and/or women. Interventions includ-ed education, coaching, and online support groups. Studiesfound no significant differences in pain reduction betweenintervention and control groups or between ethnic minoritiesand their counterparts. A high risk of bias was found in allstudies. Meta-analysis found no statistically significant differ-

Electronic supplementary material The online version of this article(doi:10.1007/s00520-015-2998-9) contains supplementary material,which is available to authorized users.

* Anna Santos Salasavs@ualberta.ca

1 Faculty of Nursing University of Alberta, Edmonton Clinic HealthAcademy, 11405 87 Avenue, Edmonton, AB T6G 1C9, Canada

2 Department of Physiotherapy, Faculty of Health Sciences,Universidad Católica del Maule, Avda. San Miguel 3605,Talca, Chile

3 Research Centre Faculty of Rehabilitation Medicine, 3-62 CorbettHall, University of Alberta, 8205 114 Street, Edmonton, AB T6G2G4, Canada

4 School of Dentistry, University of Alberta, 5-476 Edmonton ClinicHealth Academy, 11405 87 Avenue, Edmonton, AB T6G 1C9,Canada

5 Department of Symptom Control and Palliative Care, Cross CancerInstitute and Division of Palliative Care Medicine, Department ofOncology, Faculty of Medicine and Dentistry, University of Alberta,Room 2001, 11560 University Avenue, Edmonton, AB T6G 1Z2,Canada

6 John W. Scott Health Sciences Library, University of AlbertaLibraries, Edmonton, AB T6G 2R7, Canada

7 UBC Okanagan Library, The University of British Columbia,Okanagan Campus, 3333 University Way, Kelowna, BC V1V 1V7,Canada

Support Care CancerDOI 10.1007/s00520-015-2998-9

ence on pain intensity among underserved groups, ethnic mi-norities, or between ethnic minorities and white counterparts.Conclusion Results show the need to examine supportive careinterventions particularly in populations with socialdisparities.

Keywords Painmanagement . Supportive care . Healthcaredisparities .Minority groups . Social determinants of health .

Review

Severe inequities in the social determinants of health, that is,social disparities, result in poor health outcomes and generatehealth disparities for the most vulnerable [1]. While knowl-edge of the social determinants of health is extensive, howthese interact to aggravate disparities is less clear [2–4].Social disparities result from the uneven distribution of re-sources in society and increase the vulnerability of specificgroups such as low-income populations, ethnic minorities,and underserved women [5].

Health disparities comprise persistent and non-randomhealth differences among specific populations that are avoid-able [5–7]. An examination of how social disparities fosterhealth disparities is pertinent in view of global social dispar-ities [8–11]. This is particularly relevant in the context ofcancer care, given the high prevalence of cancer in Canada[12] and worldwide [13], and in light of poor cancer outcomesamong the most vulnerable [7, 14].

We report findings from a systematic review and meta-analysis of the effect of non-pharmacological cancer pain in-terventions on cancer pain intensity in populations with socialdisparities. Cancer populations with social disparities refer tovulnerable groups likely to bear a higher cancer burden thantheir counterparts. In this study, income, gender, and ethnicitywere selected to identify the populations because they havebeen recognized as markers of social inequality [15, 16] aswell as precursors of health disparities [7]. The selective focuson non-pharmacological interventions was made as a first stepto investigate the effectiveness of supportive care interven-tions in the management of cancer pain in these populations.

Cancer disparities

In 2012, cancer accounted for 8.2 million deaths across theglobe, with an estimated 14 million new cases for the sameyear [13]. Global cancer differences in incidence, prevalence,and mortality have been reported [13, 14, 17]. Cancer healthdisparities are reflected in later diagnosis and poorer outcomesin affected populations [18]. In industrialized countries, cancerhealth disparities exist among individuals from low socio-economic status, rural and remote areas, and ethnic minorities[18–20]. In USA, the cancer death rate of African Americans

has been found to be higher than their white counterparts [21].The 5-year cancer survival rate for First Nations people1 in aCanadian province was 53% compared to a 62% survival rateamong non-First Nations individuals [22]. Severe differencesin cancer survival rates between affluent and low-incomeneighbourhoods also exist [21]. Cancer health disparities area pressing issue given that cancer deaths are increasing world-wide [19, 23] and demand urgent action [24–30].

Disparities in cancer pain

About one third of individuals will experience pain in thecourse of their curative treatments and at least two thirds ofpeople with late-stage cancers will report some form of pain[31]. Cancer pain prevalence rates range from 33 to 64%,withthe highest prevalence for individuals with late-stage cancers[32].

Despite advances in cancer pain relief in Canada [33] andthe world [34], nearly 5.5 billion people cannot access propertreatment for moderate to severe pain [35]. Only 17 % of theworld population—primarily in Western Europe, NorthAmerica, and Oceania—accounted for 92 % of global mor-phine consumption in 2014 [35]. While these data need to beinterpreted with caution given variation in reporting mecha-nisms, economic disparities and inadequate infrastructure canbe significant barriers to access narcotic drugs [36].

Studies in Western countries show that poverty [37–41],ethnicity [42–48], gender [46, 49–52], and geographic loca-tion [53–55] are associated with disparities in cancer pain. Anumber of systematic reviews and meta-analyses of cancerpain interventions have been conducted [56–63]. These re-views have examined educational, psychosocial, arts-based,and knowledge translation interventions. While these studieshave included populations with social disparities, they do notrepresent the main target groups. To our knowledge, no sys-tematic review and meta-analysis has been conducted to ex-amine the effect of cancer pain interventions in populationswith social disparities.

Research objectives

The following research objectives were pursued:

1. To systematically review studies of non-pharmacologicalcancer pain interventions in adult cancer populations af-fected by income, ethnic, or gender disparities, in order toexamine the effectiveness of these interventions in

1 First Nations are one of the three Indigenous cultural groups in Canadaas recognized by the Canadian Constitution Act.

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reducing cancer pain intensity when compared to a con-trol group in the same population or their counterparts(e.g., population without social disparity)

2. To assess the quality of studies found in this systematicreview

3. To determine the magnitude of the effect on cancer painintensity of cancer pain interventions in adult cancer pop-ulations affected by income, ethnic, and gender disparitieswhen compared to a control group in the same populationor their counterparts (e.g., population without socialdisparity)

Methods

Inclusion criteria

The following inclusion criteria based on the PICO frame-work [64] stated by the Cochrane Collaboration were usedfor this systematic review:

1. Population: Individuals 18 years or older diagnosed withcancer reporting cancer-related pain (3 or higher on an 11-point scale 0–10). Studies had to report a non-pharmacological cancer pain intervention directed at indi-viduals identified on the basis of social disparities of in-come (e.g., low income), ethnicity (e.g., ethnic minori-ties), or gender (e.g., study followed a gender approachfor the intervention and analysis and specifically targetedwomen). Studies had to include any of these groups intheir samples and provide a differentiated analysis of theintervention effect based on income, ethnicity, or gender.Studies could include these populations alone (e.g., exclu-sive focus on ethnic minorities) or target groups with andwithout social disparity as long as an analysis of the in-tervention effect by income, ethnicity, or gender wasprovided.

2. Intervention: Non-pharmacological cancer pain interven-tions such as educational, psychosocial, or any types ofinterventions (e.g., policy interventions, housing support,or financial programs)

3. Comparison: Individuals with cancer-related pain fromthe same populations (e.g., ethnic minorities, low income,women) or their counterparts (e.g., non-ethnic minorities,high income, men) who, instead of the intervention, re-ceived usual care and/or waiting list. Usual care usuallyconsists of pharmacological pain management based onthe WHO analgesic ladder [31].

4. Outcome: The main outcome for this systematic reviewwas pain intensity (e.g., average pain last 24 h, last week,worst pain, least pain) as measured by any of the scaleslisted below. Given the wide range of pain measures,

studies that included other pain scales not listed in theprotocol were also considered. For all scales, a highernumber indicates worse pain.

& Visual Analogue Scale (VAS): Converts pain ratinginto a numerical score from 0 to 100

& Pain Intensity Numerical Rating Scale (PI-NRS):Measures pain rating on an 11-point numerical scalefrom 0 to 10

& Edmonton Symptom Assessment System/Scale(ESAS) [65] or ESAS-r [66] that includes a measureof pain intensity on a scale from 0 to 10.

& Brief Pain Inventory (BPI) that includes a measure ofpain intensity on a scale from 0 to 10 [67].

& Short-Form McGill Pain Questionnaire (SF-MPQ)that includes a measure of pain intensity through avisual analogue scale [68].

5. Types of studies: This systematic review targeted interven-tion studies including randomized controlled trials (RCTs),controlled trials (CT), and before and after (BA) studies.

Search methods for identification of studies

The reporting of this systematic review is based on thePreferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [69].

Search strategy A comprehensive search was developed bytwo information scientists (Chambers and Walter). The goal ofthe search was to identify all existing published studies examin-ing non-pharmacological cancer pain interventions in patientsfrom ethnic groups, or studies that explored cancer pain inter-ventions in populations identified in terms of income levels orgender. The following bibliographic databases were searched:Ovid MEDLINE In-Process & Other Non-Indexed Citations,Ovid MEDLINE Daily, and Ovid MEDLINE(R) 1946-; OvidEmbase 1988-; Cochrane Central Register of Controlled Trials;Health Technology Assessment; Database of Abstracts ofReviews of Effects; Cochrane Database of SystematicReviews; EBSCOhost CINAHL 1937-; and ProquestDissertations and Theses. The database searches were basedon the MEDLINE search (Appendix 1 as ESM). Changes weremade to ensure the search was comprehensive and reflected allthe selection criteria established at the outset of the study. Thissearch strategy was adapted for each database so that relevantcontrolled vocabulary, searching techniques, and keywordswereused. Cited reference searches were conducted for included

Support Care Cancer

studies in Scopus 1960-. In addition, the reference lists of studiesretrieved for potential eligibility found through the databasesearches were reviewed to find other potentially relevant studiesand grey literature that the database search may have missed.With the exception of dissertations and theses, no grey literatureand abstracts were included due to both funding limitations andthe respective lack of peer review and lack of detail.

Time period No date limitations were applied in order toretrieve as many intervention studies as possible. The searchwas done through May 2014.

Data extraction and data analysis

Study identification

Two reviewers (Fuentes and Saltaji) independently screened thetitles and abstracts of studies identified by the search strategyfor potentially relevant studies. If any of the reviewers identifiedan abstract of a published research article that would potentiallymeet the inclusion criteria, or if there was inadequate informa-tion to make a decision, a copy of the article was retrieved forscreening. The full text of every study retrieved for inclusionwas reviewed twice independently by the same pair ofreviewers. Discrepancies and disagreements were resolved byconsensus together with the lead investigator (Santos Salas).

Data extraction

For each part of the review, data extraction was carried outindependently by one reviewer (Fuentes) and verified byanother reviewer (Saltaji), using a standardized data extractionform. Data were extracted on study design (i.e., RCTs, CTs,before and after design), study objectives, characteristics ofstudy population, outcome measures, instrument reliabilityand validity, characteristics of the intervention(s), sample size,statistical power, key findings, statistical tests used, associatedstatistical and/or clinical significance, and strengths andweaknesses (see Tables 1 and 2). Any disagreements on dataextraction were resolved by consensus.

Quality assessment

Assessments of quality (risk of bias) of included studies werecompleted independently by four reviewers (Fuentes, Saltaji,Armijo-Olivo, and Santos Salas) using criteria stated below.

For the assessment of RCTs, we employed a compiled setof items based on the most commonly used tools in healthresearch [70]. Thus, we used seven scales (i.e., Delphi List,PEDro, Maastricht, Maastricht-Amsterdam List, Bizzini, vanTulder, and Jadad) compiled in a set of 43 items [70]. Theseitems were grouped into five categories (patient selection,blinding, intervention, outcomes, and statistics). Based on a

recent systematic review, no one scale effectively determinesthe overall methodological quality of individual studies [70,71]. Therefore, we used all of them in a compiled fashion.Studies were evaluated based only on information providedby the article. In addition, the risk of bias (ROB) tool was usedto evaluate the quality of RCTs [72]. Ratings from both thecompiled set of items and the ROB tool were compared toexamine the consistency of quality assessments. Any discrep-ancies in ratings were resolved by consensus.

The use of summary scores from quality scales has beencriticized. Items that are important in some situations may notbe relevant in others, yet they receive the same weight in thequality scale [73, 74]. Blinding of study participants is crucialfor pain yet irrelevant for all-cause mortality [75]. TheCochrane Bias Methods Group and Statistical MethodsGroup recommend that summary scores not be used.Relevant biases should be assessed one by one [76, 77].Therefore, each study was analyzed by each domain/item.

Risk of bias assessments procedure

The risk of bias of trials was assessed on six domains(7 items) of the ROB tool, namely sequence generation,allocation concealment, blinding of participants and per-sonnel, blinding of outcome assessors, incomplete out-come data, selective outcome reporting, and othersources of bias [77]. We followed the guidelines bythe Cochrane Collaboration to perform ROB assess-ments. Decision rules are available upon request.Evaluations of blinding and incomplete outcome datawere based upon the primary outcome of interest report-ed. Due to the low likelihood of locating protocols fortrials, we did not search for study protocols to assessselective outcome reporting. For a “low” ROB, publica-tions had to report all primary and secondary outcomesin the “Methods” and “Results” sections, without addingnew outcomes in the “Results” section. If the primaryoutcome was not in the “Results,” there was a high riskof selective outcome reporting bias. We also paired out-comes reported in “Methods” and “Results” sections. Ifmore than 70 % of the secondary outcomes were notreported in the “Results” or “Methods” sections, thestudy was rated as high ROB. For “other bias,” weexamined baseline comparability, control for co-interventions (contamination bias), and whether treat-ment compliance was acceptable. These criteria havebeen used by the Cochrane Back Review Group [78].

A trial was considered at low risk of bias if it was rated aslow risk in all individual domains; if the rating was unclear inat least one domain, and the other domains were unclear orlow, the overall assessment was unclear. A high risk of biaswas considered if at least one domain was rated high [79, 80].

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Tab

le1

Non-pharm

acologicalcancer

pain

interventio

nsin

populatio

nsaffected

bysocialdisparities:a

system

aticreview

andmeta-analysis.C

haracteristicsof

thestudies

i.Ty

peof

cancer

ii.So

cialdisparity

analyzed

Setting,sam

ple,andstudyarms

i.Pain

intensity

ii.Pain

treatm

ent

(WHOladder)

Outcomes

i.Interventio

nii.

Type

ofinterventio

nResults

Strengths/weaknesses

Anderson.etal.2004

Randomized

multisite

trial

i.Breast,gastrointestinal

Lung

Gynecologic

Other

ii.Ethnicity

andincome

Oncologyclinicsin

largepublic

hospitalsin

Houston,T

X;

Miami,FL

;and

SanJuan,

Puerto

Rico

Ninety-nine

participantswere

random

ized:4

2African

American

and55

Hispanic.

Participantsalso

camefrom

underservedareas.

Studyarms:

Patient

educationgroupand

controlg

roup

i.Pain

intensity

atbaselineusingthebrief

pain

inventory(BPI)

was

7.4and7.5forthe

controlg

roup

and

interventio

ngroup,

respectively

ii.Not

reported

Main:

-Pain(BPI)

-Pain-relatedinterference

(BPI)

Secondary:

-Functionalstatus

-Qualityof

life

(SFHealth

Survey)

-Perceived

controlofpain

(surveyof

pain

attitudes)

-Adherence

toanalgesics

Outcomes

wereassessed

atbaseline,week2–4,

week6–7,andweek8–

10

i.Paineducation:

Four

videos

andbookletstargeted

for

underservedAfrican

American

andHispanics.

Videos

Control:receivedanutrition

educationpackage

ii.Psychosocial

Baselinecomparability

betweengroups.

Pain

ratin

gsandpain

interference

decreased

over

timeforboth

groups

(nosignificant

difference);however,

pain

reductionwas

not

maintainedat8–

10weeks.Q

ualityof

life,perceivedpain

control,andfunctio

nal

status

werenotaffected

bythebriefeducation

interventio

n.

-Randomized

multisite

trial

-Inclusion

offollo

w-up

-Sam

plesize

calculationa

priori

-Validity

andreliability

foroutcom

esreported

-Bothintentionto

treat

andperprotocol

analyses

included

-Baselinecomparability

->20

%droppedout

-Reasons

fordropoutsnot

reported

-Blin

ding

component

not

reported

-Clin

icalsignificance

ofresults

notreported

Changrani

etal.2008

Randomized

trial

i.Breastcancer

ii.Ethnicity

Participant’s

home

Sixty-eightH

ispanicim

migrant

wom

en:4

8random

lyassigned

totheinterventio

nand20

assigned

tothecontrol

group

Studyarms:

Onlinesupportg

roup

andusual

care

controlg

roup

i.Not

reported

ii.The

authorsreportthat

participantsreceived

activetreatm

ent;

however,no

inform

ationis

provided.

Authorsdidnot

differentiatebetween

mainandsecondary

outcom

es.

-Depression(Centerfor

theEpidemiological

StudiesDepression

Scale(CES-D))

-Personalg

rowth

(post-

traumaticgrow

thinventory(PTGI))

Qualityof

life(Functional

Analysisof

Cancer

Therapy

FACT-B)P

ain

(painintensity

Likert

scale0–10,pain

interference,reactions

topain

Outcomes

wereassessed

before

andafterthe

intervention

i.Onlinesupportgroups(O

SG):

Participantsweregroupedinto

OSG

with

eightp

articipants

ineach.E

achgroupmetfor

90min

once

aweekfor

30weeks.

Control:

Participantsreceived

usualcare.

ii.Psychosocial

Noneof

theoutcom

emeasuresshow

edstatistically

significant

change

(p>0.05)pre-

postcomparedto

the

controlg

roup

-Randomized

trial

-Low

dropoutrate

-Nofollow-upincluded

-Blin

ding

component

not

reported

-Clin

icalsignificance

ofresults

notreported

-Sam

plesize

calculation

notreported

-Validity

andreliability

foroutcom

esnot

reported

-Resultsforsome

outcom

esunderreported

Support Care Cancer

Tab

le1

(contin

ued)

i.Ty

peof

cancer

ii.So

cialdisparity

analyzed

Setting,sam

ple,andstudyarms

i.Pain

intensity

ii.Pain

treatm

ent

(WHOladder)

Outcomes

i.Interventio

nii.

Type

ofinterventio

nResults

Strengths/weaknesses

Kalauokalanietal.2007

Randomized

trial

i.Leukemia,lym

phom

a,solid

tumor

ii.Ethnicity

Twooncology

clinics:

UCDCancerCenter,a

university-based

tertiary

care

center,and

atKaiser

Perm

anente,S

acramento,

CA,U

SA.

Sixty-sevenpatients:34

(8minority

)wererandom

lyallocatedintotheintervention

and33

(7minority

)were

allocatedinto

thecontrol

group.

Minority

patientscomprised

Latinos,A

sians,Blacks,and

others

Studyarms:

Individualized

educationand

coaching

(intervention)

and

standard

educationalsession

(control)

i.Baselinescores

forpain

intensity

(0–10scale)

forexperimentaland

controlg

roupswere

5.3and5.2points,

respectively

ii.Not

reported

Authorsdidnot

differentiatebetween

mainandsecondary

outcom

es.

-Average

pain

(0–10

scale)

-Misconceptionabout

pain

(Likertscale)

-Health

status

(medical

outcom

esstudyshort-

form

12-Item

Health

Survey

Questionnaire

physicalandmental

health

component

scores)

Outcomes

wereassessed

before

andtwoweeks

aftertheintervention

throughatelephone

interview

i.Educatio

nandcoaching:

Participantsreceived

a20-m

inindividualized

educationand

coaching

Control

group:

Participantsreceived

standardized

inform

ation

abouth

owto

controlp

ain.

ii.Psychosocial

Bothgroups

werenot

completely

comparableatbaselin

e.After

theinterventio

n,minority

patientsinthe

controlg

roup

(7)had

worse

pain

than

their

whitecounterparts

(6.42vs.4.65,95

%CI=

0.42

to3.13,

p=0.012).Inthe

experimentalg

roup,

minority

patientshad

less

averagepain

than

theirwhite

counterparts,alth

ough

thesedifferenceswere

notsignificant

(4.0vs.

4.31,95%

CI=

−1.39

to2.0,p=0.71).There

was

asignificant

interactionbetween

minority

status

and

studygroupindicating

agreatereffectof

the

interventio

nin

minorities

(interactio

neffect=−1

.73,95

%CI=

−0.06to

3.41,

p=0.043).M

inorities

intheexperimental

group,comparedwith

minorities

inthe

controlg

roup

andall

whitesexperiencedan

additionalreductio

nin

averagepain

equalto

1.73

pointson

a10-

pointscale

-Randomized

trial

-Valid

outcom

esincluded

-Veryshortfollow-up

-Smallsam

plesize

forthe

secondaryanalysisof

racialdisparities

-Baselinecomparability

notfully

accomplished

-Blin

ding

component

not

reported

-Clin

icalsignificance

ofresults

notreported

Support Care Cancer

Tab

le2

Non-pharm

acologicalcancer

pain

inpopulatio

nsaffected

bysocialdisparities:a

system

aticreview

andmeta-analysis.C

haracteristicsof

interventio

ns

Andersonetal.(2004).Paineducationfor

underservedminority

cancer

patients

Kalauokalanietal.(2007).C

anpatient

coaching

reduce

racial/ethnicdisparities

incancer

pain

control?

Changrani

etal.(2008).Onlinecancer

support

groups:experiences

with

underservedim

migrant

Latinas

Specificintervention

•Single-sessioneducationalintervention

thatincluded:videos,booklet,andone-

on-one

coaching

session

•Follow-upcall48–72haftervisittothe

clinicto

review

patient’spain

control

•Individualized

educationandcoaching

sessionto

assistpatient

inaddressing

pain-related

issues

•Instructio

nsupplementedwith

an11-pagebooklet

•AVirtualCom

munity

forIm

migrantswith

Cancer(VCIC)toprovidesupporttoSp

anish-

speaking

wom

enwith

breastcancerviaonlin

esupportg

roups(O

SG).Auser-friendlysite

with

culturally

appropriatevisualsandcontent

Developmento

finterventio

n•Educationalm

aterialsdevelopedbased

onstudiesof

needsof

underserved

African

American

andHispanic

patientswith

cancer

pain

•Video

scriptsreview

edby

expertsin

minority

educationandfocusgroups

oflik

epopulatio

n

•Not

reported.Interventionwas

initially

designed

forthegeneralcancerpopulation.

•Atthe

outsetof

theprogram,three

focusgroups

wereconductedwith

Spanish-speaking

breast

cancersurvivorstoobtaindirectionforcontent

anddesign

structureforwebsite,and

inform

topics

forchatsessions.

Content

ofintervention

•Materials(EnglishandSp

anish):4

videos

andbookletsspecificforunderserved

African

American

men,A

frican

American

wom

en,H

ispanicmen,

Hispanicwom

en.

•Videosaddressedmisconceptions

about

pain

treatm

entand

importance

ofreportingpain

andinsistingon

pain

relief.

•Videosincluded

exam

ples

ofcancer

patientsdescribing

howthey

obtained

good

pain

relief.

•Copiesof

videoandbookletw

eregiven

topatients.

•Content

ofvideoandbooklettargeted

specificsexandethnicgroup.

•Five

components:review

ofpatient’sbaseline

questio

nnaire(com

pleted

viatelephone1–2days

before

appointm

ent);educationabout

misconceptio

nsidentifiedin

questio

nnaire;

explanationof

WHOpain

controlg

uidelin

es;

identificationof

treatm

entg

oals;d

evelopmento

fstrategies

tomeetg

oals

•Bookletcoveredcommon

pain

managem

ent

misconceptio

ns;informationaboutcancerpain

treatm

ents;com

municationwith

physician;space

towritedownpain

controlg

oalsandquestio

ns;

andaseto

fpain

controlalgorithms.

•Languageof

interventio

nandmeasureswas

Spanish.

•Refurbished

computers,dial-up

internetaccess,

andtraining

provided

asneeded.

• Issuesof

interestto

thegroupwerediscussed

(e. g.,managingsymptom

sandmedication

side

effects,family

concerns,alienation)

•Themes

ofchatsessions

included:faith,fam

ily,

andlack

offamily

inUSA

,relationships,

financial,andinsuranceissues

(e.g.,coverage,

access

towigs),breastreconstruction,sharing

personalexperiencesandconcerns.

•Wom

enexpressedfearsandprovided

emotional

support.Painwasoftendiscussed;participants

sought

andofferedsuggestio

nsto

decrease

symptom

s.

Duration

•Eachvideowas

20min

long

•Meetin

gafterthevideolasted

30min.

•Sessions

lasted

20min

•Eachgroupmetfor90

min

once

aweekfor

30weeks.E

achgroupconsistedof

8mem

bers.

Provider

•Researchnurse

•Masterslevelp

sychologystudentand

4thyear

medicalstudent

•Trained

bilin

gualfacilitators

Intensity

•Shortterm

.30min

singleeducational

sessionfollowed

byphonecall.

•Shortterm

.One

health

educator

metin

aprivate

room

with

patient.

•Longterm

.Weeklymeetin

gsforaperiod

of30

weeks

Recipient

•Underserved

ethnicminorities

(African

AmericansandHispanics)

•Ethnicminorities

•Sp

anish-dominant-speaking

underserved

Latinowom

enwith

breastcancer

Interventio

nsreceived

bycontrolg

roup

•Nutritio

neducationpackage(Englishor

Spanish)

•Videotape

andwrittenmaterialson

nutrition

forthecancer

patient

•Researchnursemetwith

each

patientand

family

mem

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Data analysis

Data analysis was performed based on type of interventionand stratifying interventions by specific population (e.g., eth-nic minority).

Studies investigating similar interventions (e.g., education-al) and those providing clear quantitative data were grouped,evaluated for heterogeneity, and pooled. A meta-analysis wasperformed to quantify the pooled effect on pain intensity ofany type of intervention directed at ethnic minorities. Becausethe pooled effect was based on the results of diverse tools tomeasure pain (e.g., VAS, NRS, pain index), standardizedmean difference (SMD) was used to quantify the pooled ef-fect. Stata Software v.12 was used to summarize the effects(e.g., pooled SMD) and construct the forest plots for all com-parisons. The 95 % confidence interval was used. A test forheterogeneity was performed using a Chi-squared test(p<0.10) [81]. In the presence of clinical heterogeneity inthe study population or intervention, the DerSimonian andLaird random effects model of pooling was used based onthe assumption of the presence of inter-study variability toprovide more conservative estimate of the true effect [81, 82].

Results

Study selection

Following elimination of duplicates, 4240 potential recordswere obtained from our searches. We excluded 4214 recordsbased on the title/abstract screening. Full-text reports wereretrieved for the selected 26 titles/abstracts for a detailed eval-uation, of which three reports met the inclusion–exclusioncriteria. See Fig. 1 for the flow diagram and Appendix 2 asESM for search results by database.

Study characteristics

All studies were conducted in USA. Two [37, 83] were mul-ticenter randomized clinical trials while one [84] was a single-center randomized trial. All studies had a parallel group studydesign. Two studies were conducted at hospital clinics [37, 83]and one [84] in participants’ homes. Ethnic minorities werethe populations targeted in the three trials. One trial targetedunderserved African Americans and Hispanics [37] while an-other targeted underserved Latino women [84]. The trials in-cluded between 67 and 99 patients. In total, 234 individualswere enrolled with a mean age that ranged from 46.2 to58 years old. One trial included only women [84] whilethe other two trials [37, 83] included more women thanmen. A priori sample size calculation was performed inone trial only [37].T

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One trial [84] selected patients with breast cancer while inthe two other trials the sample included various types of can-cer (e.g., breast, gastrointestinal, lung, and gynecologic can-cers) [37, 83]. Table 1 provides details of included studies.

Risk of bias of included studies

The results of the ROB are displayed in Tables 3 and 4.Regarding patient selection, none of the studies met thecriteria for description and appropriateness of randomizationand concealment of allocation. Blinding was not achieved byany of the studies either. Intervention details would allow forthese to be replicated. Studies failed to fully describe whetheror not patients received co-interventions. Thus, it was unclearif the effects on pain were due to the intervention or resultedfrom co-interventions.

Testing subjects’ compliance to the intervention and havingadequate compliance was not accomplished by any of thesestudies.

All studies included information about the withdrawal/dropout rate. Only two [83, 84] had an adequate dropout rate(less than 20 %). Two trials reported validity and reliability ofoutcome measures [37, 83]. Only one study [37] reported

intra- and/or inter-rater reliability of assessors who performedoutcome measurements.

Sample size adequacywas not clearly reported in any of thestudies. The use of intention to treat analysis was not accom-plished in any of the studies.

All analyzed studies were found to have a high risk of bias.This was aligned with the findings from the compiled set ofitems.

Characteristics of the interventions

All interventions were psychosocial including pain educationversus control (nutrition education) [37], culturally sensitiveonline cancer support in Spanish versus control (usual care)[84], and education and coaching versus control (general paininformation) [83]. Only two studies [37, 84] reported steps todevelop culturally sensitive materials for their interventions.One study indicated that their materials incorporated sex-based considerations [37]. Two studies entailed a short-termsingle session intervention [37, 83], with one study employinga follow-up phone call [37]. One study involved weekly on-line support group meetings for 30 weeks [84]. Two interven-tions covered pain misconceptions, pain treatment, pain relief,and communication with health care providers [37, 83]. The

Fig. 1 PRISMA flow diagram for identification of studies

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online support group intervention encompassed topics such assymptom management, medication side effects, family

concerns, relationships, financial issues, personal experiences,and faith [84]. Providers included a research nurse [37], a

Table 3 Quality assessment of studies selected using the compiled set of items tool

Item Anderson et al. 2004 Changrani et al. 2008 Kalauokalani et al. 2007 Percentage of studies

Inclusion criteria consensus Yes Unclear Yes 67

Exclusion criteria consensus Yes Unclear Yes 67

Described as randomized consensus Yes Yes Yes 100

Method of randomization consensus Unclear No Unclear 0

Randomization concealed consensus Unclear No Unclear 0

Baseline comparability consensus Yes Yes No 67

Double-blind consensus No No No 0

Methods blinding consensus No Unclear No 0

Blinding investigator consensus Unclear Unclear Unclear 0

Blinding participants consensus No Unclear No 0

Blinding assessors consensus No Unclear No 0

Blinding therapist consensus No Unclear No 0

Blinding statistician consensus Unclear Unclear Unclear 0

Treatment group described consensus Yes Yes Yes 100

Treatment described control comparison consensus Yes No Yes 67

Treatment control comparison 2 consensus N/A N/A N/A N/A

Control group consensus Yes Yes Yes 100

Placebo consensus No No No 0

Co-interventions consensus Unclear Unclear Unclear 0

Co-interventions each group consensus No No No 0

Compliance monitored consensus Unclear Unclear Yes 33

Compliance acceptable consensus Unclear Unclear Unclear 0

Report withdrawal consensus Yes Yes Yes 100

Withdrawal acceptable consensus No Yes Yes 67

Reason for dropouts consensus Yes Yes Yes 100

Adverse effects consensus No No No 0

Short-term consensus Yes Yes Yes 100

Long-term consensus N/A N/A N/A N/A

Timing consensus Yes Unclear Yes 67

Outcomes described consensus Yes Yes Yes 100

Relevant outcomes consensus Yes Yes Yes 100

Validity consensus Yes No Yes 67

Reliability consensus Yes No No 33

Responsiveness consensus No No No 0

Scorable measures consensus Yes Yes Yes 100

Point estimates consensus Yes Yes Yes 100

Statistical analysis consensus Yes Yes Yes 100

Between groups comparisons reported consensus Yes Yes Yes 100

Sample size consensus Yes No No 33

Adequate sample consensus No Unclear No 0

Sample described consensus Yes Yes Yes 100

Intention to treat consensus No Unclear No 0

Clinical significance consensus No No No 0

Yes=the item is accomplished, No=the item is not accomplished, Unclear=insufficient information to permit judgment yes or no

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medical student, and a master’s level psychology student whoacted as health educators [83], as well as trained bilingualfacilitators [84]. Two interventions included audiovisual ma-terials in the form of videos [37] and booklets [37, 83]. Noneof the studies reported fidelity, that is, whether the interventionwas delivered exactly as planned [57]. An overview of inter-ventions is provided in Table 2.

Results reported in included studies

Anderson et al. reported a decrease in pain ratings and paininterference over time for both groups, while quality of lifeand functional status were not affected by the brief educationintervention [37]. Changrani et al. did not report statisticallysignificant changes in pain ratings and pain interference be-tween the intervention (online support groups) and controlgroups [84]. Kalauokalani et al. reported that minority patientshad less average pain than their white counterparts, with agreater effect of the intervention (coaching) in minorities [83].

Meta-analysis results

Included studies varied to a degree in terms of the na-ture of their cancer pain interventions and cancer diag-nosis. Yet, given the question of how these interventionsworked based on specific social disparities and consid-ering the relevance of understanding how social dispar-ity may affect the outcome of a particular intervention,we decided to pool the results of the included studiesby each social disparity examined in this review. Thisprovided us with an opportunity to generate an estimate

that provides initial insight into the effectiveness of theinterventions in very specific populations (e.g., under-served groups and ethnic minorities). While some het-erogeneity was observed, the interventions did sharecommonalities including the educational/coaching ap-proach and the psychosocial quality of these. In addi-tion, the three included studies in the meta-analysismeasured cancer pain intensity as an outcome.

Effectiveness of cancer pain interventions on painintensity in ethnic minorities: experimental versuscontrol group

Three studies looked at cancer pain interventions ad-dressed to individuals from various ethnic minorities.These included African Americans and Hispanics [37],Hispanics [84], and Hispanics, Asians, AfricanAmericans, and other ethnic minorities [83]. When studyresults were pooled, no significant differences were ob-tained between treatment and control groups of ethnicminority groups on pain intensity (SMD −0.30) (95 %CI −1.17 to 0.48). However, a small trend favoring theexperimental group was driven by one study [83] thathad an extremely high effect size (Fig. 2).

Effectiveness of cancer pain interventions on painintensity in underserved groups: experimental versuscontrol groups

Two studies focused on underserved ethnicminorities [37, 84]. Asensitivity analysis considering only these studies found a smaller

Table 4 Assessment of qualityusing the risk of bias (ROB) tool Items Anderson

et al. 2004Changraniet al. 2008

Kalauokalaniet al. 2007

Sequence consensus Unclear High Unclear

Allocation consensus Unclear High Unclear

Blinding participants and personnel consensus High Unclear High

Blinding of outcome assessment consensus High Unclear High

Incomplete consensus High Unclear Unclear

Selective consensus Low Low Low

Other bias consensus Unclear Unclear Unclear

Overall consensus High risk High risk High risk

Did trial have early stopping No No No

Comments stopping N/A No No

Inappropriate influence of funders Yes Yes Yes

High risk of bias: There is at least one important risk of bias

Low risk of bias: The study appears to be free of sources of bias

Unclear risk of bias: There may be a risk of bias, but there is either: Insufficient information to assess whether animportant risk of bias exists or insufficient rationale or evidence that an identified problem will introduce bias

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effect size (SMD −0.07) (95 % CI −0.71 to 0.84) that favoredneither the experimental group nor the control group (Fig. 3).

Effectiveness of cancer pain interventions on painintensity in ethnic minorities when compared with whiteparticipants: experimental minority versus experimentalwhite

One study [83] compared the effect of an educational inter-vention on white patients and ethnic minorities, reporting anon-significant difference between these groups. However,looking at the 95 % CIs, the educational intervention may bemore effective for subjects who belonged to a minority popu-lation (SMD −0.59 (95 % CI −1.4 to 0.2) (Fig. 4).

Discussion

Overall, the results of this study suggest that providing edu-cation to ethnic minority patients did not have a significant

effect on pain intensity when compared with another ethnicminority control condition. In the same way, various ethnicgroups receiving education experienced no significant differ-ences compared to their respective control groups.

Some factors related to the educational interventionmay have accounted for the modest effect size observed.The protocols used to deliver the intervention may haveobscured the possible effects of the intervention. Shortsessions [37, 83] and a limited interaction with clini-cians during the delivery of the intervention [37, 83,84] was a common factor. Interventions included 20-min videos and booklets [37], a single 20-min session[83], and online support groups [84].

These education treatment protocols contrast with the mosteffective educational interventions that consist of individual-ized, face-to-face coaching sessions, usually 30 to 60 min inlength [57]. It is possible that in a more prolonged and en-hanced interaction, patients can engage more in the treatmentprocess, which may result in better outcomes. The patient–clinician interaction has been considered a key factor in

Fig. 2 Effectiveness of cancerpain interventions on painintensity in ethnic minorities:experimental vs. control group

Fig. 3 Effectiveness of cancerpain interventions on painintensity in underserved groups:experimental vs. control groups

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improving the response to pain treatments in musculoskeletalpain [85].

Barriers related to attitudes and beliefs [61] and social bar-riers such as economic difficulties to cover the expense of painmedications may have also played a role in the modest resultsobtained in these studies. All the included studies wereconducted in USA, where both public and privatehealthcare systems participate in the provision of care.Thus, ability to access needed care in a timely mannermay have been subject to ability to pay. These barriersmay have acted against the effect of well-developedinterventions. In addition, the treatment education strat-egies for the selected studies mainly focused on theindividual with pain. Recent guidelines suggest adoptinga “family-centered” approach [86] where family mem-bers take direct participation in the decisions regardingpatient care [87].

Methodological biases common to these studies could havehad an impact on the results. Along with potential selectionbias and blinding issues, there was a lack of informationconcerning the potential effect of co-interventions. It is alsolikely that the studies were not powered enough to find sig-nificant differences due to small sample sizes. In addition, oneof the studies [83] was not originally designed to evaluate theeffectiveness of the intervention targeted to minorities.

While two studies endeavored to develop culturally sensi-tive educational interventions [37, 84], evidence that supportsthese interventions often originates in studies where ethnicminorities are usually underrepresented [88]. Thus, the inter-ventions themselves may represent the worldview of main-stream society and reflect to a lesser extent the worldviewsand preferences of minorities. There is a need to examine theviews of these populations with regards to supportive cancerpain interventions that are needed to enhance pain relief.

The lack of studies that followed a gender approach toaddress gender differences in cancer pain was noteworthy. Alimitation of this review was that only “gender” and “sex”were used as search terms. One of the studies included in thisreview focused on immigrant women [84] while anotheremployed a gender approach in the development of

educational materials [37]. This reflects the incorporation ofgender perspectives in the study of supportive cancer paininterventions with vulnerable groups. Yet research is neededto tackle potential cancer pain disparities associated with gen-der. Lastly, reports of the effectiveness of pain and palliativecare clinics are mostly retrospective and were therefore ex-cluded from this review. Future research should examine thesuccess of these programs, particularly in populations withsocial disparities.

Conclusion

Findings from this review point to the need to develop effec-tive supportive care interventions designed to serve cancerpopulations affected by social disparities. Comprehensive,long-term, gender-sensitive, and culturally appropriate inter-ventions are needed to enhance pain and symptom relief invulnerable populations. Some minorities bear a larger cancerburden than their counterparts and are therefore overrepresent-ed in the cancer population. In USA, African Americans havea higher risk of dying of cancer and lower survival rates thanthe white population [89]. Hispanics/Latino populations inUSA tend to be diagnosed at a later stage due to such issuesas accessibility and health insurance [90]. In Canada, dispar-ities in access to cancer care have been identified in immi-grant, low-income, and rural and remote populations [19].Understanding how living conditions impinge on the painexperience of the most vulnerable of society is integral tolending them the opportunity to live well at a time of deepsuffering.

Acknowledgments This study was funded by the University of AlbertaEstablishment Grant RES0019311.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict ofinterest.

Fig. 4 Effectiveness of cancerpain interventions on painintensity in ethnic minoritieswhen compared with whiteparticipants: experimentalminority vs. experimental white

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