The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment
Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer.
To examine the effect of race on physicians’ pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation.
Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles—a 62-year-old man with advanced lung cancer and uncontrolled pain—differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions.
Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians’ mean age was 52 years (SD = 27.17), 59% male, and 64% white.
Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment.
SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81).
Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain.
KEY WORDScommunication lung cancer doctor-patient relations pain management racial disparities
The National Cancer Institute (NCI) supported this project: 1R01CA155376. Results from our study have not been published or presented before this submission. The study was conducted through the investigators’ institutions: Purdue University, the University of Rochester, and the University of Michigan.
All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 1.Institute of Medicine. How Far Have We Come in Reducing Health Disparities? Progress since 2000 (Workshop Summary). Washington, DC: The National Academies Press; 2012.Google Scholar
- 2.U.S. Department of Health. HHS Action Plan to Reduce Racial and Ethnic Health Disparities Implementation Progress Report. Washington, D.C.: HHS; 2015:1–38.Google Scholar
- 6.Meghani SH, Thompson AML, Chittams J, Bruner DW, Riegel B. Adherence to analgesics for cancer pain: a comparative study of African Americans and Whites using an electronic monitoring device. J Pain. https://doi.org/10.1016/j.jpain.2015.05.009.
- 7.Stein KD, Alcaraz KI, Kamson C, Fallon EA, Smith TG. Sociodemographic inequalities in barriers to cancer pain management: a report from the American Cancer Society’s Study of Cancer Survivors-II (SCS-II). Psycho-Oncology. 2016;25(10):1212–1221. https://doi.org/10.1002/pon.4218.CrossRefPubMedGoogle Scholar
- 8.Anderson KO, Mendoza TR, Valero V, et al. Minority cancer patients and their providers. Cancer. 2000;88(8):1929–1938. https://doi.org/10.1002/(SICI)1097-0142(20000415)88:8<1929::AID-CNCR23>3.0.CO;2-2.CrossRefPubMedGoogle Scholar
- 19.Equianalgesic Table for Adults. 2017. http://www.compassionandsupport.org/pdfs/professionals/pain/equi_table_(EX).pdf. Accessed October 19, 2018.
- 21.Davis MP, Dala S, McPherson ML, Sloan PA, Goforth H, Roeland E. Essentials 3: pain assessment and management. Available from the: American Academy of Hospice and Palliative Medicine; 2017. http://aahpm.org/self-study/hpm-pass.
- 23.American Society of Clinical Oncology. Facts & Figures: Diversity in Oncology. ASCO. https://www.asco.org/practice-guidelines/cancer-care-initiatives/diversity-oncology-initiative/facts-figures-diversity. Published January 29, 2016. Accessed October 19, 2018.
- 24.Stout E, Sexton P, Meghani SH. Racial differences in adherence to prescribed analgesia in cancer patients: an integrated review of quantitative research. J Clin Outcomes Manag. 2017;24(1). https://www.mdedge.com/jcomjournal/article/145953/pain/racial-differences-adherence-prescribed-analgesia-cancer-patients. Accessed October 19, 2018.
- 31.Crimmins EM, Hayward MD, Seeman Teresa E. Race/ethnicity, socioeconomic status, and health. In: Anderson NB, Bulatao RA, Cohen B, National Research Council (US) Panel on Race E, eds. Critical perspectives on racial and ethnic differences in health in late life. Washington, D.C.: National Academies Press (US); 2004.Google Scholar
- 35.Payne R, Medina E, Hampton JW. Quality of life concerns in patients with breast cancer. Cancer. 97(1):311–317. https://doi.org/10.1002/cncr.11017.
- 36.Vicini F, Jones P, Rivers A, et al. Differences in disease presentation, management techniques, treatment outcome, and toxicities in African-American women with early stage breast cancer treated with breast-conserving therapy. Cancer. 116(14):3485–3492. https://doi.org/10.1002/cncr.25088.