Pain and Fear of Cancer Recurrence in Survivors of Childhood Cancer

Cancer-related pain in long-term survivors of oncological diseases: results of a survey on the current care situation

PURPOSE

The increasing survival rates of oncology patients have led to a corresponding increase in long-time survivors living with chronic cancer-related pain. Data is scarce on the care situation for this distinct clinical entity and on specific therapy requirements, such as interdisciplinary, multimodal pain therapy (IMPT). Our cross-sectional study aimed to assess the current care situation, distinct chronification factors, and optimization potential. This survey addresses this need in Germany, but also provides results with international implications.

METHODS

Via an online survey, German Pain Society members involved in the treatment of long-time survivors with chronic cancer-related pain assessed the current care situation, chronification factors, specific treatment needs, and the required practitioner's expertise. The German Pain Society's Cancer Pain Working Group created the non-validated questionnaire using the Delphi method.

RESULTS

One hundred fifty-nine Pain Society members across 70% of Germany's postal regions answered our survey. Respondents (primarily physicians, and 75% with + 6 years of experience) assessed the care situation as worse for chronic cancer-related pain compared to acute pain. Only 10% of the sites provided specific therapy for chronic cancer-related pain (mostly via outpatient treatment). Compared to non-cancer-related pain, additional, cancer-specific chronification factors were assumed, especially at psychological levels, and these need incorporating into therapies. A majority of practitioners recommended cancer-specific IMPT and specific pain expertise for this distinct clinical entity.

CONCLUSIONS

Members from the German Pain Society assume that there are relevant deficits in the care of long-term survivors with chronic cancer-related pain. The situation may be assessed differently by other groups, e.g., oncologists, and the data relates to Germany. Nevertheless, considering the raising survival rates, it can be supposed that there is reason to be concerned about an increasing care deficit. Thus, besides expanding the range of available treatment and raising awareness, IMPT with specially trained personnel should be developed to address the care needs of cancer survivors experiencing chronic cancer-related pain.

Characterization of chronic pain, pain interference, and daily pain experiences in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

ABSTRACT

Although survivors of childhood cancer are at an increased risk, little is known about the prevalence of chronic pain, associated interference, and daily pain experiences. Survivors (N = 233; mean age = 40.8 years, range 22-64 years; mean time since diagnosis = 32.7 years) from the Childhood Cancer Survivor Study completed pain and psychosocial measures. Survivors with chronic pain completed 2-week, daily measures assessing pain and psychological symptoms using mHealth-based ecological momentary assessment. Multivariable-modified Poisson and linear regression models estimated prevalence ratio estimates (PR) and mean effects with 95% confidence intervals (CI) for associations of key risk factors with chronic pain and pain interference, respectively. Multilevel mixed models examined outcomes of daily pain and pain interference with prior day symptoms. Ninety-six survivors (41%) reported chronic pain, of whom 23 (24%) had severe interference. Chronic pain was associated with previous intravenous methotrexate treatment (PR = 1.6, 95% CI 1.1-2.3), respiratory (PR = 1.8, 95% CI 1.2-2.5), gastrointestinal (PR = 1.6, 95% CI 11.0-2.3), and neurological (PR = 1.5, 95% CI 1.0-2.1) chronic health conditions, unemployment (PR = 1.4, 95% CI 1.0-1.9) and clinically significant depression and anxiety (PR = 2.9, 95% CI 2.0-4.2), as well as a diagnosis of childhood Ewing sarcoma or osteosarcoma (PR = 1.9, 95% CI 1.0-3.5). Higher pain interference was associated with cardiovascular and neurological conditions, unemployment and clinical levels of depression and/or anxiety, and fear of cancer recurrence. For male, but not female survivors, low sleep quality, elevated anxiety, and elevated depression predicted high pain intensity and interference the next day. A substantial proportion of childhood cancer survivors experience chronic pain and significant associated interference. Chronic pain should be routinely evaluated, and interventions are needed.

Fear of Cancer Recurrence in Adult Survivors of Childhood Cancer

Importance

Fear of cancer recurrence is common among survivors of adult-onset cancer and associated with increased distress, functional impairment, and health care utilization. However, little is known about the prevalence and risk factors of fear of cancer recurrence among adult survivors of childhood cancer who are also at high risk for subsequent malignant neoplasms.

Objective

To characterize the prevalence of and risk factors for clinically significant fear of cancer recurrence in adult survivors of childhood cancer.

Design, Setting, and Participants

This cross-sectional investigation included participants recruited from the Childhood Cancer Survivor Study, a retrospective cohort study of long-term childhood cancer survivors treated at 31 institutions between 1970 and 1999 across North America. Participants were recruited and completed psychosocial measures via online survey between October 2018 and April 2019. Cancer and treatment-related variables were abstracted from medical records. Data were analyzed from May 2023 to July 2024.

Main Outcomes and Measures

Clinically significant fear of cancer recurrence was assessed via the Fear of Cancer Recurrence Inventory-Short Form. Poisson regression models estimated prevalence ratios (PRs) with 95% CIs adjusted for age and sex to examine the associations of demographic, disease, treatment, and psychosocial variables with fear of cancer recurrence.

Results

The final sample included 229 adult survivors of childhood cancer (115 female [50.2%]; mean [SD] age, 39.6 [9.9] years; mean [SD] time since diagnosis, 31.7 [8.4] years). Among survivors, 38 (16.6%; 95% CI, 11.6%-21.6%) reported clinically significant fear of cancer recurrence, and an additional 36 (15.7%) reported high fear of cancer recurrence. Clinically significant fear of cancer recurrence was associated with unemployment (PR, 2.5; 95% CI, 1.3-4.8), presence of neurologic chronic health conditions (PR, 3.3; 95% CI, 1.8-6.1), treatment with pelvic radiation (PR, 2.9; 95% CI, 1.5-5.6), and amputation or limb sparing surgery (PR, 2.4; 95% CI, 1.2-4.9). Higher risk of clinically significant fear of cancer recurrence was also associated with having either elevated anxiety or depression (PR, 2.6; 95% CI, 1.2-5.9), having both elevated (PR, 3.2; 95% CI, 1.2-8.4), and perceived poor health status (PR, 3.0; 95% CI, 3.1-9.7).

Conclusions and Relevance

Decades following treatment, one-third of childhood cancer survivors in this study reported elevated fear their cancer will recur or a subsequent malignant neoplasm will develop. Findings suggest that fear of cancer recurrence should be routinely screened, and clinically significant symptoms intervened upon as a part of survivorship care.

Fear of cancer recurrence experienced by pediatric survivors of childhood cancer: a scoping review

PURPOSE

In contrast to the extensive literature on fear of cancer recurrence (FCR) experienced by adults, literature evaluating pediatric FCR has just begun to emerge. Given the rapidly expanding body of work assessing FCR in childhood and adolescence, a scoping review was conducted to synthesize existing findings. We aimed to assess (1) the characteristics and methods of this literature, (2) how pediatric FCR has been measured, and (3) the extant knowledge of FCR experienced by pediatric survivors of cancer.

METHODS

Inclusion criteria were: (1) original reports, (2) participants diagnosed with cancer before age 18, (3) current mean age under 18, (4) FCR was explicitly measured (quantitatively) or captured (qualitatively) via survivor self-report, and (6) published in English. Exclusion criteria were: (1) case studies, and (2) grey literature. Three databases (Embase, MEDLINE, PsycINFO) and reference lists from included studies were searched. All studies were screened for inclusion by two authors and all data were extracted by a single author.

RESULTS

Of 3906 identified studies, 19 were included. Studies (published 1991 - 2023) encompassed diverse geographical locations, study designs, and measurement methods. Few assessed FCR as a primary aim (n = 6, 32%). FCR was experienced by 43 - 90% of pediatric survivors. FCR was often positively associated with somatic symptoms and negatively associated with quality of life and emotional functioning.

CONCLUSION

FCR is a prevalent issue for children and adolescents. Additional evidence is needed to explore and confirm preliminary findings. Future pediatric FCR studies should aim to align with published priority research areas.

Benign or painful? The interpretation of pain and fear of progression in rheumatoid arthritis

ABSTRACT

People with chronic pain tend to interpret ambiguous information as health-related, more so than people without. In this study, we aimed to investigate whether people with rheumatoid arthritis (RA) exhibit this interpretation bias and whether it is associated with fear of disease progression (FoP). The interpretation biases of people with RA (n = 164) were compared with an age- and gender-matched control group. We hypothesized that (1) people with RA would have larger interpretation biases than people without; (2) those who scored in the clinical range for FoP would have larger interpretation bias than those who did not; (3) interpretation bias would moderate the relationship between pain severity and FoP; and (4) interpretation bias would explain variance in FoP above and beyond other established predictors. Our results confirmed that people with RA were more likely to interpret ambiguous information as health-related compared with people without RA. This effect was more pronounced for the RA subgroup with clinically significant FoP than those scoring in the normal range. We did not find evidence to suggest interpretation bias moderated the relationship between pain and FoP or that FoP added to the variance of other known predictors. Our results indicate that interpretation bias is common amongst people with RA and is associated with FoP. Further research is required to illuminate the exact nature of this relationship.

Total Pain and Fear of Recurrence in Post-Treatment Cancer Patients: Serial Mediation of Psychological Flexibility and Mentalization and Gender Moderation

Background: The research indicates that painful experiences can significantly affect the fear of cancer recurrence among cancer survivors, which is a distressing concern that influences both physiological and psychological recovery. This cross-sectional study aims to advance our comprehension of the associations between total pain and the fear of recurrence in post-treatment cancer patients by examining two potential mediators: psychological flexibility and mentalization. Methods: Three hundred and thirty-five participants (aged 22 to 88, 49.1% female) who had finished their cancer treatment completed self-report assessments of total pain, their fear of recurrence, psychological flexibility, and mentalization. Results: The serial mediation analysis showed that all dimensions of total pain were positively and indirectly related to the fear of recurrence through psychological flexibility and mentalization in serial. Additionally, gender was found to moderate these serial mediational effects. Conclusions: In line with the psychological flexibility model, personal capacities to face difficult internal/external problems and interpret one's behavior in motivational terms can counterbalance a patient's negative emotions and feelings related to the illness. Gender factors also determine the way in which post-treatment cancer patients manage potential future anxiety and fears.

Body Mindsets are Associated With Pain and Threat-Related Risk Factors for Pain in Survivors of Childhood Cancer

Pain is a common consequence of childhood cancer. While most research has examined biomedical predictors of post-cancer pain, biopsychosocial conceptualisations such as the cancer threat interpretation (CTI) model hold promise for guiding comprehensive pain management strategies. Guided by the CTI model, this cross-sectional study evaluated correlates of post-cancer pain in childhood cancer survivors including threat-related risk factors (bodily threat monitoring, fear of cancer recurrence, help-seeking) and mindsets about the body. In the preceding three months, 21.8% of the survivors reported chronic pain (>3 months), and 14.3% experienced pain most days. Greater bodily threat monitoring, more fear of cancer recurrence, and more help-seeking were associated with more pain. There was heterogeneity in the mindsets that survivors of childhood cancer hold about their bodies. Holding the mindset that the 'body is an adversary' was associated with more pain, greater bodily threat monitoring, and more fear of cancer recurrence. Holding the mindset that the 'body is responsive' was associated with less bodily threat monitoring, while the mindset that the 'body is capable' was associated with greater help-seeking. A path model demonstrated a significant combined indirect effect of the 'body is an adversary' mindset on pain through bodily threat monitoring and fear of cancer recurrence. Overall, this study supported that a sub-group of childhood cancer survivors experience persistent and interfering pain and provided cross-sectional support for threat-related correlates for pain aligning with the CTI model. Body mindsets were associated with pain and threat-related correlates and may represent a novel target to support survivors with pain. PERSPECTIVE: This article presents associations of body mindsets, threat-related risk factors, and pain in survivors of childhood cancer (aged 11-25), guided by the Cancer Threat Interpretation model. The study indicates that body mindsets may be novel targets to embed in comprehensive post-cancer pain management approaches to support young survivors with pain.

The bodily threat monitoring scale: Development and preliminary validation in adult and childhood cancer survivors

OBJECTIVE

Bodily threat monitoring is a core clinical feature of Fear of cancer recurrence (FCR) and is targeted in psycho-oncology treatments, yet no comprehensive self-report measure exists. The aim of this study was the theory-informed development and initial validation of the Bodily Threat Monitoring Scale (BTMS).

METHODS

Adult survivors of breast and gynaecological cancers (Study 1: N = 306, age = 37-81 years) and childhood cancer survivors (Study 2: N = 126, age = 10-25 years) completed the BTMS, designed to assess how individuals monitor for and interpret uncertain symptoms as indicating that something is wrong with their body. Participants completed measures to assess construct and criterion validity of the BTMS, and childhood cancer survivors (Study 2) completed the BTMS again 2 weeks later to assess test-retest reliability.

RESULTS

The 19-item BTMS demonstrated excellent internal consistency across adult and childhood cancer samples (α = 0.90-0.96). Factor analyses indicated two subscales capturing 1. Monitoring of bodily sensations and 2. Threatening interpretations of bodily sensations. Two-week stability estimates were acceptable. For construct validity, the BTMS correlated with body vigilance and anxiety sensitivity. The BTMS also demonstrated criterion validity, yielding significant associations with FCR, intolerance of uncertainty, help-seeking behaviours, and quality of life. The BTMS was associated with FCR while controlling for body vigilance and anxiety sensitivity, indicating a unique contribution of this theory-informed measure.

CONCLUSIONS

The BTMS shows evidence of sound psychometric properties and could be used to elucidate the role of bodily threat monitoring in the maintenance and management of FCR.

Chronic pain in children and adolescents diagnosed with cancer: the challenge of mitigating the pain and the potential of integrating exercise into pain management

BACKGROUND

Pain is one of the most common and distressing symptoms experienced by children and adolescents diagnosed with cancer. It is vital that children and adolescents receive adequate pain management early on in their cancer treatments to mitigate pain and cancer-related symptoms. Exercise training shows particular promise in the management of acute and chronic pain among children and adolescents diagnosed with cancer.

METHODS

This position paper comes to outline the challenge of mitigating pain in children and adolescents diagnosed with cancer, and the potential benefits of integrating exercise training to the management of chronic pain in this population in need.

RESULTS

Integrating exercise training into the care and pain management of children and adolescents diagnosed with cancer who have chronic pain would have the advantage of addressing several shortcomings of pain medication. Pain medication aims to temporarily manage or reduce pain; it does not have the potential to directly improve a patient's physical condition in the way that exercise training can. The current paucity of data available on the use of exercise training as a complementary treatment to pain medications to reduce chronic pain in children and adolescents diagnosed with cancer allows only for hypotheses on the effectiveness of this pain management modality.

CONCLUSION

More research on this important topic is necessary and mitigating pain effectively while also reducing the use of opioid pain medication is an important goal shared by patients, their families, clinicians, and researchers alike. Future research in this area has great potential to inform clinical care, clinical care guidelines, and policy-making decisions for pain management in children and adolescents diagnosed with cancer who experience chronic pain.

Self-compassion and fear of cancer recurrence in Chinese breast cancer patients: The mediating role of maladaptive cognitive styles

OBJECTIVES

Previous studies have examined the benefits of self-compassion for psychological symptoms in breast cancer patients; however, little is known about the role of self-compassion for patients' fear of cancer recurrence (FCR) as well as the underlying mediating mechanisms. This study aimed to examine the effect of self-compassion on FCR, and whether maladaptive cognitive styles mediate this relationship.

METHODS

This cross-sectional study included 304 females with breast cancer. A self-report questionnaire was used to assess patients' self-compassion, maladaptive cognitive styles (i.e., rumination and catastrophising), and FCR. Parallel mediation analyses were conducted to examine the research questions.

RESULTS

Approximately half of the patients with breast cancer reported elevated levels of FCR. Self-compassion was negatively related to FCR, and the relationship between self-compassion and FCR was mediated by catastrophising, whereas rumination did not significantly mediate the relationship between self-compassion and FCR.

CONCLUSIONS

Our findings suggest that self-compassion and catastrophising are closely associated with FCR in patients with breast cancer, and catastrophising is a mediator between self-compassion and FCR. Clinicians could reduce breast cancer patients' FCR by enhancing their self-compassion and improving their maladaptive cognitive styles.