“To eat is a necessity, but to eat intelligently is an art”
La Rochefoucald
The development of chronic pain is the one of the most seen sequelae in the cancer survivor population (Leysen et al., 2017). But despite that, it is an entity which is poorly studied and comprehended (Burton et al., 2007). Nowadays, scientific studies show us that variable systems and mechanisms in the body (like immune system, endocrine system etc.) can initiate pain or even cause nervous system sensitisation. The cancer process can easily activate several of these systems or mechanisms at the same time, because many oncology-related elements like inflammation, malnutrition, repeated surgery, treatment modalities (like radiotherapy, chemotherapy etc.) and psychological vulnerability are also predisposing factors of chronic pain.
Because understanding pain and its underlying mechanisms is important for pain management in cancer survivors, we emphasize the necessity of a biopsychosocial approach in clinical reasoning to shape the best treatment approach. But, may we be missing a very crucial “bio”-related component in post-cancer pain patients?
A reduction in nutritional quality and quantity is frequently acknowledged as a consequence of the cancer course and treatment (Capra et al., 2001). The aetiology of malnutrition in cancer patients is multifactorial, for instance, malnutrition may originate from the systemic influences of the tumour, the regional influences of the tumour, the adverse effects of anticancer treatment (Capra et al., 2001), or the changes in hormone levels (Argiles, 2005). All crucial cancer treatment modalities (surgery, radiation and chemotherapy) may remarkably affect nutritional needs, change normal eating habits, and adversely influence how the body digests, absorbs, and utilises food (Doyle et al., 2006).
While depending on the cancer type and stage at diagnosis, cancer may lead to intense metabolic and physiologic changes which may influence the needs on macro- and micronutrient level (Rock et al., 2012). For instance, levels of many plasma proteins (albumin, transferrin and transthyretin (prealbumin)), which are affected by several factors such as inflammatory disease, drug or hormone therapy, are markers of protein energy malnutrition (Johnson, 1999). Another affected mechanism is the carbohydrate metabolism. Alterations in carbohydrate metabolism similar to alterations in type 2 diabetes, are common in p patients with cancer-associated malnutrition (Argiles, 2005). Additionally, insufficient nutritional intake ends up with the gut lining atrophy, reduced intestinal secretions and alterations in gut flora, which further decline gut function and the capability to get nutrients from food (Argiles, 2005).
Emerging literature highlights a place for diet as a regulator in chronic pain via management of inflammation/ oxidative stress, possibly leading to a decrease in pain (Rondanelli et al., 2018). Additionally, it is just lately that the influence of nutrition on brain plasticity and function has been investigated and it has become clear that specific dietary factors (like omega-3 fatty acids, curcumin, salmon and turmeric) are significant modifiers of brain plasticity and may have an influence on central nervous system health and disease (Gomez-Pinilla and Gomez. 2011). Given the role of the central nervous system and central sensitization in cancer-related pain, it becomes relevant to focus on the association between pain and nutritional aspects in this population (Fernandez-Lao et al., 2011, Yanagisawa et al., 2010, Leysen et al., 2018). Moreover, poor eating behaviours were discovered to be highly prevalent in patients with chronic pain who experienced long-term opioid therapy (Polak et al., 2016). This supports the idea that dietary factors may be utilised as biologic-based therapies (Gomez-Pinilla and Gomez, 2011).
Moreover, after cancer treatment has been finished, the following period of cancer survival is recovery (Doyle et al., 2006). As every cell, tissue, organ and system of the human body depends on the nutritional signals that the body sends (Audette and Bailey, 2008), good nutritional habits may contribute to improving efficiency of pain treatment and quality of life in cancer survivors.
As mentioned above, in cancer survivors chronic pain involves multiple systems and mechanisms which have complex interactions. Using nutrition as a modality in pain management can provide the capability to regulate these systems on the pathophysiological level and can provide long lasting responses from treatment by changing daily diet according to the needs. But unfortunately, the association between nutrition and chronic pain in post-cancer patients is not yet fully investigated. Yet, because of the importance of both pain and nutritional aspects in cancer survivors, it becomes relevant to look at the mutual association between pain and nutrition in this population.
Sevilay Tumkaya Yilmaz
Member of the International Pain in Motion Research Group
PhD student at Vrije Universiteit Brussel, Brussels, Belgium
Funded by the Republic of Turkey, Ministry of National Education
2019 Pain in Motion
References and further reading:
ARGILES, J. M. 2005. Cancer-associated malnutrition. Eur J Oncol Nurs, 9 Suppl 2, S39-50.
https://www.ncbi.nlm.nih.gov/pubmed/16437757
AUDETTE, J. F. & BAILEY, A. 2008. Integrative pain medicine: the science and practice of complementary and alternative medicine in pain management, Springer Science & Business Media.
https://www.springer.com/us/book/9781588297860
BURTON, A. W., FANCIULLO, G. J., BEASLEY, R. D. & FISCH, M. J. 2007. Chronic pain in the cancer survivor: a new frontier. Pain Med, 8, 189-98.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Chronic+...
CAPRA, S., FERGUSON, M. & RIED, K. 2001. Cancer: impact of nutrition intervention outcome—nutrition issues for patients. Nutrition, 17, 769-772.
https://www.ncbi.nlm.nih.gov/pubmed/11527676
DOYLE, C., KUSHI, L. H., BYERS, T., COURNEYA, K. S., DEMARK‐WAHNEFRIED, W., GRANT, B., MCTIERNAN, A., ROCK, C. L., THOMPSON, C. & GANSLER, T. 2006. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA: a cancer journal for clinicians, 56, 323-353.
https://www.ncbi.nlm.nih.gov/pubmed/17135691
FERNÁNDEZ‐LAO, C., CANTARERO‐VILLANUEVA, I., FERNÁNDEZ‐DE‐LAS‐PEÑAS, C., DEL‐MORAL‐ÁVILA, R., MENJÓN‐BELTRÁN, S. & ARROYO‐MORALES, M. 2011. Widespread mechanical pain hypersensitivity as a sign of central sensitization after breast cancer surgery: comparison between mastectomy and lumpectomy. Pain medicine, 12, 72-78.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Widespre...
GOMEZ-PINILLA, F. & GOMEZ, A. G. 2011. The influence of dietary factors in central nervous system plasticity and injury recovery. PM R, 3, S111-6.
https://www.ncbi.nlm.nih.gov/pubmed/21703566
JOHNSON, A. M. 1999. Low levels of plasma proteins: malnutrition or inflammation? Clinical chemistry and laboratory medicine, 37, 91-96.
https://www.ncbi.nlm.nih.gov/pubmed/10219494
LEYSEN, L., ADRIAENSSENS, N., NIJS, J., PAS, R., BILTERYS, T., VERMEIR, S., LAHOUSSE, A. & BECKWÉE, D. 2018. Chronic Pain in Breast Cancer Survivors: Nociceptive, Neuropathic, or Central Sensitization Pain? Pain Practice.
https://www.ncbi.nlm.nih.gov/pubmed/30269431
LEYSEN, L., BECKWÉE, D., NIJS, J., PAS, R., BILTERYS, T., VERMEIR, S. & ADRIAENSSENS, N. 2017. Risk factors of pain in breast cancer survivors: a systematic review and meta-analysis. Supportive Care in Cancer, 25, 3607-3643.
https://www.ncbi.nlm.nih.gov/pubmed/28799015
POLAK, R., DACEY, M. L. & PHILLIPS, E. M. 2016. Time for Food--Including Nutrition on Physiatrists' Tables. PM R, 8, 388-390.
https://www.ncbi.nlm.nih.gov/pubmed/?term=Time+for...
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https://www.ncbi.nlm.nih.gov/pubmed/?term=Food+pyr...
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