Psychosocial predictors of posttreatment pain after nonmetastatic breast cancer treatment: a systematic review and meta-analysis of prospective studies

Cancer Pain Experience Through the Lens of Patients and Caregivers: Mixed Methods Social Media Study

BACKGROUND

Cancer pain represents a challenge for cancer patients and their family members. Despite progression in pain management, pain is still underreported and undertreated, and there is limited information on the related needs that patients and caregivers may have. Online platforms represent a fundamental tool for research to reveal the unmet needs of these users and their emotions outside the medical setting.

OBJECTIVE

This study aimed to (1) reveal the unmet needs of both patients and caregivers and (2) detect the emotional activation associated with cancer pain by analyzing the textual patterns of both users.

METHODS

A descriptive and quantitative analysis of qualitative data was performed in RStudio v.2022.02.3 (RStudio Team). We analyzed 679 posts (161 from caregivers and 518 from patients) published over 10 years on the "cancer" subreddit of Reddit to identify unmet needs and emotions related to cancer pain. Hierarchical clustering, and emotion and sentiment analysis were conducted.

RESULTS

The language used for describing experiences related to cancer pain and expressed needs differed between patients and caregivers. For patients (agglomerative coefficient=0.72), the large cluster labeled unmet needs included the following clusters: (1A) reported experiences, with the subclusters (a) relationship with doctors/spouse and (b) reflections on physical features; and (1B) changes observed over time, with the subclusters (a) regret and (b) progress. For caregivers (agglomerative coefficient=0.80), the main clusters were as follows: (1A) social support and (1B) reported experiences, with the subclusters (a) psychosocial challenges and (b) grief. Moreover, comparison between the 2 groups (entanglement coefficient=0.28) showed that they shared a common cluster labeled uncertainty. Regarding emotion and sentiment analysis, patients expressed a significantly higher negative sentiment than caregivers (z=-2.14; P<.001). On the contrary, caregivers expressed a higher positive sentiment compared with patients (z=-2.26; P<.001), with trust (z=-4.12; P<.001) and joy (z=-2.03; P<.001) being the most prevalent positive emotions.

CONCLUSIONS

Our study emphasized different perceptions of cancer pain in patients and caregivers. We revealed different needs and emotional activations in the 2 groups. Moreover, our study findings highlight the importance of considering caregivers in medical care. Overall, this study increases knowledge about the unmet needs and emotions of patients and caregivers, which may have important clinical implications in pain management.

Optimising psychological treatment for pain after breast cancer: a factorial design study protocol in Denmark

INTRODUCTION

One in five breast cancer (BC) survivors are affected by persistent pain years after completing primary treatment. While the efficacy of psychological interventions for BC-related pain has been documented in several meta-analyses, reported effect sizes are generally modest, pointing to a need for optimisation. Guided by the Multiphase Optimization Strategy, the present study aims to optimise psychological treatment for BC-related pain by identifying active treatment components in a full factorial design.

METHODS AND ANALYSIS

The study uses a 2×3 factorial design, randomising 192 women with BC-related pain (18-75 years) to eight experimental conditions. The eight conditions consist of three contemporary cognitive-behavioural therapy components, namely: (1) mindful attention, (2) decentring, and (3) values and committed action. Each component is delivered in two sessions, and each participant will receive either zero, two, four or six sessions. Participants receiving two or three treatment components will be randomised to receive them in varying order. Assessments will be conducted at baseline (T1), session by session, every day for 6 days following the first session in each treatment component, at post-intervention (T2) and at 12-week follow-up (T3). Primary outcomes are pain intensity (Numerical Rating Scale) and pain interference (Brief Pain Inventory interference subscale) from T1 to T2. Secondary outcomes are pain burden, pain quality, pain frequency, pain catastrophising, psychological distress, well-being and fear of cancer recurrence. Possible mediators include mindful attention, decentring, and pain acceptance and activity engagement. Possible moderators are treatment expectancy, treatment adherence, satisfaction with treatment and therapeutic alliance.

ETHICS AND DISSEMINATION

Ethical approval for the present study was received from the Central Denmark Region Committee on Health Research Ethics (no: 1-10-72-309-40). Findings will be made available to the study funders, care providers, patient organisations and other researchers at international conferences, and published in international, peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05444101).

Predictors of persistent post-surgical pain intensity and interference at 1 year after breast cancer surgery: assessing central sensitization, central sensitivity symptoms, and psychological factors

BACKGROUND

Persistent post-surgical pain (PPSP) is associated with upper limb dysfunction and decreased quality of life and causes long-term suffering for breast cancer survivors after surgery. However, the predictors of PPSP remain unclear. The purpose of this study was to examine predictors of PPSP intensity and interference at 1 year postoperatively, focusing on treatment-related factors, pre- and postoperative central sensitization (CS), CS-related symptoms (e.g., muscle stiffness, fatigue, sleep disturbances), and psychological factors.

METHODS

Eighty-eight women with planned unilateral breast cancer surgery were included in this longitudinal study. CS, CS-related symptoms, and psychological factors were assessed preoperatively, 1 month postoperatively, and 1 year postoperatively. Analysis of covariance was used to compare the groups with and without PPSP, accounting for treatment-related factors. Multiple regression analysis was performed to identify predictors of PPSP intensity and interference at 1 year postoperatively.

RESULTS

Even after adjusting for covariates, preoperative and 1-month postoperative Central Sensitization Inventory scores in the PPSP group were significantly higher than scores in the group without PPSP. Multiple regression analysis showed that axillary lymph node dissection (ALND) and 1-month postoperative CS-related symptoms were independent predictors of PPSP intensity and interference at 1 year postoperatively (p < 0.01).

CONCLUSION

We found that ALND and 1-month postoperative CS-related symptoms were predictors of PPSP intensity and interference at 1 year postoperatively.

A Comprehensive Analysis of the Cancer Chronic Pain Experience: A Narrative Review

Cancer-related chronic pain (CP) represents a critical clinical issue through the disease, severely compromising the quality of life (QoL) of patients and the family environment. The current review employed a narrative method to synthesize the main results about the impact of cancer-related CP on QoL, adopting a multidimensional and threefold vision: patients, caregivers, and patient–caregiver perspective. Evidence emphasizes the importance of considering a bidirectional perspective (patient–caregiver) to understand better the pain experience throughout the cancer continuum and its consequences on QoL of patients and caregivers. Moreover, a holistic and multidimensional approach to cancer-related CP and its impact on QoL of patients and caregivers is still needed, in which the interconnection between physical, psychological, and social factors should be analyzed. Theoretical and methodological issues for orienting future social and family research initiatives were discussed.

Biopsychosocial risk factors for pain and pain-related disability 1 year after surgery for breast cancer

PURPOSE

Knowledge regarding risk factors for pain in the long term after surgery for breast cancer may be of great value in preventing this prevalent and debilitating side effect. Despite the biopsychosocial nature of pain, the predictive value of both pre- and postoperative biopsychosocial functioning for long-term pain intensity and pain-related disability has not yet been studied.

METHODS

One hundred sixty-six women planned for unilateral breast cancer surgery were included in this prospective cohort study. Pre- and postoperative outcomes related to pain, psychosocial, and somatosensory functioning (questionnaires and quantitative sensory testing) were evaluated as risk factors for pain intensity (visual analog scale) and pain-related disability (pain disability index) 1 year after surgery for breast cancer. Both bivariable and stepwise linear regression analyses were performed.

RESULTS

The most consistent biopsychosocial risk factors were symptoms related to altered central somatosensory functioning (central sensitization inventory), psychological symptoms, and social support (psychological symptoms and support subscale of McGill Quality of Life Questionnaire). Results also showed that a pre- and postoperative disturbed functioning of the somatosensory nervous system in the surgical area could provide additional information regarding pain intensity or pain-related disability in the long term after surgery for breast cancer.

CONCLUSION

This study revealed several biopsychosocial characteristics that might be used to identify women more vulnerable to have pain and pain-related disability in the long term after surgery for breast cancer, allowing for more effective pain management and prevention.

Understanding the Psychological, Physiological, and Genetic Factors Affecting Precision Pain Medicine: A Narrative Review

PURPOSE

Precision pain medicine focuses on employing methods to assess each patient individually, identify their risk profile for disproportionate pain and/or the development of chronic pain, and optimize therapeutic strategies to target specific pathological processes underlying chronic pain. This review aims to provide a concise summary of the current body of knowledge regarding psychological, physiological, and genetic determinants of chronic pain related to precision pain medicine.

METHODS

Following the Scale for the Assessment of Narrative Review Articles (SANRA) criteria, we employed PubMed/Medline to identify relevant articles using primary database search terms to query articles such as: precision medicine, non-modifiable factors, pain, anesthesiology, quantitative sensory testing, genetics, pain medicine, and psychological.

RESULTS

Precision pain medicine provides an opportunity to identify populations at risk, develop personalized treatment strategies, and reduce side effects and cost through elimination of ineffective treatment strategies. As in other complex chronic health conditions, there are two broad categories that contribute to chronic pain risk: modifiable and non-modifiable patient factors. This review focuses on three primary determinants of health, representing both modifiable and non-modifiable factors, that may contribute to a patient's profile for risk of developing pain and most effective management strategies: psychological, physiological, and genetic factors.

CONCLUSION

Consideration of these three domains is already being integrated into patient care in other specialties, but by understanding the role they play in development and maintenance of chronic pain, we can begin to implement both precision and personalized treatment regimens.

Pre-surgical heart-rate variability strongly predicts less post-operative pain in patients with epilepsy

OBJECTIVES

Post-operative pain is a common clinical problem after surgery, yet its predictors are inconsistent and unclear. This study examined whether pre-surgical vagal cardiac efferent nerve activity, indirectly indexed by heart rate variability (HRV), predicts patients' pain after epileptic surgery.

METHODS

Using a prospective design, HRV was measured at rest during 5 min in n = 30 patients, prior to undergoing epileptic surgery. Post-operative pain was assessed every 8 h during the first 2 days after surgery, and our analyses focused on the worse pain level. We used multiple regression analyses and statistically considered several confounders (age, surgical duration, and analgesics during various surgical phases).

RESULTS

Multiple HRV indexes strongly and inversely predicted post-operative pain, with high-frequency HRV (HF-HRV) being the strongest predictor (r = -0.81, p < 0.001). In a hierarchical multiple regression, HF-HRV accounted for an additional and significant 18% of the variance in post-operative pain, after statistically considering effects of age, surgical duration and effects of two anaesthetics.

CONCLUSIONS

Pre-surgical HF-HRV independently, strongly and inversely predicts post-operative pain. These results are in line with a neuromodulatory role of the vagus nerve in pain and have clinical implications for predicting and managing post-operative pain.

Psychological Factors Are Associated with Pain at All Time Frames After Breast Cancer Surgery: A Systematic Review with Meta-Analyses

OBJECTIVE

This systematic review aimed to 1) assess associations between psychological factors and pain after breast cancer (BC) treatment and 2) determine which preoperative psychological factors predicted pain in the acute, subacute, and chronic time frames after BC surgery.

DESIGN

A systematic review with meta-analysis.

SUBJECTS

Women with early-stage BC.

METHODS

The Medline, EMBASE, CINAHL, and Web of Science databases were searched between 1990 and January 2019. Studies that evaluated psychological factors and pain after surgery for early-stage BC were included. Associations between psychological factors and pain, from early after surgery to >12 months after surgery, were extracted. Effect size correlations (r equivalents) were calculated and pooled by using random-effects meta-analysis models.

RESULTS

Of 4,137 studies, 47 were included (n = 15,987 participants; 26 studies ≤12 months after surgery and 22 studies >12 months after surgery). The majority of the studies had low to moderate risk of bias. Higher preoperative anxiety and depression were weak but significant predictors of pain at all time points up to 12 months (r equivalent: 0.15-0.22). Higher preoperative pain catastrophizing and distress were also weak but significant predictors of pain during the acute (0-7 days) and chronic (3-12 months) periods (r equivalent: 0.10-0.20). For the period >12 months after surgery, weak but significant cross-sectional associations with pain were identified for anxiety, depression, pain catastrophizing, and distress (r equivalents: 0.15, 0.17, 0.25, 0.14, respectively).

CONCLUSION

Significant pooled effect size correlations between psychological factors and pain were identified across all time frames. Though weak, these associations should encourage assessment of key psychological factors during preoperative screening and pain assessments at all postoperative time frames.

What Does CATS Have to Do With Cancer? The Cognitive Activation Theory of Stress (CATS) Forms the SURGE Model of Chronic Post-surgical Pain in Women With Breast Cancer

Chronic post-surgical pain (CPSP) represents a highly prevalent and significant clinical problem. Both major and minor surgeries entail risks of developing CPSP, and cancer-related surgery is no exception. As an example, more than 40% of women undergoing breast cancer surgery struggle with CPSP years after surgery. While we do not fully understand the pathophysiology of CPSP, we know it is multifaceted with biological, social, and psychological factors contributing. The aim of this review is to advocate for the role of response outcome expectancies in the development of CPSP following breast cancer surgery. We propose the Cognitive Activation Theory of Stress (CATS) as an applicable theoretical framework detailing the potential role of cortisol regulation, inflammation, and inflammatory-induced sickness behavior in CPSP. Drawing on learning theory and activation theory, CATS offers psychobiological explanations for the relationship between stress and health, where acquired expectancies are crucial in determining the stress response and health outcomes. Based on existing knowledge about risk factors for CPSP, and in line with the CATS position, we propose the SURGEry outcome expectancy (SURGE) model of CPSP. According to SURGE, expectancies impact stress physiology, inflammation, and fear-based learning influencing the development and persistence of CPSP. SURGE further proposes that generalized response outcome expectancies drive adaptive or maladaptive stress responses in the time around surgery, where coping dampens the stress response, while helplessness and hopelessness sustains it. A sustained stress response may contribute to central sensitization, alterations in functional brain networks and excessive fear-based learning. This sets the stage for a prolonged state of inflammatory-induced sickness behavior - potentially driving and maintaining CPSP. Finally, as psychological factors are modifiable, robust and potent predictors of CPSP, we suggest hypnosis as an effective intervention strategy targeting response outcome expectancies. We here argue that presurgical clinical hypnosis has the potential of preventing CPSP in women with breast cancer.

[Prevention of chronic pain in the German healthcare system : Current state and perspective]

The current healthcare provision in Germany is established, in particular, for the diagnostics and treatment of chronic pain conditions; however, the current aim is to initiate the diagnostic and therapeutic approaches oriented towards the biopsychosocial pain model in the early stages of pain, i.e. before the onset of chronification, for patients with pain and a risk of chronification in order to actively avoid chronification processes. In this context, multiple risk factors play an important role for the diagnostic and therapeutic approaches as well as for the interdisciplinary multimodal pain therapy developed for this purpose. The Global Year of the International Association for the Study of Pain (IASP) 2020 addressed the prevention of (chronic) pain, a welcome opportunity to provide a short review of the evidence for and clinical experiences with timely diagnostic and therapeutic options and to summarize the current framework conditions and scientific recommendations for Germany. At the end of this article the implications for future research are summarized, particularly for the treatment of patients with pain and risk of chronification.

Frühes interdisziplinäres Assessment zur Sekundärprävention chronischer Schmerzen

Schmerz ist ein multikausales biopsychosoziales Phänomen. Das bedeutet für eine angemessene Versorgung ein entsprechendes interdisziplinäres Vorgehen in Diagnostik und Therapie. Faktoren, die bei bestehenden Schmerzen zu einer Chronifizierung beitragen können, sollten frühzeitig im Versorgungsalltag berücksichtigt werden. Dafür sind sektorenübergreifende Vernetzungen sowie interdisziplinäre Versorgungsangebote von großer Bedeutung.

Quality of life and personal resilience in the first two years after breast cancer diagnosis: systematic integrative review

The aim of this systematic integrative review was to examine the early impacts of a breast cancer diagnosis (up to 2 years after diagnosis) in relation to quality of life and personal resilience. The bibliographic databases of Medline, CINAHL, Cochrane, and Psychology and Behavioral Science Collection were searched using predetermined search criteria. Research studies published up to February 2019 were considered and following appraisal 36 articles were included in the review. Younger age, disease progression at first presentation, personality factors such as optimism, and moderators such as social support, clinical interventions and development of self-management abilities predicted better quality of life and personal resilience. Not recovering from the physical and psychological impacts of a new diagnosis has implications for future mental and physical health. This systematic, integrative review highlighted that building resilience and working with women's strengths should be the focus for contemporary clinical interventions for women in the early period after diagnosis of breast cancer.

Identification of traits and functional connectivity-based neurotraits of chronic pain

Psychological and personality factors, socioeconomic status, and brain properties all contribute to chronic pain but have essentially been studied independently. Here, we administered a broad battery of questionnaires to patients with chronic back pain (CBP) and collected repeated sessions of resting-state functional magnetic resonance imaging (fMRI) brain scans. Clustering and network analyses applied on the questionnaire data revealed four orthogonal dimensions accounting for 56% of the variance and defining chronic pain traits. Two of these traits-Pain-trait and Emote-trait-were associated with back pain characteristics and could be related to distinct distributed functional networks in a cross-validation procedure, identifying neurotraits. These neurotraits showed good reliability across four fMRI sessions acquired over five weeks. Further, traits and neurotraits all related to the income, emphasizing the importance of socioeconomic status within the personality space of chronic pain. Our approach is a first step in providing metrics aimed at unifying the psychology and the neurophysiology of chronic pain applicable across diverse clinical conditions.

Psychological issues in cancer survivorship

Thankfully, many more women are now surviving cancer due to advances in awareness, surveillance, and treatment. In fact, many oncology clinicians now consider cancer a chronic illness. This has meant that a growing number are living with the physical and psychological consequences of the disease. The psychological impact and emotions experienced by survivors are varied. Some reactions are more common than others, including the onset of depression, anxiety, and sexual dysfunction and feelings of abandonment, isolation, grief, and fear of recurrence. Body image and sexuality are also commonly impacted by cancer, particularly by women who experience treatment-induced menopause. Existential and spiritual concerns can also cause psychological consequences. In time, however, many women adjust to life as a cancer patient and find new meaning and purpose in their lives. The aim of this article is to highlight the key psychological issues faced by women who are in the chronic or survivorship phase of their cancer experience. The article also aims to emphasize the need for ongoing evaluation of the psychological status of these women during regular follow-up appointments. This will ensure that patient-centered supportive care is optimized.

Persistent breast pain in post-surgery breast cancer survivors and women with no history of breast surgery or cancer: associations with pain catastrophizing, perceived breast cancer risk, breast cancer worry, and emotional distress

Background: Persistent breast pain (PBP) is prevalent among breast cancer survivors and has powerful negative psychological consequences. The present study provided a first test of the hypothesis that: (a) pain catastrophizing, (b) heightened perceived risk of cancer, and (c) worry that pain indicates cancer may be independent mediating links between breast cancer survivors' experiences of PBP and heightened emotional distress. Methodology: We assessed levels of PBP and psychological factors in breast cancer survivors (Survivor Group: n = 417; Stages I-IIIA; White = 88.7%; Age M = 59.4 years) at their first surveillance mammogram post-surgery (6-15 months). A comparison group of women without histories of breast surgery or cancer (Non-cancer Group: n = 587; White = 78.7%; Age M = 57.4 years) was similarly assessed at the time of a routine screening mammogram. All women completed measures of breast pain, pain catastrophizing, perceived breast cancer risk, and worry that breast pain indicates cancer, as well as measures of emotional distress (symptoms of anxiety, symptoms of depression, and mammography-specific distress). Analyses included race, age, BMI, education, and menopausal status as covariates, with significance set at 0.05. Results: As expected, PBP prevalence was significantly higher in the Survivor Group than in the Non-cancer Group (50.6% vs. 17.5%). PBP+ survivors also had significantly higher levels of emotional distress, pain catastrophizing, mammography-specific distress, and worry that breast pain indicates cancer, compared to PBP- survivors. Structural equation modeling results were significant for all hypothesized mediational pathways. Interestingly, comparisons of PBP+ to PBP- women in the Non-cancer Group showed similar results. Conclusion: These findings suggest the importance of (a) pain catastrophizing, (b) perceived breast cancer risk and, (c) worry that breast pain may indicate cancer, as potential targets for interventions aimed at reducing the negative psychological impact of PBP in post-surgery breast cancer survivors, as well as in unaffected women with PBP due to unknown reasons.

Errors in search strategies used in systematic reviews and their effects on information retrieval

Objectives

Errors in search strategies negatively affect the quality and validity of systematic reviews. The primary objective of this study was to evaluate searches performed in MEDLINE/PubMed to identify errors and determine their effects on information retrieval.

Methods

A PubMed search was conducted using the systematic review filter to identify articles that were published in January of 2018. Systematic reviews or meta-analyses were selected from a systematic search for literature containing reproducible and explicit search strategies in MEDLINE/PubMed. Data were extracted from these studies related to ten types of errors and to the terms and phrases search modes.

Results

The study included 137 systematic reviews in which the number of search strategies containing some type of error was very high (92.7%). Errors that affected recall were the most frequent (78.1%), and the most common search errors involved missing terms in both natural language and controlled language and those related to Medical Subject Headings (MeSH) search terms and the non-retrieval of their more specific terms.

Conclusions

To improve the quality of searches and avoid errors, it is essential to plan the search strategy carefully, which includes consulting the MeSH database to identify the concepts and choose all appropriate terms, both descriptors and synonyms, and combining search techniques in the free-text and controlled-language fields, truncating the terms appropriately to retrieve all their variants.

Evaluating psychosocial contributions to chronic pain outcomes

The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.

Persistent Post-Mastectomy Pain: Risk Factors and Current Approaches to Treatment

Persistent Post-Mastectomy Pain (PPMP) is a common condition that can follow surgeries for breast cancer, the most common cancer in women. Because of the frequency of PPMP and its potential severity, it has received increasing research attention. This manuscript reviews the recent research literature, beginning with a brief history and then relevant medical, surgical, demographic, and psychosocial risk factors. Subsequently, social, psychological, and functional sequelae that have been linked to PPMPS are considered, as is research on current pharmacological, psychological, and rehabilitative approaches to treatment. The review concludes with a discussion of directions for future research and treatment that might reduce the incidence and impact of PPMP on breast cancer survivors. PERSPECTIVE: This article describes current research literature involving mechanisms, risks, and treatments related to persistent post-mastectomy pain. Implications of research findings also are discussed for pre- and post-surgical approaches to pain management, current treatments, and promising research directions.