Meaning-centered pain coping skills training for patients with metastatic cancer: Results of a randomized controlled pilot trial

Trends in Outpatient Opioid Prescriptions for Cancer Pain Between 2016 and 2021

PURPOSE

Increasing opioid regulations have resulted in reduced opioid prescriptions, including for cancer pain, despite guideline exemptions. Data after 2017 following the Centers for Disease Control's 2016 pain management guidelines are limited on opioid prescribing practices of oncologists. The purpose of this study was to examine the trend in dose of opioids prescribed by oncologists to patients with cancer pain referred to outpatient palliative care between 2016 and 2021.

METHODS

A single-center, cross-sectional, retrospective study was conducted at a tertiary cancer center's outpatient palliative care clinic including 375 adult patients referred for initial consultation for cancer pain between 2016 and 2021. The main outcome was the trend in prescribed opioid doses, expressed as morphine-equivalent daily dose in mg/day. Additional analyses were conducted to identify predictors of opioid prescriptions.

RESULTS

The median age (range) was 61 (19-85), 50% were women, 67% were non-Hispanic White, 80% had advanced cancer, and 91% reported proficiency in English. Ninety-five percent had solid tumors, predominantly GI (22%), breast (15%), and genitourinary (14%). From 2016 to 2021, the median dose of opioids decreased from 37.5 to 7.5 (P < .001). The proportion of patients on long-acting opioid decreased from 26% to 12% (P = .019), whereas that of patients without opioids increased from 28% to 41% (P = .008). CAGE-AID score (reflecting potential for substance abuse; β Coefficient, 43.2 [95% CI, 23.3 to 63.2], P < .001) and pain on the Edmonton Symptom Assessment Scale (5.77 [95% CI, 2.6 to 8.9], P < .001) predicted higher opioid dose, whereas non-English language predicted lower dose (-26.9 [95% CI, -53.1 to -0.8], P = .043).

CONCLUSION

During the study period, we observed a five-fold decline in opioid dose prescribed by oncologists for cancer pain. This raises concerns for undertreatment of pain in patients with cancer.

Effectiveness of meaning-centered interventions on existential distress and mental health outcomes in cancer survivors and their family caregivers: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cancer is a global public health concern that causes psychosocial and spiritual challenges in those who suffer from it and their family caregivers. Meaning-centered interventions have a positive impact on improving anxiety and depression in patients with advanced cancer. However, the impact of meaning-centered interventions on existential distress of patients with cancer and family caregivers' mental health is still unclear.

AIMS

To examine the efficacy of meaning-centered interventions in alleviating existential distress, enhancing quality of life, and fostering a sense of meaning among cancer survivors and their family caregivers.

METHODS

This systematic review and meta-analysis were conducted according to the Preferred Reporting Item for Systematic Reviews and Meta-analysis 2020 statement. A comprehensive search was conducted from inception until September 2023 across nine databases: PubMed, Embase, Web of Science, PsycINFO, The Cochrane Library, CINAHL, Scopus, WANFANG, and CNKI. Heterogeneity testing and meta-analyses were conducted using Review Manger 5.3. We calculated standard mean deviations and 95% confidence intervals and presented forest plots for assessing intervention effects. Two reviewers independently evaluated the risk of bias of all included articles. STATA 17.0 was used for publication bias analysis.

RESULTS

The review included 25 studies with 2399 participants, and 22 were included in the meta-analysis. Meaning-centered interventions enhanced quality of life, alleviated existential distress, and reduced depressive symptoms and cancer-related fatigue. They did not affect spiritual well-being. The subgroup analysis showed that the individual form and long-term intervention (≥3 months) enhanced the quality of life in cancer survivors. Meaning-centered interventions reduce depression in advanced cancer survivors more than in mixed-stage cancer survivors. Meaning-centered interventions significantly enhanced benefit finding for family caregivers.

LINKING EVIDENCE TO ACTION

Meaning-centered interventions may improve mental health for patients with cancer and their family caregivers. Future research must include diverse cultural perspectives to understand the impact of meaning-centered interventions on various groups.

Effectiveness of meaning-centered interventions on anxiety and depressive symptoms, sense of meaning, and quality of life in patients with advanced cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

The effect of Meaning-Centered Interventions (MCI) in advanced cancer patients requires further comprehensive research.

METHODS

Two researchers independently searched the PubMed, EMBASE, SCOPUS, Cochrane, and PsycINFO databases to investigate the impact of MCI on anxiety and depressive symptoms, sense of meaning, and quality of life (QoL) in patients with advanced cancer from inception to April 2024. Statistical analyses were conducted using standardized mean difference (SMD) as the effect size with Stata 17.0 software for analysis, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was employed to assess the certainty of evidence.

RESULTS

Data from 12 eligible studies, involving a total of 1,459 participants, were included in the review. The analysis found that 3 studies with 321 participants reported an improvement in the quality of life (QoL) of patients with advanced cancer within one month after the intervention, compared to the control group (SMD, 0.27; 95% CI, 0.03 to 0.52; I2 = 0%; p = 0.03). However, this effect did not persist during the 2-6 months following the intervention. In addition, 4 studies with 434 participants indicated that MCI was associated with an enhanced sense of meaning (SMD, 0.22; 95% CI, 0.09 to 0.36; I2 = 0%; p = 0.002). Furthermore, 8 studies with 1,192 participants and 7 studies with 1,156 participants found that MCI was associated with a reduction in depressive symptoms (SMD, -0.15; 95% CI, -0.24 to -0.05; I2 = 44.8%; p = 0.002) and anxiety symptoms (SMD, -0.16; 95% CI, -0.26 to -0.07; I2 = 46.3%; p = 0.001), respectively.

CONCLUSIONS

Moderate-quality evidence indicates that MCI enhances the sense of meaning among patients with advanced cancer and reduces depressive and anxiety symptoms, but it does not improve their QoL.

Belief in living a meaningful life and adjustment to chronic pain

OBJECTIVE

Chronic pain is a global health concern and often interferes with multiple aspects of individuals' lives (eg, physical activities), diminishing a person's ability to engage in activities that promote meaning in life. However, it is not well understood how believing that one can live a meaningful life despite pain could contribute to improved function among individuals with chronic pain. The aim of the present study was to better understand the role that belief in living a meaningful life despite pain might have on adjustment to chronic pain.

METHODS

Participants (n = 164) were individuals with chronic pain who completed baseline data from 2 closely related randomized clinical trials. Hierarchical regression analyses were used to examine the hypotheses that one's belief in living a meaningful life despite pain will be associated with function (pain interference and symptoms of posttraumatic stress disorder, depression, and anxiety) and that the belief in living a meaningful life despite pain would moderate the associations between pain intensity and function.

RESULTS

Belief in living a meaningful life despite pain was significantly associated with less pain interference and less severe symptoms of posttraumatic stress disorder, anxiety, and depression, supporting the potential role of this variable in adaptive adjustment to chronic pain. However, one's belief in living a meaningful life despite pain did not moderate the associations between pain intensity and function.

CONCLUSIONS

Results provide important theoretical and clinical information about how believing that one can live a meaningful life despite pain might serve as an important process for adjustment to chronic pain.

Effect of applying digital health in palliative care for patients with advanced cancer: a meta-analysis and systematic review

PURPOSE

To assess the effectiveness of applying digital health palliative care to improve symptoms, mood, and quality of life in patients with advanced cancer.

METHODS

We searched PubMed, Embase, Web of Science, Cochrane Library (CENTRAL), and CINAHL databases on November 16, 2023, to identify randomized controlled trials of the impact of palliative care applying digital health on patients with advanced cancer. The Cochrane Risk of Bias Tool version 1.0 was used to evaluate the quality of randomized controlled trials.

RESULTS

A total of 20 randomized controlled trials were included, of which 18 were meta-analyzed. Compared with usual care, palliative care applying digital health was effective in improving symptoms (SMD = -0.21, 95% CI: -0.37 to -0.06, P = 0.007) and reducing the intensity of pain (SMD = -0.49, 95% CI: -0.85 to -0.13, P = 0.008) in patients with advanced cancer, but no effective improvement in depressive symptoms, anxiety symptoms, or quality of life was found.

CONCLUSIONS

Our systematic review provides evidence that palliative care applying digital health has great potential to improve symptoms in patients with advanced cancer, but more research is needed to explore its impact on mood and quality of life.

Impact of spiritual interventions in individuals with cancer: A systematic review and meta-analysis

PURPOSE

This meta-analysis aimed to determine how spiritual interventions affect cancer patients' physical, emotional, and spiritual outcomes and quality of life.

METHODS

Between 2012 and May 2024, the Cochrane Library, Scopus, PubMed, and Web of Science were searched considering the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Twenty-six randomized controlled trials were included, and 16 were synthesized in the meta-analysis. Bias risk was evaluated using the Cochrane risk-of-bias methodology for randomized studies. The Grading of Recommendations, Assessment, Development, and Evaluations tool was employed for evidence certainty. Heterogeneity was expressed through I2 and Q statistics. Hedge's g was calculated for effect sizes. Egger's and Kendall's Tau were used for publication bias.

RESULTS

Spiritual interventions yielded beneficial effects on fatigue (Hedges's g = 0.900, p < 0.001) and pain (Hedges's g = 0.670, p < 0.001) but not for overall symptom burden (Hedges's g = 0.208, p = 0.176). Significant effects were found for anxiety (Hedges's g = 0.301, p < 0.001), depression (Hedges's g = 0.175, p = 0.016), and psychological distress (Hedges's g = 0.178, p = 0.024), except for hopelessness (Hedges's g = 0.144, p = 0.091). Spiritual interventions enhanced faith (Hedges's g = 0.232, p = 0.035), the meaning of life (Hedges's g = 0.259, p = 0.002), spiritual well-being (Hedges's g = 0.268, p < 0.001), and quality of life (Hedges's g = 245, p < 0.001). Moderator analysis pointed out that cancer stage, total duration, delivery format, providers' qualification, content, and conceptual base of spiritual interventions significantly affect physical, emotional, and spiritual outcomes and quality of life.

CONCLUSION

This meta-analysis highlighted the benefits of spiritual interventions with varying effect sizes on patients' outcomes, as well as quality of life in cancer, and shed on how to incorporate these approaches into clinical practice.

Cognitive flexibility training for chronic pain: a randomized clinical study

Introduction

Previous studies suggest an association between cognitive flexibility and development of chronic pain after surgery. It is not known whether cognitive flexibility can be improved in patients with chronic pain.

Objectives

This study tested whether a neurocognitive training program results in improved cognitive flexibility and pain in patients with chronic pain.

Methods

We conducted a single-center, prospective, randomized study investigating 5-week daily neurocognitive training in patients with chronic pain. Participants (n = 145) were randomized into neurocognitive training or care as usual, and they completed assessments at baseline, posttreatment, and 3 months. The treatment group was asked to spend 35 minutes daily completing a program with tasks on cognitive flexibility, memory, attention, and speed. The primary outcome was performance on the neurocognitive performance test (NCPT). Secondary outcomes included levels of pain interference and severity.

Results

At 5 weeks, the treatment group showed greater improvements on NCPT compared with the control group (d = 0.37); effect size was smaller at 3 months (d = 0.18). The treatment group reported lower pain severity at 5 weeks (d = 0.16) and 3 months (d = 0.39) than the control group, but pain interference was only lower at 3 months (d = 0.20).

Conclusions

Outcomes suggest that using neurocognitive training to modify cognitive flexibility in patients with chronic pain may improve pain severity. This study provided effect size estimates to inform sample size calculations for randomized controlled trials to test the effectiveness of neurocognitive interventions for the prevention and treatment of chronic pain.

The role of spirituality in pain experiences among adults with cancer: an explanatory sequential mixed methods study

PURPOSE

Foundational research demonstrates that spirituality may affect the way people with cancer experience pain. One potential route is through alterations in thoughts and beliefs, such as pain-related catastrophizing. The purpose of this study is to understand whether spirituality impacts pain experiences through pain-related catastrophizing.

METHODS

This explanatory sequential mixed methods study was informed by an adapted Theory of Unpleasant Symptoms. Data were collected via online surveys (N = 79) and follow-up qualitative interviews (N = 25). Phase 1 employed Empirical Bayesian analysis. Phase 2 used deductive content analysis. Phase 3 involved creating a mixed methods joint display to integrate findings and draw meta inferences.

RESULTS

Results indicate that total spiritual well-being was directly negatively associated with pain-related catastrophizing, and indirectly negatively associated with the outcomes of pain interference, pain severity, and pain-related distress. Qualitative categories highlight the supportive role of spirituality when facing pain, while also shedding light on the limitations of spirituality in the context of some pain (i.e., severe, neuropathic, and/or chronic). Mixed methods findings reveal the importance of spirituality for some people as they face cancer and cancer-related pain, as well as the need for integrating spirituality as part of a larger pain management plan.

CONCLUSIONS

This research advances supportive cancer care by exploring the complex role of spirituality in pain experiences. Findings will inform further exploration into the role of spirituality in supporting holistic symptom management in the context of cancer, as well as developing and testing interventions to enhance spirituality and address symptom-related suffering.

Meaning-centered pain coping skills training for patients with metastatic cancer: Protocol for a randomized controlled efficacy trial

BACKGROUND

Many patients with advanced cancer describe pain as a debilitating symptom that greatly interferes with daily activities and enjoyment of life. Psychosocial interventions can improve cancer-related pain but rarely address spiritual concerns (e.g., loss of meaning, peace), which can influence the pain experience for those facing life-threatening illness. To address these needs, we systematically developed and pilot tested a novel psychosocial intervention called Meaning-Centered Pain Coping Skills Training (MCPC). In this randomized controlled trial, we aim to determine MCPC's efficacy for reducing pain interference (primary outcome) and improving secondary outcomes. We will also estimate MCPC's cost-effectiveness.

METHOD/DESIGN

Patients (target N = 210) with advanced solid tumor malignancies (Stage IV) and clinically-elevated pain interference will be enrolled and block randomized with equal allocation to MCPC + enhanced usual care or enhanced usual care alone. MCPC's four, videoconferenced, 45-60 min weekly sessions will be individually delivered by trained study therapists. Primary (pain interference) and secondary (pain severity, anxiety and depressive symptoms, pain self-efficacy, social support, spiritual well-being) patient-reported outcomes will be assessed at baseline, and 8-weeks (primary endpoint) and 12-weeks after baseline.

CONCLUSION

Our MCPC intervention is the first to systematically address the biopsychosocial-spiritual aspects of pain in patients with advanced cancer. If MCPC demonstrates efficacy, next steps will involve hybrid efficacy-effectiveness and implementation work to broaden access to this brief, manualized, remotely-delivered intervention, with the goal of reducing suffering in patients with life-threatening illness.

The Role of Spirituality in Pain Experiences among Adults with Cancer: An Explanatory Sequential Mixed Methods Study

Purpose

Foundational research demonstrates that spirituality may affect the way people with cancer experience pain. One potential route is through alterations in thoughts and beliefs, such as pain-related catastrophizing. The purpose of this study is to understand whether spirituality impacts pain experiences through pain-related catastrophizing.

Methods

This explanatory sequential mixed methods study was informed by an adapted Theory of Unpleasant Symptoms. Data were collected via online surveys (N = 79) and follow-up qualitative interviews (N = 25). Phase 1 employed Empirical Bayesian analysis. Phase 2 used deductive content analysis. Phase 3 involved creating a mixed methods joint display to integrate findings and draw meta inferences.

Results

Results indicate that spirituality was directly negatively associated with pain-related catastrophizing, and indirectly negatively associated with the outcomes of pain interference, pain severity, and pain-related distress. Qualitative categories highlight the supportive role of spirituality when facing pain, while also shedding light on the limitations of spirituality in the context of some pain (i.e., severe, neuropathic, and/or chronic). Mixed methods findings reveal the importance of spirituality for some people as they face cancer and cancer-related pain, as well as the need for integrating spirituality as part of a larger pain management plan.

Conclusions

This research advances supportive cancer care by exploring the complex role of spirituality in pain experiences. Findings will inform further exploration into the role of spirituality in supporting holistic symptom management in the context of cancer, as well as developing and testing interventions to enhance spirituality and address symptom-related suffering.