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11 Articles in Volume 7, Issue #4
Cervical-Medullary Meningioma
CES in the Treatment of Depression
Deep Penetration Therapeutic Laser
Fibromyalgia Patient Insights
Invoking the Placebo Effect
Multidimensional Ultrasonography
Paradigm Shift in Cancer Pain Management
Prolotherapy for Low Back Pain
Sedation Levels for Intraspinal Injections
Self-Protection Against “Off-label” Lawsuits
Viewpoint: Methadone Successes and Cautions

Paradigm Shift in Cancer Pain Management

Application of an interdisciplinary psychosocial model—along with early intervention—can change the focus from palliation of advanced pain complications to that of preempting chronicity and improving quality of life for cancer patients.

In spite of the reported high success rate in its management, national and international health organizations (e.g., World Health Organization) have concluded that cancer pain remains under-reported and under-treated. In patients with a potentially life-threatening disease, pain can add greatly to the debilitating effects of the disease, foster hopelessness and fear, and reduce the ability of the patient to comply with interventions directed at the disease itself. Generally, current treatment approaches work from a biomedical model to manage carcinoma-related pain in patients with early-staged disease. When pain presents in advanced disease and/or persists, treatment only then involves an interdisciplinary approach within a biopsychosocial context. The present paper reviews the current application of an interdisciplinary model in cancer pain management and explores the lessons that we can learn from other pain populations.

Background

In 2002, the American Society of Clinical Oncology’s (ASCO) strategic plan listed interdisciplinary collaborations in the prevention, management, and research of the wide trajectory of cancer as its main priority. To date, bits and pieces of this commitment can be seen in many areas of cancer; however, such collaborations appear to be lacking in cancer pain management. Indeed, the application of an interdisciplinary model to address pain in an oncology population ranges from being entirely absent to being in the early stages of infancy compared to non-cancer pain populations.1 This is not necessarily unexpected. Recent large-scale reviews have concluded that 90% of cancer pain in patients with early-staged disease can be effectively managed by simple medical interventions.2,3 In spite of these impressive rates, many health organizations have recently described the current treatment paradigm in addressing malignant pain as suboptimal.3-6 The complex nature of cancer and the cascade of physical and emotional consequences that accompany the disease may contribute to the under-estimation of cancer pain and/or lead to its chronicity.

Until recently, interdisciplinary approaches for non-cancer pain patients were reserved for those with more chronic, treatment-reticent pain. However, a burgeoning body of empiricism has begun to show that such approaches during the acute stage (three months or less) of pain may help prevent it from persisting.7-10 In terms of cancer pain, there is a relative paucity of data on the benefits of introducing interdisciplinary strategies to relieve pain in cancer patients with early-staged disease. Using musculoskeletal pain as a backdrop, this paper considers the current strategies in cancer pain management within an interdisciplinary, biopsychosocial context. As such, we pose the following question: Is a shift in paradigm needed in cancer pain management? Central to this paper will be the review of: (1) the current strategies for treating malignant pain; (2) the research supporting the application of an interdisciplinary model in musculoskeletal pain during the acute phase; and (3) the rationale and barriers to an interdisciplinary approach in addressing pain in patients with early-staged disease.

Definition and Epidemiology of Cancer Pain

Historically, both research and clinical realms have differentiated pain populations by classifying their pain as either malignant or non-malignant, the former referring to pain associated with a fatal (or potentially fatal) disease and the latter referring to pain without such disease. These labels were predicated upon the premise that only malignant pain was to be treated with opioids. Although dated, this distinction somewhat lingers, in that each pain population undergoes different treatment approaches. Treatment for chronic, non-malignant pain patients often involves a tertiary level of care bearing an interdisciplinary approach within a biopsychosocial context. Perhaps we view this population as having a more complex pain presentation and history than malignant pain. In turn, we recommend treatment approaches that recognize and appreciate this complexity. Alternatively, we view patients with pain related to a carcinoma as having an unremarkable pain history with symptoms that can be managed adequately by the treating physician—with anticipation that palliative care services will oversee cases of advanced disease with complicated pain.

However, we must consider several criteria in addressing cancer pain. First, the disease site often determines whether the need for pain management will arise. Certain types of cancer, as a function of location, are more painful than other types. The pain site not only suggests the presence of a tumor, but also provides a point of reference as to the difficulty in relieving the symptoms. In addition, the stage of disease also influences the risk for cancer pain, in which pain issues may only manifest in advanced-staged disease (e.g., pain resulting from tumor penetration of tissue). Alternatively, cancer pain may not stem from the malignancy itself but, instead, as a product of cancer treatment. Finally, it would be erroneous to assume that all pain reports from cancer patients relate to their carcinoma. Collectively, these issues underscore the importance of a comprehensive assessment to guide treatment planning and delivery.

Health care providers estimate that many cancer patients will experience disease- or treatment-related pain at a level of severity that will warrant clinical intervention.11-15 Approximately 1/3 of cancer patients undergoing active therapy, and 3/4 of cancer patients with advanced disease are estimated to suffer from a clinical level of pain.16,17 It is reported that the prevalence of chronic pain is about 30-50% among cancer patients during the active phase of treatment for a solid tumor. Direct tumor involvement represents the most common cause of cancer pain (approximately 85% of patients on inpatient pain services, and up to 65% of patients in outpatient pain clinics.18 The second most common type of cancer pain involves tumor infiltration of the nerve, followed by tumor infiltration of the hollow viscus (see Table 1). Even with well-controlled pain, approximately 2/3 of cancer patients experience breakthrough pain. The increased awareness of this symptom likely provided the impetus in the recent development of treatment guidelines for oncology populations, many of which, as will be discussed, advocate for an interdisciplinary approach.

Table 1. Types of Cancer Pain
Somatic
  • Most common form of pain reported by cancer patients
  • Often inflammatory, sharp, localized, aching, throbbing
  • Observed when the area is moved or touched
Visceral
  • Diffuse, gnawing, and cramps
  • Activated by nociceptors of internal organs or surrounding tissue
Neuropathic
  • Linked to anomalies in the central and/or peripheral nervous system
  • Constant dull ache
  • Often accompanied by brief intense pain

Current Strategies for Treating Malignant Pain

In 2005, the American Pain Society formed a Task Force of 11 experts from different disciplines to expand the guidelines established by American Pain Society a decade earlier (see Table 2). The task force report advocated for pain management to involve mainly analgesics according to an ascending scale, with second-line treatments to include lignocaine, mexiletine, and ketamine. Sympatholytic therapies were proposed for patients with features of chronic regional pain syndrome, and anti-inflammatory agents were proposed for neurogenic inflammation. Surgical interventions were to be considered for refractory neuropathic pain. The report underscored the critical need to reduce persistent pain and breakthrough pain, which traditionally have been addressed by way of aggressive upward dose titration.20

A myriad of factors (e.g., disease site, stage of disease, treatment type, pain duration, treatment reticence, co-existing medical conditions, etc.,) influence the management of cancer pain that ranges from a strictly biomedical model (e.g., monotherapy) to a biopsychosocial model (e.g., interdisciplinary interventions). Its successful management bears the potential to greatly influence quality of life. Estimates indicate that more than 80% of cancer patients can have their pain successfully managed if providers adhere to World Health Organization (WHO) guidelines5,16 (see Table 3). It should be noted, though, that pain management is complicated by other co-existing symptoms, which may be independent of the pain, or which may contribute to pain initiation, or may be a result of cancer-related pain (e.g., “symptom burdens” such as psychological distress, poor sleep quality, etc.). Some evidence also suggests that physician attitudes bear some burden of the blame for inadequate management of cancer pain. Elliot and Elliot,21 reported that many physicians misunderstood concepts of morphine tolerance to analgesia and to adverse events, and lacked familiarity with the use of adjuvant analgesics, efficacy of oral morphine, and the nonexistent risk of addiction in cancer pain. More recently, Menefee and Monti4 identified concern about legal and regulatory sanctions for opioid use as hindering health care providers’ efforts to address cancer pain.

Evidence-based practice strategies in managing cancer pain have been based on a body of literature bearing significant limitations. Carr and colleagues22 recently reviewed over 200 randomized clinical trials evaluating the efficacy of current efforts to treat cancer pain. Along with questionable statistical power, the reviewers noted that many of the studies failed to detail “critical” information regarding the nature of the cancer pain, its suspected mechanisms, and a lack of standardization in treatment modalities. Further, this review highlighted the lack of uniformity in measuring pain outcome as demonstrated by the large number of pain outcome measures (125) used. Overall, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, selected adjuvant agents, and palliative chemotherapy were found to relieve cancer pain. The review did not discern a significant difference in the level of efficacy among these agents. A glaring conclusion one could draw from this review and clinical practice guidelines (e.g., WHO & APS) is that cancer pain management lacks the biopsychosocial strategies evidenced in interdisciplinary models for non-malignant pain (e.g., greater patient involvement in treatment-planning, more non-pharmacological approaches, and ongoing evaluation of pain interference in daily functioning).

The notion of treating all cancer pain from an interdisciplinary model is not revolutionary. Many have advocated such an approach by implying the need for comprehensive management.23-25 The Agency for Health Care Policy and Research (AHCPR) characterized the current climate of pain management in oncology as lacking an interdisciplinary core: “Unlike non-malignant pain where the employment of such a model is no longer restricted to complex cases, there appears to be some indication that those treating cancer pain believe that the interdisciplinary management is appropriate only when pain persists and compromises life quality.”26

Interestingly, a review of many of the major cancer centers in the U.S. reveals that the pain management program falls under, or has been integrated with, palliative care services (see Table 4 for a listing of programs and their respective URLs). The logic underlying this frequently observed partnership is intuitive in that palliative care services represent the branch in medicine that provides care for patients whose medical status is not responsive to curative approaches, and whose focus centers on enhancing life quality. Silvestri et al.25 proposed a model for cancer pain management that was coined as “aggressive palliation,” leading to an earlier involvement of palliative services. With symptom relief introduced at an earlier stage of disease, the simultaneous aim of curative intent would continue.

Table 2. American Pain Society’s Expansion of 1995 Quality Improvement Guidelines for the Treatment of Acute and Chronic Pain
1) Recognize and treat pain promptly by repeated assessment.
2) Treatment should both be tailored to the individual patients and patients should be involved in the treatment decision-making process.
3) Improve treatment patterns by discontinuing “as needed" orders for analgesics.
4) Reassess and adjust the pain management plan, if needed.
5) Monitor pain management processes and outcomes.

Interdisciplinary Approach in Musculoskeletal Pain Management

Members of interdisciplinary treatment teams typically include physicians, nurses, psychologists, physical/occupational therapists, vocational counselors, and pharmacists. Arguably, the sharing of ideas across disciplines enables a comprehensive assessment of the clinical and/or research problem at hand.27 The synergism that results from successful collaborative interdisciplinary relationships may yield a combined effect greater than the sum of individual actions. Such success appears to be gradually emerging from the management camp of non-malignant pain.

The interdisciplinary approach, evidenced in the research and treatment of non-malignant pain, has contributed to instituted clinical guidelines in the treatment of musculoskeletal pain. This is perhaps no more evident than in the nomenclature of low back pain where risk factors are examined in terms of “flags” that serve as markers as to when specialization is needed (see Table 5). The purpose of the psychosocial assessment for musculoskeletal pain patients is multifold:

  • to offer an estimate of the risk for the development of long-term disability;
  • to define and/or characterize the nature of the reported pain;
  • to determine the extent to which the pain compromises daily functioning;
  • to provide information about possible mechanisms underlying the pain;
  • to identify personal variables that will assist in matching the patient with the appropriate intervention; and
  • to identify personal variables that may complicate treatment delivery.
Table 3 WHO’s Three-step process
First, treatment begins with basic analgesics & nonsteroidal anti-inflammatory drugs
Second, if pain control is inadequate, combination therapy with mild opioid & basic analgesics
Third, more potent opioids combined with “adjuvant” drugs to manage anxiety
Note: This treatment is 90% effective; surgical intervention should be used when appropriate

Collectively, these data will influence treatment planning and will inform patients and family members as to the nature and duration of treatment.9 Ultimately, these data may prove to be invaluable in the delivery of intervention that is effective in preventing persistent pain and, in turn, disability.28

The importance of a psychosocial assessment of pain from an interdisciplinary perspective was highlighted in a large, randomized trial (n=402; Hay et al. 2005).29 The investigators compared a brief pain management biopsychosocial program—designed to identify and address psychosocial risk factors for persistent, disabling pain—to a brief course of physiotherapy that included manual therapy techniques. Central to the study was the assessment of patients with non-specific low back pain of less than 12 weeks duration at three and 12 months after the program ended. The biopsychosocial intervention included a stem-and-leaf interview, which involves posing open-ended questions to be followed by the response of the participant with the eventual goal of developing a tailored management plan. Each treatment condition began with an initial 40-minute assessment/ treatment session, followed by six 20-minute treatment sessions. The results revealed that both interventions reduced disability at each follow-up, but that recipients of the biopsychosocial intervention required fewer treatments and reported lower utilization of health-care facilities in the subsequent year compared to recipients of the biomechanical program. Hay and colleagues concluded that the biopsychosocial approach should be considered an “efficient first-line approach" to care for this population. Should such consideration be extended toward a malignant pain population?

Table 4. URLs of the NCCN Centers with Multidisciplinary/Interdisciplinary Teams
City of Hope Cancer Center
Dana-Farber/Partners Cancer Center www.cancercare.harvard.edu/tre/
Duke Comprehensive Cancer Center www.cancer.duke.edu/support/ or www.cancer.duke.edu/pated/
Fox Chase Cancer Center www.fccc.edu/patients/support/pain-management/
Huntsman Cancer Institute at the University of Utahp www.huntsmancancer.org/group/painAndPalliative/programOverview.js
Fred Hutchinson Cancer Research Center www.seattlecca.org/patientsandfamilies/support/education/pain
Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at Ohio State University www.jamesline.com/patientsandvisitors/tests/posttreatment/
The Sidney Kimmel Comprehensive Cancer Center www.cancerpain.jhmi.edu/
Robert H. Lurie Comprehensive Cancer Center at Northwestern University www.cancer.northwestern.edu/CancerCare/pain.cfm
Memorial Sloan-Kettering Cancer Center www.mskcc.org/mskcc/html/474.cfm
H Lee Moffitt Cancer Center & Research Institute at the University of South Florida www.moffitt.org/ClinicalPrograms.aspx
Roswell Park Cancer Institute www.roswellpark.org/Site/Patient_Care/Cancer_Treatment/Specialized _Services/CancerPainManagementService
St. Jude Children’s Research Hospital of Tennessee Cancer Institute www.stjude.org/search/0,2616,582_3161_300.html
Stanford Hospital & Clinics cancer.stanfordhospital.com/forPatients/services/complimentary AltMed/default
University of Alabama at Birmingham Comprehensive Cancer Centerp www3.ccc.uab.edu/show.as
UCSF Comprehensive Can Center www.ucsfhealth.org/adult/special/p/11191.html
University of Michigan Comprehensive Cancer Center www.cancer.med.umich.edu/support/confronting_pain.html
UNMC Eppley Cancer Center at Nebraska Medical Center www.nebraskamed.com/services/neuro/pain_management/index.asp
The University of Texas MD Anderson Cancer Center www.mdanderson.org/departments/cancerpain/

Several studies in non-malignant pain populations have also shown that application of the biopsychosocial model influences several endpoints that would bear significance for a malignant pain population. For example, in a group of 255 arthritic pain patients, random assignment to a cognitive-behavioral group versus a standard treatment control group revealed that those assigned to the cognitive-behavioral group had significantly less disability compared to the control group.9 Similarly, Moore et al.30 found that a two-session psychologist-led intervention showed a modest effect size in effectively reducing fears about back pain, pain intensity, and interference with daily activities among low back pain patients recruited from a primary care setting.

One could argue that the research between malignant and nonmalignant pain populations should not be discussed interchangeably due to the divergent nature of these conditions. This argument is somewhat dated in that cancer pain is no longer seen as purely nociceptive or neuropathic in nature. Some might also question why we raise the issue of disability in discussing pain related to carcinomas. Perhaps it is more important than ever that consideration of disability and other endpoints in non-malignant pain be extended to malignant pain populations, as a cancer diagnosis no longer represents a death sentence. Instead, the number of cancer survivors returning to work is at an all-time high. Hence, we propose that furthering efforts to identify potential barriers to patients’ resuming their pre-morbid responsibilities (e.g., occupation) is paramount.

Rationale for an Interdisciplinary Approach to Address Pain in Early-staged Disease

We propose that patients at any point in the cancer trajectory (early- versus advanced-stage disease) would benefit from a comprehensive, interdisciplinary intervention as patients with non-malignant pain appear to do. Effective management of cancer pain depends on a comprehensive assessment of the pain including its relation to disease. Often, its assessment highlights an etiological factor, which will serve as target of subsequent intervention. Pain can greatly influence both the physical and psychosocial well-being of a patient, and can create a cluster of related problems such as chronic fatigue, sleep disturbance, excessive rest, withdrawal from social and/or work activities, and compromised immune function.31 Psychosocial factors likely play an important contributory role in the perception and reporting of pain symptoms. Comprehensive assessment represents a critical function of an interdisciplinary team, in which any member of the treatment team may influence treatment planning. In many cases, the assessment of pain leads to an intervention targeting the etiology of the pain.9,17,32

Once thought to be a correlate of cancer pain, evidence suggests that psychosocial distress may further heighten the interference of the pain on daily activity. Mystakidou and colleagues44 assessed both pain severity and pain interference in a relatively large sample of patients (n=120) with advanced cancer. In this patient sample, pain interference and, to a lesser extent, pain severity was significantly associated with psychological distress (anxiety and pain), whereas pain interference to “walking ability," “normal work," and “relations with other people" presented as more salient and troubling to patients’ anxiety than to patients’ depression. These outcome variables will likely receive greater consideration in future oncology research due to the fact that multiple factors (e.g., improved surveillance activities, increased treatment modalities) are contributing to greater numbers of cancer survivors.

Table 5. Flag System for Assessment in Musculoskeletal Pain
Red Flags Need for surgical evaluation
Yellow Flags Method of screening for normal psychosocial process that may inhibit or facilitate participation in treatment
Orange Flags Screening for signs of psychopathology
Blue Flags Characteristics of the work environment
Black Flags Social & economic factors influencing the return-to-work

Many non-pharmacological treatment approaches could help cancer patients better manage their pain. As with non-malignant pain, these approaches would serve as an adjunct, not as a substitute, to the medical intervention. For example, simple cognitive-behavioral skills training or psycho-education interventions could promote active participation in the control of symptoms and provide the tools associated with better outcomes.13,33 Albeit with a small sample size, Robb et al.6 recently found that patients suffering from chronic malignant pain reported a significant level of pain relief after undergoing a brief intervention, which included both cognitive-behavioral therapy and an exercise regimen. The ongoing monitoring of symptoms and strong communication among the treatment team are factors that will likely result in successful pain management.34 A brief review of the efficacy of non-pharmacological approaches in cancer pain reveals a few systematic efforts to evaluate their efficacy in treating cancer pain (see Table 6).

We propose that patients at any point in the cancer trajectory (early- versus advanced-stage disease) would benefit from a comprehensive, interdisciplinary intervention as patients with non-malignant pain appear to do."

The influence of psychosocial factors on the perception of pain (of any type) is well-established. Years of research have shown that perceived control, anxiety, appraisal, and contingencies of reinforcement can both shape the interpretation and treatment of pain symptoms.28 This backdrop of research has helped define the role of a psychologist on an interdisciplinary treatment team. Using these psychological processes as mechanisms of change, psychologists can assist pain patients, with either malignant or non-malignant pain, in reinterpreting or reappraising noxious sensations and modify any other processes that contribute to initiating, maintaining, and/or exacerbating pain.

Although somewhat less sophisticated compared to non-malignant pain’s well-developed nomenclature, several predictors for treatment outcome for cancer pain have been reported throughout the literature. These variables include age (e.g., older patients are at greater risk), distress, minority patients, women, patients whose pain has been attributed to non-cancer related causes, and the discrepancy between the physician and patient rating of pain severity including its compromising effects on daily activities.35,36 The quality of poor assessment also increases the likelihood for inadequate pain management.37 Further clinical and research investigations would provide the necessary vehicle in establishing a flag-like system in a malignant-pain population.

Finally, further inclusion of non-pharmacological approaches may enhance the therapeutic benefits of current pharmacological regimens or result in lower doses. The AHCPR continues to advocate for increased use of adjuvant drugs for cancer pain management in the effort to reach an “opioid-sparing effect."20,38 The analgesic benefit derived from the adjuvant drugs, coupled with lower levels of opioids, would lead to fewer opioid-related side effects and possibly overall better pain management.20 In a relatively recent article, Paice39 recommended procedures for neuropathic pain in cancer patients that some thought exceeded previously established guidelines. Neuropathic pain may respond well to several classes of adjuvant medications, but concerns have been raised that the potential side-effects outweigh their benefits.40 As evidenced in Table 6, several studies evaluating the efficacy of non-pharmacological interventions cited decreased pain medications as an obtainable endpoint.

It could be argued that the treatment of cancer pain does adhere to the model established in musculoskeletal populations in that both acute pain in non-malignant patients and pain in early-staged cancer patients are generally spearheaded by the biomedical model.41 However, there is increasing evidence that suggests psychosocial factors once believed to be active only during the chronic stage of musculoskeletal pain are, indeed, very much active during the acute stage of pain (see Garofalo et al.7 for a review). Although preliminary, early intervention during the acute stage has shown to be effective in reducing the likelihood that the musculoskeletal pain will persist, which in turn,will prove to be more cost-efficient than addressing the pain when it becomes more treatment refractory.28

Table 6. Review of Non-pharmacological Approaches in Cancer Populations
Authors N Population Intervention Results
Anderson et al, 2006 57 Chronic cancer-related pain taking opioids 3 brief CBT techniques: relaxation, distraction, positive mood, or wait-list Relaxation and distraction reduced pain intensity post-treatment, but not maintained
Elkins et al, 2006 6 Colonoscopy patients Hypnosis Reduced need for sedation and pain relief for colonoscopy
Renzi et al, 2006 86 Surgery for anorectal diseases Relaxation techniques & guided imagery tape pre-, during, and post-surgery Reduced pain following anorectal surgery
Andersen et al, 2006 54 Chemotherapy cancer patients 6-week intervention with structured physical activity, relaxation, body-awareness techniques and massage Decrease in treatment side-effects, including pain
Robb et al, 2006 13 Chronic treatment-related cancer pain CBT pain program (e.g., education, exercise training, relaxation & goal setting) Improvement in coping with pain (P
Dalton et al, 2004 131 Cancer patients during active phase of treatment CBT protocols tailored to patient characteristics vs standard CBT (five 50-minute treatment sessions) Less interference in activities, relationships, walking, & sleep among those receiving profile-tailored therapy
Puder, 1988 69 Outpatients (ages 27- 80) 10-week group CBT (stress inoculation training) Decreases in medication use & interference with activity; increased ability to cope with pain; benefits @ 6-month f/u
Syrjala et al, 1995 94 Oral mucositis pain in cancer patients receiving BMT Support vs relaxation-imagery training vs CBT (coping skills, including relaxation & imagery) Relaxation-imagery reduced cancer treatment-related pain; adding CBT to relaxation with imagery did not
Turner-Stokes et al, 2003 113 Adults (with average age=38) Individual CBT (relaxation & education) vs group-based multidisciplinary program Both programs appear equal for pain management
Cassileth & Vickers, 2004 1,290 A large group of patients Massage therapy Inpatient pain scores were reduced by 50%; outpatients improved 10% > inpatients
Aubin et al, 2006 80 Advanced cancerpatients with >6 month life expectancy Educational homecare program on pain relief Average pain was reduced
Miaskowski et al, 2004 174 Outpatients with pain from bone metastasis PRO-SELF Pain Control Program Pain intensity scores decreased from baseline in PRO-SELF
Haase et al, 2005 60 Colorectal cancer patients undergoing conventional resection Brief psychologic interventions (guided imagery & progressive muscle relaxation) 90% of the patients indicated that they would recommend it to other patients
Wells-Federman et al, 2002 154 Patients with chronic pain CBT pain management program on self-efficacy, pain intensity, & pain-related disability Patients reported significant improvements in all scores post-program
Alimi et al, 2003 90 Cancer patients Auricular acupuncture Reduction in pain intensity

Barriers to an Interdisciplinary Approach to Address Pain in Early-staged Disease

If such evidence contributes to the acceptance of the interdisciplinary model, then why is the established psychosocial comorbidity observed in patients with cancer pain viewed any differently?9 In light of the complexity of cancer and its overall impact on psychosocial well-being, it should not come as a surprise that both symptom perception and interpretation are susceptible to modulation, further complicating the management of cancer pain. Some resistance, in part, may involve the lack of consensus as to whether or not cancer pain causes changes in mood states or whether changes in mood leads to increased pain perception and/or reporting.42,43 Clearly, during the cancer trajectory, there are many sources, aside from pain, that can lead to poorer quality of life (e.g., fears associated with cancer diagnosis and/or treatment).44

Lyne and colleagues24 cited several barriers to the successful management of pain symptoms among cancer survivors. Many of these barriers were financial in nature, or reflected a poor understanding of cancer pain including a lack of training/education of a health professional, inadequate reimbursement for pain treatment, bureaucratic regulations (e.g., requiring triplicate prescriptions), medication costs, fear of addition, and denial of pain in fear that it signals disease recurrence. These findings coincided with survey results overseen by the Eastern Cooperative Oncology Group that attributed under-treatment of cancer pain to inadequate assessment.18,36,37

Another barrier to interdisciplinary intervention may have to do with the current service that oversees management of cancer pain: palliative care. Speculatively, there may be a hesitance to refer patients with early-stage disease to a palliative care team due to the association some may have with that service. One possible solution is for these services to collaborate with available behavioral medicine services, whose involvement may be less threatening to patients and their family members. However, efforts to date to demonstrate the efficacy of non-pharmacological interventions in malignant pain populations have been few, yet promising.6,33,34 In spite of their apparent efficacy, these studies have been limited by methodological issues and the lack of cost-benefits analyses observed in the non-malignant pain populations. In terms of their methodology, many of the studies have been limited by their small sample sizes comprised of different cancer types, which may ultimately hinder efforts to better support the benefits of non-pharmacological approaches. In terms of the cost-benefits analyses, unlike non-malignant pain (see Gatchel28), we are unaware of any study that examines such fiscal endpoints in cancer patients with early-staged disease undergoing an interdisciplinary intervention.

Conclusions

The psychosocial component of pain is well established. Decades of research have shown how psychosocial and behavioral factors influence the initiation, maintenance, and/or exacerbation of pain symptoms. The dynamic interplay between psychosocial and physical factors underscores the complexity of the pain experience. Somehow, the importance of this interplay is beginning to resonate in all phases of non-malignant pain, but does not exert the same influence in malignant pain. Hence, one could argue that the failure to address this component of cancer pain may represent a major reason why pain relief is currently deemed to be suboptimal for cancer patients.

The impetus for early intervention for cancer pain is two-fold: to better serve patients suffering from a complex, common, yet underreported symptom; and to determine whether the benefits of early interdisciplinary intervention in non-malignant pain will translate in malignant pain. Early and comprehensive intervention allows treatment teams the opportunity to assess and assist patients to recognize their symptoms, educate them about the nature of their pain, teach them to evaluate it’s compromising effects and, in turn, address any risk factors that may contribute to the maintenance of pain. Clinicians and researchers must restructure cancer pain management programs to incorporate a psychosocial component. Ultimately, the goal is to establish a standard of practice that revolutionizes the manner in which we view and address cancer pain. n

Last updated on: April 12, 2017
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