title: Diagnosis and management of breakthrough cancer pain: Have all the questions been resolved? A Delphi-based consensus assessment (DOIRON).
abstract: OBJECTIVE
  To ascertain the level of agreement and achieve a consensus among cancer pain specialists in Spain with regard to the optimal definition, diagnosis, and management of breakthrough cancer pain (BTcP).
  
  
  METHODS
  Two-round Delphi methodology survey (February-May 2013) using seven-point Likert scales (ranging from 1 "strongly disagree" to 7 "strongly agree") was carried out. Mean scores >5 or <3 indicated, respectively, agreement or disagreement. Scores from 3 to 5 indicated no consensus.
  
  
  RESULTS
  A total of 126 experienced specialists were surveyed. Response rates were 68 % in round 1 and 90 % in round 2. Agreement (mean Likert score) was strongest for the proposed BTcP definition (6.6), the use of oral (6.1), and intranasal (6.0) transmucosal fentanyl, the need for early assessment after BTcP treatment initiation, and the need to improve staff knowledge of BTcP. Broad agreement was also reached regarding the need to systematically screen all cancer patients for BTcP (5.9). Most respondents (82 %) considered strong opioids to be appropriate treatment. In contrast, no consensus was reached regarding strong opioid treatment for baseline pain as a prerequisite for BTcP diagnosis.
  
  
  CONCLUSIONS
  Consensus was strong for most treatment, and diagnostic aspects were evaluated in the study. However, several important issues remain unresolved, particularly whether the diagnostic criteria must include strong opioids for background pain. Nurses' awareness and understanding of BTcP was considered insufficient, and more training is needed in this area. Overall, agreement among specialists was good, but more work is needed to better define the optimal diagnostic features and treatments for this condition.
authors.affiliation: Palliative Care Service, Institut Català d'Oncologia (ICO), Bellvitge Biomedical Research Institute (IDIBELL), WeCare Chair: End of Life Care, Institut Català d'Oncologia, Barcelona, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Porta-Sales
authors.affiliation: Pain Clinic, Hospital Universitario de la Princesa, C/Diego de León 62, 28002, Madrid, Spain.
authors.forename: C
authors.initials: C
authors.lastname: Pérez
authors.affiliation: Department of Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
authors.forename: Y
authors.initials: Y
authors.lastname: Escobar
authors.affiliation: Medical Manager Takeda, Madrid, Spain. Vicente.martinez@takeda.com.
authors.forename: V
authors.initials: V
authors.lastname: Martínez
mesh_terms: D059390:Breakthrough Pain / Q000175:diagnosis* / Q000628:therapy*; D000072716:Cancer Pain / Q000175:diagnosis* / Q000628:therapy*; D003697:Delphi Technique; D006801:Humans; D008495:Medical Oncology; D059408:Pain Management / Q000379:methods; D013030:Spain
keywords: Breakthrough cancer pain; Cancer pain; Consensus; Delphi method; Pain