Post Treatment Pain: The Experience of Cancer Survivors

1. Post Treatment Pain: The Experience of Cancer Survivors Tracy Gosselin, RN, MSN, AOCN® Clinical Director, Oncology Services Duke University Hospital

2. IOM Report From Cancer Patient to Survivor: Lost in Transition • > 10 million cancer survivors • > 6 million over the age of 65 • 10% are uninsured who are < 65 year old • 20% have work limitations 5 years out of treatment

3. Prevalence Rates • 50% at time of diagnosis, increasing to 75% in advanced disease • Post-treatment pain syndromes • Surgery • Chemotherapy • Radiation therapy • Variety of predisposing factors prior to a diagnosis/treatment of cancer Burton, A.W., et al. (2007). Pain Med,8(2), 189-198.

4. Surgery • Predictors – preop pain, repeat surgery, psychological vulnerability, nerve damage, previous chemotherapy and radiation • Chronic pain after breast surgery ~ 50% • Chronic pain post thoracotomy ~ 80% 3 mos. post and decreases to 60% at 1 year • Chronic pain in head and neck cancer ~ 40% at 1 year and 15% at 5 years • Phantom limb pain ~ 7-72% depending upon location Burton, A.W., et al. (2007). Pain Med,8(2), 189-198. Borsje, S., et al. (2004). Disabil Rehabil, 26, 905-910. Perkins, F.M., et al. (2000). Anesthesiology, 93, 1123-1133.

5. Chemotherapy • Peripheral neuropathy – dose limiting side effect • 4-76% during treatment, prevalence less well documented post treatment • Agents – paclitaxel, docetaxel, vincristine, cisplatin, oxaliplatin, thalidomide, & bortuzamib • Use of corticosteroids and risk for osteonecrosis ~ within 3 years of steroid use • Adults with acute lymphoblastic leukemia ~ 55% developed avascular necrosis Burton, A.W., et al. (2007). Pain Med,8(2), 189-198. Chan-Lam, D., et al. (1994). Br J Haematol, 86, 227-230.

6. Radiation Therapy • Onset of symptoms may range 6 month to 20 years • Brachial plexopathy • Mild ~ 9% • Disabling ~ 1-5% • Pelvic radiation • Painful dysuria up to 1 year ~20% • ? Risk of future hip fractures • 2-5% develop chronic proctitis • Radiation myelopathy Burton, A.W., et al. (2007). Pain Med,8(2), 189-198. Baxter, N.N., et al. (2005). JAMA, 294, 2587-2593. Colwell, J.C., et al. (2000). J Wound Ostomy Continence Nurs, 27(3), 179-187.

7. Effects of Pain on Long-term Survivors • Older adults > 60 years old • 59% female; 41% male • Disease sites • Breast (n = 123) • Prostate (n = 86) • Colorectal (n = 86) • Number of treatments • 1 treatment = 51.5% • 2 treatments = 31.5% • 3 treatments = 13.2% • 88% had surgery • 32% had radiation therapy • 19% received chemotherapy Deimling, G.T., et al. (2007). Cancer Nurs,30(6), 421-433.

8. Effects of Pain on Long-term Survivors Pain Frequency • 0 = Never, 16% • 1 = Rarely, 31% • 2 = Occasionally, 27% • 3 = Frequently, 16% • 4 = Always, 10% • Mean 1.7; SD (1.2) Pain Intensity • 1 = No pain, 3% • 2-3 = 30% • 4-6 = 48% • 7-9 = 13% • 10 Unbearable, 6% • Mean 4.7; SD (2.2) Deimling, G.T., et al. (2007). Cancer Nurs,30(6), 421-433.

9. Effects of Pain on Long-term Survivors • Pain correlations showed • Race and sex • Number of health conditions • Functional difficulty • Current symptoms not cancer related • Breast cancer more significant than prostate or colorectal cancer • Regression analyses • Chemotherapy • Years since diagnosis Deimling, G.T., et al. (2007). Cancer Nurs,30(6), 421-433.

10. Symptoms in Ovarian Cancer Survivors • Secondary data analysis • From data that looked at the psychometric properties of a new health related QOL instrument • 76 ovarian cancer survivors • Mean age 52.5 years • 72% married • 97% surgery; 60% chemotherapy (30% at time of study) • Fox Simple Quality of Life Scale (FSQOLS) • Short-Form-36 Health Status Survey (SF-36) Fox, S.W., et al. (2007). Cancer Nurs, 30(5), 354-361.

11. Symptoms in Ovarian Cancer Survivors • 100% of patients reported pain • Mean 68.2 (SD = 22.5) • Pain and fatigue were significantly correlated (r = 0.35; P= 0.01) • Pain was not significantly correlated with QOL • First study to document the symptom cluster of fatigue and depression in patients with ovarian cancer Fox, S.W., et al. (2007). Cancer Nurs, 30(5), 354-361.

12. Factors that Contribute to Underreporting and Undertreatment of Pain in Cancer Survivors • Patient related factors • Reluctance to report due to Worries about long-term use of medications • Beliefs that pain relief may not be possible Fear, fear, fear Polomano, R.C., et al. (2006). AJN,106(3), Suppl 39-47.

13. Factors that Contribute to Underreporting and Undertreatment of Pain in Cancer Survivors • Practice related factors • Knowledge deficits • Limited clinical experience • Failure to acknowledge • Failure to inform patients of the risk • Infrequent follow up • Perceptions that it will get better • Failure to refer Polomano, R.C., et al. (2006). AJN,106(3), Suppl 39-47.

14. Factors that Contribute to Underreporting and Undertreatment of Pain in Cancer Survivors • Science related factors • Limited research • Wide variation in estimates of prevalence • Lack of universal measurement • Insufficient data related to effectiveness measures • Gaps in research assessing quality of life along a continuum Polomano, R.C., et al. (2006). AJN,106(3), Suppl 39-47.

15. Interventions • Screen, assess, reassess and refer • Other comorbidities • Psychosocial distress • Referrals may take on many forms • Psychosocial services • Counseling • Cognitive behavioral therapy (CBT) • Physical and occupational therapy • Integrative medicine • Chronic pain clinic • Development of survivorship clinics as well as advanced symptom management clinics • Development of prospective studies to understand difference amongst patient populations and treatments • Use of the National Comprehensive Cancer Network (NCCN) – Adult Cancer Pain Guideline • Professional education and asking the questions