Key Points

• The prevalence of chronic pain among adult cancer survivors was nearly double that of adults without a cancer diagnosis.
• Patients who had been diagnosed with cancer and who experienced chronic pain were more likely to feel depressed and/or anxious and to have problems with basic ADLs and employment issues compared with survivors without chronic pain.

…based upon my own experience, patients sometimes feel embarrassed or ashamed to mention that they continue to have pain, out of stigma and concern about being labeled as medication seeking.”–Nina Niu Sanford, MD

With a growing number of cancer patients and survivors, and continued alarm regarding the opioid crisis, a new study in Cancer (2019;125:4310‐4318. doi:10.1002/cncr.32450) examines how widespread chronic pain is among cancer survivors and the psychological and functional problems associated with chronic pain.

“To the best of our knowledge, this is the first comprehensive study assessing the rate of chronic pain among cancer patients and survivors,” says Nina Niu Sanford, MD, an assistant professor of radiation oncology and Dedman Family Scholar in Clinical Care at the University of Texas Southwestern Medical Center in Dallas, Texas. “The prevalence of chronic pain among this population was quite high at about one‐third and was associated with worse psychological and functional outcomes.”

Study Details

Data for the study were drawn from the National Health Interview Survey (NHIS) Cancer Control Supplement, which is co‐sponsored by the Centers for Disease Control and Prevention and the National Cancer Institute, primarily to monitor progress toward nationwide cancer control objectives. Although this survey includes information regarding a broad range of general and cancer‐related risk factors, health behaviors, and health outcomes, for the current study the researchers focused on how often participants experienced pain over the most recent 3‐month period, with possible responses including never, some days, most days, every day, and unknown. The survey noted whether participants had received a cancer diagnosis and, if so, when and what type; survivors of nonmelanoma skin cancer were excluded from the study for consistency with prior studies, as were patients diagnosed fewer than 2 years prior to the interview to avoid confusion between chronic pain and acute pain related to treatments and medical procedures. Participants also were asked if and how often they were depressed, worried, nervous, or anxious, with possible responses being daily, weekly, monthly, a few times a year, never, or did not know. Subjects also were asked if they had missed work because of health issues and whether they needed help with activities of daily living (ADLs; eg, eating, dressing, walking or transferring from one position to another, bathing, toileting, and maintaining bowel and bladder continence) and/or instrumental ADLs (8 activities such as food preparation, housekeeping, handling finances, and medications).

Study Results

After applying all inclusion and exclusion criteria, a total 115,091 participants remained, 7565 (6.6%) of whom were cancer survivors. The median age of the participants who reported a cancer history was 68 years, whereas the median age of those who had never been diagnosed with cancer was 47 years (P < .001). Researchers found that the prevalence of chronic pain (defined as that occurring daily or on most days) among cancer survivors was nearly double that for individuals without a cancer history (30.8% and 15.7%, respectively). Females reported chronic pain more often than males (18.3% and 14.8%, respectively).

The researchers found that older age increased the odds of chronic pain only in participants without cancer. Chronic pain was reported by 23.2% of those without cancer who were older than the median age of 48 years compared with by 10.1% of those younger than the median age (P < .001), whereas the prevalence of chronic pain among cancer survivors was similar among those older versus younger than the median age (31.1% vs 30.7%, respectively).

Among cancer survivors, those with sarcoma were found to have the highest prevalence of chronic pain. Compared with those participants without a cancer diagnosis, chronic pain was significantly more common among survivors of all cancer types except for bladder, prostate, and breast cancers.

Cancer survivors who reported chronic pain were significantly more likely to report several adverse psychological and functional outcomes compared with survivors without chronic pain. Among cancer survivors, chronic pain was significantly associated with the prevalence of depression (32.8% vs 11.1% for survivors with and without chronic pain); feeling worried, nervous, or anxious (44.7% vs 22.8%); inability to work because of health problems (32.5% vs 7.7%); and needing assistance with ADLs (10.6% vs 2.5%) or instrumental ADLs (19.6% vs 5.2%).

“We have known for decades that our cancer therapies are associated with pain both during and beyond completion of therapy,” says Kevin C. Oeffinger, MD, founding director of the Duke Cancer Institute Center for Onco‐Primary Care and director of the Duke Supportive Care and Survivorship Center at the Duke Cancer Institute in Durham, North Carolina. “However, the comprehensive view that Sanford and colleagues took, using NHIS data, was an interesting way to compare cancer survivors and noncancer patients.”

According to Dr. Oeffinger, the single greatest limitation in NHIS data is the lack of information regarding each patient's treatments. “That may be why they didn't see the changes with breast and prostate [cancers] since we don't know which patients underwent chemotherapy and with what regimens—if they were treated with taxanes or not and so on. They all get mixed into the same group,” he said. “Still, they had some interesting associations which confirmed…associations we have seen or suspected, and they documented that chronic pain is an immense problem.”

Dr. Sanford says she and the research team believe the study will help to make clinicians aware of the high prevalence of chronic pain, even many years into cancer survivorship, and that they should screen for it. “They may be surprised that their patients are continuing to experience pain and are taking medications to address [it],” she says. However, by bringing up the topic, physicians may help patients to feel more comfortable discussing it. “Based upon my own experience, patients sometimes feel embarrassed or ashamed to mention that they continue to have pain, out of stigma and concern about being labeled as medication seeking,” Dr. Sanford says. “For researchers, better strategies for pain management should be explored, including those not reliant on opioid medications.”

Dr. Oeffinger agrees. “The primary care providers, including nurse practitioners and physician assistants, are critical in assessing and managing patients' pain during therapy. They know their patients, they know the patient dynamics, they know the patients' resources, and that's an underutilized resource from the oncology perspective that we don't tap into nearly as often as we should.”

“We don't do a good job, in general, of managing pain in the US,” Dr. Oeffinger adds. “And that's especially unfortunate in this population [cancer survivors], which has an increased risk of pain.” Dr. Oeffinger says he is a great believer in an array of nonpharmacologic approaches to pain management, including the right form of exercise. “There definitely is a place for opioids, but we need to be careful that we're managing and treating the pain appropriately.”

Nevertheless, Dr. Sanford says she is hopeful that shedding light on the prevalence and impact of chronic pain may help to open lines of communication between physicians, patients, and policymakers and provide a benchmark with which to evaluate the efficacy of any future policy changes.

For further information regarding the care of cancer survivors, Dr. Oeffinger recommends the National Cancer Survivorship Resource Center toolkit (smhs.gwu.edu/gwci/survivorship/ncsrc/national-cancer-survivorship-center-toolkit), developed by the American Cancer Society and the George Washington University Cancer Center, and the American Society of Clinical Oncology's Survivorship Compendium (asco.org/practice-policy/cancer-care-initiatives/prevention-survivorship/survivorship/survivorship-compendium?).

中文翻译：

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探索引起慢性癌症疼痛的原因和可能的补救措施。

关键点

• 成年癌症幸存者中慢性疼痛的患病率几乎是没有癌症诊断的成年人的两倍。
• 与没有慢性疼痛的幸存者相比，已被诊断出患有癌症并经历了慢性疼痛的患者更有可能感到沮丧和/或焦虑，并出现基本ADL和就业问题。

……根据我自己的经验，患者有时会因感到羞耻而感到尴尬或羞愧，因为他们受到耻辱并担心被贴上寻求药物的标签。” –医学博士Nina Niu Sanford

随着越来越多的癌症患者和幸存者以及关于阿片类药物危机的持续警惕，癌症领域的一项新研究（2019; 125：4310-4318。doi：10.1002 / cncr.32450）检验了癌症幸存者和癌症患者中慢性疼痛的普遍程度与慢性疼痛有关的心理和功能问题。

“就我们所知，这是第一项评估癌症患者和幸存者中慢性疼痛发生率的综合研究，”大学放射肿瘤学助理教授兼临床医学家戴德曼家族学者尼娜·纽·桑福德说。德克萨斯州达拉斯的得克萨斯州西南医学中心的总部。“该人群中慢性疼痛的患病率很高，约为三分之一，并且与较差的心理和功能结局有关。”

研究细节

该研究的数据来自美国疾病预防控制中心和美国国家癌症研究所共同赞助的《美国国家健康访问调查（NHIS）癌症控制增刊》，主要目的是监测全国癌症控制目标的进展情况。尽管此调查包括有关广泛的一般和与癌症相关的危险因素，健康行为和健康结果的信息，但对于本研究，研究人员关注的是参与者在最近3个月内经历疼痛的频率，并可能做出回应包括从不，某些天，大多数天，每天和未知。该调查指出参与者是否接受了癌症诊断，如果接受了诊断，何时何类型。非黑色素瘤皮肤癌的幸存者与先前研究一致，因此被排除在研究之外，以及在访谈前不到2年被确诊的患者，以避免与治疗和医疗程序有关的慢性疼痛和急性疼痛之间的混淆。参与者还被问到是否沮丧，担心，焦虑，紧张或焦虑，多久一次，可能的回应是每天，每周，每月，每年几次，从不或不知道。还询问受试者是否由于健康问题而错过了工作，以及他们是否需要在日常生活活动中寻求帮助（ADL；例如，进食，穿衣，步行或从一个位置转移到另一个位置，洗澡，上厕所以及保持肠道和膀胱）节制）和/或工具性ADL（8种活动，如食物准备，家务管理，财务处理和药物治疗）。

研究结果

在应用所有纳入和排除标准后，总共剩余115,091名参与者，其中7565名（6.6％）是癌症幸存者。报告癌症病史的参与者的中位年龄为68岁，而从未被诊断出癌症的参与者的中位年龄为47岁（P  <.001）。研究人员发现，癌症幸存者中慢性疼痛（定义为每天或大多数天发生）的患病率几乎是没有癌症史的人的两倍（分别为30.8％和15.7％）。女性比男性报告慢性疼痛的频率更高（分别为18.3％和14.8％）。

研究人员发现，老年患者仅在没有癌症的参与者中增加了慢性疼痛的几率。据报道，年龄在48岁以下的无癌症患者中有23.2％患有慢性疼痛，而年龄在48岁以下的癌症患者中则有10.1％（P  <.001），而癌症幸存者中慢性疼痛的患病率为在年龄中位数与年龄中位数之间的年龄相似（分别为31.1％和30.7％）。

在癌症幸存者中，发现肉瘤患者的慢性疼痛患病率最高。与没有癌症诊断的参与者相比，在所有癌症类型的幸存者中，除膀胱癌，前列腺癌和乳腺癌外，慢性疼痛更为常见。

与没有慢性疼痛的幸存者相比，报告慢性疼痛的癌症幸存者更有可能报告几种不良的心理和功能结局。在癌症幸存者中，慢性疼痛与抑郁症的患病率显着相关（32.8％vs.有和没有慢性疼痛的幸存者）；感到担心，紧张或焦虑（44.7％vs 22.8％）；由于健康问题而无法工作（32.5％比7.7％）；以及需要ADL（10.6％vs 2.5％）或工具性ADL（19.6％vs 5.2％）的帮助。

“数十年来，我们已经知道癌症疗法与治疗过程中及结束后的疼痛有关，”杜克大学癌症研究所肿瘤主要治疗中心创始主任，杜克支持者办公室主任凯文·C·奥芬格医师说北卡罗来纳州达勒姆市杜克癌症研究所的护理和生存中心。“但是，桑福德和同事使用NHIS数据得出的综合观点是比较癌症幸存者和非癌症患者的有趣方法。”

根据Oeffinger博士的说法，NHIS数据的最大局限性在于缺乏有关每个患者治疗方法的信息。“这可能就是为什么他们没有看到乳腺和前列腺癌改变的原因，因为我们不知道哪些患者接受了化学疗法以及采用了何种治疗方案-是否接受过紫杉烷类药物的治疗等等。” 他们都混在同一个小组中，”他说。“不过，他们还有一些有趣的关联，这些关联证实了……我们已经看到或怀疑的关联，并且他们证明了慢性疼痛是一个巨大的问题。”

桑福德博士说，她和研究小组相信，这项研究将使临床医生意识到慢性疼痛的高患病率，即使癌症存活期长达数年，也应该对此进行筛查。她说：“他们可能会感到惊讶的是，他们的患者持续遭受痛苦并正在服用药物来解决它。” 但是，通过提出该主题，医生可能会帮助患者更轻松地讨论该主题。桑福德博士说：“根据我自己的经验，患者有时会因感到羞耻而感到尴尬或羞愧，他们继续感到痛苦，出于耻辱，并担心被贴上寻求药物的标签。” “对于研究人员，应该探索更好的疼痛管理策略，包括那些不依赖阿片类药物的策略。”

奥芬格博士同意。“初级保健提供者，包括执业护士和医师助理，对于评估和管理患者在治疗过程中的疼痛至关重要。他们了解患者，了解患者动态，了解患者的资源，从肿瘤学的角度来看，这是一种未得到充分利用的资源，我们没有像我们应该经常使用的那样。”

Oeffinger博士补充说：“总的来说，我们在管理疼痛方面做得不好。” “这在[癌症幸存者]人群中尤其不幸，这增加了痛苦的风险。” Oeffinger博士说，他非常相信一系列非药物方法来控制疼痛，包括正确的锻炼方式。“肯定有阿片类药物的地方，但是我们需要谨慎对待并适当地控制和治疗疼痛。”

不过，桑福德博士说，她希望阐明慢性疼痛的患病率和影响可能有助于打开医生，患者和决策者之间的沟通渠道，并为评估未来任何政策变化的有效性提供基准。

有关癌症幸存者护理的更多信息，Oeffinger博士建议由美国癌症协会开发的国家癌症幸存者资源中心工具包（smhs.gwu.edu/gwci/survivorship/ncsrc/national-cancer-survivorship-center-toolkit）学会和乔治华盛顿大学癌症中心，以及美国临床肿瘤学会生存指南（asco.org/practice-policy/cancer-care-initiatives/prevention-survivorship/survivorship/survivorship-compendium？）。