Pain is a major healthcare problem for patients with cancer  and is one of the most frequently feared symptoms [2, 3]. In 2007, in a Dutch study 64% of patients with metastatic, advanced, or terminal disease , 59% of those on anti-cancer treatment and 33% of patients after curative treatment experienced pain . Often, pain control is inadequate [2–9]. In 2007, Deandrea et al. demonstrated that pain in nearly one-half patients with cancer is undertreated . As illustrated by the high prevalence of pain, for most patients acceptable pain reduction has not yet been reached. Up to now, no hospital-wide intervention has yet improved the treatment of pain in general .
A key barrier to adequate treatment of pain is ineffective communication between patients and healthcare providers about their pain [12, 13]. Patients often consider information they receive from providers to be unclear [14, 15]. Generally, patients lack knowledge about pain and pain management [16, 17]. Several studies show that informing and educating the patient about treatment of cancer pain reduces pain intensity [18–21].
Professionals do not ask their patients systematically about their pain [22, 23]. Moreover, patients seem to be reluctant to talk about their pain or to ask for pain medication [24–26] for a variety of reasons, such as concerns about addiction, tolerance, desire to please providers, and fear that reporting pain will take the physician's time away from the treatment of their cancer [27, 28].
One further aspect of underreporting pain concerns assessment and documentation. There is evidence that careful and regular, systematic assessment of pain improves the perception of physicians and nurses concerning cancer pain and enhances the quality of pain management [29, 30].
Healthcare providers tend to show a lack of attention to and knowledge about pain management [29, 31–33] and consequently do not always treat pain according to specific guidelines [31, 32]. This has been regarded as one of the main factors causing inadequate pain relief in cancer patients [29, 34, 35]. For these patient- and professional-related reasons, inadequate treatment of cancer pain persists, despite decades of efforts to provide clinicians with information on analgesics and pain-relieving techniques [36–42], and despite the availability of evidence-based guidelines on cancer pain .
The prevailing principle for treatment of cancer pain is the World Health Organization (WHO) three-step pain ladder, published in 1986 . If this guideline is well applied, it is possible to achieve adequate pain relief in 70 to 90% of cancer patients [44–47].
Based on this pain ladder, a more detailed European recommendation for the use of morphine and alternative opioids has been published by the European Association for Palliative Care (EAPC). The final version of the 'Evidence-based guidelines for the use of opioids analgesics in the treatment of cancer pain: The EAPC recommendations' is in development .
The Dutch guideline 'Pain in patients with cancer' is one of the most recent guidelines on this topic in Europe. It combines new insights and existing knowledge derived from evidence-based medicine. All relevant professional organizations of the Netherlands as well as the patient association have been involved in the development process. In a comparative study of European guidelines on this topic with the AGREE II instrument, this Dutch guideline appeared to have followed a good development process . Yet, under-treatment of cancer pain may be partly caused by a lack of implementation of these clinical practice guidelines (CPGs)[10, 52–54].
The present study aims to evaluate the implementation of the Dutch guideline 'Pain in patients with cancer' to improve pain reporting, pain measurement, and hence pain control in patients with cancer and pain. A randomised controlled trial (RCT) with two arms will be performed in which professionals will be trained and Short Message Service with Interactive Voice Response (SMS-IVR) will be used to monitor and report pain.
Using Short Message Service (SMS) as a reminder and as tool to collect data on pain scores is innovative and promising . Mobile phones are part of daily life; in 2009, nine out of ten Dutch inhabitants used a mobile phone . SMS alerts have been used for asthma management [57–59], management of irritable bowel syndrome [60, 61] management of diabetic patients  and recurrent pain in children aged 9 to 15 . These studies concluded that SMS can serve as a tool to support self-management of patients. The use of mobile phone SMS alerts in the present study may be a way to encourage patient empowerment, because the patients' role in their pain management becomes more active. Empowerment has been defined by its absence of helplessness, or the feeling of having greater control over one's life .
We expect that SMS-IVR will increase the percentage of patients with cancer who receive adequate pain treatment and reduce pain intensity in patients with cancer, because pain will be measured systematically. In addition, patients are expected to become less reluctant to report pain and physicians will ask patient more frequently about pain.
The primary research question of the present study is: Will implementation of the Dutch guideline improve pain reporting, pain measurement, and adequate pain therapy?
A RCT will be implemented, with clustering based on number of beds and number of medical oncologists to increase comparability of hospitals and to reduce contamination . Differences of the effectiveness of the intervention between subgroups are expected. Factors that may predict inadequate cancer pain treatment include gender, race, low education, a better physical condition without metastatic disease, and age . This paper describes the aims and methods of an RCT to evaluate on effectiveness of implementation of the Dutch guideline to improve pain reporting, pain measurement, and adequate pain therapy. The results of this study will be published in several scientific papers.