Treating persistent pain after breast cancer: practice gaps and future directions   May 22nd, 2022

A new international, multidisciplinary collaborative has been formed with world-leading experts in pain science education, (cancer) pain, and oncological rehabilitation: Pain Education after CANcer.

PECAN is building on the lessons learned from musculoskeletal science for how to make pain science education ‘stick’, as well as focusing on the unique considerations of cancer populations. Their first joint publication discusses the growing problem of persisting pain after successful treatment of breast cancer and presents recommendations for improving pain related outcomes for this group. The paper can be accessed here (1).

Breast cancer is the most common cancer among women. Seventy-three percent of people diagnosed with breast cancer have their cancer successfully treated, defined here as being alive 5 years after diagnosis, but 19.5-21.8% of them experience persisting moderate-to-severe pain (2). Management of persisting pain problems in non-cancer populations has moved beyond medication-based approaches. Education, active and psychological therapies, and self-management skills, are now considered and recommended as frontline interventions and are endorsed as such in clinical guidelines almost wherever they exist. By drawing on these transformative changes in treatment approaches to persistent non-cancer related pain, we describe the potentially powerful role that pain science education may play in improving pain and disability outcomes after successful breast cancer treatment. For this, we highlight the importance of the adaptation of the content and delivery models of contemporary pain science education to the post-breast cancer context.

A recent mixed-method study in people who had recovered from a range of chronic pain states, revealed three key concepts they considered to hold most value for pain science education (3). The first concept ‘Pain does not mean my body is damaged’ captures the importance of abandoning pre-existing ideas that pain indicates tissue damage. Second, ‘Thoughts, emotions and experiences affect pain’ captures the value of recognising multifactorial (biopsychosocial) influences on pain. And third, ‘I can retrain my overprotective pain system’ captures the importance of conceptualising persistent pain as a persistently heightened protective response that can be modified. Although these key target concepts identified in non-cancer population certainly hold value in the post-breast cancer population as well, the complexity and unique characteristics of post-breast cancer pain limit simple transfer from the non-cancer population to the cancer population. As such, additional cancer-specific concepts might well be added, just as musculoskeletal-specific concepts (e.g. ‘an intervertebral disc can’t slip’) might be dropped. Tailoring pain science education to the cancer population will need to account for other comorbidities (for which a lot of biomedical information is provided by leaflets, books, and the internet), serious unique biopsychosocial factors, the possible specific sequelae of cancer treatments, and the already long and often intensive follow-up and after-care. Cancer-specific concepts that can be integrated with the key concepts that underpin pain science education are for example:

1) Unusual sensations related to scars. The mechanisms involved in scar tissue formation, related sensations, psychological impact, and how to manage and soften scars should be addressed. Learning goals can be introducing the idea that it is safe (and beneficial) to move and reframing every scar as a story of strength and survival.

2) Damaged nerves send false danger messages. The mechanisms behind neuropathic pain (and related unusual sensations) need to be explained. This concept is relevant in the context of (painful and non-painful) neuropathies related to surgery, radiotherapy, and chemotherapy. Leaning goals can be understanding the mechanisms behand neuropathic pain and setting correct expectations for recovery time and implications for helpful or unhelpful strategies.

3) Living with pain-related uncertainty. Interpreting everyday aches and pains as a sign of cancer recurrence will substantially increase the threat value of pain. Leaning goals can be becoming aware on over-monitoring daily aches and pain, and learning skills and strategies to manage these uncertainties.

The PECAN team argues for new innovative collaborative pain management programs that incorporate pain science education tailored to the specific needs of the growing population of men and women with persistent post-breast cancer pain.

An De Groef - @AnDeGroef

2022 Pain in Motion

References and further reading:

(1) De Groef A, Meeus M, Heathcote LC, et al. Treating persistent pain after breast cancer: practice gaps and future directions. Journal of cancer survivorship 2022: 1-10. doi: 10.1007/s11764-022-01194-z

(2) Wang L, Cohen JC, Devasenapathy N, et al. Prevalence and intensity of persistent post-surgical pain following breast cancer surgery: a systematic review and meta-analysis of observational studies. British journal of anaesthesia 2020; 125(3): 346-57. doi: 10.1016/j.bja.2020.04.088

(3) Leake HB, Moseley GL, Stanton TR, O'Hagan ET, Heathcote LC. What do patients value learning about pain? A mixed-methods survey on the relevance of target concepts after pain science education. Pain 2021; 162 (10):2558-2568. doi: 10.1097/j.pain.0000000000002244