Background: Breakthrough cancer pain (BTcP) represents a significant clinical challenge for oncology patients worldwide. While global data on BTcP prevalence exist, researchers have not systematically documented its specific clinical reality in North Africa, where rapid-onset opioids often remain inaccessible. To address this gap, we conducted the first standardised assessment of BTcP in the region, characterising its clinical and psychosocial impact in Eastern Morocco and proposing a preliminary, resource-adapted management pathway.
Methods: We conducted a cross-sectional study from January to June 2025 at the Regional Oncology Center Hassan II of Oujda. We assessed 312 consecutive adult cancer patients with controlled background pain (Numerical Rating Scale score ≤ 4) using the standardised Davies algorithm. We selected candidate predictor variables - age, sex, cancer site, presence of metastasis and performance status - based on their established clinical relevance in the BTcP literature. We evaluated the multidimensional impact of BTcP using the Hospital Anxiety and Depression Scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30. Researchers previously validated both instruments linguistically and culturally for the Moroccan Arabic-speaking population. We examined associations between BTcP status and psychological and quality-of-life outcomes using the Mann–Whitney U test, given the non-normal distributions observed. Based on our findings, we developed a preliminary risk-stratified clinical pathway. We present adjusted odds ratios (aORs) with 95% confidence intervals (CIs) throughout.
Results: We identified a BTcP prevalence of 41.7% (130 out of 312; 95% CI: 36.4%–47.2%). Patients reported a mean of 2.3 episodes daily (SD 1.1), each lasting a mean of 35 minutes (SD 12) with severe intensity (mean Numerical Rating Scale score of 8.1 out of 10, SD 1.4). Multivariable logistic regression analysis revealed that bone metastases (aOR = 2.3; 95% CI: 1.4–3.8; p = 0.001) and poor performance status (ECOG score ≥ 2; aOR = 1.8; 95% CI: 1.1–2.9; p = 0.02) represented the strongest independent predictors. Advanced disease stage (Stage IV) also showed a significant association (aOR = 1.9; 95% CI: 1.2–3.1; p = 0.01).
Conclusion: This study reveals that nearly half of patients surveyed experience severe episodic pain flares despite stable background control. To bridge the gap between international guidelines and local resource constraints, we propose a preliminary clinical pathway - ‘The Oujda Protocol’ - that prioritises nurse-led triage, safety-checked multimodal analgesia and pre-emptive oral morphine dosing. This protocol requires prospective validation before it can inform standard clinical practice.
