The Biopsychosocial Model of Cancer Pain
By: Tamara Harduwar, Rebecca Harrison, Lynn Gauthier, Lucia Gagliese
Cancer Pain Research Unit, Princess Margaret Cancer Centre
Although cancer is associated with a broad spectrum of distressing symptoms, pain is the most significant in terms of reducing a patient’s quality of life.1 Despite advances in our understanding of cancer and its treatments, pain management has not improved significantly.2 Unrelieved cancer pain is associated with increased physical impairment,3 psychological distress,4 delirium,5 hastened diseased progression and increased morbidity.6
Cancer pain is multidimensional. It is affected by biological, cognitive and emotional factors, which all interact in complex ways. Similarly, aging involves multiple, interacting changes, which are not uniform across systems, but dramatically impact each other. We have barely begun to identify the ways in which cancer pain and its effects on physical and psychological functioning differ with age. We do not know if the pharmacological and psychosocial cancer pain management strategies that are helpful in middle-aged adults are effective in older patients. We do not understand if the psychosocial barriers to obtaining medical and surgical treatment for cancer pain are similar in older and younger adults. As the population ages, it is increasingly important to understand age-related patterns in cancer pain, in order to apply safe and effective pain management strategies.
The Cancer Pain Research Lab, based at York University and the University Health Network, works from a biopsychosocial model of cancer pain to approach these issues. Our research aims to better understand the psychological and social impact of pain on patients and family members, to determine the biological indicators of pain, and to aid in developing effective and safe pain management strategies for people across the adult lifespan. Our lab is made up of research staff, graduate and undergraduate trainees, co-operative education secondary school students, and volunteers. Our studies aim to capture the experience of cancer pain across the disease spectrum, ranging from a few weeks after diagnosis to a few days before the end of life. In our research we consider both acute and chronic pain, and study two aspects of cancer pain: that associated with the disease process itself and pain related to treatments, namely surgery. We also look at how cancer-related pain impacts (and is impacted by) the patients’ social support network.
One of our current studies examines age-related patterns in postoperative pain in women undergoing lumpectomy or mastectomy surgery. Based on 2009 estimates, about 1 in 9 Canadian women will develop breast cancer during her lifetime.7 In addition to the women who require surgery as treatment for their cancer, many choose to undergo prophylactic surgery to reduce their risk. After surgery, many women experience moderate to severe pain, and an estimated 60% develop chronic pain.8 In this longitudinal study, we investigate how pain after breast cancer surgery differs across age groups, and how psychological and biological factors impact pain and recovery over a two-year span.
Beginning prior to surgery, we measure various biological, psychological and social factors that impact the pain experience. While most studies of chronic pain must recruit patients following an injury, the unique advantage of this patient group is that it allows for examination of pre-injury factors. In this way, we can identify which factors influence the development of chronic pain, and how these aspects may affect long-term outcomes for patients.
By following this patient group for two years, we have the opportunity to examine the potential development of pain, the long-term recovery process, and how pain intensity, biomarkers for pain, and psychosocial well-being change over time.
Biologically, aging has many interacting effects on the immune, endocrine and nervous systems, which affect how the body responds to injury.9,10,11 With age comes an increase in pro-inflammatory cytokines and cytokine responses, which may lead to an increased nervous system response to injury, ultimately resulting in pain experienced as a result of normally non-painful stimuli.11 At the same time, estrogen and progesterone levels, which may have a neuroprotective effect on this process,12,13 decrease with age.
Current research on the impact of age on postoperative cancer pain has widely varied results, likely because most studies do not examine age as a primary focus. As there are many confounding factors to account for when examining the effects of age on the disease process, our study hopes to bridge this gap in the literature by matching women based on age and surgery type.
Through increased understanding of the predictors of pain, the results of the study will help identify the unique needs of older patients, and lead to the development of management interventions tailored to their special needs. In addition, the detailed pain sensitivity and psychosocial testing may allow us to identify patient subgroups who may be at a higher risk of developing chronic pain, based on their unique symptom profile. With this information, we hope to help advance breast cancer pain palliation and improve health and quality of life for cancer patients across the adult lifespan.
- Mercadante S, Armata M, Salvaggio L: Pain characteristics of advanced lung cancer patients referred to a palliative care service. Pain. 1994;59(1): 141-5.
- Zeppetella G, O’Doherty CA, Collins S. Prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice. J Pain Symptom Manage 2000;20:87–92.
- Given CW, Given B, Azzouz F, Stommel M, Kozachik S: Comparison of changes in physical functioning of elderly patients with new diagnoses of cancer. Medical Care. 2000;38(5):482-93.
- Turk DC, Sist TC, Okifuji A, Miner MF, Florio G, Harrison P, Massey J, Lema ML, Zevon MA: Adaptation to metastatic cancer pain, regional/local cancer pain and non-cancer pain: role of psychological and behavioral factors. Pain. 1998;74(2-3):247-56.
- Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER: The impact of postoperative pain on the development of postoperative delirium. Anesthesia and Analgesia. 1998;86:781-785.
- Okusaka T, Okada S, Ueno H, Ikeda M, Shimada K, Yamamoto J, Kosuge T, Yamasaki S, Fukushima N, Sakamoto M: Abdominal pain in patients with resectable pancreatic cancer with reference to clinicopathologic findings. Pancreas. 2001;22(3):279-84.
- Advisory Committee on Cancer Statistics. (2014). Canadian Cancer Statistics 2014. Toronto, ON: Canadian Cancer Society.
- Jung BF, Ahrendt GM, Oaklander AL, Dworkin RH. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain. 2003;104:1-13.
- Franceschi C, Valensin S, Bonafe M, Paolisso G, Yashin AI, Monti D, De Benedictis G. The network and the remodeling theories of aging: historical background and new perspectives. Experimental Gerontology. 2000;35(6-7):879-96.
- Straub RH, Cutolo M, Zietz B, Scholmerich J. The process of aging changes the interplay of the immune, endocrine and nervous systems. Mechanisms of Ageing & Development. 2001;122 (14):1591-611.
- Watkins LR, Maier SF, Goehler LE. Immune activation: the role of pro-inflammatory cytokines in inflammation, illness responses and pathological pain states. Pain. 1995;63(3):289-302.
- Sohrabji F. Estrogen: a neuroprotective or proinflammatory hormone? Emerging evidence from reproductive aging models. Annals of the New York Academy of Sciences: 1052, 2005.
- Rehman HU, Masson EA. Neuroendocrinology of female aging. Gender Medicine. 2005;2(1):41-56.