Breast cancer is the most frequent malignancy among women worldwide. Despite the high incidence in Western countries, an increase in survival and life expectancy has been observed due to the ongoing improvement of detection method accuracy, early diagnosis and breast cancer treatment (Ferlay et aL., 2015). Consequently, more attention is warranted towards the debilitating problems accompanying this disease and its treatment, which can persist for months or even years after diagnosis. In addition to fatigue, pain is the most frequent and persistent symptom following cancer and cancer treatment. Between 27% and 79% of women report pain 1 month after surgery, usually attributed to local pain mechanisms induced by treatment-related tissue injury (Rietman et al., 2003; Hidding et al., 2014; Wang et al., 2016; Leysen et al., 2017). One would expect the prevalence rate to diminish as healing occurs, yet this does not seem to be the case. In fact, 12%–82% of women still report persistent pain 1 year after surgery or even longer (Wang et al., 2016), which could indicate that (besides local nociceptive and neuropathic pain mechanisms) a third mechanism may be responsible for pain. This mechanism is characterized by altered nociceptive processing in the absence of both tissue damage and disease or lesion of the somatosensory system (De Groef et al., 2018; Nijs et al., 2016; Nijs et al., 2018). More importantly, pain interferes with pain-, physical-, emotional- and work-related functioning and therefore severely prejudices a person’s quality of life and participation in society (Kudel et al., 2007; Sun et al., 2017; Shin et al., 2017). Hence, adequate pain management in the early stage of breast cancer treatment is necessary to prevent and improve pain and pain-related disability, both at short and long term.
Despite the effectiveness of currently applied physical therapy modalities after breast cancer surgery (such as manual techniques, specific exercises and general exercises), up to 72% of women still experience pain and the resulting disabilities after finishing breast cancer treatment (De Groef et al., 2015). Over the past decades, awareness on the important role of educational interventions in the management of cancer pain has increased (Bennett et al., 2009; Armes et al., 2007; Ling et al., 2012). These general educational interventions have been shown to be effective for improving pain severity, self-efficacy and knowledge and attitude to pain and analgesia in patients with cancer. However, effect sizes are only moderate and of limited clinical relevance (Bennett et al., 2009). This can be explained by the fact that these educational interventions mainly focus on tissue and tissue injury as the source of pain and are often restricted to biomedical pain management instructions and general advice on physical activity and analgesics (Bennett et al., 2009; Armes et al., 2007; Ling et al., 2012). They focus on explaining treatment side effects and improving patients’ coping strategies. Recently, increased knowledge on pain mechanisms has led to a more modern educational approach, also known as pain neuroscience education (PNE) (Moseley et al., 2015; Nijs et al., 2011; Nijs et al. 2011; Nijs et al., 2014). This explains the neurophysiology of chronic pain and the ability of the nervous system to modulate pain experience, as well as the potential influences such as sleep, thoughts, feelings and culture, among others, on pain. Thereby, it targets a reconceptualization from a biomedical or structural model to an actual biopsychosocial model of pain.
Through the knowledge that pain is often an unreliable indicator of the presence or extent of tissue damage, patients may become open to exploring broader contributions to pain. Thereby pain-related behavior might change by shifting from passive therapy receiving to active self-management. Increased knowledge of the broad contributions to pain (Wang et al., 2016), as well as awareness of different pain mechanisms following breast cancer treatment (De Groef et al., 2018; Nijs et al., 2016; Nijs et al., 2018) provides justification for the integration of PNE in this population. Applying PNE could enhance the effectiveness of the currently applied physical therapy modalities for prevention and treatment of pain and related disabilities after breast cancer treatment, compared with a traditional biomedical educational intervention. Indeed, encouraging people to address emotional, cognitive and broader health-related factors in the early stage of cancer treatment may enhance recovery during and after the treatment. To our knowledge, only one controlled trial investigated the effectiveness of PNE in the early stage of breast cancer treatment (Sato et al., 2014). Although the results were very promising for shoulder function, only short-term effects were examined, no randomization was performed and no pain-related or other health-related outcomes were evaluated.
The main scientific objective of the EduCan Trial, a double-blinded randomized controlled trial, is to examine the effectiveness of PNE, in addition to a standard best evidence physical therapy program, on pain-, physical-, emotional- and work-related functioning in the early stage of breast cancer treatment, compared with a traditional biomedical educational intervention, up to 1.5 years after surgery.
Elien Van der Gucht & Lore Dams
Research Group for Rehabilitation of Internal Disorders, KU Leuven.
2019 Pain in Motion
References and further reading:
Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359–86.
Rietman JS, Dijkstra PU, Geertzen JH, et al. Short-term morbidity of the upper limb after sentinel lymph node biopsy or axillary lymph node dissection for Stage I or II breast carcinoma. Cancer 2003;98:690–6.
Hidding JT, Beurskens CH, van der Wees PJ, et al. Treatment related impairments in arm and shoulder in patients with breast cancer: a systematic review. PLoS One 2014;9:e96748.
Wang L, Guyatt GH, Kennedy SA, et al. Predictors of persistent pain after breast cancer surgery: a systematic review and meta-analysis of observational studies. CMAJ 2016;188:E352–61.
Leysen L, Beckwée D, Nijs J, et al. Risk factors of pain in breast cancer survivors: a systematic review and meta-analysis. Support Care Cancer 2017;25:3607–43.
De Groef A, Meeus M, De Vrieze T, et al. Unraveling self-reported signs of central sensitization in breast cancer survivors with upper limb pain: prevalence rate and contributing factors. Pain Physician 2018;21:E247–56.
Nijs J, Leysen L, Adriaenssens N, et al. Pain following cancer treatment: Guidelines for the clinical classification of predominant neuropathic, nociceptive and central sensitization pain. Acta Oncol 2016;55:659–63.
Nijs J, Leysen L, Pas R, et al. Treatment of pain following cancer: applying neuro-immunology in rehabilitation practice. Disabil Rehabil 2018;40:714–21.
Kudel I, Edwards RR, Kozachik S, et al. Predictors and consequences of multiple persistent postmastectomy pains. J Pain Symptom Manage 2007;34:619–27.
Sun Y, Shigaki CL, Armer JM. Return to work among breast cancer survivors: a literature review. Support Care Cancer 2017;25:709–18.
Shin WK, Song S, Jung SY, et al. The association between physical activity and health-related quality of life among breast cancer survivors. Health Qual Life Outcomes 2017;15:132.
De Groef A, Van Kampen M, Dieltjens E, et al. Effectiveness of postoperative physical therapy for upper-limb impairments after breast cancer treatment: a systematic review. Arch Phys Med Rehabil 2015;96:1140–53.
Bennett MI, Bagnall AM, José Closs S. How effective are patientbased educational interventions in the management of cancer pain? Systematic review and meta-analysis. Pain 2009;143:192–9.
Armes J, Chalder T, Addington-Hall J, et al. A randomized controlled trial to evaluate the effectiveness of a brief, behaviorally oriented intervention for cancer-related fatigue. Cancer 2007;110:1385–95.
Ling CC, Lui LY, So WK. Do educational interventions improve cancer patients' quality of life and reduce pain intensity? Quantitative systematic review. J Adv Nurs 2012;68:511–20.
Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain 2015;16:807–13.
Nijs J, Meeus M, Van Oosterwijck J, et al. Treatment of central sensitization in patients with 'unexplained' chronic pain: what options do we have? Expert Opin Pharmacother 2011;12:1087–98.
Nijs J, van Wilgen CP, Van Oosterwijck J, et al. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines. Man Ther 2011;16:413–8.
Nijs J, Torres-Cueco R, van Wilgen CP, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician 2014;17:447–57.
Sato F, Ishida T, Ohuchi N. The perioperative educational program for improving upper arm dysfunction in patients with breast cancer: a controlled trial. Tohoku J Exp Med 2014;232:115–22.
Free PDF available from: