Assessment of neuropathic pain management knowledge, attitudes, and practices among urology trainees and consultants in prostate cancer care: a survey-based study

Background Effective neuropathic pain management is crucial in improving the quality of life for patients with prostate cancer. There is an abundance of research about cancer pain and guidelines that have been developed by World Health Organization including the analgesia stepladder, yet patients with cancer pain are still sub optimally analgesed. This is due to a variety of both patient and physician factors which include: lack of knowledge on the use of adjuvant medication, fear of addiction and poor characterization of the type of pain. This study intended to assess the knowledge, attitudes, and practices of urology trainees and consultants in the the context of neuropathic pain in prostate-cancer care. Methods The study involved 91 urologists, comprising of junior registrars, medical officers and experienced specialists who are members of the South African Urological Association (SAUA). Data was collected through a 25-question web-based survey. The survey covered: demographic information, knowledge, attitudes, and practices related to cancer pain management. Results The study revealed that a significant proportion of urologists assessed neuropathic pain reactively, with only 8% of respondents being familiar with screening scales. Approximately, one-third preferred referrals, and 74% expressed confidence in self-treatment. Concerns regarding opioid prescription were observed in 40.4% of respondents. Furthermore, the usage of adjuvant medications was limited, with only 35% proficiently combining analgesia and adjuvants. Notably, 65% continued to escalate analgesic monotherapy. Conclusion Effective neuropathic pain management in prostate cancer care necessitates a multidisciplinary approach, comprehensive assessment and expertise in adjuvant medication usage. The discrepancies observed among urologists are likely due to variations in experience levels. The study


Background
Prostate cancer is the most common non-cutaneous malignancy in men, with presentations that can range from mild disease to advanced metastasis [1,2].Advanced prostate cancer patients frequently grapple with the burden of pain as a complication of the disease, with 60-90% experiencing moderate to severe pain [3][4][5].This, significantly, impacts their quality of life (QOL), hinders their economic productivity, and may lead to depression and hopelessness [6,7].
It is; therefore, natural that the targeted management of pain in prostate cancer becomes a cornerstone in the daily care of patients and their families [8,9].Cancerrelated pain can be broadly classified into nociceptive and neuropathic types of pain [10,11].Nociceptive pain, typically, arises from direct tumor invasion of surrounding tissues, while neuropathic pain, which accounts for approximately 21% of all cancer pain, is postulated to result from the invasion of central nervous system (CNS) or peripheral nervous system (PNS) structures by the tumor mass [10][11][12][13].Clinically, individuals often characterize this discomfort as a burning sensation, shooting pain, a prickling sensation, an electric-like feeling, or numbness.Moreover, it tends to extend along dermatomal patterns.Neuropathic pain alone is often observed in 35-56% of patients with metastatic disease, in contrast to the 6-17% prevalence in non-metastatic cases [10,11].
A subset of prostate cancer pain patients may present with a mixed type of pain syndrome.Recognizing this is crucial, as neuropathic pain is generally more challenging to control due to its limited responsiveness to typical opioid monotherapy [14].This underscores the necessity for a multifaceted approach to pain management in this patient group [15].
The WHO analgesic guidelines provide a systematic stepwise ladder approach for treating cancer-related pain, which includes that of prostate cancer have been found to be very effective in treatment of pain [16].These advocate for the consideration of adjuvant medications at any step of the treatment ladder to achieve complete control of cancer pain [17].
Despite the availability of the WHO analgesic guidelines for cancer pain management, mounting evidence highlights that cancer pain remains inadequately treated in approximately half of all cases [18][19][20][21].Various reasons contribute to this discrepancy, which can be categorized as healthcare provider, regulatory, patient, and family barriers to effective pain control [22,23].
Healthcare-provider related barriers to effective pain management in cancer include lack of knowledge about the assessment and diagnosis of neuropathic pain, as well as fear and anxiety about prescribing opioids, their potential side effects, and the need for monitoring and titration [15,24].Healthcare providers also tend to have limited understanding of available options regarding adjuvant treatments [25][26][27][28][29].
The use of validated questionnaires, such as the DN4 and the pain DETECT questionnaires, can play an essential role in the rapid assessment and diagnosis of patients with neuropathic cancer pain [25,29].
This precise evaluation of neuropathic pain can be achieved through thorough methodical and targeted questioning methods.These represent a gold standard in the diagnosis of neuropathic pain [13,29,30].However, the knowledge of how to use these questionnaires lies solely with the treating team.
The general approach to pain management in cancerrelated pain entails the primary use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and opioids for somatic pain, while adjuvants such as antidepressants and antiseizure drugs are employed to address neuropathic pain [31][32][33].For instance, combining gabapentin and an opioid as a first-line treatment strategy for neuropathic pain may be more effective than opioid monotherapy [10,34].
Although opioids are considered safe for managing cancer pain, reluctance to use them may stem from concerns among patients, families and healthcare workers.These concerns revolve around how to aggressively employ opioid monotherapy in cases of treatment failure [10,24,35,36].
This hesitation may be due to a lack of confidence among healthcare providers regarding dosage, frequency and escalation strategies when using opioids, as well as concerns about the risk of adverse effects such as respiratory depression or addiction [10,24,37,38] Effective control of neuropathic pain in cancer patients leads to statistically significant improvements in the quality of life, reduced depression, enhanced sleep quality, overall well-being and reduced anxiety as well as depression [8,39,40].
Managing cancer pain in developing countries poses unique challenges.These include long distance trips by patients to obtain medication, language barriers hindering effective communication and the challenge of patient illiteracy.Combined, all these factors render pain assessment, management and optimization difficult [10].
It is, therefore, evident that in order to effectively manage cancer patients' pain and avoid the common mistake of undertreatment, healthcare professionals overseeing their care must possess a comprehensive understanding of the modern tools employed in evaluating neuropathic pain in cancer cases and their treatment [38,[40][41][42].
The primary aim of this study was to, comprehensively, assess urologists' understanding of neuropathic pain within the context of prostate cancer, while also scrutinizing their approach to the assessment and treatment of this condition.To attain this overarching goal, the study was structured around the following research objectives: 1. Ascertaining the extent of urologists' comprehension and awareness regarding the neuropathic component in prostate cancer pain, 2. Scrutinizing urologists' familiarity with drug classes recognized for their efficacy in the treatment of neuropathic pain, 3. Evaluating urologists' confidence levels in prescribing opioids for patients with prostate cancer, and 4. Exploring the presence of a multidisciplinary approach in the management of prostate cancer and to identify the various disciplines engaged in this process.

Study design
This study employed a cross-sectional, prospective, descriptive survey design.

Participant selection
This study was conducted among urology professionals consisting of consultants and trainees who are registered members of the South African Urological Association (SAUA).SAUA plays a pivotal role in the networking and knowledge sharing of urologists across Southern Africa, covering South Africa, Namibia, Botswana and Zimbabwe.This association has a robust and engaging membership base, and it serves as a comprehensive hub and educational resource for urologists in the region.There are 374 active members comprising of 303 consultants and 71 trainees.For the purpose of this study, we specifically targeted consultants and trainees who are actively practicing and registered with SAUA.

Survey instrument
A standardized internet−based survey questionnaire was developed to comply with the requirements of this study and it proved reliable and feasible.This questionnaire was administered to obtain data and information from each participant.The questionnaire comprehensively covered topics relating to the management of prostate cancer, with emphasis on the neuropathic pain.

Survey delivery
The distribution of the survey questionnaire was facilitated through a secure website accessible to all members of SAUA.Access to the questionnaire can be obtained through this link: [Survey Questionnaire] (https:// preto ria.eu.qualt rics.com/ jfe/ previ ew/ SV_ dbwlV hsJFq ezOg5?Q_ CHL = preview).

Ethical considerations
Ethical approval for this study from the University of Pretoria ethics committee with ethical clearance [334/2021] was obtained before commencing with the investigation.

Questionnaire structure
The standardized questionnaire comprised of a balanced blend of two questions.The first comprised of the validated, which were adapted from knowledge and attitudes regarding cancer pain management among oncology nurses in China by Dan Li et al. ( 2001), and the second was the non-validated type.The questionnaire was categorized into demographic data and an in-depth information of participants' knowledge, attitudes and practices concerning cancer pain management.Also, the questionnaire used Likert scale items and open-ended questions, encouraging comprehensive responses.In total, the questionnaire had 25 concise questions.

Questionnaire refinement
A pilot study was conducted within the department of Urology at the University of Pretoria.The sample size for the pilot study included randomly selected 13 trainees and 4 consultants.This served as an essential phase in assessing the survey feasibility and refining the questionnaire based on feedback from the participants.In order to eliminate the possibility of duplicate responses and avoid bias, these participants were excluded from the main study.

Data collection 2.2.1 Data collection period
Data collection extended over a period of 11 months.

Response rate enhancement
Strategies employed to enhance response rates included automated reminders dispatched via the Qualtrics system to non-respondents within five days of the initial distribution.
Additionally, the survey link was directly disseminated to Urology Heads of Department (HoDs) for further circulation within their departments, facilitating engagement with urology trainees not registered with SAUA.

Study population 2.3.1 Inclusion criteria
The study's inclusion criteria encompassed urology consultants and trainees, actively involved in the management of prostate cancer.

Exclusion criteria
Excluded from the study were: retired urologists, urologists not engaged in prostate cancer management and urologists who had participated in the pilot study.

Sample size 2.4.1 Participant selection
The sample is composed of a convenience sample of 91 urology trainees and consultants actively practicing and registered with the SAUA.

Database size
The SAUA database comprises approximately of 370 participants, with at least 50% meeting our inclusion criteria.

Initial sample size aim
Initially, our target sample size was 111, with an anticipated response rate of 60%.However, the survey successfully gathered responses from 91 participants.

Results
Out of the 111 participants targeted for the survey, 91 responses from urologists, which indicated an 82% response rate.These respondents encompassed both experienced and inexperienced urologists involved in the treatment of cancer pain.

Knowledge
Among the participants, 92% lacked formal pain management training while a minority (8%) have received such training, indicating a significant knowledge gap in this area (Fig. 1).Self-assessed knowledge varied widely, with ratings ranging from excellent (2.20%) to poor (4.40%), highlighting diverse perceptions of competence in pain management Fig. 2. The majority (92%) did not employ questionnaires in the assessment of neuropathic pain in cancer patients, indicating limited utilization of standardized tools for evaluating pain (Fig. 3).

Attitude
A substantial majority (74%) of the respondents displayed a high level of confidence in their abilities and preferred a self-treatment approach for managing cancer pain.This attitude suggests a certain level of self-reliance.A smaller proportion (26%) opted for referrals, possibly reflecting a more collaborative or cautious attitude, seeking additional expertise or support in managing pain (Fig. 4).Concerns about opioid prescription practices revealed that 24.20% expressed worries about the safety of prescribing opioids, and 19.80% cited concerns about potential side effects, indicating a cautious attitude toward these medications.A smaller fraction (4.40%) expressed concerns about the risk of addiction associated with opioid prescriptions, reflecting a more reserved attitude regarding the potential for addiction (Fig. 5).

Practice
In the management of cancer pain, 65% of the participants preferred an analgesic monotherapy approach which uses analgesic medications, exclusively.The remaining 35% adopted a combined approach, incorporating adjuvants alongside analgesics, reflecting a more comprehensive and multidisciplinary practice in pain management (Fig. 6).Referral practices among participants highlighted diverse approaches.Among those who referred patients, 60% referred to oncologists, 36% referred to pain specialists, and 4% referred to psychologists or psychiatrists, reflecting different referral practices to address various aspects of pain management (Fig. 7).

Discussion
The primary findings of this study indicate that: firstly, only 8% of the study respondents received formal training on pain management, while on the other hand, 92% Additionally, participants' self-assessed knowledge spans from excellent (2.20%) to poor (4.40%), while their self-perceived competency ratings during medical school, internship, and as medical officers demonstrate varied percentages in respective categories.This graphical representation provides valuable insights into participants' training backgrounds and self-assessed competence, offering a glimpse into their capabilities in pain management Fig. 3 This bar graph illustrates the distribution of assessment methods used by participants when evaluating neuropathic pain in cancer patients.It reveals that a significant majority, comprising 92%, do not employ questionnaires in their assessments, while 8% utilize them as part of their evaluation process.It also assesses the use of WHO guidelines in cancer patients.A significant number (45%) does not use the WHO stepladder which is an evidenced approach method of the respondents did not receive formal training.This, potentially, indicates that the minority of urologists used the validated questionnaires in the assessment of neuropathic pain in cancer patients.Studies by Gudala et al. [26] and Attal et al. [29] confirm that the use of validated questionnaires such as the Douleur Neuropathique 4 (DN4) and pain DETECT as screening tools in determining neuropathic pain is effective.Bennet et al. [13] indicated that in the case where screening tools were not employed to identify neuropathic pain, this often resulted in delayed diagnosis and suboptimal pain management.Effective pain management for these prostate cancer patients necessitates a comprehensive approach, involving the thorough characterization and quantification of neuropathic pain.This indicates that ascertaining the extent of urologists' comprehension and awareness regarding neuropathic component in prostate cancer patients is crucial.This; however, was not the case in this study as the majority of urologists did not receive training regarding using the validated questionnaire as a screening tool for neuropathic pain management.
Secondly, in managing cancer pain, the majority (65%) of the study participants preferred an analgesic monotherapy approach, and the remaining 35% used a combined approach involving analgesic and adjuvants.The exclusive use of analgesic monotherapy by many participants underscores a knowledge gap that serves as a barrier to optimized pain control against prostate cancer neuropathic pain [14].Further to this, the WHO stepladder analgesic guidelines provide an evidence-based approach to cancer pain management and it is in support of the combined approach [16][17][18]43].In this study, only 55% of participants treating prostate cancer patients utilized the WHO analgesic ladder, while 45% (32 and 13%) were either not familiar with it or did not use it at all.When appropriately employed, it has been established that the WHO analgesic ladder can effectively control pain in 70-90% of patients [16].Adherence to these Fig. 4 This pie chart depicts the treatment approach adopted by participants in managing cancer pain.The data illustrates that 26% of participants opt for referrals, while the majority, (74%) undertake the treatment themselves Fig. 5 Participants' concerns about prescribing opioids varied.The majority (24.20%) voiced concerns about safety, followed by 19.80% citing worries about side effects.Additionally, 4.4% of participants expressed concerns about addiction, and a similar percentage (4.4%)apprehended the diversion of drugs to the illegal market.These findings underscore the multifaceted considerations surrounding opioid prescription within the study cohort guidelines, which includes, prescribing the appropriate analgesics or adjuvants at correct doses, schedules, and monitoring adverse effects is crucial for optimal pain control [16][17][18]43].Thus the majority (65%) of urologists in this study used a monotherapy approach.This is despite the fact that they have familiarity (55%) with the WHO analgesic stepladder guideline of drug classes that are recognized for their efficacy in the treatment of neuropathic pain.In addition, the study participants demonstrated limited knowledge about using adjuvants when treating neuropathic pain.This was evident in the fact that 65% of them opted for a monotherapy approach.
In evaluating urologists' confidence levels in prescribing opioids for patients with prostate cancer, 24.2% of study participants expresses worries about their safety while 19.8% cited concerns about potential side effects, and indicated a cautious attitude toward these medications.Only 4.4% expressed concerns about the risk of addiction.The traditional ladder approach, which typically starts with non-opioids administration, may not be effective for neuropathic pain [5] and controlling this neuropathic pain in cancer patients can enhance their quality of life [39].Furthermore, 40% expressed discomfort with prescribing opioids as shown by Fig. 5, which is worrisome because among these study participants, concerns about adverse effects of medication, addiction and illegal diversion were cited as reasons for apprehension over opioid prescriptions.However, limited evidence supports the prevalence of opioid addiction among cancer patients receiving adequate analgesic treatment, which then runs against the fact that the fear of opioid use has led to under treatment of pain [15,44] (Fig. 8).
Effective pain management often necessitates a multidisciplinary approach which involves specialists such Fig. 6 This bar graph represents participants' approaches to prescribing analgesics in the management of cancer pain.A majority, accounting for 65%, opt for the use of analgesics exclusively, while 35% employ a combined approach involving both analgesics and adjuvants Fig. 7 This pie chart presents the distribution of referral practices among participants who opt to refer patients for cancer pain management.The data reveals that among these participants, 60% refer patients to oncologists, 36% to pain specialists, and 4.40% to psychologists or psychiatrists as: oncologists, pain specialists, psychologists and psychiatrists [40,45].In our study, 74% of respondents were confident in managing the pain component on their own, while 26% opted to refer patients to a multi-disciplinary team for optimized pain care, underscoring the need for improved collaboration in managing cancer pain.An early referral pattern to the multi-disciplinary team might represent a better approach in cases of uncertainty in cancer management paradigms.Despite more than 50% of participants rating their knowledge as average, the actual responses concerning attitudes and practices unveiled that only around 30% of them were effectively managing neuropathic pain linked to prostate cancer.This discrepancy may stem from a subset of respondents who had privileged access to streamlined multidisciplinary teams such as senior urologists and those in private practice.The limited number of respondents who received formal pain education within the context of cancer is indicative to the pressing need for a more structured approach to teaching and learning in this field.This is crucial not only for enhancing the knowledge of trainees but also for improving the quality of life for their patients who grapple with neuropathic pain on a daily basis.

Study limitations
Response rate: While our intended sample size was 111, we obtained responses from 91 individuals, yielding an 82% response rate.The 91 respondents provided valuable insights into the issues surrounding the management of cancer pain in prostate cancer.
The initial plan was to conduct a physical survey at the SAUA congress.However, due to global COVID-19 pandemic, we successfully transitioned to an electronic survey format, thereby broadening our reach beyond geographical boundaries.
Different levels of experience between respondents: This survey collected responses from a diverse group of urologists, including both trainee urologists and experienced practitioners.
This diversity provides valuable insights, but it is important to acknowledge that differences in experience and exposure could influence attitudes, knowledge and practices related to pain management.

Conclusion
In conclusion, the findings from this study suggest that urologists are not providing optimal treatment for neuropathic pain, particularly, in the context of prostate cancer.
Factors contributing to suboptimal care include a lack of knowledge about cancer pain, underutilization of pain assessment tools and inadequate familiarity with adjuvant medications.
This situation leaves patients with limited treatment options, and negatively impacts their quality of life.Further research into the management of neuropathic pain in prostate cancer is warranted to bridge the existing knowledge and practice gaps and improve patient outcomes.
data analysis, methodology, and also played a role in formal analysis and validation.

Funding
There was no funding used in the study.

Fig. 1 Fig. 2
Fig. 1 Training in Pain Management: This pie chart reveals participants' training status in pain management.A significant majority (92%) have not undergone specific pain management training, while a minority (8%) have received such training.This representation highlights the prevalence of training gaps in pain management among participants