Trajectories of Pain in Patients Undergoing Lung Cancer Surgery: A Longitudinal Prospective Study

Pain trajectories and neuropathic pain symptoms following lung cancer surgery: A prospective cohort study

BACKGROUND

Persistent postsurgical pain (PPSP) after lung cancer surgery is common and current definitions are based on evaluations at a single time point after surgery. Pain intensity and symptoms may however fluctuate and change over time, and be impacted by multiple and shifting factors. Studies of postoperative recovery patterns and transition from acute to chronic pain are needed for further investigation of preventive measures and treatments to modify unfavourable recovery paths.

METHODS

In this explorative study, 85 patients undergoing surgery due to either presumptive or confirmed lung cancer reported pain intensities bi-monthly for 12 months. Pain trajectories during recovery were investigated, using group-based trajectory modelling. Associations with possible risk factors for PPSP, including clinical variables and anxiety and depression score (HADS), were also explored.

RESULTS

A trajectory model containing three 12-month pain recovery groups was computed. One group without PPSP fully recovered (50%) within two to three months. Another group with mild-intensity PPSP followed a protracted recovery trajectory (37%), while incomplete recovery was observed in the last group (13%). Acute postoperative pain and younger age were associated with a less favourable recovery trajectory. More neuropathic pain symptoms were observed in patients with incomplete recovery.

CONCLUSIONS

Three clinically relevant recovery trajectories were identified, based on comprehensive pain tracking. Higher acute postoperative pain intensity was associated with an unfavourable pain recovery trajectory.

SIGNIFICANCE STATEMENT

Understanding the transition from acute to chronic postoperative pain and identifying preoperative risk factors is essential for the development of targeted treatments and the implementation of preventive measures. This study (1) identified distinct recovery trajectories based on frequent pain assessment follow-ups for 12 months after surgery and (2) evaluated risk factors for unfavourable postoperative pain recovery paths. Findings suggest that early higher postoperative pain intensity is associated with an unfavourable long-term recovery path.

Pain Trajectory after Short-Stay Anorectal Surgery: A Prospective Observational Study

The evolution of pain after anorectal surgery has not been well characterized. The main objective of this study is to evaluate patterns in acute postoperative pain in patients undergoing short-stay anorectal surgery. A total of 217 patients were included in the study, which used group-based trajectory modeling to estimate postoperative pain and then examined the relationships between sociodemographic or surgical factors and pain trajectories. Three distinct postoperative pain trajectories were determined: hemorrhoidectomy (OR, 0.15), higher anxiety (OR, 3.26), and a higher preoperative pain behavior score (OR, 3.15). In multivariate analysis, they were associated with an increased likelihood of being on the high pain trajectory. The pain trajectory group was related to postoperative analgesic use (p < 0.001), with the high-low group needing more nonsteroidal analgesics. The study showed that there were three obvious pain trajectories after anorectal surgery, including an unreported low-moderate-low type. More than 60% of patients maintained moderate to severe pain within 7 days after the operation. These postoperative pain trajectories were predominantly defined by surgery factors and patient factors.

Symptom severity trajectories and distresses in patients undergoing video-assisted thoracoscopic lung resection from surgery to the first post-discharge clinic visit

This study aimed to characterize patients' symptom severity trajectories and distresses from video-assisted thoracoscopic lung resection to the first post-discharge clinic visit. Seventy-five patients undergoing thoracoscopic lung resection for diagnosed or suspected pulmonary malignancy prospectively recorded daily symptom severity on a 0-10 numeric scale using the MD Anderson Symptom Inventory until the first post-discharge clinic visit. The causes of postoperative distresses were surveyed, and symptom severity trajectories were analyzed using joinpoint regression. A rebound was defined as a statistically significant positive slope after a statistically significant negative slope. Symptom recovery was defined as symptom severity of ≤3 in two contiguous measurements. The accuracy of pain severity on days 1-5 for predicting pain recovery was determined using area under the receiver operating characteristic curves. We applied Cox proportional hazards models for multivariate analyses of the potential predictors of early pain recovery. The median age was 70 years, and females accounted for 48%. The median interval from surgery to the first post-discharge clinic visit was 20 days. Trajectories of several core symptoms including pain showed a rebound from day 3 or 4. Specifically, pain severity in patients with unrecovered pain had been higher than those with recovered pain since day 4. Pain severity on day 4 showed the highest area under the curve of 0.723 for predicting pain recovery (P = 0.001). Multivariate analysis identified pain severity of ≤1 on day 4 as an independent predictor of early pain recovery (hazard ratio, 2.86; P = 0.0027). Duration of symptom was the leading cause of postoperative distress. Several core symptoms after thoracoscopic lung resection showed a rebound in the trajectory. Specifically, a rebound in pain trajectory may be associated with unrecovered pain; pain severity on day 4 may predict early pain recovery. Further clarification of symptom severity trajectories is essential for patient-centered care.

Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis

Experiencing pain and insufficient relief can be devastating and negatively affect a patient's quality of life. Developments in oncology such as new treatments and adjusted pain management guidelines may have influenced the prevalence of cancer pain and severity in patients. This review aims to provide an overview of the prevalence and severity of pain in cancer patients in the 2014-2021 literature period. A systematic literature search was performed using the databases PubMed, Embase, CINAHL, and Cochrane. Titles and abstracts were screened, and full texts were evaluated and assessed on methodological quality. A meta-analysis was performed on the pooled prevalence and severity rates. A meta-regression analysis was used to explore differences between treatment groups. We identified 10,637 studies, of which 444 studies were included. The overall prevalence of pain was 44.5%. Moderate to severe pain was experienced by 30.6% of the patients, a lower proportion compared to previous research. Pain experienced by cancer survivors was significantly lower compared to most treatment groups. Our results imply that both the prevalence of pain and pain severity declined in the past decade. Increased attention to the assessment and management of pain might have fostered the decline in the prevalence and severity of pain.

Pain prevalence and characteristics in survivors of solid cancers: a systematic review and meta-analysis

PURPOSE

The latest systematic review on the prevalence of pain in cancer survivors was published 5 years ago. The current review aims to provide an extended overview on the prevalence of pain, pain mechanisms, pain characteristics, and assessment methods in cancer survivors.

METHODS

A systematic research was conducted on 17th of April 2020 using MEDLINE, Embase, Scopus, Web of Science, and Cochrane looking at studies from 2014 to 2020. Studies had to report pain prevalence rates in cancer survivors with a solid tumor who finished curative treatment at least 3 months ago. Methodological quality was assessed by two independent reviewers using the Joanna Briggs Institute quality appraisal tool. Characteristics of the included studies, participants and reported pain prevalence rates were extracted. The reported prevalence rates of the individual studies were pooled within a meta-analysis. Meta-regressions were performed to identify possible determinants of the pooled pain prevalence.

RESULTS

After deduplication, 7300 articles were screened, after which 38 were included in the meta-analysis. Risk of bias was rated low in 26 articles and moderate in 12 articles. The pooled pain prevalence was 47% (95%CI 39-55), with a heterogeneity of 98.99%.

CONCLUSION

This meta-analysis suggests that nearly half of cancer survivors report pain after completing curative treatment at least 3 months ago. However, substantial unexplained heterogeneity warrants cautious interpretation of these results. Meta-regression using cancer type, treatment location, pain measurement, and follow-up time as a covariate could not explain influencing factors explaining the high heterogeneity.

Profiling symptom burden and its influencing factors at discharge for patients undergoing lung cancer surgery: a cross-sectional analysis

Background

Following lung cancer surgery, patients often experience severe symptoms which are not properly assessed at discharge. The aim of this study was to identify the clinical presentation at discharge and the influencing factors of postoperative symptoms in patients who have undergone lung cancer surgery.

Methods

This cross-sectional study analysed data from patients who participated in a prospective cohort study that enrolled patients who underwent lung cancer surgery at six tertiary hospitals in the People’s Republic of China, from November 2017 to January 2020. Patient symptoms at discharge were measured using the MD Anderson Symptom Inventory Lung Cancer module. The five core symptoms were defined according to ratings of moderate to severe symptoms (≥ 4 on a 0–10 scale). A multivariate linear regression model was used to identify the influencing factors of each symptom at discharge.

Results

Among the 366 participants, 51.9% were male and the mean (SD) age was 55.81 (10.43) years. At discharge, the core symptoms were cough (36.4%), pain (28.2%), disturbed sleep (26.3%), shortness of breath (25.8%), and fatigue (24.3%), and more than half of the participants (54.6%) had one to five of the core symptoms, with moderate to severe severity. A low annual income and the use of two chest tubes were significantly associated (P = 0.030 and 0.014, respectively) with higher mean scores of the core symptoms.

Conclusion

Though clinically eligible for discharge, more than half of the participants had severe symptoms at discharge after lung cancer surgery. Special attention should be given to patients who have two chest tubes after surgery and those who have a low annual income.

Postoperative Symptom Burden in Patients Undergoing Lung Cancer Surgery

CONTEXT

Previous studies on quality of life (QOL) after lung cancer surgery have identified a long duration of symptoms postoperatively. We first performed a systematic review of QOL in patients undergoing surgery for lung cancer. A subgroup analysis was conducted focusing on symptom burden and its relationship with QOL.

OBJECTIVE

To perform a qualitative review of articles addressing symptom burden in patients undergoing surgical resection for lung cancer.

METHODS

The parent systematic review utilized search terms for symptoms, functional status, and well-being as well as instruments commonly used to evaluate global QOL and symptom experiences after lung cancer surgery. The articles examining symptom burden (n = 54) were analyzed through thematic analysis of their findings and graded according to the Oxford Centre for Evidence-based Medicine rating scale.

RESULTS

The publication rate of studies assessing symptom burden in patients undergoing surgery for lung cancer have increased over time. The level of evidence quality was 2 or 3 for 14 articles (cohort study or case control) and level of 4 in the remaining 40 articles (case series). The most common QOL instruments used were the Short Form 36 and 12, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, and the Hospital Anxiety and Depression Score. Thematic analysis revealed several key findings: 1) lung cancer surgery patients have a high symptom burden both before and after surgery; 2) pain, dyspnea, cough, fatigue, depression, and anxiety are the most commonly studied symptoms; 3) the presence of symptoms prior to surgery is an important risk factor for higher acuity of symptoms and persistence after surgery; and 4) symptom burden is a predictor of postoperative QOL.

CONCLUSION

Lung cancer patients undergoing surgery carry a high symptom burden which impacts their QOL. Measurement approaches use myriad and heterogenous instruments. More research is needed to standardize symptom burden measurement and management, with the goal to improve patient experience and overall outcomes.

Pain Prevalence During Cancer Treatment: A Systematic Review and Meta-Analysis

CONTEXT

Pain is one of the most complex and prevalent symptoms in the cancer population. Despite the protective role of acute cancer-related pain, it is also an important predictor for the likelihood of developing chronic pain after cancer treatment.

OBJECTIVES

Since the last systematic review on pain prevalence rates during cancer treatment dates already from 2016, the aim of the present systematic review was to provide an overview of pain prevalence rates during cancer treatment since this previous review.

METHODS

A systematic search of the literature, including studies between 2014 and 2020, was conducted using the databases Pubmed, Embase, Scopus, Web of Science and Cochrane. Studies reporting pain prevalence rates during or within three months after curative cancer treatment was included. Title/abstract and full-text was screened double-blinded, followed by independent evaluation of the risk of bias. All prevalence rates were pooled within meta-analyses and a meta-regression was performed to clarify the amount of heterogeneity.

RESULTS

Of the 9052 studies, 12 studies were included in the meta-analysis of which 10 included breast cancer and two lung cancer patients. The pooled pain prevalence rate was 40% (95%CI 0.29-0.51), with a heterogeneity of 96%. Out of the meta-regression, only the covariate "method of pain measurement" significantly clarified the heterogeneity (P < 0.05), resulting in a residual heterogeneity of 94.88%.

CONCLUSION

Five years after the last systematic review published on this topic, pain is still very prevalent during cancer treatment. However, the pain prevalence rates were also very heterogeneous. These two findings emphasize the need for further research on the development of adequate pain assessment and pain management approaches during cancer treatment.

Presurgical distress about bodily sensations predicts chronic postsurgical pain intensity and disability 6 months after cardiothoracic surgery

ABSTRACT

Chronic postsurgical pain (CPSP) and disability after cardiothoracic surgery are highly prevalent and difficult to treat. Researchers have explored a variety of presurgical risk factors for CPSP and disability after cardiothoracic surgery, including one study that examined distress from bodily sensations. The current prospective, longitudinal study sought to extend previous research by investigating presurgical distress about bodily sensations as a risk factor for CPSP and disability after cardiothoracic surgery while controlling for several other potential psychosocial predictors. Participants included 543 adults undergoing nonemergency cardiac or thoracic surgery who were followed over 6 months postsurgically. Before surgery, participants completed demographic, clinical, and psychological questionnaires. Six months after surgery, participants reported the intensity of CPSP on a 0 to 10 numeric rating scale and pain disability, measured by the Pain Disability Index. Multinomial logistic regression analyses were conducted to evaluate the degree to which presurgical measures predicted pain outcomes 6 months after surgery. The results showed that CPSP intensity was significantly predicted by age and presurgical scores on the Symptom Checklist-90-Revised Somatization subscale (Nagelkerke R2 = 0.27, P < 0.001), whereas chronic pain disability was only predicted by presurgical Symptom Checklist-90-Revised Somatization scores (Nagelkerke R2 = 0.29, P < 0.001). These findings demonstrate that presurgical distress over bodily sensations predicts greater chronic pain intensity and disability 6 months after cardiothoracic surgery and suggest that presurgical treatment to diminish such distress may prevent or minimize CPSP intensity and disability.

Ascertaining Design and Implementation Requirements for a Perioperative Neurocognitive Training Intervention for the Prevention of Persistent Pain After Surgery

BACKGROUND

Persistent postsurgical pain (PPSP) is a common complication that impacts quality of life, often necessitating long-term opioid treatment. Certain neurocognitive factors, including reduced performance on cognitive flexibility tasks, are associated with increased risk of PPSP. We examine the perceptions of surgical patients and clinicians with regard to perioperative pain management activities and needs; patient acceptance and use of a perioperative neurocognitive training intervention; and implementation feasibility.

METHODS

We conducted both individual and focus group interviews with patients undergoing thoracic surgery and clinicians in an academic medical center. The Consolidated Framework for Intervention Research guided the development of interview questions related to the adoption and implementation of a neurocognitive intervention to mitigate PPSP. A thematic analysis was used to analyze the responses.

RESULTS

Forty patients and 15 clinicians participated. Interviews revealed that there is minimal discussion between clinicians and patients about PPSP. Most participants were receptive to a neurocognitive intervention to prevent PPSP, if evidence demonstrating its effectiveness were available. Potential barriers to neurocognitive training program adoption included fatigue, cognitive overload, lack of familiarity with the technology used for delivering the intervention, and immediate postoperative pain and stress. Implementation facilitators would include patient education about the intervention, incentives for its use, and daily reminders.

CONCLUSION

The study identified several guiding principles for addressing patients' and clinicians' barriers to effectively implementing a neurocognitive training intervention to mitigate PPSP after surgery. To ensure the sustainability of neurocognitive interventions for preventing PPSP, such interventions would need to be adapted to meet patients' and clinicians' needs within the perioperative context.

Trajectories of Pain After Cardiac Surgery: Implications for Measurement, Reporting, and Individualized Treatment

BACKGROUND

Postoperative pain after cardiac surgery is a significant problem, but studies often report pain value as an average of the study cohort, obscuring clinically meaningful differences in pain trajectories. We sought to characterize heterogeneity in postoperative pain experiences.

METHODS

We enrolled patients undergoing a cardiac surgery at a tertiary care center between January 2019 and February 2020. Participants received an electronically-delivered questionnaire every 3 days for 30 days to assess incision site pain level. We evaluated the variability in pain trajectories over 30 days by the cohort-level mean with confidence band and latent classes identified by group-based trajectory model. Group-based trajectory model estimated the probability of belonging to a specific trajectory of pain.

RESULTS

Of 92 patients enrolled, 75 provided ≥3 questionnaire responses. The cohort-level mean showed a gradual and consistent decline in the mean pain level, but the confidence bands covered most of the pain score range. The individual-level trajectories varied substantially across patients. Group-based trajectory model identified 4 pain trajectories: persistently low (n=9, 12%), moderate declining (initially mid-level, followed by decline; n=26, 35%), high declining (initially high-level, followed by decline; n=33, 44%), and persistently high pain (n=7, 9%). Persistently high pain and high declining groups did not seem to be clearly distinguishable until approximately postoperative day 10. Patients in persistently low pain trajectory class had a numerically lower median age than the other 3 classes and were below the lower confidence band of the cohort-level approach. Patients in the persistently high pain trajectory class had a longer median length of hospital stay than the other 3 classes and were often higher than the upper confidence band of the cohort-level approach.

CONCLUSIONS

We identified 4 trajectories of postoperative pain that were not evident from a cohort-level mean, which has been a common way of reporting pain level. This study provides key information about the patient experience and indicates the need to understand variation among sites and surgeons and to investigate determinants of different experience and interventions to mitigate persistently high pain.

What's going on after hospital? - Exploring the transition from hospital to home and patient experiences of nurse-led follow-up phone calls

AIMS AND OBJECTIVES

To explore the transition from hospital to home and patient experiences of nurse-led post-operative follow-up phone calls after thoracic surgery.

BACKGROUND

Enhanced Recovery After Surgery protocol places new demands on patients after hospital. Need for a proactive approach to improve the post-operative follow-up process in the home is required.

DESIGN

Qualitative intervention study.

METHODS

Interviews were conducted with patients who had received a post-operative phone call after hospital discharge (n = 15). The analysis was inspired by Gadamer and Meleis. COREQ guidelines were followed.

RESULTS

Two overall themes emerged: (1) The follow-up phone call, which concerns experiences involving the actual call and (2) Transitioning from hospital to home, which through four subthemes illuminates; how patients describe their initial time at home, that patients experience a changed body after surgery, that patients feel alone after returning home and that a call from a nurse can help patients not to feel left out and finally why it is absolutely essential that nurses initiate the phone call.

CONCLUSION

Patients are at different stages in their transition process after hospital, making timing of follow-up tricky. Being part of an Enhanced Recovery After Surgery programme has implications for the initial period after discharge; dominated by fatigue, pain and experiences of a changed body. Patients experience being left alone with their illness, and the phone call helps to relieve this isolation. It is essential that the nurse call the patient since the patients want to avoid disturbing the staff.

RELEVANCE TO CLINICAL PRACTICE

Healthcare workers can use the findings to understand how patients experience the transition from hospital to home when enrolled in an Enhanced Recovery After Surgery programme. Need for support from a nurse following discharge is suggested.