***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Most patients with advanced or metastatic cancer experience pain and despite several guidelines , undertreatment is well documented . A multicenter , open-label , prospect i ve , non-r and omised study was launched in Italy in 2006 to evaluate the epidemiology , patterns and quality of pain care of cancer patients . To assess the adequacy of analgesic care , we used a st and ardised measure , the  pain management index ( PMI ) , that compares the most potent analgesic prescribed for a patient with the reported level of the worst pain of that patient together with a selected list of clinical indicators . A total of 110 centres recruited 1801 valid cases . 61 % of cases were received a WHO-level III opioid ; 25.3 % were classified as potentially undertreated , with wide variation ( 9.8–55.3 % ) according to the variables describing patients , centres and pattern of care . After adjustment with a multivariable logistic regression model , type of recruiting centre , receiving adjuvant therapy or not and type of patient recruited ( new or already on follow-up ) had a significant association with undertreatment . Non-compliance with the predefined set of clinical indicators was generally high , ranging from 41 to 76 % . Despite intrinsic limitations of the PMI that may be considered as an indicator of the poor quality of cancer pain care , results suggest that the recourse to WHO third-level drugs still seems delayed in a substantial percentage of patients . This delay is probably related to several factors affecting practice in participating centres and suggests that the quality of cancer pain management in Italy deserves specific attention and interventions aim ed at improving patients ’ outcomes CONTEXT Published literature has not defined the effectiveness of st and ardized educational tools that can be self-administered in the general oncology population with pain . OBJECTIVES We sought to determine if an educational intervention consisting of a video and /or booklet for adults with cancer pain could improve knowledge and attitudes about cancer pain management , pain levels , pain interference , anxiety , quality of life , and analgesic use . METHODS Eligible participants had advanced cancer , a pain score > /=2 of 10 in the last week , English proficiency , an estimated prognosis of more than one month , and were receiving outpatient cancer treatment at participating hospitals . Participants completed baseline assessment s and then were r and omly allocated to receive a booklet , a video , both , or neither , in addition to st and ard care . Outcome measures at two and four weeks included the Barriers Question naire ( BQ ) , Brief Pain Inventory , Global Quality of Life Scale , and Hospital Anxiety and Depression Scale . Adequacy of analgesia and severity of pain were assessed with the Pain Management Index and a daily pain diary . RESULTS One hundred fifty-eight participants were recruited from 21 sites over 42 months . Baseline mean barriers scores were lower than reported in previous Australian studies at 1.33 ( st and ard deviation : 0.92 ) . Mean average pain and worst pain scores improved significantly in patients receiving both the video and booklet by 1.17 ( st and ard error [ SE ] : 0.51 , P=0.02 ) and 1.12 ( SE : 0.57 , P=0.05 ) , respectively , on a 0 - 10 scale . The addiction subscale of the BQ score was improved by 0.44 ( SE : 0.19 ) for participants receiving any part of the intervention ( P=0.03 ) . CONCLUSION Provision of a video and /or booklet for people with cancer pain was a feasible and effective adjunct to the management of cancer pain PURPOSE An American Society of Clinical Oncology ( ASCO ) provisional clinical opinion ( PCO ) offers timely clinical direction to ASCO 's membership following publication or presentation of potentially practice -changing data from major studies . This PCO addresses the integration of palliative care services into st and ard oncology practice at the time a person is diagnosed with metastatic or advanced cancer . CLINICAL CONTEXT Palliative care is frequently misconstrued as synonymous with end-of-life care . Palliative care is focused on the relief of suffering , in all of its dimensions , throughout the course of a patient 's illness . Although the use of hospice and other palliative care services at the end of life has increased , many patients are enrolled in hospice less than 3 weeks before their death , which limits the benefit they may gain from these services . By potentially improving quality of life ( QOL ) , cost of care , and even survival in patients with metastatic cancer , palliative care has increasing relevance for the care of patients with cancer . Until recently , data from r and omized controlled trials ( RCTs ) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving st and ard oncology care have not been available . RECENT DATA Seven published RCTs form the basis of this PCO . PROVISIONAL CLINICAL OPINION Based on strong evidence from a phase III RCT , patients with metastatic non-small-cell lung cancer should be offered concurrent palliative care and st and ard oncologic care at initial diagnosis . While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology setting s , substantial evidence demonstrates that palliative care-when combined with st and ard cancer care or as the main focus of care-leads to better patient and caregiver outcomes . These include improvement in symptoms , QOL , and patient satisfaction , with reduced caregiver burden . Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice , and reduced use of futile intensive care . While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving , no trials to date have demonstrated harm to patients and caregivers , or excessive costs , from early involvement of palliative care . Therefore , it is the Panel 's expert consensus that combined st and ard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and /or high symptom burden . Strategies to optimize concurrent palliative care and st and ard oncology care , with evaluation of its impact on important patient and caregiver outcomes ( eg , QOL , survival , health care services utilization , and costs ) and on society , should be an area of intense research . NOTE ASCO 's provisional clinical opinions ( PCOs ) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and setting s for further research . Because of the rapid flow of scientific information in oncology , new evidence may have emerged since the time a PCO was su bmi tted for publication . PCOs are not continually up date d and may not reflect the most recent evidence . PCOs can not account for individual variation among patients and can not be considered inclusive of all proper methods of care or exclusive of other treatments . It is the responsibility of the treating physician or other health care provider , relying on independent experience and knowledge of the patient , to determine the best course of treatment for the patient . Accordingly , adherence to any PCO is voluntary , with the ultimate determination regarding its application to be made by the physician in light of each patient 's individual circumstances . ASCO PCOs describe the use of procedures and therapies in clinical trials and can not be assumed to apply to the use of these interventions in the context of clinical practice . ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO 's PCOs , or for any errors or omissions BACKGROUND No study has so far addressed whether differences do exist in the management of cancer-related pain in patients admitted to oncology and non-oncology setting s. PATIENTS AND METHODS A multicentre cross-sectional study in 48 Italian hospitals has enrolled 819 patients receiving analgesic therapy for cancer-related pain . Demographics and clinical and analgesic therapy information have been prospect ively collected by st and ardized forms . Adequacy of pain management has been evaluated by the Pain Management Index ( PMI ) . RESULTS Differences in the analgesic drug administration according to setting s of care have been evident , non-opioids more frequently being administered in non-oncology units ( 19.6 % versus 7.0 % ; P < 0.0001 ) , while strong opioids are more frequently used in the oncology units ( 69.5 % versus 51.9 % ; P < 0.0001 ) . The number of patients receiving inadequate therapy ( PMI < 0 ) has lowered in oncology compared with non-oncology units ( 11.3 % versus 18.8 % ; P = 0.0024 ) . Results of multiple logistic regression analysis have shown that the admission to non-oncology setting [ odds ratio ( OR ) = 1.75 , 95 % confidence interval ( CI ) = 1.15 - 2.67 ; P = 0.0096 ] and the absence of metastatic disease ( OR = 1.60 , 95 % CI = 1.04 - 2.44 ; P = 0.0317 ) were independent factors associated with an increased risk of receiving an inadequate analgesic therapy .  CONCLUSION Oncology wards provide the most adequate st and ard of analgesic  therapy  for cancer-related pain & NA ; Two hundred and sixty‐three ambulatory patients older than 21 years of age who were attending clinics at an oncology hospital in San Juan , Puerto Rico , were studied . They completed a question naire  ( BQ‐PR ) that measures 8 concerns about reporting pain and using analgesics , such as fears of addiction and tolerance and the belief that reporting pain can distract a physician from focusing on curing one 's disease . Ninety percent of the patients had at least some concern about each of the 8 topics , and mean scores on the 8 subscales were near the midpoint on a 0–5 scale . There were significant inverse relationships between level of education , income , and BQ‐PR total score . Those persons who experienced cancer‐related pain on the day they completed the question naire were categorized as using adequate versus not adequate analgesic medication , a determination that was based on a comparison of their level of pain to the medication they were using . Those who were not using adequate analgesic medication had higher BQ‐PR total scores than did those who were using adequate medication Few studies have evaluated sex differences in the adequacy of pain management in cancer . Existing studies have been marked by method ological limitations and results have been mixed . The present study sought to determine whether sex was associated with pain severity and pain management in cancer patients newly referred by their primary oncology team to a multidisciplinary cancer pain clinic . One hundred thirty-one cancer patients completed the  Brief Pain Inventory-Short Form and medical chart review was conducted to obtain patients ' clinical characteristics and pain treatment data . There were no differences between males and females in ratings of worst pain in the last week . Females were significantly less likely to have been prescribed high potency opioids  by their primary oncology team and significantly more likely to report inadequate pain management as measured by Pain Management Index scores . These results suggest a sex bias in the treatment of cancer pain and support the routine examination of the effect of sex in cancer pain research OBJECTIVE This analysis , carried out in the context of a wider observational prospect i ve study , tried to explore whether four World Health Organization/step-III opioids ( morphine , oxycodone , fentanyl , and buprenorphine ) had different effectiveness when using several different outcomes and endpoints . DESIGN Cross-sectional and longitudinal design . SETTING Oncologic , palliative , and pain centers in Italy . PATIENTS Two hundred fifty-eight cancer patients monitored over a 3-week follow-up program . Intervention . Not applicable . OUTCOME MEASURES The analgesic efficacy was assessed using effectiveness endpoints , such as pain intensity , pain intensity difference ( PID ) , proportion of nonresponders ( NR ) and full-responders ( FR ) subjects , percentage of switches and dose escalation . RESULTS Mean values of PID led to differences among opioids ranging from 10 % to 30 % . FR ( PID ≥ 30 % ) were more frequent in buprenorphine-fentanyl-oxycodone groups than in morphine ; NR ( PID ≤ 0 % ) were variable . The percentage of switches result ed three times more frequent when using morphine than buprenorphine ( 24.4 % vs 8.6 % ) . An increase of dose ≥ 5 % a day was observed in 33.3 % of fentanyl patients vs 15 % of buprenorphine . As a whole , opioids show some different behaviors on the basis of the considered endpoints . CONCLUSIONS The observed results , even if the small sample size and the nature itself of the study do not allow a definitive evaluation of the effectiveness of the drugs , underline a degree of variability among opioids and address toward a correct planning of a comparative r and omized clinical trial that is now underway in Italy . For this reason , a confirmative effectiveness r and omized controlled trial is required PURPOSE S Determine adequacy of management of pain  secondary to bone metastases by physicians referring to specialized outpatient palliative radiotherapy ( RT ) clinics in Canada ; compare geographic differences in adequacy of pain management and pain severity between these cohorts ; compare results with published international literature . METHODS Prospect ively collected data from three participating centers were used to calculate the Pain Management Index ( PMI ) by subtracting the patient-rated pain score at time of initial clinic visit from the analgesic score . Scores were 0 , 1 , 2 , and 3 when patients reported no pain ( 0 ) , mild ( 1 - 4 ) , moderate ( 5 - 6 ) , or severe pain ( 7 - 10 ) , respectively , on the Edmonton Symptom Assessment System or Brief Pain Inventory . Analgesic scores of 0 , 1 , 2 , and 3 were assigned for no pain medication , nonopioids , weak opioids , and strong opioids respectively . A negative PMI suggests inadequate pain management . R 
    Output:
    
Analysis of 46 articles published from 1994 to 2013 using the PMI to assess the adequacy of analgesic therapy suggests the quality of pharmacologic pain management has improved .
However , approximately one third of patients still do not receive pain medication proportional to their pain intensity