Why is managing pain important?
When pain is controlled, quality of life improves dramatically. Uncontrolled pain, on the other hand, creates unnecessary suffering, “not only by causing immediate physical suffering, but also by increasing the anxiety level and the fear about the future and future problems.”1Strang P. Existential consequences of unrelieved cancer pain. Palliative Medicine. 1997 Jul;11(4):299-305.
Evidence shows that pain may affect survival, body terrainthe internal conditions of your body, including nutritional status, fitness, blood sugar balance, hormone balance, inflammation and more factors, symptoms, and side effects common among people with cancer. The way you manage stress, tension, and emotions can amplify or reduce your suffering related to pain. People often underestimate the effect that persistent pain has on quality of life, and so tend to “put up with it,” which can make things worse.
Connections to cancer survival
Cancer-related pain may increase mortality, although separating the effects of pain from the effects of advancing cancer and of pain medications on survival is difficult.
- Higher overall mortality among people with prostate cancer reporting pain compared to no pain, but no evidence of an effectoverall, one or more studies did not demonstrate that a treatment or intervention led to an expected outcome; this does not always mean that there is no effect in clinical practice, but that the studies may have been underpowered (too few participants) or poorly designed. Larger, well-designed studies provide more confidence in making assessments. among people with breast, colorectal, or lung cancer in an analysis of 50 observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods studies2Zylla D, Steele G, Gupta P. A systematic review of the impact of pain on overall survival in patients with cancer. Supportive Care in Cancer. 2017 May;25(5):1687-1698.
- Slightly higher mortality among people with cancer reporting pain compared to no pain in an observational analysis within a large meta-analysisa statistical analysis that combines the results of two or more research studies; the results of smaller research studies addressing the same or similar questions can be analyzed as though they are one bigger, more powerful study of RCTsrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects3Quinten C, Coens C et al; EORTC Clinical Groups. Baseline quality of life as a prognostic indicator of survival: a meta-analysis of individual patient data from EORTC clinical trials. Lancet Oncology. 2009 Sep;10(9):865-71.
- Slightly higher mortality among people with non-small cell lung cancer with higher self-reported pain scores compared to lower scores in a mid-sized observational study4Efficace F, Bottomley A et al; EORTC Lung Cancer Group and Quality of Life Unit. Is a patient’s self-reported health-related quality of life a prognostic factor for survival in non-small-cell lung cancer patients? A multivariate analysis of prognostic factors of EORTC study 08975. Annals of Oncology. 2006 Nov;17(11):1698-704.
- Higher cancer-specific mortality among people with cancer reporting cancer-related pain compared to no pain or less pain in a mid-sized observational study5Zheng J, He J et al. The impact of pain and opioids use on survival in cancer patients: Results from a population-based cohort study and a meta-analysis. Medicine (Baltimore). 2020 Feb;99(9):e19306.
- Higher risk of life expectancy of less than 6 months among people with newly diagnosed metastatic solid tumors and with pain compared to people without pain in a secondary analysis of a mid-sized observational study6de la O Murillo A, Torres AC et al. Association of pain with the presence of additional supportive care (SC) needs in patients with advanced cancer. Journal of Clinical Oncology. 2022 Jun 1;40(16_suppl):e24071-e24071.
Better communication of pain and other symptoms may lead to improved survival among people with cancer.
- Slightly better survival among people initiating routine chemotherapy for metastatic solid tumors participating in an intervention in which they reported a severe or worsening symptom online, triggering an email alert to a clinical nurse responsible for the care of that patient an generating a report profiling each participant’s symptom burden history at clinic visits for the treating oncologist, compared to usual care in a large RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects7Basch E, Deal AM et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA. 2017 Jul 11;318(2):197-198.
Connections to body terrain factors
An imbalanced terrain can promote pain. Chronic inflammation, for instance, is directly related to pain processes. Pain can also affect terrain factors, such as suppressing certain immune functions and increasing risk for infection. We summarize evidence for these connections. We encourage you to work with a healthcare professional to assess terrain imbalances and create a plan to both balance terrain and manage pain.
Pain is linked to insulin resistance.
Some evidence shows that inducing pain increases insulin resistance.8Pappolla MA, Manchikanti L et al. Insulin resistance is associated with central pain in patients with fibromyalgia. Pain Physician. 2021 Mar;24(2):175-184; Ljungqvist J. Insulin resistance in surgery. Cirugía y Cirujanos. 2016;84(Supl 1):51-54; Greisen J, Juhl CB et al. Acute pain induces insulin resistance in humans. Anesthesiology. 2001 Sep;95(3):578-84.
Pain is linked to imbalances or disruption in stress hormones and sex hormones.
The experience of pain can promote the release of stress hormones. For instance, pain increases the release of cortisol and pregnenolone, the two major internal steroids (glucocorticoids) that control inflammation. Intractable pain can cause stress to the hypothalamus and pituitary, leading to abnormal hormone levels.
“Severe pain causes a hyperarousal of the hypothalamic–pituitary–adrenal system which results in elevated serum hormone levels such as adrenocorticotropin, cortisol, and pregnenolone. If the severe pain does not abate, however, the system cannot maintain its normal hormone production and serum levels of some hormones may drop below normal range.”9Tennant F. The physiologic effects of pain on the endocrine system. Pain and Therapy. 2013 Dec;2(2):75-86.
Pain decreases the amount of testosterone in the body.10Tennant F. Hormone testing and replacement in pain patients made simple. Practical Pain Management. 2012;12(6).
Because pain is a potent stressor, it initially causes elevated levels of hormones from the pituitary, adrenal glands, and gonads. If severe pain goes uncontrolled for too long, however, hormone levels decrease in the blood.11Tennant F. Hormone testing and treatment enters pain care. Hospital Practice. (1995). 2014 Dec;42(5):7-13. As a result, pain can lead to either high or low levels of these hormones.
- Lower cortisol levels in saliva in the evening among people with chronic multisite musculoskeletal pain (not specific to cancer), and also lower levels at awakening and a less change in levels throughout the day (blunted diurnal slope) only among people without depressive and/or anxiety disorder, compared to other people in a large observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods study12Generaal E, Vogelzangs N, Macfarlane GJ, Geenen R, Smit JH, Penninx BW, et al. Reduced hypothalamic-pituitary-adrenal axis activity in chronic multi-site musculoskeletal pain: partly masked by depressive and anxiety disorders. BMC Musculoskeletal Disorders. 2014;15:227.
- Higher blood cortisol levels, with significant elevation of the daily average, among people with acute or chronic pain compared to controls in a small observational study; the researchers speculate that the underlying cause of chronic and episodic pain relate to long-term activation of the fight-or-flight stress response, not related to pain, and probably linked to depressive symptoms and disruption of circadian rhythms of cortisol release controlled by the hypothalamus.13Strittmatter M, Bianchi O et al. Funktionsstörung der hypothalamisch-hyphophysär-adrenalen Achse bei Patienten mit akuten, chronischen und intervallartigen Schmerzsyndromen [Altered function of the hypothalamic-pituitary-adrenal axis in patients with acute, chronic and episodic pain] German. Schmerz. 2005 Apr;19(2):109-16.
Pain can suppress the immune system.
Signaling between pain-sensing nerves (nociceptor neurons) and the immune system regulates pain and inflammation.14Pinho-Ribeiro FA, Verri WA Jr, Chiu IM. Nociceptor sensory neuron–immune interactions in pain and inflammation. Trends in Immunology. 2017 Jan;38(1):5-19. Pain can suppress the immune system and increase the time it takes your body to heal.15Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.
Surgery is linked to decreased resistance to metastasis. Managing pain at the time of surgery is probably a critical factor preventing this resistance and reducing metastasis.16Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.
Preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently) of higher systemic inflammation and poorer blood insulin levels among people with ovarian cancer with higher reported pain
All pain is accompanied by inflammation, including nerve inflammation. Pain increases the release of cortisol and pregnenolone, the two major steroids (glucocorticoids) that control inflammation.17Tennant F. Hormone testing and replacement in pain patients made simple. Practical Pain Management. 2012;12(6). Elevated markers of inflammation (C-reactive protein) are present in a majority of chronic pain conditions.18Totsch SK, Waite ME, Sorge RE. Dietary influence on pain via the immune system. Progress in Molecular Biology and Translational Science. 2015;131:435-69.
Inflammation is an immune process that releases substances that cause pain. Acute inflammation is a necessary, sometimes life-saving, response to acute injury. However, chronic low-grade inflammation may dysregulate the innate immune system, increasing risk of infection.19Goldberg EL, Shaw AC, Montgomery RR. How inflammation blunts innate immunity in aging. Interdisciplinary Topics in Gerontology and Geriatrics. 2020;43:1-17.
Preliminary evidence of higher systemic inflammation and poorer blood insulin levels among people with ovarian cancer with higher reported pain
- Poorer CRP levels, suggesting higher systemic inflammation and poorer blood insulin levels, within 6 months of completing cancer treatment among people with ovarian cancer with higher reported pain compared to lower pain in an observation from a mid-sized RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects20Crane TE, Miller A, Skiba MB, Donzella S, Thomson CA. Association of chronotype and pain at baseline in ovarian cancer survivors participating in a lifestyle intervention (NRG/GOG 0225). Journal of Clinical Oncology. 2020;38(suppl) abstr 6018).
Connections to symptoms and side effects
Probably no other symptom is connected to as many other cancer-related symptoms as cancer-related pain. Pain can affect your mood, your sleep, your energy, your nutritional requirements, your quality of life and ability to function, your stress, and your connection to others. In turn, many of these symptoms can affect your pain, as we illustrate in the graphic in the section “What approaches can help you manage pain?” We cannot stress enough how important it is to report all your symptoms to your doctor so they can help you manage them. You are not bothering them—you are not a complainer—you are a reporter. The very best care places improving your comfort and quality of life as important as treating your cancer.
Modest evidencesignificant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observational studies), or several small studies aggregated into a meta-analysis (this is the CancerChoices definition; other researchers and studies may define this differently) of higher levels of anxiety among people with cancer experiencing pain
The relationship between pain and anxiety is bidirectional—each can trigger and impact the other.21Thielking PD. Cancer pain and anxiety. Current Pain and Headache Reports. 2003 Aug;7(4):249-61; Theobald DE. Cancer pain, fatigue, distress, and insomnia in cancer patients. Clinical Cornerstone. 2004;6 Suppl 1D:S15-21.
- Higher levels of anxiety among people with breast or prostate cancer with increased pain compared to other people in an observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods analysis of a mid-sized RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects22Charalambous A, Giannakopoulou M, Bozas E, Paikousis L. Parallel and serial mediation analysis between pain, anxiety, depression, fatigue and nausea, vomiting and retching within a randomised controlled trial in patients with breast and prostate cancer. BMJ Open. 2019 Jan 24;9(1):e026809.
- Higher levels of anxiety among people with cancer of unknown primary with physical symptoms comprising pain, fatigue, and sleep disturbance compared to other people in a mid-sized observational study23Wolyniec K, Sharp J, Fisher K, Tothill RW, Bowtell D, Mileshkin L, Schofield P. Psychological distress, understanding of cancer and illness uncertainty in patients with cancer of unknown primary. Psycho-Oncology. 2022 Jun 28.
- Higher risk of anxiety or depression among people with newly diagnosed metastatic solid tumors and with pain compared to people without pain in a secondary analysis of a mid-sized observational study24de la O Murillo A, Torres AC et al. Association of pain with the presence of additional supportive care (SC) needs in patients with advanced cancer. Journal of Clinical Oncology. 2022 Jun 1;40(16_suppl):e24071-e24071.
- Higher anxiety scores among older people with cancer living at home with high pain scores compared to people with lower pain scores in a mid-sized observational study25Solvik E, Ytrehus S, Utne I, Grov EK. Pain, fatigue, anxiety and depression in older home‐dwelling people with cancer. Nursing Open. 2019 Nov 5;7(1):430-438.
- Higher anxiety before surgery among people (not exclusive to cancer) with worse pain and function compared to other people, and higher anxiety after surgery among people with higher pain compared to other people in an observational study26Tarrasch J, England P, Hurst VT, McDonald D, O’Keefe R, Cipriano C. Patients with metastatic disease are at highest risk for anxiety and depression in an orthopedic oncology patient population. JCO Oncology Practice. 2022 Jun 1:OP2100905.
- A link between chronic pain and anxiety among elderly people in a mid-sized observational study27McCarthy LH, Bigal ME, Katz M, Derby C, Lipton RB. Chronic pain and obesity in the elderly: results from the Einstein aging study. Journal of the American Geriatrics Society. 2009 Jan;57(1):115-9.
- More anxiety among people with cancer with cancer-related breakthrough pain compared to those without breakthrough pain in a mid-sized observational study28Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999 May;81(1-2):129-34.
- More fear about the future, worries about pain progression, and higher general anxiety that hampered daily living among people with insufficient control of cancer-related pain compared to those with sufficient pain control in a small observational study29Strang P. Existential consequences of unrelieved cancer pain. Palliative Medicine. 1997 Jul;11(4):299-305.
- Higher rates of anxiety during treatment among people with lung cancer reporting higher pain intensity compared to other people in a mid-sized observational study30Lekka D, Pachi A et al. Pain and anxiety versus sense of family support in lung cancer patients. Pain Research and Treatment. 2014;2014:312941.
- Higher prevalence of anxiety among people with cancer reporting high pain levels compared to low pain levels in a small observational study31Spiegel D, Sands S, Koopman C. Pain and depression in patients with cancer. Cancer. 1994 Nov 1;74(9):2570-8.
Preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently) of higher risk of needing nutritional interventions among people with newly diagnosed metastatic solid tumors and experiencing pain
- Higher risk of needing nutritional interventions among people with newly diagnosed metastatic solid tumors and with pain compared to people without pain in a secondary analysis of a mid-sized observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods study32de la O Murillo A, Torres AC et al. Association of pain with the presence of additional supportive care (SC) needs in patients with advanced cancer. Journal of Clinical Oncology. 2022 Jun 1;40(16_suppl):e24071-e24071.
Pain is linked to increased risk of cardiovascular events.
“The cardiovascular system responds to stress of pain by activating the sympathetic nervous system, which produces a variety of unwanted effects. In the postoperative period, these include hypercoagulation [increased blood clotting] and increased heart rate, blood pressure, cardiac workload, and oxygen demand. Aggressive pain control is required to reduce these effects and prevent thromboembolic complications. Cardiac morbidity is the primary cause of death after anesthesia and surgery.”33Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.
Modest evidence of a link between depression and pain among people with cancer
- Higher levels of depression among people with breast or prostate cancer with increased pain in an observational analysis of a mid-sized RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects34Charalambous A, Giannakopoulou M, Bozas E, Paikousis L. Parallel and serial mediation analysis between pain, anxiety, depression, fatigue and nausea, vomiting and retching within a randomised controlled trial in patients with breast and prostate cancer. BMJ Open. 2019 Jan 24;9(1):e026809.
- Links between cancer pain and depression, and between pain intensity and depression in a review of 14 observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods studies35Laird BJ, Boyd AC, Colvin LA, Fallon MT. Are cancer pain and depression interdependent? A systematic review. Psycho-Oncology. 2009 May;18(5):459-64.
- Higher levels of depression among people with cancer of unknown primary with physical symptoms comprising pain, fatigue, and sleep disturbance compared to other people in a mid-sized observational study36Wolyniec K, Sharp J et al. Psychological distress, understanding of cancer and illness uncertainty in patients with cancer of unknown primary. Psycho-Oncology. 2022 Jun 28.
- Higher depression before surgery among people with cancer and other diseases with worse pain and function compared to other people, and higher depression after surgery among people with higher pain compared to other people in an observational study37Tarrasch J, England P, Hurst VT, McDonald D, O’Keefe R, Cipriano C. Patients with metastatic disease are at highest risk for anxiety and depression in an orthopedic oncology patient population. JCO Oncology Practice. 2022 Jun 1:OP2100905.
- Higher risk of anxiety or depression among people with newly diagnosed metastatic solid tumors and with pain compared to people without pain in a secondary analysis of a mid-sized observational study38de la O Murillo A, Torres AC et al. Association of pain with the presence of additional supportive care (SC) needs in patients with advanced cancer. Journal of Clinical Oncology. 2022 Jun 1;40(16_suppl):e24071-e24071.
- A link between chronic pain and depression among elderly people in a mid-sized observational study39McCarthy LH, Bigal ME, Katz M, Derby C, Lipton RB. Chronic pain and obesity in the elderly: results from the Einstein aging study. Journal of the American Geriatrics Society. 2009 Jan;57(1):115-9.
- Worse mood among people with cancer with cancer-related breakthrough pain compared to those without breakthrough pain in a mid-sized observational study40Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999 May;81(1-2):129-34.
- Higher risk and severity of depression among people with chronic cancer pain with more severe pain compared to less severe pain in a small observational study41Susilo RC, Utariani A, Susila A. Opioid use and pain intensity as risk factors of cancer-related depression. International Journal of Innovative Science and Research Technology. 2021 Nov;6(11):105-109.
- Increasing risk of depressive symptoms among survivors of pediatric hematopoietic stem cell transplant with increasing pain intensity in a small observational study42Klages KL, Chardon ML et al. Pain, depressive symptoms, and health-related quality of life among survivors of pediatric hematopoietic stem cell transplant. Pediatric Blood & Cancer. 2022 Jun 22:e29846.
Modest evidence of a link between pain and fatigue among people with cancer
The relationship between pain and fatigue is bidirectional—each can trigger and impact the other.43Theobald DE. Cancer pain, fatigue, distress, and insomnia in cancer patients. Clinical Cornerstone. 2004;6 Suppl 1D:S15-21.
- Higher levels of fatigue among people with breast or prostate cancer with increased pain in an observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods analysis of a mid-sized RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects44Charalambous A, Giannakopoulou M, Bozas E, Paikousis L. Parallel and serial mediation analysis between pain, anxiety, depression, fatigue and nausea, vomiting and retching within a randomised controlled trial in patients with breast and prostate cancer. BMJ Open. 2019 Jan 24;9(1):e026809.
- Higher risk of fatigue among people with newly diagnosed metastatic solid tumors and with pain compared to people without pain in a secondary analysis of a mid-sized observational study45de la O Murillo A, Torres AC et al. Association of pain with the presence of additional supportive care (SC) needs in patients with advanced cancer. Journal of Clinical Oncology. 2022 Jun 1;40(16_suppl):e24071-e24071.
- Higher fatigue scores among older people with cancer living at home with high pain scores compared to people with lower pain scores in a mid-sized observational study46Solvik E, Ytrehus S, Utne I, Grov EK. Pain, fatigue, anxiety and depression in older home‐dwelling people with cancer. Nursing Open. 2019 Nov 5;7(1):430-438.
- Increasing risk of fatigue among people with metastatic breast cancer with increasing pain intensity or frequency in a small observational study47Spiegel D, Sands S, Koopman C. Pain and depression in patients with cancer. Cancer. 1994 Nov 1;74(9):2570-8.
Modest evidence of a link between pain and worse physical function and quality of life among people with cancer
“Patients suffer from pain in many ways. Pain robs patients of their lives. Patients may become depressed or anxious and want to end their lives. Patients are sometimes unable to do many of the things they did without pain, and this state of living in pain affects their relationships with others and sometimes their ability to maintain employment.”48Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.
- Higher need for physical therapy or risk of an abnormal geriatric screening among people with newly diagnosed metastatic solid tumors and with pain compared to people without pain in a secondary analysis of a mid-sized observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods study49de la O Murillo A, Torres AC et al. Association of pain with the presence of additional supportive care (SC) needs in patients with advanced cancer. Journal of Clinical Oncology. 2022 Jun 1;40(16_suppl):e24071-e24071.
- More pain-related functional impairment among people with cancer with cancer-related breakthrough pain compared to those without breakthrough pain in a mid-sized observational study50Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999 May;81(1-2):129-34.
- Worse health-related quality of life, mediated by depression, among survivors of pediatric hematopoietic stem cell transplant with increasing pain intensity in a small observational study51Klages KL, Chardon ML et al. Pain, depressive symptoms, and health-related quality of life among survivors of pediatric hematopoietic stem cell transplant. Pediatric Blood & Cancer. 2022 Jun 22:e29846.
Modest evidence of more sleep disturbance among people with cancer experiencing pain
The relationship between pain and sleep disturbance is bidirectional—each can trigger and impact the other.52Theobald DE. Cancer pain, fatigue, distress, and insomnia in cancer patients. Clinical Cornerstone. 2004;6 Suppl 1D:S15-21.
- Higher risk of sleep disturbance among people with newly diagnosed metastatic solid tumors and experiencing pain compared to people without pain in a secondary analysis of a mid-sized observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods study53de la O Murillo A, Torres AC et al. Association of pain with the presence of additional supportive care (SC) needs in patients with advanced cancer. Journal of Clinical Oncology. 2022 Jun 1;40(16_suppl):e24071-e24071.
- More sleep disturbance in the first year after mastectomy among people with breast cancer experiencing higher pain compared to lower pain in a mid-sized observational study54Azizoddin DR, Soens MA et al. Perioperative sleep disturbance following mastectomy: a longitudinal investigation of the relationship to pain, opioid use, treatment, and psychosocial symptoms. Journal of Clinical Oncology. 2021 Oct 1;39(28_suppl:192.
Modest evidence of a link between distress or stress and pain among people with cancer
Pain is a stressor.55Chapman CR, Gavrin J. Suffering and its relationship to pain. Journal of Palliative Care. 1993;9(2):5-13; Page GG, Ben-Eliyahu S. The immune-suppressive nature of pain. Seminars in Oncology Nursing. 1997 Feb;13(1):10-5.
“Pain causes stress. The endocrine system reacts by releasing an excessive amount of hormones, ultimately resulting in carbohydrate, protein, and fat catabolism (destruction); poor glucose use; and other harmful effects. This reaction combined with inflammatory processes can produce weight loss, tachycardia [fast heart rate], increased respiratory rate, fever, shock, and death. Unrelieved pain prolongs the stress response, adversely affecting the patient’s recovery.”56Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.
Pain is one of the main contributors to the stress response during surgery, especially during major surgery. A longer stress response after surgery is linked to worse outcomes such as stress-related insulin resistance, greater risk of functional decline after surgery, and impaired organ function.57Tebala GV, Gordon-Dixon A, Imtiaz M, Shrestha A, Toeima M. Enhanced recovery after rectal surgery: what we have learned so far. Mini-invasive Surgery. 2018;2:32; Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. European Journal of Surgical Oncology. 2018;44(7):919-926.
Modest evidence of a link between distress or stress and pain among people with cancer
- Link between increased pain and increased distress among people with cancer in 14 of 19 studies in a review58Zaza C, Baine N. Cancer pain and psychosocial factors: a critical review of the literature. Journal of Pain and Symptom Management. 2002 Nov;24(5):526-42.
- More psychological stress among people with cancer experiencing cancer-related breakthrough pain compared to those without breakthrough paina sudden increase in pain in people who already have chronic pain, more intense but usually in the same location and the same type of pain as the chronic pain; breakthrough pain may occur with stress, illness, and activities such as exercising or coughing, or when pain medication wears off in a mid-sized observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods study59Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999 May;81(1-2):129-34.
- Higher prevalence of emotional distress among people with cancer reporting high pain levels compared to low pain levels in a small observational study60Spiegel D, Sands S, Koopman C. Pain and depression in patients with cancer. Cancer. 1994 Nov 1;74(9):2570-8.
- Greater total life stress among people with metastatic and/or recurrent breast cancer experiencing higher pain intensity compared to lower intensity in a mid-sized observational study61Koopman C, Hermanson K, Diamond S, Angell K, Spiegel D. Social support, life stress, pain and emotional adjustment to advanced breast cancer. Psycho-Oncology. 1998 Mar-Apr;7(2):101-11.
Pain is linked to impaired gastrointestinal function.
Good evidencesignificant effects in one large or several mid-sized and well-designed clinical studies (randomized controlled trials (RCTs) with an appropriate placebo or other strong comparison control or observational studies that control for confounds) (this is the CancerChoices definition; other researchers and studies may define this differently) of higher incidence of severe sleep problems among people experiencing pain
Gastrointestinal symptoms: the stress response to pain “can cause temporary impairment of gastrointestinal function and increase the risk of ileus.”62Wells N, Pasero C, McCaffery M. Improving the Quality of Care through Pain Assessment and Management. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 17.
Sleep disturbance: good evidence of higher incidence of severe sleep problems among people experiencing pain
- Substantially higher incidence of severe sleep problems among people in low- and middle-income countries with pain compared to people without pain in a very large observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods analysis63Stubbs B, Vancampfort D et al. Pain and severe sleep disturbance in the general population: Primary data and meta-analysis from 240,820 people across 45 low- and middle-income countries. General Hospital Psychiatry. 2018 Jul-Aug;53:52-58.
- Higher rates of sleep disturbance among people with HIV with pain compared to people without pain in a meta-analysisa statistical analysis that combines the results of two or more research studies; the results of smaller research studies addressing the same or similar questions can be analyzed as though they are one bigger, more powerful study of 2 observational studies 64Scott W, Arkuter C et al. Psychosocial factors associated with persistent pain in people with HIV: a systematic review with meta-analysis. Pain. 2018 Dec;159(12):2461-2476.
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Authors
Laura Pole is senior clinical consultant for CancerChoices. Laura is an oncology clinical nurse specialist who has been providing integrative oncology clinical care, navigation, consultation, and education services for over 40 years. She is the co-creator and co-coordinator of the Integrative Oncology Navigation Training at Smith Center for Healing and the Arts in Washington, DC. Laura also manages the “Media Watch Cancer News That You Can Use” listserv for Smith Center/Commonweal. In her role as a palliative care educator and consultant, Laura has served as statewide Respecting Choices Faculty for the Virginia POST (Physician Orders for Scope of Treatment) Collaborative as well as provided statewide professional education on palliative and end-of-life care for the Virginia Association for Hospices and Palliative Care.
For CancerChoices, Laura curates content and research, networks with clinical and organizational partners, brings awareness and education of integrative oncology at professional and patient conferences and programs, and translates research into information relevant to the patient experience as well as clinical practice.
Laura sees her work with CancerChoices as a perfect alignment of all her passions, knowledge and skills in integrative oncology care. She is honored to serve you.
Ms. Hepp is a researcher and communicator who has been writing and editing educational content on varied health topics for more than 20 years. She serves as lead researcher, program manager, and writer for CancerChoices. Her graduate work in research and cognitive psychology, her master’s degree in instructional design, and her certificate in web design have all guided her in writing and presenting information for a wide variety of audiences and uses. Nancy’s service as faculty development coordinator in the Department of Family Medicine at Wright State University also provided experience in medical research, plus insights into medical education and medical care from the professional’s perspective.
Reviewer
Dr. Wayne B. Jonas is a practicing family physician, an expert in integrative health and healthcare delivery, and a widely published scientific investigator. Dr. Jonas is the executive director of Samueli Integrative Health Programs, an effort supported by Henry and Susan Samueli to increase awareness and access to integrative health and supporting the scientific investigation of healing processes in the areas of stress, pain, and resilience. Additionally, Dr. Jonas is a retired lieutenant colonel in the Medical Corps of the United States Army. From 2001 to 2016, he was president and chief executive officer of Samueli Institute, he was the director of the Office of Alternative Medicine at the National Institutes of Health (NIH) from 1995 to 1999, and prior to that served as the director of the Medical Research Fellowship at the Walter Reed Army Institute of Research. He is a Fellow of the American Academy of Family Physicians.
Dr. Jonas’s research has appeared in peer-reviewed journals such as the Journal of the American Medical Association, Natural Medicine, The Journal of Family Practice, The Annals of Internal Medicine, and The Lancet. His books include the 2018 best seller How Healing Works: Get Well and Stay Well Using Your Hidden Power to Heal.
Dr. Jonas received the 2015 Pioneer Award from the Integrative Healthcare Symposium, the 2007 America’s Top Family Doctors Award, the 2003 Pioneer Award from the American Holistic Medical Association, the 2002 Physician Recognition Award of the American Medical Association, and the 2002 Meritorious Activity Prize from the International Society of Life Information Science in Chiba, Japan.
Dr. Jonas’s view: “We know so little about the mystery of life and the body that we need to consider all systems and explanations for their wisdom.”
Last update: September 15, 2023
Last full literature review: August 2022
We are grateful to Dr. Giovanni Elias for his review of several sections of this handbook.
CancerChoices provides information about integrativein cancer care, a patient-centered approach combining the best of conventional care, self care, and evidence-informed complementary care in an integrated plan cancer care. We review complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocialtherapy, and acupuncture therapies and self carelifestyle actions and behaviors that may impact cancer outcomes; examples include eating health-promoting foods, limiting alcohol, increasing physical activity, and managing stress practices to help patients and professionals explore and integrate the best combination of conventionalthe cancer care offered by conventionally trained physicians and most hospitals; examples are chemotherapy, surgery, and radiotherapy and complementary therapies and practices for each person.
Our staff have no financial conflicts of interest to declare. We receive no funds from any manufacturers or retailers gaining financial profit by promoting or discouraging therapies mentioned on this site.
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