TABLE OF CONTENTS
CHAPTER 1 EXECUTIVE SUMMARY 3
Scope of the analysis 3
Datamonitor insight into the cancer pain market 3
Contributing experts 5
Related reports 5
Upcoming related reports 6
CHAPTER 2 INTRODUCTION AND SCOPE 16
Coverage of the Stakeholder Insight Survey 16
Epidemiology and patient segmentation 18
Assessment, treatment rates and professional involvement 18
Treatment options 18
Treatment trends 18
Key prescribing influences and brand assessment 19
Improving treatment outcomes 19
Assumptions and caveats 19
Future trends 20
CHAPTER 3 COUNTRY TREATMENT TREES 21
Introduction to treatment trees 21
US 22
Japan 25
France 28
Germany 31
Italy 34
Spain 37
UK 40
CHAPTER 4 EPIDEMIOLOGY AND PATIENT SEGMENTATION 43
Disease definition 44
Neuropathic and non-neuropathic cancer pain 44
Breakthrough pain 45
Etiology 46
Cancer pain may be caused by both the disease and associated treatments 46
Tumor growth often results in nociceptive pain 47
Chemotherapy, radiotherapy and surgery are key causes of treatment-related cancer pain 47
Breakthrough pain may occur spontaneously or be precipitated 48
For some cancer patients, pain may arise from pre-existing health conditions 49
Symptomatology 49
Acute versus chronic 50
Pain severity 50
Prevalence of cancer pain 51
An estimated 6.7 million individuals suffer from cancer pain across the seven major markets in 2009 51
Published epidemiological estimates of cancer pain prevalence vary widely 53
Neuropathic versus non-neuropathic cancer pain 58
Distinguishing between neuropathic and non-neuropathic pain is often difficult 58
Neuropathic cancer pain affects almost 2.3 million individuals across the seven major markets 59
Non-neuropathic cancer pain affects an estimated 4.4 million patients across the seven major markets 61
Breakthrough cancer pain 64
Almost 3.2 million patients with cancer pain suffer from breakthrough pain across the seven major markets 64
Trends in cancer pain prevalence 70
Pain prevalence typically increases with disease progression 70
Treatment-related chronic pain is common in cancer survivors 71
Projected increase in cancer rates will cause cancer pain population to grow 72
Impact of cancer pain 73
Cancer pain has a deleterious impact on quality of life 73
Breakthrough pain is a common cause of hospital admissions 74
CHAPTER 5 ASSESSMENT, PHARMACOLOGICAL TREATMENT RATES AND PROFESSIONAL INVOLVEMENT 75
Assessment of cancer pain 76
Pain subtype 77
Pain severity 78
Pharmacological treatment rates 80
Cancer pain is sub optimally treated across the seven major markets 80
Chronic neuropathic cancer pain 81
Chronic non-neuropathic cancer pain 85
Over a fifth of breakthrough cancer pain patients do not receive pharmacological treatment 88
Potential reasons for under-use of pharmacological treatments 90
Under-reporting of pain by patients 90
Inadequate pain assessment by physicians 92
Patient and physician concerns surrounding use of opioids 95
Professional involvement 97
Oncologists initiate analgesic treatment in the majority of cancer pain patients 98
Analgesic treatment is predominantly initiated by non-specialists in palliative care or pain medicine 100
Cancer pain treatment is largely managed by oncologists 101
Non-specialists in palliative care or pain medicine typically manage analgesic treatment 105
CHAPTER 6 TREATMENT OPTIONS AND CLINICAL GUIDELINES 106
Treatment options 107
Pharmacological treatment options 107
Non-steroidal anti-inflammatory drugs 107
Opioids 108
Antidepressants 110
Anticonvulsants 110
Other pharmaceutical treatment options 111
Treatment guidelines 112
The World Health Organization’s three-step ‘analgesic ladder’ 113
Only 50% of US physicians adhere to WHO cancer pain guidelines 115
Adherence to WHO guidelines is highest among UK-based physicians 117
American Pain Society 118
European Society for Medical Oncology 118
Scottish Intercollegiate Guidelines Network 118
Japanese Society for Palliative Medicine 119
CHAPTER 7 TREATMENT TRENDS 120
Trends in first-line treatment 121
The proportion of patients receiving the most commonly prescribed first-line drug therapy increases with pain severity 121
Chronic neuropathic and non-neuropathic cancer pain 121
Breakthrough cancer pain 123
Chronic neuropathic cancer pain 124
Mild 127
Moderate 128
Severe 130
Chronic non-neuropathic cancer pain 131
Mild 134
Moderate and severe 135
Breakthrough cancer pain 136
Progression to second-line analgesia 140
Chronic neuropathic cancer pain 141
Progression to second-line treatment among patients with chronic neuropathic cancer pain is highest in France 141
Other than failure to achieve pain relief, onset of action and gastrointestinal side effects are key factors considered by physicians 142
Chronic non-neuropathic cancer pain 144
Comparable proportions of patients with chronic non-neuropathic and neuropathic cancer pain progress to second-line analgesic treatment 145
Aside from failure to achieve pain relief, gastrointestinal side effects are a key factor considered by physicians 145
Breakthrough pain 147
Almost one third of breakthrough cancer pain patients progress to second-line treatment 147
Cost and lack of flexible dosing frequency are of least importance when physicians progress breakthrough cancer pain patients to second-line therapy 148
CHAPTER 8 PRESCRIBING INFLUENCES AND BRAND ASSESSMENT 150
Factors influencing physician decision making 151
Non-drug factors 151
Published guidelines represent the greatest non-drug influence on prescribing decisions 152
Drug factors 153
Neuropathic cancer pain 154
Breakthrough cancer pain 155
Physician perception of key brands 156
Total scores per drug 158
Overall score 160
Lyrica (pregabalin; Pfizer) 161
Physicians rated Lyrica relatively highly in terms of duration of action 163
Actiq (oral transmucosal fentanyl; Cephalon) 165
Actiq is the more widely recognized of Cephalon’s two fentanyl products 166
Contrary to clinical trial data, physicians rated Actiq’s onset of action on a par with Fentora 167
Fentora (fentanyl buccal tablet; Cephalon) 169
Fentora’s ratings for convenience of administration marginally outperform Actiq 170
CHAPTER 9 IMPROVING TREATMENT OUTCOMES AND UNMET NEEDS 172
Effectiveness of available prescription pain medicines 173
Surveyed physicians believe that there is room for improvement in the effectiveness of available mediations for cancer pain 173
Physicians are least satisfied with current treatments for neuropathic cancer pain 174
Unmet needs 175
Non-clinical unmet needs 176
Physician education represents the most pressing unmet need in the management of cancer pain 176
Clinical unmet needs: neuropathic cancer pain 179
Improved efficacy 179
Improved side-effect profile 181
Reduced time to onset of action 181
Fewer drug-drug interactions 182
Reduction in pill burden 182
Clinical unmet needs: non-neuropathic cancer pain 182
Reduction in opioid-related adverse events 183
Reduction in the abuse and overdosing potential of opioids 184
Clinical unmet needs: breakthrough cancer pain 184
Reduction in opioid-related adverse events 185
Need for an analgesic that acts rapidly, predictably and just for the duration of a breakthrough pain episode 186
Quick, simple and safe drug administration 187
Improved convenience, cost and safety of patient-controlled analgesia 188
Need for standardized diagnosis and assessment tools for breakthrough pain 189
BIBLIOGRAPHY 190
Datamonitor reports 190
Posters 190
Books 190
Journal papers 191
Websites 204
APPENDIX A 210
Physician research methodology 210
Physician sample breakdown 210
US 210
Japan 212
France 213
Germany 214
Italy 215
Spain 216
UK 217
Contributing experts 218
APPENDIX B 219
The survey questionnaire 219
Screener questions 219
Section 1 – Prevalence of cancer pain 221
Section 2 – Referral patterns 222
Section 3 – Treatment of chronic neuropathic cancer pain 224
Section 4 – Treatment of chronic non-neuropathic cancer pain 233
Section 5 – Treatment of breakthrough cancer pain 236
Section 6 – Prescribing influences and product profiles 238
Section 7 – Treatment outcomes 241
Demographics 242
About Datamonitor 244
About Datamonitor Healthcare 244
About the Central Nervous System pharmaceutical analysis team 245
Disclaimer 247