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Recenti Prog Med 2016; 107: 418-421
The underestimated role of psychological and rehabilitation
approaches for management of cancer pain.
A brief commentary
MARCO CASCELLA1, NICHOLAS SIMONDS THOMPSON2, MARIA ROSARIA MUZIO3,
CIRA ANTONIETTA FORTE4, ARTURO CUOMO1
1
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori “Fondazione G. Pascale” - IRCCS,
Naples, Italy; 2Department of Psychology Clark University, Worcester, MA, US; 3Division of Infantile Neuropsychiatry , UOMI - Maternal and
Infant Health, Torre del Greco, Naples, Italy; 4Psychology, Division of Pain Medicine, Department of Anesthesia, Endoscopy and Cardiology
Istituto Nazionale Tumori “Fondazione G. Pascale” - IRCCS, Naples, Italy.
Pervenuto il 16 aprile 2016. Accettato dopo revisione il 1° luglio 2016.
Summary. Individually tailored pharmacological regimen
is the standard approach for treating patients affected by
cancer pain, allowing the control of symptoms in approximately 90% of cases. If this strategy is ineffective it is possible to use more complex invasive, or minimally invasive,
techniques. Nevertheless, both patients and health care
professionals often underestimate the impact of cancer
pain on psychological distress, and do not consider the
potential benefits of psychological treatments to help
manage cancer pain. These non-pharmacological strategies should be part of the multidisciplinary pain therapy,
supporting and strengthening drug therapy. The purpose
of this brief commentary is to discuss the role of psychological and rehabilitation approaches for improving the
quality of life and the psychosocial outcomes in patients
with cancer pain.
Breve commento sull’importanza spesso sottovalutata
degli approcci psicologici e riabilitativi nella gestione del
dolore oncologico.
Key words. Cancer pain, cognitive behavioral therapy,
pain management, physical medicine, psychological techniques.
Parole chiave. Dolore oncologico, gestione del dolore,
medicina fisica, tecniche psicologiche, terapia cognitivocomportamentale.
Introduction
Individually tailored pharmacological regimen is
the standard approach for treating patients affected
by cancer pain, allowing the control of symptoms in
approximately 90% of cases1. If this approach is ineffective it is possible to use more complex invasive, or
minimally invasive, techniques1. Nevertheless, both
patients and health care professionals often underestimate the impact of cancer pain on psychological
distress, and do not consider the potential benefits of
psychological treatments to help manage cancer pain2.
According to Dame Cicely Saunders cancer pain is a
“total pain” because the patient’s pain experience has
physical, emotional, social and spiritual dimensions3.
Cancer diseases can have a great psychological
impact. For instance, cancers of the cervix can lead
to well-known problems involving sexuality, femi-
Riassunto. L’approccio farmacologico personalizzato (tailored) rappresenta la terapia standard per i pazienti affetti
da dolore oncologico, consentendo il controllo della sintomatologia in circa il 90% dei casi. Qualora tale strategia risulti inefficace è possibile ricorrere a più complesse
tecniche, invasive o mini-invasive. Tuttavia, sia da parte dei
pazienti sia degli operatori viene sottostimato il disagio psicologico sotteso al dolore oncologico e non si considerano
i potenziali benefici dei trattamenti di supporto psicologico
e riabilitativi nella gestione del dolore da cancro. Queste
strategie non farmacologiche dovrebbero essere parte integrante di un più globale approccio multidisciplinare alla
terapia del dolore, affiancando e amplificando gli effetti
della terapia farmacologica. Tale breve rassegna narrativa
ha la finalità di offrire una panoramica sul ruolo dei possibili
interventi psicologici e riabilitativi atti al miglioramento della
qualità della vita in pazienti affetti da dolore oncologico.
ninity and social isolation; thus, sexual dysfunction
and alteration of the body image often represent a
major concern, as well as an important cause of distress among women4. For survivors of prostate cancer,
overall satisfaction with follow-up care was high, but
was lower for psychosocial than physical aspects of
care. A survey found that 17% of men reported potentially moderate-to-severe levels of anxiety and 10.2%
reported moderate-to-severe levels of depression5.
Moreover, the emotional state of patients with permanent colostomy is typically characterized by fear,
and worry about their current process, and body image, self-esteem, social activities and sexuality are the
aspects that most affect the patients6.
Psychological distress is related to the symptoms
of patients with cancer of the pelvis and, consequently, psychological support and care must be integral to
the cancer treatment. According to previous finding,
there is a strong linkage between the degree, and the
M. Cascella et al.: The underestimated role of psychological and rehabilitation approaches for management of cancer pain
length of the cancer pain experience, and the psychological functioning, especially in terms of negative effect on mood, with anxiety, depressive feelings
and suicidal thoughts7. Compared to pain-free cancer
patients, cancer patients with pain had significantly
higher levels of anxiety, depression, and anger, and
patients with higher pain intensity and longer duration of pain had the highest levels of mood disturbance8. Several studies showed that social activities,
such as visits and conversations decreased significantly with increasing pain; thus, pain not only causes
physical suffering, but also influences different aspects of Quality of life (QoL)9, becoming a significant
source of emotional, social and existential distress10.
In addition, especially in patients with advanced
cancer, unrelieved emotions, depressive or anxious
symptoms, delirium, difficulties communicating,
greatly influence the expression of pain. Because all
these findings indicate that in cancer patients psychological factors influence both the experience of
pain and the response to pain treatment, psychological and behavioral treatments are not of secondary
importance in cancer patient management, and the
possibility of reducing psychological distress, may
improve pain management in any phase of care11. The
aim of this work is to provide an exhaustive summary
of current literature on psychological, and rehabilitation approaches for management of pain in cancer
patients.
Psychological interventions
Numerous kinds of non-medical interventions are
used to manage cancer pain, including interventions often designated psychological and behavioral with the purpose to teach patients to respond to
pain awareness with a shift in their thoughts and/
or coping behaviors. The rationale is that people
who experience cancer pain typically develop and
use a number of coping strategies to cope with, deal
with, or minimize the effects of pain12. On this basis,
because health professionals should make efforts
to understand how each patient copes with pain,
also supporting the patient in developing pain coping skills, the presence of a cognitivist psychologist
as component of the pain management team is often mandatory. As support of these observations, a
meta-analysis concluded that cognitive behavioral
therapy techniques have beneficial effects on pain
and distress in women with breast cancer, finding
moderate effect sizes of drugs used in pain management13.
Psychological therapy may help patients cope
with cancer and the psychosocial problems associated with cancer and cancer treatment, but is less
likely to help with common physical issues such as
loss of strength and flexibility, weight gain, and reduced physical function14. Thus, some authors prefer
behavioral approaches that are based on behavioral
training studied to teach patients the use of adaptive
behaviors, like engaging in distracting activities, pacing activities, and appropriate use of medications or
physical modalities15. Patients may be taught to observe what increases pain and to take a pain medication before that activity, or they may learn when their
pain is less severe in a specific moment of the day, in
order to do their priority activities during that time.
Behavioral approaches are also relaxation, imagery,
exercise, or yoga. These treatments provide physiologic benefits, adding competing sensory input to
the brain, which can shift thoughts and emotional
responses. Yoga, for example, is feasible for patients
with cancer, with improved sleep, QoL, mood and
levels of stress16. Other strategies, such as meditation
or hypnosis, shift focus away from pain, in adult and
pediatric patients, in which these therapies has been
shown to reduce anticipatory anxiety, procedure-related pain, procedure-related anxiety, and behavioral
distress during venipuncture17.
Educational interventions often include both behavioral approaches and cognitive behavioral therapy elements that provide adaptive coping skills and
address barriers to the use of treatments for pain, as
well as increase understanding of how to use treatment options and how to communicate with health
care providers about pain. Other psychosocial methods include a focus on partner/caregiver responses to
pain or supportive-expressive or meaning-centered
therapies that allow patients to explore their feelings,
needs, and interpretation of their experiences with a
supportive and facilitating therapist.
Psychologists have also a paramount role in the
doctor-patient relationship. In fact, cancer patients
should be full partners in decision-making, and the
pluses and minuses of each option should be explained and in most instances the patient should
have the final call. Nevertheless, physicians may
encounter communication difficulties, then the opportunity to receive help from psychologist is not to
be underestimated, for example, to better explain to
patients probable side-effects and complications of
treatments.
Rehabilitation approaches
Because cancer pain may be due to the cancer itself
or secondary to immobility and debilitation, it may
benefit from interventions that focus on function. For
this purpose, mobility – and consequently pain – may
be improved by strengthening, stretching, and the use
of assistive devices, thus, including a rehabilitation
medicine specialist in the pain management team is
often a winning move.
Treatment objectives of cancer rehabilitation are
preventive, to improve function and reduce morbidity
and disability, restorative, for patients with potential
cure of cancer whose residual disability can be appropriately controlled or eliminated, supportive for patients who must continue with cancer but can expect
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relative control or remission of appreciable time, and
palliative.
Rehabilitative and physical modalities used to
manage pain can be grouped into four categories:
those that modulate nociception, stabilize or unload
painful structures, influence physiological processes
that indirectly influence nociception, or alleviate pain
arising from the overloading of muscles and connective tissues that often occurs after surgery or with
sarcopenia in late-stage cancer. Cancer rehabilitative
treatments include physical therapy, occupational
therapy, lymphedema therapy, recreational therapy,
speech and language pathology therapies, and the use
of prosthetics and orthotics. These treatments may
be particularly beneficial to patients with movementassociated pain18 and in some clinical condition, for
instance to manage post radiation complications, like
neuromuscular and musculoskeletal complications
of the radiation fibrosis syndrome19.
Specific therapies, such as occupational therapy,
can be particularly effective to help pain management
in selected cases of cancer patients, also in pelvic neoplastic diseases. The role of occupational therapy in
oncology and cancer-related pain management is well
recognized today20. Occupational therapy is a rehabilitation approach which uses assessment and treatment to develop, recover, or maintain the daily living
and work skills of people with a physical, mental, or
cognitive disorder. In oncology it can help patients to
continue or resume usual roles despite cancer-related
pain, indeed, by this intervention the patient receives
a constructive help to build perceived personal control
or self-efficacy to manage cancer pain21. Occupational
therapy works through interventions on productivity
and leisure, self-care – for instance with the purpose
of maintaining or increasing autonomy in performing
activities of daily living, or creating an action plan to
optimize treatment adherence – cognitive and affective aspects, physical aspect of the person and spirituality22. According to Lapointe, an optimal occupational intervention should be personalized. It should be
well chosen, carefully graded and monitored, and appropriate to the patient’s cancer stage23. Occupational
therapy could be effective in sick cancer patients and
in those with cognitive impairments, mental illness,
language barriers or suspected substance abuse.
Probably, the odds of having any potentially modifiable functional deficit are higher in patients with increasing age, comorbid conditions, and with less than
a college degree24. However, as reported by Mackenzie Pergolotti et colleagues only 32% of adult patients
used occupational therapy within the first two years
of their cancer diagnosis (also prostate and colorectal
cancer), a rate lower that the estimated 87% who are
in need of such approach25.
Conclusions
For all these considerations, in cancer pain the most
suitable psychological and rehabilitation approach
should be chosen after a case-by-case analysis, to
improve the QoL and the psychosocial outcomes, the
compliance to the therapy and the doctor-patient interaction/relationship.
Conflict of interests: the authors declare that there are no conflicts
of interest.
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Correspondence to:
Marco Cascella, MD
Division of Anesthesia
Department of Anesthesia, Endoscopy and Cardiology
Istituto Nazionale Tumori “Fondazione G. Pascale” - IRCCS
Via Mariano Semmola 52
80131 Naples, Italy
E-mail: [email protected]
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