A systematic review of self-reported pain in childhood cancer survivors

Incidence and prevalence of musculoskeletal health conditions in survivors of childhood and adolescent cancers: A report from the Swiss childhood cancer survivor study

PURPOSE

Childhood cancer and its treatment can cause damage to the musculoskeletal system. We aimed to determine the incidence and prevalence of musculoskeletal health conditions (MSHC) in survivors, and to investigate differences by cancer-related characteristics.

METHODS

We used data from the Childhood Cancer Registry and the Swiss Childhood Cancer Survivor Study, including survivors (≥5 years since diagnosis; diagnosed 1976-2015 at <20 years of age) aged ≥15 years at study. Cumulative incidence and prevalence of MSHCs (osteoporosis, limb length discrepancy, limited joint mobility, bone/joint pain, scoliosis, changes to chest/ribs and amputation) were calculated from self-reported data.

RESULTS

We included 2645 survivors (53% men; median age 24 years, range 15-59 years). Prevalence and cumulative incidence of any MSHC was 21% and 26%, respectively. Incidence rate for any MSHC was 15.6/1000 person-years. Scoliosis (8%), bone/joint pain (7%) and limited joint mobility (7%) were the most prevalent MSHC. MSHC co-occurred with other health conditions in 87% of survivors. We found increased rates of MSHC in women (RR = 1.4, 95%CI: 1.2-1.7), bone tumour survivors (RR = 6.0, 95%CI: 4.5-7.9), survivors older at diagnosis (11-15 years: RR = 1.8, 95%CI: 1.5-2.3), after a relapse (RR = 1.5, 95%CI: 1.3-1.9), treatment with surgery (RR = 1.2, 95%CI: 1.0-1.5), chemotherapy (RR = 1.4, 95%CI: 1.1-1.8) or stem cell transplantation (RR = 1.6, 95%CI: 1.0-2.5), and more recent year of diagnosis (2011-2015: RR = 4.3, 95%CI: 2.8-6.8).

CONCLUSION

MSHCs are prevalent in survivors, the risk is increasing in younger survivor cohorts, and MSHCs usually occur in multimorbid survivors. Strengthening of rehabilitation services and appropriate referrals are needed to mitigate the effects of the cancer and cancer treatment.

Healthcare providers' promotion of physical activity among child and adolescent cancer survivors: strategies and challenges

PURPOSE

This study aims to investigate how healthcare providers (HCPs) promote physical activity (PA) to child and adolescent cancer survivors.

METHODS

Semi-structured interviews were conducted with HCPs (n = 16; women n = 12; men n = 4) who provide care for cancer survivor youth (age 3 to 18). Participants represented 7 professions, including child life specialists, oncologists, nurse practitioners, physical therapists, and social workers. A reflexive thematic analysis was conducted to explore the techniques that HCPs use to promote PA for this patient population and ways PA promotion can improve.

RESULTS

HCPs use five strategies to promote PA to cancer survivor youth: (1) broadening the definition of PA, (2) tailoring PA recommendations, (3) including families, (4) connecting patients to programming, and (5) promoting patient motivation.

CONCLUSIONS

This research highlights techniques that HCPs use to promote PA to young cancer survivors and reveals the need for additional ways to support HCPs to improve PA promotion for child and adolescent cancer survivors. While HCPs emphasized the importance of PA for this patient population, they navigate barriers that limit the quality of PA discussions.

IMPLICATIONS FOR CANCER SURVIVORS

Further research should explore interventions to improve PA promotion and PA participation among child and adolescent cancer survivors. By understanding the perspectives of HCPs, patients, and their families, PA promotion strategies can be improved, and more programs that support both patients and practitioners may be developed.

Pain Assessment in Pediatric Patients with Primary Bone Cancer in a Single Site Cohort

Introduction: Pain is the main symptom described in cancer patients. Objective: To assess pain classification and management in pediatric patients with primary bone cancer over time: admission, during treatment and follow-up, and to investigate factors associated with pain classification at the last assessment. Method: Retrospective cohort study of osteosarcoma and Ewing's sarcoma cases in individuals <19 years old treated at a single cancer referral site and followed up by a multidisciplinary team. The primary endpoint was pain score at the last assessment. Secondary outcome: evolution of pharmacological treatment. Results: 142 patients were included. The frequency of pain assessment increased during the study period from 53.5% at admission to 68.3% during treatment and 85.9% in follow-up. Of the patients who had pain assessed, 65.8% had pain at admission and 26.2% at the end of the study. There was an increase in the use of strong opioids and antidepressants. In the last evaluation, 56 patients (39.4%) were at the end-of-life and this was not associated with more pain (p=0.68). Meanwhile, those who had more pain used strong opioids (p=0.01) or steroids (p=0.03). Conclusion: Pain management during treatment resulted in increased use of strong opioids and antidepressants with pain reduction, revealing that pain control is possible. In the last assessment, end-of-life patients no longer had pain and patients with pain were the ones who used strong opioids and steroids at the most, showing the difficulty of pain control in some patients.

Childhood cancer confers increased risk of migraine - A Danish nationwide register study

BACKGROUND

Investigations of migraine among childhood cancer survivors have predominantly relied on self-reported information and hospital discharge diagnoses. Alone, both approaches are liable to bias. We used Danish nationwide registers to obtain data on both prescriptions of acute migraine medications (antimigraines) and hospital discharge diagnoses of migraine to assess the relative risk of migraine across a wider spectrum of migraine presentations than previously studied.

METHODS

We followed a Danish population-based cohort of 7771 individuals with childhood cancer diagnosed in the period from Jan 1st, 1978 to Dec 31st, 2017, for risk of prescription antimigraine initiation and for risk of hospitalization due to migraine. Rates of hospitalization were assessed for the entire follow-up period whereas rates of antimigraine initiations were assessed in the period from Jan 1st, 1997, to Dec 31st, 2017. Relative to the general population without childhood cancer, standardized incidence ratios (SIRs) were calculated for each outcome.

RESULTS

Individuals exposed to childhood cancer were at increased risk of antimigraine initiation (SIR of 1.24, 95% CI: 1.11-1.38) and of migraine hospitalization (SIR of 2.44, 95% CI: 1.87-3.12) from the day of their cancer diagnosis and up to 40 years after.

CONCLUSIONS

Individuals diagnosed with childhood cancer have a higher risk of migraine of varying presentations, in addition to migraine resulting in hospitalization as previously reported. This potentially preventable problem warrants clinical attention.

Unique associations of pain frequency and pain-related worry with health-related quality of life in survivors of childhood cancer

More than one-third of childhood cancer survivors are worried about pain as a sign of disease recurrence; pain-related worry explained unique variance in health-related quality of life.

Introduction:

Pain is common during childhood cancer treatment, can persist into survivorship, and can negatively affect health-related quality of life in survivors of childhood cancers (SCCs).

Objective:

The objective of this brief report was to assess pain frequency, pain-related worry, and their (unique) associations with health-related quality of life in SCCs.

Methods:

One hundred eleven SCCs (52% female individuals, M age: 17.67 years, range 8–25 years) completed self-report measures of pain frequency, pain-related worry, and health-related quality of life.

Results:

More than two-thirds (70%) of SCCs reported pain in the previous month (M = 1.39, SD = 1.17), and 15% reported experiencing pain often or almost always. More than one-third (39%) reported worrying about pain as a sign of cancer recurrence (M = 0.73, SD = 1.07), and 9% reported worrying about pain a lot or a whole lot. In multivariate regression models that controlled for sex, age at diagnosis, and time off treatment, both pain frequency and pain-related worry were significantly associated with physical health-related quality of life, indicating that they contribute unique variance to health-related quality of life after childhood cancer. For emotional health-related quality of life, pain frequency was no longer a significant predictor once pain-related worry was added to the model, indicating that pain-related worry may be particularly important for understanding emotional health-related quality of life.

Conclusion:

Postcancer pain may contribute to health-related quality of life through multiple mechanisms, including by triggering concerns of recurrence. There is a need for clinical interventions that target both the frequency of pain (eg, behavioral interventions) and pain-related worry (eg, psychoeducation and cognitive interventions) to improve health-related quality of life after childhood cancer.

Factors Associated with Interest in Complementary and Alternative Medicine Among Young Adult Survivors of Childhood Cancer

Background: Use of complementary and alternative medicine (CAM) by those undergoing cancer treatment is common. While some childhood cancer survivors (CCS) may use CAM to treat late effects, others may lack information about available alternative therapies. We sought to determine characteristics associated with seeking more information about CAM among an ethnically diverse sample of young adult CCS. Methods: Young adult CCS were selected from the population-based Los Angeles SEER cancer registry and surveyed at ages 18 to 39 as part of the Project Forward Cohort. Associations between demographic, clinical, and other factors with seeking information on CAM were examined with t-tests, Chi Square analyses, and logistic regression. Results: Among 1106 participants surveyed, 182 (18%) reported interest in obtaining more information on CAM. Interest in CAM was highest among males, older (vs. younger) participants, those born outside the U.S., those with a history of relapsed/recurrent or second cancers, those with greater depressive symptoms, and those with poorer self-rated health. Among Hispanic/Latino/Latinx respondents, depressive symptoms, birth outside the U.S., and higher Latino culture orientation was positively associated with CAM interest. Discussion: Depressive symptoms and unresolved health problems are associated with a need for information about alternative forms of therapy, particularly in those with born outside the U.S. Healthcare providers caring for CCS can incorporate appropriate CAM information to help address unmet physical and mental health needs.

Phenotyping peripheral neuropathic pain in male and female adolescents: pain descriptors, somatosensory profiles, conditioned pain modulation, and child-parent reported disability

ABSTRACT

Neuropathic pain (NeuP) can be difficult to diagnose and manage in children. Data regarding prevalence and sex-dependent differences are limited, and more detailed phenotyping is needed. This observational cohort study recruited adolescents (10-17 years) with NeuP or complex regional pain syndrome (CRPS). After pain history and NeuP questionnaires, quantitative sensory testing was performed. Individual z-score plots were calculated with body-region control measures and matched to mechanism-related sensory profiles (sensory loss, thermal hyperalgesia, and mechanical hyperalgesia). Conditioned pain modulation was assessed with pressure pain threshold and a contralateral cold conditioning stimulus, and meaningful conditioned pain modulation defined as twice the standard error of measurement. Patients and parents completed validated questionnaires for child quality of life (QoL), pain catastrophizing, and self-reported anxiety/depression. Males (n = 23) and females (n = 43) with NeuP (n = 52) or CRPS (n = 14) reported moderate-severe pain with neuropathic sensory descriptors. Mixed patterns of sensory gain/loss at pain sites were not sex-dependent. Thermal hyperalgesia was common in both NeuP and CRPS, whereas sensory loss occurred only with NeuP and in a smaller proportion than adult cohorts. Conditioned pain modulation was inhibitory in 54%, facilitatory in 14%, and nonresponders had variable cold conditioning sensitivity. Males and females reported marked impairment of QoL, increased emotional distress, and pain catastrophising. Child-parent QoL scores correlated, but catastrophizing scores were discordant when parents or adolescents reported higher anxiety/depression. NeuP in adolescents is associated with significant pain, physical impairment, and psychosocial impairment. Quantifying alterations in somatosensory profiles, descending modulation, child and parent psychological function will inform individualized therapy and stratification for future clinical trials.

Pain in survivors of Ewing sarcoma: Prevalence, associated factors and prediction of recurrence

BACKGROUND

While the prognosis of patients with Ewing sarcoma (EwS) is improving, little is known about the frequency of pain and its risk factors in survivors of EwS. This study aims to analyse the prevalence and risk factors of pain and its predictive value for recurrence.

PATIENTS AND METHODS

In patients with remission after treatment of EwS, frequency and characteristics of pain within the first 5 years of follow up were assessed retrospectively.

RESULTS

Of 80 patients, 37 (46%) presented with at least one episode of pain. Chronic pain (>3 months) was observed in 10 patients (13%). Experience of at least one episode of pain was associated with prior combined local treatment (surgery and radiation compared to surgery alone; odds ratio [OR] 5.83, 95% confidence interval [CI] 1.43-34.9, P = .007). A total of 59 episodes of pain were observed, including 47 acute and 12 chronic episodes. Lower limb pain accounted for 46% (27/59) of all episodes of pain, and was associated with primary tumour of the pelvis or lower extremity (OR 4.29, 95% CI 1.18-18.21, P = .025), which represented 64% (51/80) of all EwS. The positive predictive value of pain for recurrence was only 12%.

CONCLUSION

Pain is a common problem in survivors of EwS, which mostly affects the lower extremity, and should be regularly assessed. Interventions to reduce pain may be particularly important in patients with combined local treatment with surgery and radiation, who seem to be at considerably increased risk for pain. Patients presenting with pain should be examined for recurrence.

Managing childhood cancer pain into survivorship: recognition and emerging principles

PURPOSE OF REVIEW

Continual refinement and further stratification of childhood cancer treatment has led to increased survivorship with recognized improvements in many long-term health outcomes. Despite this progress, persisting pain prevalence in childhood cancer survivors is increasing and emerging as a significant long-term health concern.

RECENT FINDINGS

Currently, there is no guidance on how to approach and manage persisting pain in survivors of childhood cancer.

SUMMARY

Clinicians should work with children and young people to optimize the management of pain and other symptoms on treatment. Focusing on an early post treatment screening for pain and other symptoms (including sleep and fatigue), and the role of on-going analgesic use. Follow-up should offer a multidisciplinary approach, aimed at lessening reliance on pharmacological approaches to pain management, addressing psychological concerns and promoting increased physical activity. The onus is on clinicians to mitigate the long-term risk of pharmacological reliance, particularly opioid dependency, in patients leaving their care and heading into adulthood. In this article, we highlight the emerging evidence of persisting pain in survivors of childhood cancer as a significant long-term health outcome and consider some initial principles of management.

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action

PURPOSE OF REVIEW

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management.

RECENT FINDINGS

Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.