Psychosocial Influences On Painrelated Limitations In Cancer Survivors

Many individuals either discontinue or avoid activities that are associated with pain.97,98 These might include activities of daily living, social and recreational activities, or occupational activities.23 Research suggests that 15-20% of individuals with chronic musculoskeletal pain conditions will become permanently occupation-ally disabled.99,100

Few research investigations have addressed the nature or severity of functional limitations due to pain in cancer survivors.17,23,101 It is possible that the prevalence of pain-related disability in cancer survivors might be comparable to that observed in other pain conditions.97 102 In the study by Bishop and Warr,50 only one third of breast cancer survivors were employed outside the home; 20% were receiving disability benefits. Little is currently known about the degree to which pain accounts for reduced occupational involvement of cancer survivors. Changes in life priorities, or other symptoms such as fatigue might also contribute to reduced occupational involvement.

Although pain has typically been considered the primary determinant of functional limitations in chronic pain sufferers, it has also been suggested that pain and disability are distinct and partially independent phenomena.99,103 Research suggests that, in chronic pain patients, pain intensity rarely accounts for more that 10% of the variance in the severity of functional limitations.97 Although the relation between pain and functional limitations has yet to be examined in cancer survivors, Sullivan et al9 reported that pain symptoms accounted for only 9% of the variance in self-rated functional limitations in a sample of mixed neuropathic pain patients. In recent years, increasing attention has been devoted to assessing the degree to which psychosocial factors might contribute to heightened risk for prolonged pain-related functional limitations.

Numerous investigations have been conducted addressing the role of psychosocial factors in the prediction of prolonged pain and disability associated with work-related musculoskeletal conditions.26,104,105 Systematic reviews of prospective cohort studies indicate that initial levels of pain severity are predictive of prolonged pain-related disability.106 Gheldolf et al.107 found that pain-related fears were significant determinants of the inability to work in individuals with back pain. Cross-sectional and prospective studies have shown that high levels of pain catastrophizing are associated with more intense pain, more severe functional limitations, and more prolonged work absence.108-110 Lack of confidence in the ability to perform physical activities has been associated with more severe functional limitations.62,111 Pain severity and depressive symptoms have been associated with premature termination of involvement in pain management programs, with greater occupational disability, and have been implicated as factors contributing to the transition from acute to chronic pain.86,112-114 On the basis of this research, variables such as pain catastrophizing, pain-related fears (i.e., fear of movement/re-injury), self-efficacy, outcome expectancies, and depression have come to be construed as psychosocial risk factors for chronic pain and disability.104,115,116 Future research should examine whether psychosocial risk factors for pain-related disability identified in other pain conditions also predict pain-related disability in cancer survivors.

Table 1 provides a selective list of potential psychosocial risk factors for prolonged pain and disability in cancer survivors and the instruments commonly used to assess them.117-129 It is important to note that these scales were not specifically developed for use with cancer survivors and therefore reliability and validity of these scales with cancer survivors must be investigated rather than assumed.

Only recently has research begun to investigate risk factors for pain and functional limitations in cancer survivors. Presurgical pain severity has been shown to predict the development of chronic pain symptoms in women treated for breast cancer.130,131 Presurgical pain has been shown to contribute to acute pain following surgery and to acute and chronic phantom breast syndrome in women treated for breast cancer.132,133 Presurgical emotional distress has also been shown to predict postsurgical acute pain in women with breast cancer.134

Table 1. Measurement Instruments for Psychosocial Risk Factors for Pain and Disability

Risk factor

Measure

Reference

Catastrophizing Pain-related fears

Depression

Anxiety

Self-efficacy

Coping

Perceived limitations/ Pain beliefs

Person-Environment factors

Pain Severity

Pain Catastrophizing Scale Tampa Scale for Kinesiophobia Fear-Avoidance Beliefs Questionnaire

Beck Depression Inventory II Centre for Epidemiological Studies Scale for Depression

State-Trait Anxiety Inventory Pain Anxiety Symptom Scale

Chronic Pain Self-Efficacy Scale The Functional Self-Efficacy Scale

Coping Strategies Questionnaires Multidimensional Pain Inventory Vanderbilt Pain Management Inventory Pain Disability Index

Survey of Pain Attitudes Biobehavioral Pain Profile

McGill Pain Questionnaire Neuropathic Pain Scale

Sullivan et al11"7 Kori et al.118 Waddell et ai119 Beck et ai120 Radloff121

Spielberger et al122 McCracken123 Anderson et al124 Barry et al.64 Rosenstiel and Keefe46 Kerns et al.1'25 Brown and Nicassio68

Pollard126

Jensen et al}'22 Dalton et al.53

Melzack128

Galer and Jensen129

Pain severity in cancer survivors might impact on function by interfering with an individual's ability to attend or concentrate on a particular task to the degree required for successful completion.135 Numerous investigations have shown that pain engages attention and interrupts current cognitive activity.136 The attentional disruption effects of pain are greatest when the pain is novel, and unpredictable.137138 For the cancer survivor who experiences intermittent or persistent pain, negative effects of pain on attention might have a deleterious impact on his or her ability to perform social, recreational or occupational tasks. The relation between pain and compromised attentional processing in cancer survivors with pain should be investigated in future research.

Emotional arousal states such as anxiety and fear, particularly when associated with pain, can have a marked negative impact on task-related attentional engagement.136,139 Emotional distress has also been shown to impact negatively on individuals' ability to adequately perform cognitive tasks. Depressive symptoms can interfere with the processing of complex information.140 Depressive symptoms can also compromise the engagement of motivational resources necessary to perform various physical or cognitive tasks.141 The adequate management of emotional distress states might be a key component of success for treatment programs that aim to facilitate social, recreational, and occupational re-integration of the cancer survivor with pain.

Risk factor research with cancer survivors should lead to the development of screening tools for the identification of individuals at risk for problematic outcomes following cancer treatment. Individuals identified at risk might then be considered for targeted interventions that might prevent the development of persistent pain and disability following treatment. In the absence of knowledge about relevant prognostic factors for problematic outcomes, interventions specifically targeting prognostic factors cannot be developed as yet.96

7.0. THE TREATMENT OF PAIN AND PAIN-RELATED DISABILITY IN CANCER SURVIVOR WITH PERSISTENT PAIN

A number of pharmacological interventions for cancer pain and post-cancer pain have been described in the literature.142 Different classes of medication such as over-the-counter analgesics, opioids, and anticonvulsant drugs have been shown to yield significant pain relief benefit, at least for a certain percentage of patients.2,3 The medical management of pain in cancer survivors is described in more detail in Chapter 10.

However, there are indications that cancer survivors might not always take full advantage of the pain management options available to them.143,144 Ward145 described a number of factors that influence individuals' decisions about the type of pain management approaches they will consider for the treatment of their pain. Ward reported that patients' fears about side effects or addiction, or concerns that pain complaints might be negatively perceived by treating professionals interfered with the proper management of pain symptoms. It has been suggested that the provision of accurate information about pain management options, and education about the appropriate use of pain medication should be an integral component of the treatment of cancer survivors.143-146

Concerns about side effects of pain medication might be particularly pertinent to the cancer survivor who wishes to resume pre-cancer role responsibilities. Certain medications used in the management of pain, such as some forms of antidepres-sants, can lead to excessive morning fatigue, dry mouth, nausea, and lethargy. Other medications, such as opioids, can result in mental clouding, and impaired coordination that can interfere with the adequate or safe performance of many activities of daily living. Although many side effects of pain medication dissipate in time, some individuals will continue to experience medication side effects of significant severity even after extended use. The cost-benefit analysis of balancing the pain reduction with the adverse side effects of medication might present particular challenges for the cancer survivor with pain who wishes to resume occupational involvement.

Cognitive-behavioral approaches have dominated psychological intervention research on cancer pain management. Cognitive-behavioral perspectives proceed from the view that an individual's interpretation, evaluation and beliefs about their health condition, and their coping repertoire with respect to pain and disability will impact on the degree of emotional and physical disability that will be associated with cancer.25,28 It is important to note that the term cognitive-behavioral does not refer to a specific intervention but, rather, to a class of intervention strategies. The strategies included under the heading of cognitive-behavioral interventions vary widely and may include self-instruction (e.g., motivational self-talk), relaxation or biofeedback, developing coping strategies (e.g., distraction, imagery), increasing assertiveness, minimizing negative or self-defeating thoughts, changing maladaptive beliefs about pain, and goal setting.67 A client referred for cognitive-behavioral intervention may be exposed to varying selections of these strategies.

In the early years of psychosocial oncology, numerous investigations assessed the effectiveness of cognitive-behavioral techniques to minimize the negative impact of aversive cancer treatment interventions.147 148 Education has been a key feature of many interventions aimed at assisting individuals cope with aversive effects of cancer treatment or persistent pain following treatment.144 145 149 Educational approaches have been used to increase individuals' understanding about pain symptoms, minimizing barriers to accessing options for pain treatment, and methods of managing the stresses associated with pain. Educational interventions have been offered as stand alone interventions, or in combination with interventions aimed at increasing the cancer survivors' ability to cope with pain symptoms.28

A number of cognitive-behavioral interventions have been developed to assist patients in coping with acute procedural pain that might be experienced during cancer treatment. For example, distraction strategies and imagery-based strategies have been used for the management of procedural pain in both children and adults.147,148 Pain control strategies are typically taught prior to exposure to the painful procedure, and patients might then be coached through the procedure by a clinician. The results of several investigations suggest that these methods can be effective in reducing pain symptoms and emotional distress associated with painful cancer treatment.150-152

Albeit important intervention tools for acute procedural pain, strategies such as distraction, imagery, and hypnosis may have limited applicability for persistent pain. The high attentional resource demands of these strategies might interfere with a person's ability to engage in any other activity while utilizing the strategy. The attentional resource demands of these strategies also place limits on the duration of time that they can be invoked to deal with a pain episode. For the patient who must deal with pain symptoms throughout the day, for months or years, even though they may wax and wane, alternate approaches to pain management are needed.

Keefe et al.153 described a three-session cognitive-behavioral, partner-assisted, pain-management intervention for terminally ill cancer patients. The program of intervention was developed on the basis of research with osteoarthritis patients showing that partner-assisted pain management improved the physical and emotional function of the pain patient as well as the emotional functioning of the spouse or caregiver.153 The three-session program included (1) education about the nature of pain experience and different options for pain control, (2) instruction in the use of pain coping strategies, and (3) instruction in activity pacing. The intervention program was delivered by nurse educators. Patient and partner outcomes following participation in the partner-assisted intervention were compared to a usual care control group. Although there were no significant differences between groups on patient outcomes, there was a trend toward reduced pain and increased quality of life. The partners in the partner-assisted intervention showed significant increases of confidence in their ability to assist the patients in methods of pain control.146 The authors suggested that the modest impact of the intervention on patient outcomes might have been due to the severity of physical and emotional distress experienced by the terminally ill patients. It is possible that this type of intervention, perhaps longer in duration, or combined with medication, might be useful for cancer survivors and their partners.

Few interventions have addressed the efficacy of pain management interventions for cancer survivors.22,154 In a recent study, Dalton et al}hh examined the effects of coping skills training on pain and distress of cancer survivors. In one group, patients received a standardized intervention program consisting of education, coping skills training, problem-solving, cognitive-restructuring, and relaxation. A second treatment condition consisted ofsimilar elements but was customized to the patients'

pain problem profile. Both treatment conditions yielded more positive pain-related outcomes than the control group.155 Tailoring the intervention to the patient's pain profile led to more rapid improvement than the standardized intervention.

Clinical findings suggesting that pain contributes only modestly to disability, and that pain management programs yield only minimal change in pain levels have led many investigators to reconsider whether pain reduction should be the primary goal of psychological interventions for individuals with persistent pain.96,156 Research suggests that programs that maximize activity involvement and resumption of key life roles are the ones most likely to be associated with return to pre-illness (or pre-injury) levels of functioning.157-159

As can be seen from the list of strategies included in cognitive-behavioral pain management programs, some are clearly linked to facilitating resumptions of life role activities (e.g., goal setting) while others are primarily palliative in nature (e.g., relaxation, imagery). In a related fashion, many cognitive-behavioral interventions have as their primary focus the reduction of emotional distress or the reduction of pain. While emotional distress and pain no doubt contribute to functional limitations, the reduction of emotional distress and pain are typically not sufficient to contribute in a meaningful manner to resumption of life role activities.159 There are grounds to caution the use of overly palliative or passive psychological intervention strategies in the treatment of individuals with persistent pain when functional restoration is also a major goal. In other domains of practice, palliative or passive intervention strategies have been shown to accentuate as opposed to ameliorate pain-related disability.97

There have been a number of recent studies that have highlighted that the psychological predictors of pain are quite distinct from the psychological predictors of disability.110,160 These findings suggest that if disability reduction is the goal of treatment, interventions will differ from those that would be considered if pain reduction was the goal of treatment.161 Clearly, from a quality of life perspective, maximizing or restoring function in cancer survivors is of primary concern.

In recent years, a number of risk factor targeted interventions have been developed for the prevention of pain-related disability associated with musculoskeletal conditions.162-164 These approaches differ from traditional psychosocial interventions for pain insofar as individuals are selected for treatment on the basis of psychosocial risk profiles, and interventions are designed to specifically target prognostic factors for pain-related disability. Research to date indicates that treatment-related reductions in psychological risk factors can yield significant improvement in pain severity, depression, and return to work.115,162-165 Intervention approaches that target risk factors for disability associated with post-cancer pain might prove to be effective in restoring function, maximizing full social participation and increasing quality of life in cancer survivors.

8.0. FUTURE RESEARCH

As this review indicates, questions concerning the psychosocial dimensions of pain and function in cancer survivors have yet to find a place on the priority list of many research agendas. Although the magnitude of the pain problem in cancer survivors has been known for some time, basic questions about the nature and severity of functional limitations in cancer survivors with pain have yet to be addressed. Research describing the adverse impact of pain symptoms on the lives of cancer survivors will

Table 2. Building a Research Agenda: Priority Areas

1. Determining the prevalence of mental health problems in cancer survivors with pain.

2. Identification of vulnerability and resilience factors for depression in cancer survivors with pain.

3. The development and evaluation of interventions for the management of depression in cancer survivors with pain.

4. Examining the influence of opioids on the efficacy of interventions for depression in cancer survivors with pain.

5. Identification of vulnerability and resilience factors for functional limitations in cancer survivors with pain.

6. Development of screening measures for the detection of risk factors for pain and functional limitations in cancer survivors.

7. Investigating the role of fatigue as a determinant of health and behavioral health outcomes in cancer survivors with pain.

8. Investigating the effects of pain severity on attention and concentration in cancer survivors with pain.

9. Examining the determinants of decisions to discontinue employment in cancer survivors with pain. 10. Investigating the efficacy of interventions designed to reduce functional limitations and facilitate life role reintegration in cancer survivors with pain.

be required in order to mobilize the resources necessary to meet the treatment needs of this ever-growing population.

Research will also be required to identify the determinants of behavioral health outcomes and functional limitations in cancer survivors with pain. In the absence of this information, the development of intervention programs is likely to proceed with little empirical direction. In the interim, based on the literature addressing the psychological determinants of pain and pain-related disability in other domains of pain research, intervention strategies that aim to reduce helplessness and catastrophic thinking, increase perceived control and self-efficacy, and maximize resumption of important life role activities may contribute to more positive health and behavioral health outcomes for cancer survivors.28,165,166 Table 2 provides a summary of priority research areas relevant to psychosocial factors associated with pain outcomes in cancer survivors.

Cancer survivors will continue to experience debilitating symptoms of pain following treatment that can impact on function. Once symptoms of pain become chronic, available methods of managing pain, whether pharmacological or psychological, have only modest impact on suffering and function. If individuals at risk for persistent post-cancer pain and those with high levels of pain-related disability can be identified before the problem becomes chronic, individuals' suffering might be prevented or reduced to a significant degree. There is an urgent need to develop a stronger research basis for the development of interventions aimed at preventing and managing the pain and its functional impact among cancer survivors with different types of cancers. Given the pending increase in the size of the cancer survivor population and the inherent morbidity and personal and societal costs associated with persistent pain following cancer treatment, increased knowledge ofthe determinants of post-cancer pain and disability will be important both for improving quality of life of patients and maximizing the overall cost-effectiveness of cancer treatment.

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