Pain is one of the most common byproducts of cancer and its treatment. Tumors, surgery, intravenous chemotherapy, radiation therapy, targeted therapy, supportive care therapies (such as bisphosphonates), and diagnostic procedures can all cause pain in patients and may contribute to symptoms of psychological distress, including anxiety and depression.1
According to the results of a large retrospective study by Sarah K. Galloway, PhD, a psychologist in the Section of Psycho-Oncology of the Department of Supportive Oncology at the Levine Cancer Institute in Charlotte, North Carolina, and her colleagues, the increased levels of psychological distress associated with cancer-related pain further exacerbate the pain patients experience, and these associations often remained after accounting for patient characteristics.2 What can help mitigate the negative impact of anxiety and depression on pain intensity is having a greater network of social support, the study results showed.
Sarah K. Galloway, PhD
In the study, Dr. Galloway and her colleagues analyzed information from nearly 12,000 patients with stage I to IV cancer who completed a routine tablet-based psychosocial distress screening. The patients were matched to 7,333 patients in a cancer registry. Clinicodemographic factors were incorporated into lasso regression models, which identified pain predictors from self-reported anxiety, depression, and social support. Dr. Galloway and her colleagues then analyzed whether the effect of anxiety and depression on pain intensity differed by the levels of instrumental and emotional support. The study found that tumor site, especially gastrointestinal and gynecologic cancers, advanced stage of disease, Black ethnicity, and lower income were independently associated with severe pain.
In an interview with The ASCO Post, Dr. Galloway discussed her study findings and how early palliative care interventions may help mitigate the psychosocial and physical distress caused by cancer and its treatment.
Evaluating the Multidimensional Aspects of Pain
Please talk about the connection between anxiety and depression and cancer pain intensity.
Contemporary pain models and research have expanded our understanding that pain is more than just a nociceptive experience. The biopsychosocial model of pain conceptualizes pain as a multidimensional and complex integration of sensory, affective, cognitive, and social components. Sensory aspects help to identify the location, size, and intensity associated with the noxious stimuli, whereas affective components of pain refer to the unpleasantness or distress associated with the physical sensation of pain. Lastly, cognitive components include the evaluation and interpretation of the meaning of the pain experience.
Anxiety and depression commonly occur in patients with cancer who are facing multiple biological and psychosocial stressors. Furthermore, patients suffering from pain often experience psychological distress in the form of anxiety and depression. Clinically, we see a dynamic interaction, in which pain, depression, and anxiety exacerbate each other. Previous research has demonstrated neurobiological connections between pain, depression, and anxiety.
If the level of pain was on the lower end of the scale, did those patients still have anxiety and depression? Was their level of pain connected to how severe their feelings of anxiety and depression were?
Jamie H. Von Roenn, MD, FASCO
In these particular analyses, we measured anxiety, depression, and pain on continuous scales. Through our regression analyses, after we accounted for clinical and demographic factors, increased levels of anxiety and depression were associated with higher levels of pain. Due to study design and selected analyses, we were not able to make causative inferences.
Your study results showed that tumor site, advanced stage of disease, Black race, and lower income were independently associated with severe pain. How do these factors influence the level of pain?
There is a confluence of societal and socioeconomic factors that impact patients’ ability to access health care and affect their pain experience. We know from previous research that there are racial and health disparities in oncology. Racial and ethnic minorities often encounter barriers to accessing health care, including lower income, lack of paid leave, inadequate insurance coverage, and discrimination. Individuals with lower socioeconomic status tend to be less likely to engage in preventive care and may delay medical treatment due to the high cost of health care, insurance problems, and issues with transportation; as a result, they may present with more advanced disease.
Our finding that patients with gastrointestinal, thoracic, gynecologic, and bone cancers were more likely to report severe pain than patients with other cancer types is consistent with previous research.
Recognizing the Importance of Social Support in Cancer Care
In your study, the effect of anxiety and depression on pain differed depending on the patients’ level of social support. Please talk about the importance of social support on the psychological distress patients experience after a cancer diagnosis.
Social support is an important resource utilized by patients to cope with cancer and its treatment. Furthermore, studies have demonstrated that patients with cancer who have higher levels of social support report decreased affective distress. In our current study, we found that patients with high levels of emotional and instrumental support (for example, transportation to medical appointments) reported lower levels of pain intensity.
Interestingly, we found that for patients who were 1 year from diagnosis, the impact of depression and anxiety on pain intensity varied by their level of social support. Future longitudinal studies can help us to better understand the differential impact of social support on mood, anxiety, and pain across the cancer trajectory—from diagnosis through survivorship.
Assessing Patients’ Mental Distress to Measure Pain Intensity
When assessing patients’ pain level, in addition to measuring their pain on the 0–10 pain scale, should oncologists ask patients about their feelings of anxiety and depression to gauge pain intensity?
Yes, that is one of the take-home messages from this study. Our research further emphasizes that we need to assess for psychological symptoms when addressing cancer-related pain. It additionally underscores the impact of interpersonal relationships and community on pain and illness.
Our institution has a made structural and organizational commitment to systematic symptom evaluation of all our patients. We work to engage our patients in early screening of common symptoms and barriers to care to quickly identify their needs and then make referrals for targeted supportive care.
“Contemporary pain models and research have expanded our understanding that pain is more than just a nociceptive experience.”— Sarah K. Galloway, PhD
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Holistic Palliative Care Approach
How can palliative medicine address the issues of anxiety and depression and their impact on pain? When should oncologists call in the palliative care team for patient evaluation?
Anxiety, depression, and social support are modifiable factors that can greatly impact a patient’s cancer pain experience. Our study results demonstrate the need for interdisciplinary, multimodal pharmacologic and nonpharmacologic interventions for cancer-related pain. In addition to managing pain, palliative care can also ease other distressing symptoms caused by cancer and its treatment, including depression, anxiety, fatigue, nausea, vomiting, insomnia, and shortness of breath. The early engagement of holistic palliative medicine in patients’ care can be hugely beneficial, and it is definitely advocated.
Psycho-oncology can play a large role in the evaluation and treatment of complex pain and may identify the cognitive, affective, and behavioral factors contributing to an individual patient’s pain experience. Furthermore, in addition to medication, psychoeducation, cognitive behavioral therapy, mindfulness-based strategies, biofeedback, and relaxation techniques can help relieve pain, anxiety, and depression as well as improve personal relationships.
Members of the multidisciplinary supportive oncology team, including integrative medicine practitioners, cancer rehabilitation therapists, nutritionists, psychologists, nurse navigators, and social workers, provide integral care targeting symptom management, patient education, and connection to community resources that are essential for patients’ well-being and quality of life.
DISCLOSURE: Dr. Galloway reported no conflicts of interest.
1. Fischer DJ, Villines D, Kim YO, et al: Anxiety, depression and pain: Differences by primary cancer. Support Care Cancer 18:801-810, 2010.
2. Galloway S, Meadors P, Boselli, et al: Anxiety, depression, pain, and social support in a large representative cancer population. 2019 Supportive Care in Oncology Symposium. Abstract 76. Presented October 26, 2019.