Clinician Perspectives on Managing Chronic Pain After Curative-Intent Cancer Treatment

Abstract

PURPOSE: Among cancer survivors who have completed curative-intent treatment, the high prevalence and adverse consequences of chronic pain are well documented. Yet, research on clinicians' experiences with and perspectives on managing chronic pain among cancer survivors is critically lacking. METHODS: We conducted semistructured interviews with 17 clinicians (six oncology, three palliative care, and eight primary care) affiliated with an academic medical center. Interview questions addressed clinicians' experiences with and perspectives on managing chronic pain (with or without opioid therapy) during the transition from active treatment to survivorship. A multidisciplinary team conducted content analysis of interview transcripts to identify and refine themes related to current practices and challenges in managing chronic pain in this context. RESULTS: Overall, clinicians perceived chronic pain to be relatively uncommon among cancer survivors. Identified challenges included a lack of clarity about which clinician (or clinicians) are best positioned to manage chronic pain among cancer survivors, and (relatedly) complexities introduced by long-term opioid management, with many clinicians describing this practice as outside their skill set. Additionally, although most clinicians recognized chronic pain as a biopsychosocial phenomenon, they described challenges with effectively managing psychosocial stressors, including difficulty accessing mental or behavioral health services for cancer survivors. CONCLUSION: Discovered challenges highlight unmet needs related to cancer survivor-clinician communication about chronic pain and the absence of a chronic pain management home for cancer survivors, including those requiring long-term opioid therapy. Research evaluating routine pain monitoring and accessible, tailored models of multimodal pain care in survivorship may help to address these challenges.

Managing Chronic Pain in Cancer Survivorship: Communication Challenges and Opportunities as Described by Cancer Survivors

“…[10,18,30] Nonetheless, providers may underestimate the prevalence and severity of chronic pain among cancer survivors. [15] Similar to another study, [8] participants in our study reported sometimes feeling dismissed by providers when presenting with pain. They described inadequate pain assessment and some participants described minimizing their own pain for fear of being dismissed or seen as complaining to providers who may have saved their lives.…”

“…These include concerns about opioid addiction (particularly in the context of the ongoing overdose crisis), [9][10][11] limited access to multimodal pain treatment, 12 and limited provider training in managing chronic pain. [13][14][15] Patients may also under-report chronic pain to their providers during clinical encounters. 10 These challenges may be exacerbated in the cancer survivorship context, where care is often fragmented.…”

“…16 In addition, providers may underappreciate the prevalence of chronic pain following completion of cancer treatment and may feel that managing opioids or other narcotics is outside their expertise. 15 Yet few studies have actually documented cancer survivors' experiences with chronic pain management, 8,[17][18][19] none of which explored strategies that may lead to more constructive interactions related to chronic pain management in cancer survivorship.…”

Psychosocial factors contribute to the disability and distress associated with chronic pain in ambulatory patients attending an Australian cancer center

“…Pain intensity and pain interference: BPI-SF scores categorized as 1-4 for mild, 5-6 for moderate and 7-10 for severe. [21] Depression: DASS-21 score categorized according to cut points used in Australian pain clinics, viz., normal (0-9), mild (10)(11)(12)(13), moderate (14)(15)(16)(17)(18)(19)(20), severe (21)(22)(23)(24)(25)(26)(27) or extremely severe (≥28).…”

The Contribution of Cancer-Specific Psychosocial Factors to the Pain Experience in Cancer Survivors

“…11,12 Although chronic pain is widely recognized as a biopsychosocial phenomenon, 13 prior qualitative work inclusive of palliative care clinicians documents insufficient knowledge of managing psychosocial stressors in cancer survivors with chronic pain. 14 In addition, given the challenges to accessing multimodal comprehensive pain treatments, opioids often remain the mainstay of treatment, with cancer survivors prescribed long-term opioid therapy at 5 times the rate of the general population. 15 There is a need to develop a deeper understanding of the complex experience of cancer survivors living with chronic pain who do fall clearly into noncancer pain and acute cancer-related pain treatment paradigms.…”