Measurement of affective and activity pain interference using the Brief Pain Inventory (BPI): Cancer and Leukemia Group B 70903

Living well with chronic pain: a 12-month randomized controlled trial revealing impact from the digital pain self-management program EPIO

Introduction

Chronic pain affects a wide range of physical and psychological aspects of life for those impacted. Psychosocial treatment approaches may be of support, but outreach is still limited.

Objectives

To evaluate the efficacy of EPIO, an evidence-informed, user-centered digital self-management intervention for people with chronic pain, in a 12-month randomized controlled trial.

Methods

People living with chronic pain (N = 266) were randomized to the EPIO intervention (n = 132) or a usual-care control group (n = 134). The intervention was delivered in a simple blended care model, and outcome measures collected at baseline, 6 months, and 12 months. Generalized linear models for repeated measures were fitted to compare groups over time.

Results

Participants were primarily female (81%), median age 49 years (range 22-78), with heterogeneous pain conditions, and had lived with pain >5 years (77.6%). A mixed linear model with all timepoints included revealed no statistically significant group differences for the primary outcome of pain interference. Significant psychological benefits in favor of the intervention group were however detected for depression (P = 0.022), self-regulatory fatigue (P = 0.024), vitality (P = 0.016), and mental health (P = 0.047). Baseline to 12-month changes showed additional favorable effects for anxiety (between-group mean differences [MDs] = 0.79, P = 0.047), depression (MD = 1.08, P = 0.004), self-regulatory fatigue (MD = 2.42, P = 0.021), pain catastrophizing (MD = 2.62, P = 0.009), and health-related quality of life.

Conclusions

The EPIO program aims to improve outreach of evidence-based pain self-management interventions. Findings demonstrate how using EPIO can lead to sustainable psychological change, enhancing mental health and health-related quality of life for people suffering from pain, providing a chance to live well with the pain.

Validation of the Chinese version of the Brief Pain Inventory in patients with knee osteoarthritis

BACKGROUND

Knee osteoarthritis (KOA) primarily presents with symptoms of pain and compromised functionality. Pain is a subjective manifestation that necessitates the employment of reliable evaluation tools for practical assessment, thereby enabling the formulation of appropriate interventional strategies. The Brief Pain Inventory (BPI) is a widely utilized questionnaire for evaluating the status of chronic pain. The purpose of the present study is to translate the short form of BPI into Chinese version (BPI-CV) and conduct cross-cultural adaptation to evaluate the psychometric characteristics of BPI-CV in KOA patients.

METHODS

BPI-CV was translated and cross-culturally adapted according to internationally recognized guidelines. A cohort comprising 150 patients diagnosed with KOA successfully completed the demographic questionnaire, BPI-CV, Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and the EuroQoL Group's five-dimension questionnaire (EQ-5D). Internal consistency and test-retest analysis were used to evaluate the reliability. The internal consistency of the scale items was evaluated by calculating the Cronbach's α value (> 0.7). We chose to employ two scales commonly used in the evaluation of KOA patients: the disease-specific WOMAC scale and the universal EQ-5D scale. Construct validity was determined through Pearson correlation analysis, comparing BPI scores with those obtained from the WOMAC and EQ-5D scales. Exploratory factor analysis was used to structural validity.

RESULTS

The BPI-CV was well accepted with no ceiling or floor effect. Cronbach's α for assessing internal consistency was 0.894. Test-retest reliability was excellent with an ICC of 0.852 (95%CI 0.785-0.905). The BPI-CV showed moderate to strong correlations with the pain dimension (r = 0.496-0.860) and the functional interference dimension (r = 0.517-0.712) of the WOMAC and the EQ-5D (r = 0.527-0.743). Three factors resulted using exploratory factor analysis: pain severity, activity interference, and emotional interference, accounting for 79.0% of the total variance. Standard error of measurement was 0.539.

CONCLUSION

BPI-CV has good feasibility, reliability, and validity. It can be recommended for KOA patients in mainland China.

Perceived pain and smoking interrelations among veterans with chronic pain enrolled in a smoking cessation trial

INTRODUCTION

The Pain and Smoking Inventory (PSI) measures patients' perceived interrelations of their pain and smoking behavior, and comprises three conceptually-distinct domains: smoking to cope with pain (PSI-Cope), pain as a motivator of smoking (PSI-Motivate), and pain as a barrier to cessation (PSI-Barrier). Associations between PSI scores and pain interference and self-efficacy to quit smoking, two measures that can affect cessation outcomes, remain unclear.

METHODS

Secondary analysis of baseline data from 371 Veterans with chronic pain (88% male, M  age = 60) enrolled in a randomized smoking cessation trial. We used sequential multivariate regression models to examine associations between the three PSI domains and pain interference/self-efficacy.

RESULTS

Of 371 Veterans who completed baseline surveys, 88% were male with median age 60 years. PSI-Motivate scores were positively associated with pain interference (B: 0.18, 95% CI: 0.02, 0.34). PSI-Barrier sub-scores were negatively associated with self-efficacy (B: -0.23, 95% CI:-0.36, -0.10).

CONCLUSION

Findings suggest that individuals who hold maladaptive perceptions of pain-smoking interrelations may be more likely to endorse higher pain interference and lower self-efficacy-two established predictors of cessation outcomes. Moreover, each PSI subscale demonstrated unique relationships with the dependent variables, and our results provided support for a three-factor structure. These findings further demonstrate that the PSI comprises three conceptually and empirically distinct domains; future research should evaluate the clinical utility of assessing each domain in relation to cessation outcomes.

Background pain in persons with chronic leg ulcers: An exploratory study of symptom characteristics and management

This exploratory descriptive study aimed to describe characteristics and management of background pain related to chronic leg ulcers. A total of 121 participants were recruited from two wound care clinics using a consecutive sampling method. Data were obtained through screening interview, clinical examination, and questionnaires. The mean average background pain intensity was 4.5 (SD 2.56) (CI 95% 4.0-5.0). Pain interfered mostly with general activity (mean 4.3), sleep (mean 4.1), and walking ability (mean 4.0) (0-10 NRS). The most frequently reported descriptors of background pain were 'tender', 'stabbing', 'aching', and 'hot-burning'. Most of the participants stated that the pain was intermittent. Less than 60% had analgesics prescribed specifically for ulcer related pain, and the respondents reported that pain management provided a mean pain relief of 45.9% (SD 33.9, range 0-100). The findings indicate that ulcer related background pain is a significant problem that interferes with daily function, and that pain management in wound care is still inadequate.

Improving Documentation of Pain and Constipation Management Within the Cancer Center of a Large Urban Academic Hospital

PURPOSE:

Pain and constipation are common among patients with cancer and remain inadequately controlled in many. The Quality Oncology Practice Initiative assessment of pain and constipation at the Georgia Cancer Center for Excellence at Grady Health System identified documentation to be below benchmark levels. A quality improvement initiative to improve pain and constipation management was conducted.

METHODS:

Given the low baseline documentation rates for pain (60%) and constipation (20%), we aimed for an increase of 20 percentage points within 1 year. On the basis of cause-and-effect analysis and provider questionnaires to understand fully the causal factors, our multidisciplinary team developed a new provider note template to integrate nurse’s assessment of pain and constipation into the provider’s documentation. A new order panel was developed in the electronic medical record to link appropriate orders with the pain and constipation plan.

RESULTS:

The integration of the initial nursing assessment into the provider note template increased pain score documentation from 66.7% to 100% ( P < .01), and the pain management plan improved from 65.3% to 86.4% ( P = .06). Similarly, constipation assessment documentation improved from 20.4% to 100% ( P < .01), and a documented constipation plan improved accordingly from 11.2% to 29.1% ( P < .01). As a result of this intervention, pain control at the third clinic visit improved from 61.5% to 86.8% ( P < .01). Emergency department visits related to pain and constipation decreased (16.2% to 14.9%; P = .19), and hospitalizations marginally increased (1.6% to 3.6%) during the study period ( P =.28).

CONCLUSION:

A standardized visit template and hardwired assessment of pain and constipation exceeded the goal for improvement in documentation and positively affected outcomes.

Exploring novel diabetes surveillance methods: a comparison of administrative, laboratory and pharmacy data case definitions using THIN

Background

The objective of this study was to identify patients with diabetes in a comprehensive primary care electronic medical records database using a number of different case definitions (clinical, pharmacy, laboratory definitions and a combination thereof) and understand the differences in patient populations being captured by each definition.

Methods

Data for this population-based retrospective cohort study was obtained from The Health Information Network (THIN). THIN is a longitudinal, primary care medical records database of over 9 million patients in UK. Primary outcome was a diagnosis of diabetes, defined by the presence of a diabetes read code, or an abnormal laboratory result, or a prescription for an Oral Anti-diabetic drug or insulin. A 2-year washout period was applied prior to the index of diabetes to avoid inclusion of prevalent cases for each case definition.

Results

This study demonstrated that different case definitions of diabetes identify different sub-populations of patients. When the cohorts were observed based on any measure of central tendency, each of the cohorts were reasonably comparable to each other. However, the distribution of each of the cohorts when grouped by age categories and sex, reveal differences. For example, using pharmacy case definition results in a bimodal distribution among women, one between 1-19 year and 35-39 age categories, and then again between 60-64 and 85 years-however, the histogram becomes more normally distributed when metformin was removed from the case definition.

Conclusion

Our results suggest that clinical, pharmacy, laboratory case definitions identify different sub-populations and using multiple case definitions is likely required to optimally identify the entire diabetes population within THIN. Our study also suggests that age and sex of patients may affect the indexing of diabetes in THIN and is critical to better understand these variations.

Ten-year experience of the multidisciplinary Osteoncology Center

PURPOSE

Bone metastases (BMs) are responsible for high morbidity in patients. A multidisciplinary approach involving a team of specialists offers an effective therapeutic strategy based on disease characteristics, medical history, and performance status. We evaluated the impact of our 10-year multidisciplinary experience on the management of patients with BM.

METHODS

We retrospectively analyzed 2194 medical reports of 1628 patients referred to our Osteoncology Center from 2005 to 2015. Cases were discussed weekly by a multidisciplinary team.

RESULTS

Eight hundred thirty-eight (38.2%) of the 2194 visits were requested because of a risk of complications from BM. Antiblastic treatment and bone-targeted therapy were modified in 709 (66.3%) and 309 (31%) of cases, respectively. Radiotherapy was scheduled in 220 (20%) of the 1099 patients for whom information was recorded. Patients completed the Brief Pain Inventory (BPI) during their first visit, 1296 (59.1%) reporting pain (median intensity 4), and 537 (41.4%) experiencing a level that interfered substantially with daily activities. New ortheses and/or antalgic therapy was prescribed accordingly. After 7 days, 208 (16%) patients were re-evaluated and a new BPI administered. A significant improvement in the worst (p < 0.0001) and current pain (p = 0.03) was seen, together with a favorable impact on daily activities (p = 0.02). Two thousand fifty-one patients completed an anonymous questionnaire on the quality of the service, the majority (69.4%) expressing high satisfaction.

CONCLUSIONS

Our 10-year osteoncology experience confirms the importance of a multidisciplinary approach to optimize BM management. Further evaluations are needed in relation to quality of life, outcome, and costs.

Brief Pain Inventory: A proposal to extend its clinical application

BACKGROUND

This study presents an adaptation of the Brief Pain Inventory (BPI) extending its use in clinical/epidemiological contexts and the evaluation of the properties of BPI (short form) in a sample of Brazilian adults.

METHODS

Part of item 1 of this instrument was removed because it prevented the participation of individuals with usual pain. In addition to the reference period of original response "last 24 hr," a new period "last pain experience" was proposed. Individuals responded about the presence/lack and onset of pain. Individuals who reported pain in the last 24 hr before the interview answered the BPI considering both reference periods. Confirmatory factor analysis was performed to check the fit of five theoretical BPI models.

RESULTS

A total of 1,176 adults participated (79.0% women; 38.7 (SD = 10.8) years), 29.2% did not report pain in the last 24 hr, 33.6% reported pain <3 months and 37.2% pain ≥3 months. All theoretical BPI models presented adequate fit indices (GFI ≥ 0.9; RMSEA < 0.1; α ≥ 0.7) when both reference periods were used. In conclusion, the adaptations proposed can contribute to extend the use of BPI.

CONCLUSIONS

The reference period of responses and the theoretical model used must be chosen according to the needs of the researcher and/or physician.

SIGNIFICANCE

This study presents evidence related to the validity of applying the Brief Pain Inventory (BPI) in adults with and without pain considering the present pain or memory of pain, enabling the clinician to collect additional information that may be relevant to the clinical management of pain.

Quality of life and impact of pain in women treated with aromatase inhibitors for breast cancer. A multicenter cohort study

Women with hormone-dependent breast cancer are treated with aromatase inhibitors (AI) to slow disease progression by decreasing estrogen levels. However, AI have adverse effects, including pain, with potentially serious impact on quality of life (QOL) and treatment compliance. We evaluated quality of life during the first year of AI treatment, focusing particularly on the impact of pain. In a multicenter cohort study of 135 women with early-stage breast cancer, free of pain at the initiation of AI treatment, quality of life (by the EORTC QLQ-BR23), somatic and psychic symptoms, psychological characters, temperament and coping strategies were assessed at baseline and at each follow-up visit (1, 3, 6 and 12 months). The impact of treatment-induced pain on quality of life during follow-up was determined with repeated-measures regression models. These models were constructed to assess the effects of pain and pain type on quality of life during follow-up, taking into account predictors associated with quality of life at baseline. Prior ganglion resection, taxane treatment and chemotherapy, a high amplification score on the pain catastrophizing scale, and a high harm avoidance score on the personality questionnaire were associated with a significantly lower baseline QOL. Fifty-seven percent of women developed pain of five different types: upper or lower limb joint pain, diffuse pain, neuropathic pain, tendon pain and mixed pain. A significant decrease in QOL was noted in the women with pain, particularly for body image, sexual functioning and future perspectives. Moreover, the impact of pain on QOL depended on the type of pain experienced. In conclusion, women treated with aromatase inhibitors display changes in quality of life and the degree of change in quality of life depends mostly on the type of pain experienced. Oncologists and patients should be aware of painful adverse effects of AI and encouraged to provide or receive earlier and more appropriate management of these effects.

Influence of Social and Health Indicators on Pain Interference With Everyday Activities Among Older Black and White Cancer Patients

Objective: This prospective study aimed to determine the influence social and health factors have on pain interference with everyday activities among older patients receiving outpatient treatment services from a comprehensive cancer center. Method: Participants were surveyed on questions assessing pain interference, and social (communication), health (pain severity, comorbidities), behavioral (self-efficacy, affect), and demographic characteristics. Multivariate analyses were specified to examine determinants of pain interference, with items loading on separate cluster composites: physical interference and psychosocial interference. Results: Pain severity was a significant indicator for physical interference. Similarly, pain severity, education, self-efficacy, negative affect, and communication were predictors of psychosocial interference. Discussion: Factors defining the daily lived experiences of older adults are important in providing baseline information on functional status. This emphasizes the need to rigorously examine the association between pain, and clinical and psychosocial indicators, but more importantly indicators that contribute to the patient’s ability to perform normal everyday activities.

Validación del Brief Pain Inventory en personas con enfermedad renal crónica

Objetivo: comprobar las propiedades psicométricas de la versión portuguesa del Brief Pain Inventory, en personas con enfermedad renal crónica sometidas a hemodiálisis. Método: estudio metodológico. La muestra seleccionada está compuesta por 171 personas con enfermedad renal crónica que presentan dolor durante al menos 24 horas y realizan hemodiálisis en dos clínicas de la región de Lisboa, Portugal. Los datos se recogieron entre mayo y junio del 2015. Se evaluaron las siguientes propiedades psicométricas: validez (constructo, convergente y discriminante), confiabilidad (α de Cronbach) y estabilidad (test-retest). Resultados: se obtuvo información que apoya adecuadamente una estructura bifactorial (interferencia del dolor y grado de severidad del dolor), con confiabilidad (α = 0,90 y α = 0,80, respectivamente) y estabilidad. Las medidas registradas están correlacionadas de forma positiva con el afecto negativo, y de forma negativa, con las medidas de calidad de vida, que sustentan la validez concurrente. Se comprobó la existencia de apoyo para la validez predictiva. Conclusiones: las medidas del “grado de severidad del dolor” e “interferencia del dolor” que se obtuvieron a través del Brief Pain Inventory son válidas y reproducibles en personas con enfermedad renal crónica que presentaron dolor en las últimas 24 horas, cuando se utiliza el cuestionario y la entrevista.

Confirmatory factor analysis of 2 versions of the Brief Pain Inventory in an ambulatory population indicates that sleep interference should be interpreted separately

Background

The Brief Pain Inventory (BPI-SF) is a widely-used generic pain interference scale, however its factor structure remains unclear. An expanded 10-item version of the Interference subscale has been proposed, but the additional value of the 3 extra items has not been rigorously evaluated. The purpose of this study was to evaluate and contrast the factorial and concurrent validity of the original 7-item and 10-item versions of the BPI-SF in a large heterogeneous sample of patients with chronic pain.

Methods

Exploratory and confirmatory factor analyses were conducted on independent subsets of the sample, and concurrent correlations with scales capturing similar constructs were evaluated.

Results

Two independent exploratory factor analyses (n = 500 each) supported a single interference factor in both the 7- and 10-item versions, while confirmatory factor analysis (N =1000) suggested that a 2-factor structure (Physical and Affective) provided better fit. A 3-factor model, where sleep interference was the third factor, improved in model fit further. There was no significant difference in model fit between the 7- and 10-item versions. Concurrent associations with measures of general health, pain intensity and pain-related cognitions were all in the anticipated direction and magnitude and were not different by version of the BPI-SF.

Conclusions and implications

The addition of 3 extra items to the original 7-item Interference subscale of the BPI-SF did not improve psychometric properties. The combined results lead us to endorse a 3-factor structure (Physical, Affective, and Sleep Interference) as the more statistically and conceptually sound option.

The Association of Smoking and Surgery in Inflammatory Bowel Disease is Modified by Age at Diagnosis

Objectives:

We assessed the association of smoking at diagnosis of inflammatory bowel disease (IBD) on the need for an intestinal resection.

Methods:

The Health Improvement Network was used to identify an inception cohort of Crohn's disease (n=1519) and ulcerative colitis (n=3600) patients from 1999–2009. Poisson regression explored temporal trends for the proportion of newly diagnosed IBD patients who never smoked before their diagnosis and the risk of surgery within 3 years of diagnosis. Cox proportional hazard models assessed the association between smoking and surgery, and effect modification was explored for age at diagnosis.

Results:

The rate of never smokers increased by 3% per year for newly diagnosed Crohn's disease patients (incidence rate ratio (IRR) 1.03; 95% confidence interval (CI): 1.02–1.05), but not for ulcerative colitis. The rate of surgery decreased among Crohn's disease patients aged 17–40 years (IRR 0.96; 95% CI: 0.93–0.98), but not for ulcerative colitis. Smoking at diagnosis increased the risk of surgery for Crohn's disease patients diagnosed after the age of 40 (hazard ratio (HR) 2.99; 95% CI: 1.52–5.92), but not for those diagnosed before age 40. Ulcerative colitis patients diagnosed between the ages of 17 and 40 years and who quit smoking before their diagnosis were more likely to undergo a colectomy (ex-smoker vs. never smoker: HR 1.66; 95% CI: 1.04–2.66). The age-specific findings were consistent across sensitivity analyses for Crohn's disease, but not ulcerative colitis.

Conclusions:

In this study, the association of smoking and surgical resection was dependent on the age at diagnosis of IBD.

Invasive treatment of pain associated with pancreatic cancer on different levels of WHO analgesic ladder

Background

Pancreatic cancer is a malignant neoplasm with a high mortality rate, often associated with a delayed diagnosis, the early occurrence of metastasis and an overall, poor response to chemotherapy and radiotherapy. Pain management in pancreatic cancer consists mainly of pharmacological treatment according to the WHO analgesic ladder. Surgical treatment for pain relief, such as splanchnicectomy, is considered amongst the final step of pain management. It has been proven that splanchnicectomy is a safe procedure with a small percentage of complications, nevertheless, it is often used as a last resort, which can significantly decrease its effectiveness. Performance of thoracoscopic splanchnicectomy along the first step of the analgesic ladder may lead to long-lasting protection against the presence and severity of pain.

Methods/Design

A prospective, open label, 1:1 randomized, controlled trial, conducted at a single institution to determine the effectiveness of invasive treatment of pain via splanchnicectomy, in patients with advanced pancreatic cancer. The size of tested group will consist of 26 participants in each arm of the trial, to evaluate the level of pain relief and its impact on quality of life. To evaluate the influence on patients’ rate of overall survival, a sample size of 105 patients is necessary, in each trial arm. Assessments will not only include the usage of analgesic pharmacotherapy throughout the course of disease, and overall patient survival, but also subjective pain perception at rest, in movement, and after meals (measured by NRS score questionnaire), the patient’s quality of life (measured using the QLQ-C30 and FACIT questionnaires), and any pain-related suffering (measured with the PRISM projection test). The primary endpoint will consist of pain intensity. Questionnaires will be obtained upon the initial visit, the day of surgery, the day after surgery, as well as during long-term follow-up visits, held every two weeks thereafter.

Discussion

Earlier implementation of invasive treatment, such as thoracoscopic splanchnicectomy, can provide a higher efficacy of pain management, prevent deterioration in the patient’s quality of life, and lengthen their overall survival.

Trial registration

ClinicalTrials.gov identifier: NCT02424279. Date of registration January 2, 2015.

Frameless stereotactic magnetic resonance imaging-guided laser interstitial thermal therapy to perform bilateral anterior cingulotomy for intractable pain: feasibility, technical aspects, and initial experience in 3 patients

BACKGROUND

Bilateral anterior cingulotomy is well described for certain pain and psychiatric disorders. Typically, stereotactic frame-based radiofrequency ablation is used. We report the feasibility of a frameless approach using magnetic resonance imaging-guided laser induced thermal therapy (MRgLITT).

OBJECTIVE

To report experience and outcomes for MRgLITT in bilateral anterior cingulotomy.

METHODS

Three patients with chronic refractory cancer-related pain underwent bilateral anterior cingulotomy. The Brief Pain Inventory (Short Form) was used for pain evaluation. Frameless stereotaxy using the Medtronic S7 Navigation system was used for laser catheter placement. Patients were followed for evaluation of pain control outcomes.

RESULTS

Four MRgLITT bilateral cingulotomy procedures were performed in 3 patients. Two patients had a single MRgLITT procedure while the third had repeat ablation after pain recurrence. First time ablation coordinates were (medians): x = 7.9 mm (range, 6.9-8.6); y = 20.5 mm (range, 20-22); z = 6.9 mm (range, 2.9-7.0) above the lateral ventricle roof. Median trajectory length was 85.5 mm (range, 80-90). Median ablation volume was 1.5 cm3 (range, 0.6-1.2). Median ablation time was 257 seconds (range, 136-338) per cingulum and power was 10.0 Watts (range, 10-11). Median preoperative pain severity (PSS) and interference scores (PIS) were 7.7 (range, 7.5-9.3) and 9.9 (range, 9.7-10.0), respectively. Median postoperative PSS and PIS scores were 1.6 (range, 1.0-2.8) and 2.0 (range, 0.3-2.6), respectively.

CONCLUSION

MRgLITT cingulotomy is well tolerated for treatment of cancer pain and can be easily performed framelessly for appropriate candidates.

One, two, or three? Constructs of the brief pain inventory among patients with non-cancer pain in the outpatient setting

CONTEXT

Either a two-factor representation (pain intensity and interference) or a three-factor representation (pain intensity, activity interference, and affective interference) of the modified Brief Pain Inventory (BPI) is appropriate among cancer patients.

OBJECTIVES

To evaluate the extent to which a three-factor representation (pain intensity, activity interference, and affective interference) is appropriate for BPI among patients with noncancer pain seen in an outpatient setting.

METHODS

We conducted a prospective, multicenter, observational, nonrandomized study using patient pain registry data from outpatient settings. Seven hundred forty-one patients with acute episodes of noncancer pain requiring treatment with a prescription medication containing oxycodone immediate-release on an as-needed basis for at least five days participated. Baseline measurements included the modified BPI pain intensity (right now, average, and worst in 24 hours) and pain interference with general activities, walking, work, mood, relations with others, sleep, and life enjoyment. Confirmatory factor analysis was conducted for the overall sample and among postoperative patients (n = 133), patients with back and neck pain (n = 202), patients with arthritis (n = 148), and patients with injury or trauma (n = 204).

RESULTS

Both the two-factor and three-factor models were statistically better than the one-factor model (P < 0.05), with the two-factor model performing better than the three-factor model. Configural invariance, but not metric invariance by patient cohort group was demonstrated.

CONCLUSION

Consistent with analyses among cancer patients, a two-factor representation of BPI is appropriate for noncancer patients seen in an ambulatory setting. This work lends additional support for the psychometric properties of BPI.

Classification of and risk factors for estrogen deprivation pain syndromes related to aromatase inhibitor treatments in women with breast cancer: a prospective multicenter cohort study

Aromatase inhibitors (AIs) are the first-line treatment in women with breast cancer for total estrogen depletion. Half the treated women may develop pain, and this condition may therefore be seen as a clinical model of pain related to estrogen deprivation. In this prospective multicenter study, we classified AI-related pain syndromes and identified their predictors. A 1-year, prospective, multicenter cohort study, with 6 visits, was carried out on 135 women with early-stage breast cancer and no pain at the start of AI treatment. At initial assessment, we investigated clinical (demographic and psychosocial, cancer characteristics and treatment, sleep, quality of life), biological (sex hormones, vitamin D, bone biomarkers, oxidative stress, immunologic and inflammatory markers), environmental, and genetic (polymorphism for pain mechanisms) risk factors for pain. During 1 year of follow-up, 77 women (57%) developed pain, leading to AI discontinuation in 12 cases. Five pain syndromes were identified: joint pain (36%), diffuse pain (22%), tendinitis (22%), neuropathic pain (9%), and mixed pain (11%), which are mostly persistent (57%), with diffuse and joint pains the most intense. Risk factors for the development of pain included higher levels of anxiety and impaired quality of life at the initial assessment, whereas cancer characteristics, genetic background, inflammation, and immunologic and hormonal status at baseline were not significant predictors.

PERSPECTIVE

This article presents a classification of AI-related pain syndromes induced by estrogen deprivation that were previously described as arthralgia, but not as neuropathic, diffuse, and mixed pain. This estrogen deprivation-related condition represents a clinical model of pain, and our study identified mostly psychological risk factors for pain development.